Factors ,symptoms ,treatment for macular degeneration

What are risk factors for macular degeneration?

The greatest risk factor is age. Although AMD may occur during middle age, studies show that people over age 60 are clearly at greater risk than other age groups. Middle-aged people have about a 2% risk of getting AMD while people over age 75 have a nearly 30% risk.
Other risk factors include smoking, obesity, white race, female gender, a family history of macular degeneration, a diet low in fruit and vegetables, high blood pressure, and elevated blood cholesterol.

What are macular degeneration symptoms?

Neither dry nor wet AMD cause any eye pain.
The most common early symptom in dry AMD is blurred vision. As fewer cells in the macula are able to function, people will see details less clearly in front of them, such as faces or words in a book. Often this blurred vision will go away in brighter light. If the loss of these light-sensing cells becomes great, people may see a small black or gray blind spot in the middle of their field of vision.
Dry macular degeneration symptoms usually develop gradually and do not include total blindness. However, the symptoms may worsen the quality of life by making reading, driving, and facial recognition difficult Other symptoms may include decreased night vision, a decrease in the intensity or brightness of colors, increase in the haziness of overall vision.
Dry macular degeneration may affect one eye or both eyes. If only one eye is affected, symptoms may not be noticed because the unaffected eye has no visual symptoms.
All of the above symptoms may also be noticed in the wet form of AMD. In addition, the most common symptom in wet macular degeneration is straight lines appearing crooked or wavy. This results when fluid from the leaking blood vessels gathers within and lifts the macula, distorting vision. Larger areas of gray or black in the central area of vision may also occur. The central vision may decrease over a short period of time.

What are signs of macular degeneration?

In both dry and wet forms of macular degeneration, the ophthalmologist may find decreased visual clarity (acuity) with preservation of peripheral vision and changes in the central retina visible with the ophthalmoscope.

How is macular degeneration diagnosed?

Your ophthalmologist may suspect the diagnosis of AMD if you are over age 60 and have had recent changes in your central vision. To look for signs of the disease, he or she will use eyedrops to dilate, or enlarge, your pupils. Dilating the pupils allows your ophthalmologist to view the back of the eye better.
Early AMD is often diagnosed during a comprehensive eye exam in patients without significant symptoms. This eye exam includes having drops placed in your eyes to enlarge, or dilate, the pupils. Your ophthalmologist will carefully examine the central portion of the retina to determine the presence or absence of AMD using various illuminating and magnifying devices.
During the eye exam, you may be asked to look at a checkerboard pattern called an Amsler grid. When looking at an Amsler grid with one eye, patients with AMD may notice that the straight lines of the checkerboard appear wavy or are missing.
Other diagnostic tests that your ophthalmologist may perform include retinal photography, fluorescein angiography and optical coherence tomography. All of these can help to differentiate between dry and wet forms of AMD and also document the abnormalities so that progression and response to treatment can be better measured.

What is the treatment for wet macular degeneration?

Wet AMD can be treated with laser surgery, photodynamic therapy, and injections into the eye. None of these treatments is a permanent cure for wet AMD. The disease and loss of vision may progress despite treatment.
Laser surgery is used to destroy the fragile, leaky blood vessels. A high energy beam of light is aimed directly onto the new blood vessels to eradicate them, preventing further loss of vision. However, laser treatment may also destroy some surrounding healthy tissue and some vision. Because of this, only eyes with new vessels away from the exact center of the vision can be treated. This represents only a small proportion of patients with AMD. Laser surgery is only effective in halting or slowing visual loss if the leaky blood vessels have developed away from the fovea, the central part of the macula. Even in treated cases, the risk of new blood vessels recurring after treatment is significant and further or other treatment may be necessary.
Photodynamic therapy uses a drug called verteporfin (Visudyne) being injected into a vein of the arm. A light is then directed into the eye to activate the drug adhering to the blood vessels in the eye. The activated drug destroys the new blood vessels and leads to a slower rate of vision decline. Photodynamic therapy may slow the rate of vision loss. It does not stop vision loss or restore vision in eyes already damaged by advanced AMD. Treatment results often are temporary. Retreatment may be necessary.
Within the last seven years, injections into the eye with drugs specifically developed to stop the growth of new blood vessels have revolutionized the treatment of wet macular degeneration. We have learned that a specific chemical called vascular endothelial growth factor (VEGF) is necessary for the new blood vessels to grow under the retina. Drugs that counter VEGF (anti-VEGF pharmacotherapy) can be injected into the eye to arrest development of new blood vessels and sometimes cause them to regress. These drugs are injected in the ophthalmologist's office and may need to be given as frequently as monthly. Careful observation of the eye on a monthly basis to determine the drug effect is necessary. With this treatment, visual loss can often be halted or slowed and some patients will even experience some improvement of vision. Newer drugs currently under review may need to be given less frequently.
In patients with far advanced macular degeneration on both eyes, surgery to implant a telescopic lens in one eye is an option. The telescope implant, which surgically replaces the eye's natural lens, magnifies images while reducing the field of vision (peripheral vision). The telescopic lens implant may improve both distance and close-up central vision.

What is the treatment for dry macular degeneration?

There is currently no treatment available to reverse dry macular degeneration. However, dry macular degeneration is usually slowly progressive and most patients with this condition are able to live relatively normal, productive lives. Often one eye is affected more than the other.
Once dry AMD reaches the advanced stage, no form of treatment can prevent further vision loss. However, treatment can delay and possibly prevent intermediate AMD from progressing to the advanced stage of severe vision loss. The National Eye Institute's Age-Related Eye Disease Study (AREDS) found that taking a specific high-dose formulation of antioxidants and zinc significantly reduces the risk of advanced AMD and it's associated vision loss. Slowing AMD's progression from the intermediate stage to the advanced stage is helpful in reducing the progression of visual loss in many people.
In this study, researchers used an antioxidant formulation that included vitamin C, vitamin E, beta carotene (or vitamin A), and zinc. For people with early-stage dry macular degeneration, there is no evidence that these vitamins provide a benefit. It is recommended that people with intermediate-stage dry AMD in one or both eyes or advanced stage AMD (dry or wet) in one eye, but not the other eye, take the AREDS formulation. Patients with increased risk of lung cancer should not take beta carotene. Studies involving other supplements such as lutein and bilberry are currently being performed.
The progression of dry age-related macular degeneration can also be slowed through lifestyle changes. These include changing the diet to include more fruits and vegetable, choosing healthy unsaturated fats, such as olive oil, over unhealthy saturated fats, such as butter, eating whole grains rather than refined grains and adding fish high in omega-3 fatty acids.

What are complications of macular degeneration?

Progression to wet macular degeneration is the main complication of dry age-related macular degeneration. At any time, dry macular degeneration can progress to the more severe form of the disease called wet macular degeneration, which may cause rapid vision loss. There's no accurate way to predict who will eventually develop wet macular degeneration.
Other eye diseases such as cataracts, glaucoma, retinal detachment, or dry eyes are not complications of macular degeneration. Patients with macular degeneration can, however, develop these or other eye diseases.

What is the prognosis for macular degeneration?

Macular degeneration in its advanced form can cause loss of all central vision in both eyes. In the absence of other eye diseases, peripheral vision is maintained. Therefore, patients with advanced macular degeneration are, in most cases, able to see enough to get around in familiar situations.
The use of magnifying devices can often improve vision in macular degeneration to allow for reading or watching of television.

Macular Degeneration

Macular degeneration facts

• The macula is in the center of the retina, the light-sensitive layer of tissue at the back of the eye. The macula is responsible for central vision (straight-ahead vision). Degeneration of the macula occurs most often after the age of 60 years and is termed age-related macular generation (AMD).
• AMD is a painless condition.
• There are two types of AMD: dry AMD and wet AMD.
• Smoking, high blood pressure, obesity, a diet high in unsaturated fats and simple carbohydrates and lack of exercise all increase the risk of AMD.
• Early symptoms of dry AMD include slightly blurred vision, the need for more light for reading, and difficulty recognizing faces until very close to the person. A symptom of more advanced dry AMD is the presence of a blurred spot in the center of vision. An early symptom of wet AMD is the wavy appearance of straight lines.
• Dry AMD cannot be treated at present, but progression can be slowed through a healthy lifestyle and, in certain cases, through anti-oxidant vitamins. Injections into the eye of anti-angiogenic agents are successfully used in arresting or slowing wet AMD. Because of new therapies for the wet form of AMD, early diagnosis of wet AMD is particularly critical. 

What is macular degeneration?

Macular degeneration is a common, painless eye condition in which the central portion of the retina deteriorates and does not function adequately.

What is the retina?

The retina is the light sensitive tissue located in the back of the eye. It is like the film in a camera, recording the images we see and sending them via the optic nerve from the eye to the brain. The retina instantly converts light images into electrical impulses through a chemical reaction. The retina then sends these impulses or signal, to the brain, where we interpret what we see, process the visual information, and relate what we see to the rest of our environment.

What is the macula?

The macula is a small portion of the retina located in the central portion of the retina. The macula is responsible for central vision (straight-ahead vision) and provides the ability to see fine detail in your direct line of sight. We use the macula of each eye to have the clear vision that allows us to read, drive a car, and recognize faces or colors. The non-macular areas of the retina provide us with our side vision and best night vision.

What is age-related macular degeneration (AMD)?

Although there are many types of macular degeneration, age-related macular degeneration (AMD or ARMD) is by far the most common type. AMD is a disease associated with aging that gradually destroys sharp central vision that is needed for seeing objects clearly and for common daily tasks such as reading and driving. In some cases, AMD advances so slowly that people notice little change in their vision. In others, the disease progresses faster and may lead to a loss of vision in both eyes. AMD is the leading cause of vision loss in Americans 60 years of age and older. AMD usually affects both eyes, although the clinical appearance and degree of visual loss may vary a great deal between the two eyes.
AMD occurs in two forms. "Wet" age-related macular degeneration is less common but more aggressive in its progression to severe central vision loss. "Dry" age-related macular degeneration is the more common type and is more slowly progressive in causing visual loss..

What is wet age-related macular degeneration?

Wet AMD occurs when abnormal blood vessels grow from the choroid (the layer of blood vessels between the retina and the outer firm coat of the eye called the sclera) under and into the macular portion of the retina. These new blood vessels (known as choroidal neovascularization or CNV) tend to be very fragile and often leak blood and fluid. The blood and fluid raise the macula from its normal place at the back of the eye and interfere with the retina's function and causes the central vision to blur. Under these circumstances, vision loss may be rapid and severe. Some patients, however, do not notice visual changes despite the onset of CNV. Therefore, periodic eye examinations are very important for patients at risk for CNV.
Once CNV has developed in one eye, whether there is a visual loss or not, the other eye is at relatively high risk for the same change.
All wet AMD is described as advanced AMD, whether or not there is serious visual loss. Wet AMD does not have not have stages like dry AMD. The wet form generally leads to significantly more vision loss than the dry form.
All people who have the dry form of AMD are at risk for development of the wet form. All people who have the wet form had the dry form first. The dry form can advance and cause vision loss without turning into the wet form. The dry form also suddenly can turn into the wet form. Currently, there is no certain way to predict if or when the dry form will turn into the wet form.

What are retinal drusen?

Retinal drusen are yellow deposits under the retina. They often are found in people over 60 years of age. Your eye-care professional can detect drusen during a comprehensive dilated eye exam.
Drusen alone do not usually cause vision loss. In fact, scientists are unclear about the connection between drusen and AMD. It is not clear if an increase in the size or number of drusen raises a person's risk of developing either advanced dry AMD or wet AMD. These changes can cause serious vision loss.

What is dry age-related macular degeneration?

In dry AMD, the light sensitive cells in the macula slowly break down. With less of the macula functioning, central vision diminishes. Dry AMD often occurs in just one eye at first. Later, the other eye can be affected. The cause of dry AMD is unknown.
Dry AMD has three stages, early, intermediate, or advanced, all of which may occur in one or both eyes. People with early AMD have either several small drusen or a few medium-sized drusen. At this stage, there are no symptoms and no vision loss.
People with intermediate AMD have either many medium-sized drusen or one or more large drusen. Some people see a blurred spot in the center of their vision. More light may be needed for reading and other tasks.
In addition to drusen, people with advanced dry AMD have a breakdown of light-sensitive cells and supporting tissue in the central retinal area. This breakdown can cause a blurred spot in the center of your vision. Over time, the blurred spot may get bigger and darker, taking more of your central vision. You may have difficulty reading or recognizing faces until they are very close to you.
The dry form is much more common than the wet form. In dry AMD, there is no CNV (abnormal new blood vessel formation under the retina) and no fluid or blood leakage into the retina (retinal swelling or bleeding). More than 85% of all people with intermediate and advanced AMD combined have the dry form. However, if only advanced AMD is considered, about two-thirds of patients have the wet form.
Dry AMD can advance and cause vision loss without turning into wet AMD. Dry AMD can also rapidly transform into the wet form by the growth of new blood vessels.

What causes macular degeneration?

We do not know the precise cause for the development of ARMD. However, we do know that there are certain risk factors for the development of age-related macular degeneration.

Treatment for childhood obesity

What are risk factors for childhood obesity?

There are several substantial risk factors for the development of pediatric obesity.

1. Genetics: While several genetic syndromes are associated with obese stature (for example, Prader-Willi syndrome), genetics are not responsible for the obesity epidemic currently taking place. There has been no change in the gene pool over the last 30 years. Most recent studies indicate that if one parent is obese the likelihood of having an obese child is three times higher than otherwise. If both parents are obese, the likelihood is 10 times higher.
2. Social: Limited school athletic activities coupled with excessive time-utilizing social networks, TV, and computer games are a prime reason for pediatric obesity. Watching TV while eating a meal as well as the excessive consumption of takeout/fast food are also both risk factors for both pediatric and adult obesity. Recent studies indicate that only 20% of children experience more than two episodes of vigorous play per week, and 25% of these children watched more than four hours of TV per day. This does not include additional time engaging in computer games, texting, or talking on the phone with friends. Having a TV in the bedroom is a strong predictor of pediatric obesity.
3. Cultural: Many societies follow either a healthier food palate (traditional oriental, Mediterranean, etc.) or eat smaller portions of higher-fat-content foods (European). The Americanization of such foods coupled with excessive portions is a prime cause of obesity.
4. Diseases: Thyroid disease, polycystic ovary disease, brain tumors, mental retardation, and other conditions are a small contributor to the risk factors for obesity.
5. Medications: Chronic oral steroids, some classes of antidepressants, and other drugs may also contribute (in a very small way) to pediatric obesity.
6. Psychological: Many individuals overeat in an attempt to deal with emotionally stressful lifestyles. Often the excessive weight further aggravates their emotional turmoil.

What the risks, complications, and long-term health effects of childhood obesity?

The consequences of childhood obesity may be grouped into three areas: physical, mental, and economic. The known physical side effects of obesity are multiple and broad spectrum in character. These include: (1) increase in risk of developing type 2 diabetes mellitus due to excessive insulin secretion and organ resistance to insulin; (2) menstrual irregularity and infertility; (3) heart attack and stroke due to hypercholesterolemia, hyperlipidemia, and hypertension; (4) pulmonary issues centering on asthma and obstructive sleep apnea; (5) orthopedic issues of bowed legs and hip instability (for example, slipped capital femoral epiphysis); and (6) metabolic issues (nonalcoholic fatty liver disease, gallstones and gastroesophageal reflux [GERD]).
Equally as important as these physical side effects of obesity are the psychological consequences. These include (1) lowering of self-esteem often reinforced by teasing and bullying at school as well as a recurring barrage of the normal/ideal physique displayed by the media and entertainment industries and (2) depression, leading to possible further eating or an exaggerated overcorrection leading to eating disorders such as bulimia and anorexia nervosa.
The economic costs of childhood obesity are not often considered but are very important. Such effects include: (1) the direct costs of medical office visits, diagnostic studies and therapeutic services; and (2) indirect costs are both long- and short-term and include decrease in productivity, absenteeism, and premature death. Estimates for both direct and indirect costs for 2008 were $147 billion.

What is the treatment for childhood obesity?

The treatment for childhood obesity is no different than many diseases -- determine the cause and control or eradicate it. Since the overwhelming number of obese individuals are consuming too many calories relative to their energy expenditure ("burning them off"), therapy is directed toward reversing this metabolic equation. Simply put, consume fewer calories and use more up. There are many dietary programs that attempt to address this issue. None is superior over the long term unless the participant embraces these nutritional changes as part of a larger lifestyle recommitment. Drugs and surgery should be restricted to severe cases of childhood (and adult) obesity.

Can childhood obesity be prevented?

Benjamin Franklin's famous dictum "an ounce of prevention is worth a pound of cure" is ironically the perfect approach to childhood obesity. The CDC has recently raised the notion that should the alarming increase in childhood obesity not be reversed, the consequences may make the current pediatric population be the first generation to not exceed the life span of their parents. Studies have indicated that childhood obesity must be attacked prior to the teen years. Twenty percent of obese 4-year-old children will grow up to become obese adults; 80% of obese teens will continue their obesity into adulthood. All of the above reviewed consequences of pediatric obesity are brought forward into the adult years. Two amazing observations: (1) children 6 months to 6 years of age watch an average of two hours of television per day; (2) children 8-18 years of age spend an average of seven and a half hours per day involved with entertainment media activity such as television, computer games, video games and cell phone calls/texting.
Social and cultural changes are necessary to effectively address the pediatric obesity epidemic. A basic approach would entail the following:

1. Advocate breastfeeding during the first year of life. Studies strongly reinforce that breastfed children have a lower risk of infant, childhood, and adolescent obesity.
2. Drastically overhaul the school breakfast and lunch programs to favor heart-healthy food choices. Encouraging salad bars, banning sugar drinks, and flavored milk are options.
3. Guarantee safe neighborhood environments which foster outside play activities.
4. Limit TV/computer/social-network communication or other activities which encourage sedentary behaviors.
5. Encourage vigorous physical education programs for 45 minutes daily.
6. Revamp restaurant portion sizes. Studies had repeatedly demonstrated a link to the rise in pediatric obesity with fast-food restaurants' adoption of supersized portions as well as the bundling of food options (for example, deals for hamburger, french fries, and soda meals).
7. Encourage the development of activity-friendly infrastructure in communities -- bike lanes, regional parks, etc. Many studies have shown that the social and cultural changes above must be accompanied by a strong family and community support structure, without which these approaches often fall short.

Childhood Obesity

Childhood obesity facts

• Adult and childhood obesity has increased substantially in the last 30 years. Currently, 31% of adults and 18% of children at obese, as defined by excess body mass index (BMI).
• The vast majority of obesity represents an imbalance in calories ingested vs. calories expended. Other causes of obesity (metabolic, medicines, and other diseases) are very rare.
• Loosing body fat requires both caloric restriction and daily vigorous exercise.
• The immediate and long-term effects of obesity include physical, psychological, and economic issues.
• Obesity prevention will require both a personal and social/cultural change in lifestyle. A large volume of current research will help clarify what will be most helpful. 

What is childhood obesity?

In order to systematically describe obesity, the concept of body mass index (BMI) was developed. BMI is the ratio between an individual's weight to height relative to their gender and age. BMI addresses the following question: Is the weight of the subject in excess of what is healthy for a given height? Generally (but not always), BMI correlates with the amount of body fat, but it is not a measurement of fat. An individual who has more than the average muscle mass for a given height (for example, weight lifters, some athletes) will have an elevated BMI but clearly will not be obese. Nomograms for both adults and children have been developed to graphically represent the range of normal when measuring BMI. An individual is overweight when their BMI is between 25.0-29.9. Obesity is defined as a BMI greater than 30.0. Many web sites have calculators to measure BMI (for example, http://www.cdc.gov/
healthyweight/assessing/bmi/). Measuring body fat may be done via skin-fold-thickness measurement, waist-to-hip-circumference ratio and neutral buoyancy (water displacement) measurements. BMI is not used for children under 2 years of age.

How prevalent is childhood obesity?

The national statistics regarding childhood obesity prevalence (total number of cases in the pediatric population) have risen remarkably. In the 1970s and 1980s, approximately 5% of children were obese. By 2000, over 13% were obese, and 2009 statistics indicate pediatric obesity to be leveling off at approximately 18% of the population. (In contrast, approximately 31% of adults are obese.) While the frequency of obesity appears to be leveling off, the amount of excess weight has continued to rise (for example, BMI value has risen higher per individual).
The Midwest and South have the highest frequency of obesity (28%), with Mississippi the highest frequency (34%) and Colorado the lowest (18%). Of the remaining states, 24 have an obese population of over 25%; nine states have over 30% of their population being obese. In 2000, no states had more than 30% of their population considered obese.
The Center for Disease Control and Prevention's web site (http://www.cdc.gov) has an excellent demonstration of the rise in obesity over the last 30 years by using an interactive map of the United States (http://www.cdc.gov/obesity/data/
trends.html#State).
An area of concern is that the statistics gathered in many studies are self-reported by the individual and may therefore be overly optimistic (for example, purposely underestimating weight and overestimating height).

What causes childhood obesity?

Most obesity is caused by excessive daily caloric intake relative to daily caloric expenditure. Excessive intake of calories is most commonly associated with poor food-quality choices (for example, fast food high in fat calories) but may also result from over-ingestion of "healthy foods." The simple biological fact is that all excessive calories (regardless whether triple cheese meat lovers pizza vs. fat free yogurt with berries) will be stored by the body and only as fat. Attempts at only reducing caloric intake without increasing caloric utilization (read: 30 minutes daily vigorous exercise) will only help temporarily. If calorie restriction is the sole approach toward losing weight, the body's metabolism adopts a conservation mode and learns how to get by on fewer calories. Adding physical activity to the calorie-burning equation encourages breakdown of excessive carbohydrate and fat stores allowing for more functional and long-term health.
Body weight (not necessarily excessive body fatness) is a reflection of genes, metabolism, behaviors, culture, and socioeconomic status. These relatively infrequent causes of obesity will be detailed below.

What are childhood obesity symptoms and signs?

Measurement of height and weight are the most commonly used tools to quickly evaluate the proportionality of children. These measurements allow calculation of the body mass index (BMI). It is important to consider the physique of the individual. While having a weight in excess of what would be expected for a certain height is most commonly a documentation of excessive fat tissue, certain individuals may be overmuscled (for example, weight lifters). With the exception of very rare bone diseases, the idea of an individual's excessive weight due to being big boned is an urban myth.

What about bed bugs in hotels?

Many news reports in recent years have focused on the discovery of bed bugs in upscale hotels, and a number of lawsuits have been filed by guests in these fashionable hotels who awoke to find hundreds of bed bug bites covering their skin. Searching on TripAdvisor and other travel-review web sites regularly reveals information and even photos confirming the presence of bed bugs in numerous hotels.
Since the bed bugs can arrive on the clothing or in the suitcases of guests from infested homes or other hotels harboring the pests, hotels can be an easy target for bed bug infestations.

How are bed bugs spread?

Bed bugs live in any articles of furniture, clothing, or bedding, so they or their eggs may be present in used furniture or clothing. They spread by crawling and may contaminate multiple rooms in a home or even multiple dwellings in apartment buildings. They may also be present in boxes, suitcases, or other goods that are moved from residence to residence or from a hotel to home. Bed bugs can live on clothing from infested homes and may be spread by a person unknowingly wearing infested clothing.

What are the symptoms and signs of bed bug bites?

Bed bugs bite and suck blood from humans. Bed bugs are most active at night and bite any exposed areas of skin while an individual is sleeping. The face, neck, hands, and arms are common sites for bed bug bites. The bite itself is painless and is not noticed. Small, flat, or raised bumps on the skin are the most common sign; redness, swelling, and itching commonly occur. If scratched, the bite areas can become infected. A peculiarity of bed bug bites is the tendency to find several bites lined up in a row. Infectious disease specialists refer to this as the "breakfast, lunch, and dinner" sign signifying the sequential feeding that occurs from site to site.
Bed bug bites may go unnoticed or be mistaken for flea or mosquito bites or other types of rash or skin conditions, since they are difficult to distinguish from other bites. Bed bugs also have glands whose secretions may leave odors, and they also may leave dark fecal spots on bedsheets and around their hiding places (in crevices or protected areas around the bed or anywhere in the room).
Bed bugs have not been conclusively proven to carry infectious microbes. However, researchers have implicated bed bugs as possible vectors of American trypanosomiasis (Chagas disease), and studies are ongoing to determine whether bed bugs may serve as disease carriers.

What is the treatment for bed bug bites?

Typically, no treatment is required for bed bug bites. If itching is severe, steroid creams or oral antihistamines may be used for symptom relief. Secondary bacterial infections that develop over heavily scratched areas may require the use of antibiotics.

How do I detect a bed bug infestation in my home?

You can look to see if you can identify the fecal stains, egg cases, and exuviae (shed skins) in crevices and cracks on or near beds. You should also look at other areas such as under wallpaper, behind picture frames, in couches and other furniture, in bedsprings and under mattresses, and even in articles of clothing. While fecal stains and skin casts suggest that bed bugs have been present, these do not confirm that the infestation is still active. Observing the bed bugs themselves is definitive confirmation that an area is infested. You may require professional assistance from a pest-control company in determining whether your home contains bed bugs.

How do I get rid of bed bugs in the home?

Getting rid of bed bugs is not an easy process, and most cases of bed bug infestation will require treatment by a pest-control expert. A variety of low-odor sprays, dusts, and aerosol insecticides can be used to eradicate bed bugs. These must be applied to all areas where the bugs are observed as well as spaces where they may crawl or hide. The pest-control company can help you determine if the mattress can be disinfected or must be discarded. Since beds cannot readily be treated with insecticides, it's often necessary to discard infested mattresses and beds.
The pest-control expert may recommend certain forms of deep-cleaning such as scrubbing infested surfaces with a stiff brush to remove eggs, dismantling bed frames and furniture, filling cracks in floors, walls, and moldings, encasing mattresses within special bags, or using a powerful vacuum on cracks and crevices.

What about prevention of bed bug bites?

Avoidance of infested areas is the method for prevention of bed bug bites. Recognition of bed bug infestation and proper treatment of affected rooms (usually with the help of a pest-control specialist) is the best way to prevent bed bugs in the home. Those concerned about the potential for bed bugs bites in hotels should examine hotel beds and mattresses for signs of a bed bug infestation. Sealing your mattress in a bed bug prevention casing can be beneficial.

Bed Bugs At A Glance

• Bed bugs are small, oval, non-flying insects that feed by sucking blood from humans or animals.
• Bed bugs can live in any area of the home and can reside in tiny cracks in furniture as well as on textiles and upholstered furniture. They tend to be most common in areas where people sleep and generally concentrate in beds, including mattresses, boxsprings, and bed frames.
• Bed bugs are most active at night and bite any exposed areas of skin while an individual is sleeping. The face, neck, hands, and arms are common sites for bed bug bites.
• A bed bug bite is painless and is not noticed. Small, flat, or raised bumps on the skin are the most common sign; redness, swelling, and itching commonly occur.
• Typically, no treatment is required for bed bug bites. If itching is severe, steroid creams or oral antihistamines may be used for symptom relief.
• Fecal stains, egg cases, and exuviae (shed skins) of bed bugs in crevices and cracks on or near beds are suggestive that bed bugs may be present, but only observing the bugs themselves can confirm an active infestation.
• A professional pest-control company may be required to help identify and remove bed bugs from the home.

Bed Bugs

What are bed bugs? What do bed bugs look like?

Bed bugs are small, oval, non-flying insects that belong to the insect family Cimicidae, which includes three species that bite people. Adult bed bugs reach 5-7 mm in length, while nymphs (juveniles) are as small as 1.5 mm. Bed bugs have flat bodies and may sometimes be mistaken for ticks or small cockroaches. Bed bugs feed by sucking blood from humans or animals. Adult bed bugs are reddish brown in color, appearing more reddish after feeding on a blood meal. Nymphs are clear in color and appear bright red after feeding. The wings of bed bugs are vestigial, so they cannot fly.

Where are bed bugs found?

Bed bugs were common in the U.S. before World War II and became rare after widespread use of the pesticide DDT began in the 1940s and 1950s. They remained prevalent in other areas of the world and, in recent years, have been increasingly observed again in the U.S. Increases in immigration and travel from the developing world as well as restrictions on the use of stronger pesticides may be factors that have led to the relatively recent increase in bed bug infestations. While bed bugs are often reported to be found when sanitation conditions are poor or when birds or mammals (particularly bats) are nesting on or near a home, bed bugs can also live and thrive in clean environments. Crowded living quarters also facilitate the spread of bed bugs.
Bed bugs can live in any area of the home and can reside in tiny cracks in furniture as well as on textiles and upholstered furniture. They tend to be most common in areas where people sleep and generally concentrate in beds, including mattresses, box springs, and bed frames. They do not infest the sleeping surfaces of beds as commonly as cracks and crevices associated with the bed frame and mattress. Other sites where bed bugs often reside include curtains, edges of carpet, corners inside dressers and other furniture, cracks in wallpaper (particularly near the bed), and inside the spaces of wicker furniture.
Since bed bugs can live for months without feeding, they can also be found in vacant homes.
Pictures of bed bugs

What does a bed bug look like? Photo: CDC

Picture of an adult bed bug; Photo: CDC

Angina

Why is it important to establish the diagnosis of angina?

Angina is usually a warning sign of the presence of significant coronary artery disease. Patients with angina are at risk of developing a heart attack (myocardial infarction). A heart attack is the death of heart muscle precipitated by the complete blockage of a diseased coronary artery by a blood clot.
During angina, the lack of oxygen (ischemia) to the heart muscle is temporary and reversible. The lack of oxygen to the heart muscle resolves and the chest pain disappears when the patient rests. In contrast, the muscle damage in a heart attack is permanent. The dead muscle turns into scar tissue when healed. A scarred heart cannot pump blood as efficiently as a normal heart, and can lead to heart failure.
Up to 25% of patients with significant coronary artery disease have no symptoms at all, even though they clearly lack adequate blood and oxygen supply to the heart muscle. These patients have "silent" angina. They have the same risk of heart attack as those with symptoms of angina.

How is angina diagnosed?

The electrocardiogram (EKG, ECG) is a recording of the electrical activity of the heart muscle, and can detect heart muscle which is in need of oxygen. The EKG is useful in showing changes caused by inadequate oxygenation of the heart muscle or a heart attack.
Exercise stress test
In patients with a normal resting EKG, exercise treadmill or bicycle testing can be useful screening tools for coronary artery disease. During an exercise stress test (also referred to as stress test, exercise electrocardiogram, graded exercise treadmill test, or stress ECG), EKG recordings of the heart are performed continuously as the patient walks on a treadmill or pedals on a stationary bike at increasing levels of difficulty. The occurrence of chest pain during exercise can be correlated with changes on the EKG, which demonstrates the lack of oxygen to the heart muscle. When the patient rests, the angina and the changes on the EKG which indicate lack of oxygen to the heart can both disappear. The accuracy of exercise stress tests in the diagnosis of significant coronary artery disease is 60% to 70%. If the exercise stress test does not show signs of coronary artery disease, a nuclear agent (thallium) can be given intravenously during exercise stress test. The addition of thallium allows nuclear imaging of blood flow to different regions of the heart, using an external camera. A reduced blood flow in an area of the heart during exercise, with normal blood flow to the area at rest, signifies significant artery narrowing in that region of the heart.
Stress echocardiography
Stress echocardiography combines echocardiography (ultrasound imaging of the heart muscle) with exercise stress testing. Like the exercise thallium test, stress echocardiography is more accurate than an exercise stress test in detecting coronary artery disease. When a coronary artery is significantly narrowed, the heart muscle supplied by this artery does not contract as well as the rest of the heart muscle during exercise. Abnormalities in muscle contraction can be detected by echocardiography. Stress echocardiography and thallium stress tests are both about 80% to 85% accurate in detecting significant coronary artery disease.
When a patient cannot undergo exercise stress test because of neurological or orthopedic difficulties, medications can be injected intravenously to simulate the stress on the heart normally brought on by exercise. Heart imaging can be performed with a nuclear camera or echocardiography.
Cardiac catheterization
Cardiac catheterization with angiography (coronary arteriography) is a technique that allows x-ray pictures to be taken of the coronary arteries. It is the most accurate test to detect coronary artery narrowing. Small hollow plastic tubes (catheters) are advanced under x-ray guidance to the openings of the coronary arteries. Iodine contrast "dye" is injected into the arteries while an x-ray video is recorded. Coronary arteriography gives the doctor a picture of the location and severity of coronary artery disease. This information can be important in helping doctors select treatment options.
CT coronary angiogram
CT coronary angiography is procedure that uses an intravenous dye that contains iodine, and CT scanning to image the coronary arteries. While the use of catheters is not necessary (thus the term "noninvasive" test applies to this procedure), there are still some risks involved, including the following:

• Patients allergic to iodine
  
• Patients with abnormal kidney function
  
• Radiation exposure which is similar to, if not greater than, that received with a conventional coronary angiogram.

Nonetheless, this is generally a very safe test for most people. It is a major tool in the diagnosis of coronary artery disease in patients:

• at high risk for developing coronary disease (cigarette smokers, those with genetic risk, high cholesterol levels, hypertension, or diabetes),
  
• who have unclear results with exercise stress tests or other testing, or
  
• who have symptoms suspicious of coronary disease 

What are the treatment options for angina patients?

Treatment options include:

• rest,
  
• medications (nitroglycerin, beta blockers, calcium channel blockers),
  
• percutaneous transluminal coronary angioplasty (PTCA), or
  
• coronary artery bypass graft surgery (CABG).

Angina medications

Nitroglycerin

Resting, nitroglycerin tablets (placed under the tongue), and nitroglycerin sprays all relieve angina by reducing the heart muscle's demand for oxygen. Nitroglycerin also relieves spasm of the coronary arteries and can redistribute coronary artery blood flow to areas that need it most. Short-acting nitroglycerin can be repeated at five minute intervals. When 3 doses of nitroglycerin fail to relieve the angina, further medical attention is recommended. Short-acting nitroglycerin can also be used prior to exertion to prevent angina.
Longer-acting nitroglycerin preparations, such as Isordil tablets, Nitro-Dur transdermal systems (patch form), and Nitrol ointment are useful in preventing and reducing the frequency and intensity of episodes in patients with chronic angina. The use of nitroglycerin preparations may cause headaches and lightheadedness due to an excess lowering of blood pressure.

Beta Blockers

Beta blockers relieve angina by inhibiting the effect of adrenaline on the heart. Inhibiting adrenaline decreases the heart rate, lowers the blood pressure, and reduces the pumping force of the heart muscle, all of which reduce the heart muscle's demand for oxygen. Examples of beta blockers include:

• acebutolol (Sectral)
  
• atenolol (Tenormin)
  
• bisoprolol (Zebeta)
  
• metoprolol (Lopressor, Lopressor LA, Toprol XL)
  
• nadolol (Corgard)
  
• propranolol (Inderal)
  
• timolol (Blocadren)

Side effects include of beta blockers include:

• worsening of asthma,
  
• excess lowering of the heart rate and blood pressure,
  
• depression,
  
• fatigue,
  
• impotence,
  
• increased cholesterol levels, and
  
• shortness of breath due to diminished heart muscle function (congestive heart failure).

Calcium Channel Blockers

Calcium channel blockers relieve angina by lowering blood pressure, and reducing the pumping force of the heart muscle, thereby reducing muscle oxygen demand. Calcium channel blockers also relieve coronary artery spasm. Examples of calcium channel blockers include:

• amlodipine (Norvasc)
  
• bepridil (Vascor)
  
• diltiazem (Cardizem)
  
• felodipine (Plendil)
  
• isradipine (Dynacirc)
  
• nicardipine, (Cardene)
  
• nifedipine (Adalat, Procardia)
  
• nimodipine (Nimotop)
  
• nisoldipine (Sular)
  
• verapamil (Calan)

Side effects of calcium channel blockers include:

• swelling of the legs,
  
• excess lowering of the heart rate and blood pressure, and
  
• depressing heart muscle function.

Other anti-anginal drugs

Ranolazine (Ranexa) is indicated for the treatment of chronic angina. Ranexa may be used with beta-blockers, nitrates, calcium channel blockers, antiplatelet therapy, lipid-lowering therapy, ACE inhibitors, and angiotensin receptor blockers.

Angina

ntroduction to angina

Chest pain is a common symptom that is caused by many different conditions. Some causes require prompt medical attention, such as angina, heart attack, or tearing of the aorta. Other causes of chest pain that may not require immediate medical intervention include spasm of the esophagus, gallbladder attack, or inflammation of the chest wall. An accurate diagnosis is important in providing proper treatment to patients with chest pain.
The diagnosis and treatment of angina is discussed below, as well as the diagnosis of other causes of chest pain that can mimic angina.

What is angina, and what are the symptoms of angina?

Angina (angina pectoris - Latin for squeezing of the chest) is chest discomfort that occurs when there is a decreased blood oxygen supply to an area of the heart muscle. In most cases, the lack of blood supply is due to a narrowing of the coronary arteries as a result of arteriosclerosis.
Angina is usually felt as:

• pressure,
  
• heaviness,
  
• tightening,
  
• squeezing, or
  
• aching across the chest, particularly behind the breastbone.

This pain often radiates to the neck, jaw, arms, back, or even the teeth.
Patients may also suffer:

• indigestion,
  
• heartburn,
  
• weakness,
  
• sweating,
  
• nausea,
  
• cramping, and
  
• shortness of breath.

Angina usually occurs during exertion, severe emotional stress, or after a heavy meal. During these periods, the heart muscle demands more blood oxygen than the narrowed coronary arteries can deliver. Angina typically lasts from 1 to 15 minutes and is relieved by rest or by placing a nitroglycerin tablet under the tongue. Nitroglycerin relaxes the blood vessels and lowers blood pressure. Both rest and nitroglycerin decrease the heart muscles demand for oxygen, thus relieving angina.
Angina is classified in one of two types: 1) stable angina or 2) unstable angina.
Stable angina
Stable angina is the most common type of angina, and what most people mean when they refer to angina. People with stable angina have angina symptoms on a regular basis and the symptoms are somewhat predictable (for example, walking up a flight of steps causes chest pain). For most patients, symptoms occur during exertion and commonly last less than five minutes. They are relieved by rest or medication, such as nitroglycerin under the tongue.
Unstable angina
Unstable angina is less common and more serious. The symptoms are more severe and less predictable than the pattern of stable angina. Moreover, the pains are more frequent, last longer, occur at rest, and are not relieved by nitroglycerin under the tongue (or the patient needs to use more nitroglycerin than usual). Unstable angina is not the same as a heart attack, but it warrants an immediate visit to your healthcare provider or hospital emergency department as further cardiac testing is urgently needed. Unstable angina is often a precursor to a heart attack.

What causes angina?

The most common cause of angina is coronary artery disease. A less common cause of angina is spasm of the coronary arteries.
Coronary artery disease
Coronary arteries supply oxygenated blood to the heart muscle. Coronary artery disease develops as cholesterol is deposited in the artery wall, causing the formation of a hard, thick substance called cholesterol plaque. The accumulation of cholesterol plaque over time causes narrowing of the coronary arteries, a process called arteriosclerosis. Arteriosclerosis can be accelerated by smoking, high blood pressure, elevated cholesterol, and diabetes. When coronary arteries become narrowed by more than 50% to 70%, they can no longer meet the increased blood oxygen demand by the heart muscle during exercise or stress. Lack of oxygen to the heart muscle causes chest pain (angina).
Coronary artery spasm
The walls of the arteries are surrounded by muscle fibers. Rapid contraction of these muscle fibers causes a sudden narrowing (spasm) of the arteries. A spasm of the coronary arteries reduces blood to the heart muscle and causes angina. Angina as a result of a coronary artery spasm is called "variant" angina or Prinzmetal angina. Prinzmetal angina typically occurs at rest, usually in the early morning hours. Spasms can occur in normal coronary arteries as well as in those narrowed by arteriosclerosis.
Coronary artery spasm can also be caused by use/abuse of cocaine. The spasm of the artery wall caused by cocaine can be so significant that it can actually cause a heart attack.

What are other causes of chest pain?

In caring for patients with chest pain, the doctor distinguishes whether the pain is related to a lack of oxygen to the heart muscle (as in angina or heart attack), or is due to another process. Many conditions are considered that can cause chest pain which is similar to that of a heart attack or angina. Examples include the following:

• Pleuritis (pleurisy): Inflammation of the lining of the lungs (pleuritis) causes sharp chest pain, which is aggravated by deep breathing and coughing. Patients often notice shortness of breath, in part due to their shallow breathing to minimize chest pain. Viral infections are the most common causes of pleurisy. Other systemic inflammatory conditions, such as systemic lupus, can also cause pleurisy.
  
• Pericarditis: Pericarditis is inflammation of the lining around the heart. Symptoms of pericarditis are similar to that of pleuritis.
  
• Pneumonia: Pneumonia (bacterial infection of the lung) causes fever and chest pain. Chest pain in bacterial pneumonia is due to an irritation or infection of the lining of the lung (pleura).
  
• Pulmonary embolism: blood clots travel from the veins of the pelvis or the lower extremities to the lung, the condition is called pulmonary embolism. Pulmonary embolism can cause death of lung tissue (pulmonary infarction). Pulmonary infarction can lead to irritation of the pleura, causing chest pain similar to pleurisy. Some common causes of blood clots in these veins is deep vein thrombosis (prolonged immobility, recent surgery, trauma to the legs, or pelvic infection).
  
• Pneumothorax: Small sacs in the lung tissue (alveoli) can spontaneously burst, causing pneumothorax. Symptoms of pneumothorax include sudden, severe, sharp chest pain and shortness of breath. One common cause of pneumothorax is severe emphysema.
  
• Mitral valve prolapse: Mitral valve prolapse is a common heart valve abnormality, affecting 5% to 10% of the population. MVP is especially common among women between 20 to 40 years of age. Chest pain with MVP is usually sharp but not severe. Unlike angina, chest pain with MVP rarely occurs during or after exercise, and usually will not respond to nitroglycerin.
  
• Aortic dissection: The aorta is the major vessel delivering blood from the left ventricle to the rest of the body. Aortic dissection (tearing of the aorta wall) is a life-threatening emergency. Aortic dissection causes severe, unrelenting chest and back pain. Young adults with aortic dissection usually have Marfan's syndrome, an inherited disease in which an abnormal form of the structural protein called collagen causes weakness of the aortic wall. Older patients develop aortic dissection typically as a result of chronic, high blood pressure, in addition to generalized hardening of the arteries (arteriosclerosis).
  
• Costochondritis, rib fractures, muscle strain or spasm: Pain originating from the chest wall may be due to muscle strain or spasm, costochondritis, or rib fractures. Chest wall pain is usually sharp and constant. It is usually worsened by movement, coughing, deep breathing, and direct pressure on the area. Muscle spasm and strain can result from vigorous, unusual twisting and bending. The joints between the ribs and cartilage next to the breastbone can become inflamed, a condition called costochondritis. Fractured ribs resulting from trauma or cancer involvement can cause significant chest pain.
  
• Nerve compression: Compression of the nerve roots by bone spurs as they exit the spinal cord can cause pain. Nerve compression can also cause weakness and numbness in the upper arm and chest.
  
• Shingles (herpes zoster infection of the nerves): Shingles is nerve irritation from the infection, which can cause chest pain days before any typical rash appears.
  
• Esophageal spasm and reflux: The esophagus is the long muscular tube connecting the mouth to the stomach. Reflux, or regurgitation of stomach contents and acid into the esophagus can cause heartburn and chest pain. Spasm of the muscle of the esophagus can also cause chest pain which can be indistinguishable from chest pain caused by angina or a heart attack. The cause of esophageal muscle spasm is not known. Pain of esophageal spasm can respond to nitroglycerin in a similar manner as angina.
  
• Gallbladder attack (gallstones): Gallstones can block the gallbladder or bile ducts and cause severe pain of the upper abdomen, back and chest. Gallbladder attacks can mimic the pain of angina and heart attack.
  
• Anxiety and panic attacks: Anxiety, depression, and panic attacks are frequently associated with chest pain lasting from minutes to days. The pain can be sharp or dull. It is usually accompanied by shortness of breath, or the inability to take a deep breath. Emotional stress can aggravate chest pain, but the pain is generally not related to exertion, and is not relieved by nitroglycerin. These patients often breath too fast (hyperventilate), causing lightheadedness, numbness, and tingling in the lips and fingers. Coronary artery disease risk factors are typically absent in these patients. Since there is no test for panic attacks, patients with chest pain usually undergo tests to exclude coronary artery disease and other causes of chest pain. 

Pregnancy Planning

How does alcohol affect pregnancy?

Alcohol has been implicated in infertility, early miscarriage, as well as in birth defects. The amount of alcohol consumption necessary to cause these problems is not known, and varies among women. Some women can drink excessively and have normal infants. Others consume considerably less alcohol but still give birth to babies with cognitive disabilities and/or other birth defects. It is generally believed that the greater the amount of alcohol consumed during pregnancy, the greater the risk of pregnancy-related problems and birth defects.
It is recommended that pregnant women avoid all consumption of alcohol. Fetal alcohol spectrum disorders are a group of conditions reflecting the possible effects of prenatal exposure to alcohol. The FASDs include fetal alcohol syndrome (FAS), alcohol-related birth defects (ARBD), and alcohol-related neurodevelopmental disabilities (ARND). Fetal alcohol syndrome (FAS) is the extreme end of the fetal alcohol spectrum disorders and is a leading cause of cognitive disabilities.

How do high blood pressure and diabetes affect pregnancy?

Elevated blood pressure (hypertension) that is present before pregnancy can interfere with growth of the fetus and increase the risk of fetal death. Therefore, controlling blood pressure with carefully chosen blood pressure medications is important during pregnancy and before conception.
In addition, underlying hypertension can increase the risk for a condition called preeclampsia, a potentially very dangerous complication of pregnancy. It is sometimes difficult for doctors to distinguish between high blood pressure alone and high blood pressure occurring from preeclampsia. For those reasons, and given the risk of birth defects from many of the blood pressure medications, women with high blood pressure who become pregnant should be followed very carefully by a medical expert who is familiar with this type of situation. Ideally, medication would be switched to a relatively safe medication before the woman even becomes pregnant.
Poorly controlled diabetes can lead to high blood sugar levels. High blood sugar levels during early pregnancy can lead to miscarriages and birth defects. Therefore, controlling diabetes is important for a good pregnancy outcome, and the blood sugar should ideally be controlled before becoming pregnant. It is important to consider that control of blood sugar during pregnancy is important, but control prior to pregnancy may be just as important.
Oral diabetes medications may be dangerous to the fetus, but insulin is not dangerous to the fetus. Insulin is the key treatment for diabetes during pregnancy. Not only is insulin safe to the baby and mother, but it also helps prevent the complications that the baby could have suffered from the mother's sugar being uncontrolled. Insulin is usually substituted for pills as soon as a woman with diabetes is considering pregnancy. The ideal time to control blood sugar is before pregnancy, because control of sugar levels even in early pregnancy (when the mother does not yet know she is pregnant) is important for the developing baby's health.

What are examples of commonly-used medications that are dangerous in pregnancy?

Many women do not know that over-the-counter medications can be dangerous. In fact, many prescription and over-the-counter medications harm the fetus very early in pregnancy at a time that the mother does not even know she is pregnant. Even aspirin use by the mother can cause defects in the fetus. For this reason, as soon as pregnancy is being contemplated, women should avoid all over-the-counter and prescription medications until reviewed with their doctor.
Acne medications, such as isotretinoin (Accutane) can cause birth defects, and should be discontinued before conception. Since many medications and substances can affect fetal growth and development, pregnancy planning is important so that potentially harmful substances can be stopped before conceiving.
Unplanned pregnancy during oral contraceptive use is not felt to pose a significant danger to the fetus, although deliberate use of oral contraceptives during pregnancy is not advisable. Women who become pregnant during oral contraceptive use have the same risk of birth defects in their newborns as the general population of women, in the range of 2% to 3%.

How do kidney and heart disease affect pregnancy?

Because pregnancy is associated with an increase in blood volume and an increase in cardiac output as well as other changes in the circulatory system, many types of heart disease may worsen or be associated with poor outcome during pregnancy. While many mild chronic heart conditions may be well tolerated during pregnancy, other conditions pose a significant risk to mother and fetus. Women with preexisting heart disease should always consult an expert when planning a pregnancy to examine their own degree of risk, potential outcomes, and treatment options.

What infections affect pregnancy?

Certain infections during early pregnancy can cause birth defects in the fetus. Rubella (German measles) virus infection during early pregnancy can cause birth defects and even miscarriages. Therefore, women of child bearing age are tested for blood antibodies against this virus. Women lacking rubella virus antibodies are susceptible to rubella infection, and should be vaccinated against this virus. Pregnancy should be avoided for one month after vaccination, due to the theoretical concern that the vaccine virus itself may cause fetal damage.
Toxoplasmosis is a small parasite that is transmitted through cat feces and raw meats, especially pork. Toxoplasmosis, like the rubella virus, can cause severe birth defects if the infection occurs during early pregnancy. Women planning pregnancy should avoid raw meat and avoid handling the cat litter box. Many people have been exposed to toxoplasmosis without even knowing it. As a result, they develop a protective immunity from the "silent" infection. Women who have a blood test that is positive for toxoplasmosis immunity can be reassured that they will not develop toxoplasmosis complications during pregnancy.
Hepatitis B is the only type of hepatitis that is known to affect the newborn infant.
Female healthcare workers, dental assistants, and others exposed to hepatitis B should receive hepatitis B vaccination to avoid chronic infection by this virus. The majority of hepatitis B virus infections resolve spontaneously without treatment. Patients whose disease resolves completely are no longer contagious. Approximately 10% of hepatitis B virus infections do not resolve, and become chronic. Patients chronically infected with hepatitis B virus may have no symptoms of liver disease early on, but they remain contagious. Over time, chronic hepatitis B infection can lead to liver cirrhosis and/or liver cancer.
Women with chronic hepatitis B infection can transmit the virus to their babies at birth. Babies infected are at risk of developing chronic liver disease, liver cirrhosis, and liver cancer in later life. Currently, infants born to mothers infected with the hepatitis B virus are given both the hepatitis B antibodies and hepatitis B vaccinations at birth for protection. Therefore, pregnant women are often tested for signs of hepatitis B infection, even if they do not have any symptoms or knowledge of past infection. The babies of infected mothers detected in this manner would receive special care at (and after) delivery.
Cytomegalovirus (CMV) is a common viral infection worldwide that often does not produce any symptoms. Women who become infected or have a reactivation of a previous infection during pregnancy may pass the infection along to their babies. Congenital CMV infection is the most common congenital viral infection. Although the majority of infected infants will not have any symptoms, up to 20% will have symptoms that may include an enlarged spleen, jaundice, or rash. Rarely, involvement of many organs may occur resulting in severe illness or disability.
Genital herpes may also result in the passage of the infection to the infant at the time of delivery. The risk of transmission is increased if the genital lesions are from a herpesvirus (HSV) infection acquired during the pregnancy, rather than simply a reactivation of previous disease. HSV infection can have multiple effects in the newborn. Disease may be limited to the eyes, skin and mouth; may be localized to the central nervous system; or may be widespread and involve many organs. Treatment involves administration of antiviral medications to the newborn and supportive care.
Parvovirus B19 is a virus that causes the condition known as Fifth disease, a common mild disease of childhood. Transmission is by droplets in the air (respiratory secretions) or through blood. Pregnant women who have not previously had fifth disease should avoid contact with those who have it because parvovirus B-19 can infect a fetus prior to birth. Although no birth defects have been reported as a result of fifth disease, it can cause the death of an unborn fetus. This occurs in less than 5% of pregnant women who become infected with the virus.
When traveling to a foreign country, it is important to determine what diseases are common, whether vaccines are needed, and whether they are safe during pregnancy. Human immunodeficiency virus (HIV) infection can be passed from a mother to her baby. The chances of this happening are decreased substantially with certain medication programs during pregnancy. Pregnant women are routinely offered testing for HIV infection. Women with previously undetected infection who are found to have HIV infection can be given special medication to try to protect the baby. At the same time, the medication may benefit the health of the mother herself.
Varicella, or chickenpox, can cause pneumonia or even death in older adults and in pregnant women. Varicella vaccine is available for women who are not immune to chickenpox. Women who had chickenpox in the past do not need a vaccine because they are immune. Women who are not sure if they are immune can receive a blood test to determine immunity status. A vaccine would be given if the blood test showed they were not immune.

Is it safe to exercise during pregnancy?

Recommendations from the American College of Obstetrics and Gynecology say that pregnant women who have an uncomplicated pregnancy should participate in at least 30 minutes of moderate exercise on most, if not all, days of the week. A few exceptions are noted: ice hockey, kickboxing, soccer, and horseback riding probably should be avoided because they are activities with higher risk of trauma to the abdomen. Also, scuba diving poses a risk of decompression sickness ("the bends") to the fetus and should be avoided. Exercise programs should be discussed with the monitoring health care professional.
Elevated temperatures can have adverse effects on the development of the fetus. Therefore, hot tubs and sauna baths should be avoided when trying to conceive and during pregnancy.

Pregnancy Planning

Pregnancy Planning Facts

• Pregnancy planning can address issues of nutrition, vitamins, body weight, exercise, and potentially harmful medications and illnesses as well as immunizations and genetic counseling.
  
• Women who take folic acid at least four weeks prior to conception can reduce their baby's risk of birth defects of the spinal cord and skull by 70%.
  
• Alcohol has been implicated in infertility, early miscarriage, and birth defects.
  
• Certain acne medications and other prescription and OTC medications can cause birth defects.
  
• Babies of older women have an increased risk of having chromosomal abnormalities.
  
• The timing of sexual intercourse in relation to ovulation does not influence the gender of the baby.

What is pregnancy planning and why is it important?

Having a baby is one of the most important events in a woman's life. Women considering pregnancy are encouraged to start planning for the pregnancy with their doctors early. This early planning process is called pregnancy planning. The goals of pregnancy planning are to create a healthy environment for the fetus and to prevent birth defects and other pregnancy related problems to the greatest extent possible. The issues addressed during pregnancy planning include nutrition, vitamins, body weight, exercise, avoidance of certain medications and alcohol, immunizations, and genetic counseling. Even though many women will have normal pregnancies without any planning, pregnancy planning improves the chances of a smooth pregnancy and a healthy baby. Unfortunately, many more women who are anticipating conceiving do not seek prior medical consultation.
Pregnancy planning can help prevent exposure of the mother to potentially harmful medications or substances during the early days of pregnancy. The baby's organs begin developing as early as 17 days after conception, and the fertilized egg begins to grow even before the first day of the missed period. Some women continue to have light bleeding that may be mistaken for a menstrual period during the first few months of pregnancy and may not even realize that they are pregnant. Others may not recognize that they are pregnant until they experience weight gain or abdominal enlargement. By then, they may have already been exposed to medications or substances potentially harmful to the fetus.
In addition to avoiding medications and substances that are potentially harmful to the fetus, other important health issues are addressed during pre-pregnancy planning.

• Conditions such as diabetes, high blood pressure, kidney disease, thyroid disease, and heart disease in the mother are controlled to optimize pregnancy outcome.
  
• The status of the woman's immunity against German measles (rubella) and varicella (chickenpox) is also determined. Women lacking rubella antibodies are immunized before conceiving (see medical issues below). Women who are not immune to varicella (chickenpox) can be vaccinated, but should wait 30 days after vaccination before becoming pregnant.
  
• Women who are carriers of the hepatitis B virus can be identified by blood tests, and their infants can be protected from hepatitis B infection by immunizations at the time of delivery. Women with HIV (human immunodeficiency virus) infection should take certain medications during pregnancy to decrease not only their risks but those of the fetus as well.

The effects of diet, exercise, and each of the medical conditions previously discussed will be reviewed below.

What are pregnancy symptoms?

There are both symptoms and signs of pregnancy. These symptoms and signs depend upon the time in pregnancy. In the first trimester of pregnancy, the first sign of pregnancy is most often a missed menstrual period. If a sexually active woman's periods are generally regular, missing a period for a week or more is presumptive evidence of pregnancy.
Early symptoms of pregnancy also include feelings of breast swelling and tenderness, and nausea sometimes with vomiting. "Morning sickness" does not always occur in the morning, and the nausea of pregnancy can occur at any time of day. Many women become fatigued early in pregnancy, and some may feel abdominal enlargement (bloating).
Early in pregnancy, the woman may feel she has to urinate frequently, especially at nighttime, and she may leak urine when coughing, sneezing or laughing. This is also normal later in pregnancy and is not a problem.
Other changes characteristic of pregnancy include the deepening color of the areola (area surrounding the nipple), increased body temperature, the so-called "mask of pregnancy" (darkening of skin on the forehead, bridge of the nose, or cheekbones), and a dark line going down from the middle of the central abdomen area to the pubic area. Eventually, enlargement of the abdomen is a normal feature of the growing fetus.

What is a pregnancy calculator and calendar?

A pregnancy calendar or calculator can allow a pregnant woman to understand what is happening to her body and to the developing embryo or fetus at each stage of pregnancy. Most pregnancy calendars explain the changes of pregnancy on a week-to-week level and can be found online or in print form. In many cases, pregnancy calendars contain photos or diagrams to illustrate the appearance of the fetus at each stage.

How effective are home pregnancy tests?

At-home pregnancy tests, first introduced in 1975, are very accurate and reliable when used correctly. These tests measure the presence of the hormone human chorionic gonadotropin in the urine, which, when present, is indicative of pregnancy. The same hormone is measured in blood and urine pregnancy tests available at clinics and doctors' offices. Currently, the blood test is the most specific and sensitive pregnancy test available, although urine tests have become increasingly sensitive. For example, home urine tests may be able to detect the pregnancy hormone at 8 to 9 days after conception, or a few days before the missed menstrual period.
While many manufacturers claim that their home pregnancy tests are 99% accurate, a number of factors influence the accuracy of these kits. Studies have shown that false negative results may occur when very low levels of the pregnancy hormone are present, and that home test kits from different manufacturers differ in their sensitivity for detection of the very low levels of the pregnancy hormone in the early days of pregnancy. If a woman takes a home pregnancy test too soon, the result may be negative even though she is in the first stages of pregnancy. A repeat test should always be performed a week later if a home test is negative and a woman suspects that she might be pregnant.

How can diet and nutrition affect early pregnancy?

The developing fetus receives its nutrition from the mother's blood. Therefore high fat diets and some vegetarian diets are discouraged during pregnancy because they may not provide all the nutrition needed for the developing fetus. Bulimia, anorexia nervosa and other eating disorders in the mother are addressed and treated. Weight reduction diets are avoided during pregnancy. Excess intake of sugar, alcohol, megavitamins, and caffeine are also avoided Because a "safe" amount of caffeine has never been confirmed to date, it is best to avoid caffeine entirely. Women who feel strongly that they need some coffee are advised to drink no more than one cup per day. There is no proof that 1 to 2 cups of coffee daily cause pregnancy complications.
Listeria is a type of bacteria found in contaminated food that can cause miscarriage and other problems in a fetus. Because of the danger of getting a listeria infection, pregnant women should avoid unpasteurized milk, soft cheeses, cold cuts, and undercooked or raw animal foods. In addition, fruits and vegetables should be washed completely prior to consumption.
Phenylketonuria is an inherited disease that affects the utilization of a certain protein component in foods. This disorder can be detected by a blood test. Mothers with phenylketonuria may give birth to developmentally disabled children unless their diets are strictly controlled to exclude phenylalanine.
Megavitamins contain double or even triple the recommended daily allowances of vitamins and minerals. High doses of vitamin A have been implicated in producing birth defects. The better idea is to avoid megavitamins and instead follow the recommendation that has proven benefit: take a prenatal vitamin containing folic acid.
Folic acid intake in the mother prior to, and during pregnancy has been shown to reduce the risk of birth defects involving the brain and spinal cord. The United States Public Health Service recommends folic acid for all women of child-bearing capacity. Studies have shown that if folic acid is begun at least 4 weeks prior to conception, the risk of birth defects of the spinal cord and skull can be reduced by more than 70%. In women with or even without a history of having infants with birth defects of the spinal cord or skull, folic acid should be taken one month before conception and continued through the 12th week of pregnancy. In fact, continuing prenatal vitamins through pregnancy and even through nursing is probably wise. These prenatal vitamins are available over-the-counter. If a particular brand makes you feel nauseated, simply switch to another brand or try taking the vitamin at night.
Because of the risks of mercury poisoning and nervous system damage in the fetus from contaminated fish, pregnant women are advised to eliminate consumption of certain types of fish that are known to be high in mercury, including shark, swordfish, tilefish, and king mackerel. Tuna steaks, made from large tuna, may also have high mercury levels. Canned tuna is made from smaller fish that typically have lower levels of mercury than larger fish.

Irritable Bowel Syndrome (IBS) Triggers and Prevention

Irritable bowel syndrome (IBS) triggers and prevention introduction

By taking steps to prevent the symptoms of irritable bowel syndrome (IBS), it is possible to lead a productive, healthy life. With some planning, you can avoid IBS triggers that cause symptom flares. Your doctor can provide a complete treatment plan for IBS prevention.
Print out this list of common IBS triggers and prevention strategies. Keep it handy for reference. It may help you identify your personal triggers in your IBS symptom journal. Triggers and symptoms may vary depending on your type of IBS. And when you're having a bad day, remember to persist with healthy management of your condition.
"Realize that it's not always smooth sailing. That's a part of IBS," says Leslie Bonci, MPH, RD, author of the American Dietetic Association Guide to Better Digestion. "You can't beat yourself up."

1. Diet Triggers for IBS Constipation

Some foods can worsen IBS-related constipation. These include:

• Refined breads and cereals
  
• Refined foods such as chips and cookies
  
• Drinks such as coffee, carbonated drinks, and alcohol
  
• High-protein diets - Learn about the healthy foods on a high protein diet.

Prevention Strategies:

• Gradually boost fiber intake by two to three grams per day until you're eating 20 to 35 grams per day. Good sources of fiber include whole grain bread and cereals, beans, fruits, and vegetables.
  
• Consume a moderate amount of foods higher in sorbitol, such as dried plums and prune juice.
  
• Drink eight 8-ounce glasses of plain water a day.
  
• Try ground flaxseed. It can be sprinkled on salads and cooked vegetables.

2. Diet Triggers for IBS Diarrhea

Some foods can worsen IBS-related diarrhea. These include:

• Too much fiber, especially insoluble fiber found in the skin of fruits and vegetables
  
• Food and drinks with chocolate, alcohol, caffeine, fructose, or the sugar substitute sorbitol
  
• Carbonated drinks
  
• Large meals
  
• Fried and fatty foods
  
• Food and drinks with dairy
  
• Foods with wheat -- Some people may be allergic or have a negative reaction to gluten

Prevention Strategies:

• Eat a moderate amount of soluble fiber. It adds bulk to the colon and can help prevent spasms. Good sources are whole wheat breads, oats, barley, brown rice, pasta, the flesh of fruit (as opposed to the skin), and dried fruits.
  
• Don't consume foods with extreme temperatures, such as ice-cold water and steaming hot soup, in the same meal.
  
• Stay away from broccoli, onions, and cabbage. They can cause gas, which can make diarrhea sufferers feel worse.
  
• Eat smaller portions.
  
• Drink six to eight glasses of plain water a day, but drink the water an hour before or after meals, not with meals.
  
• Consult with your doctor or a dietitian if you suspect you may have a wheat allergy.

Some people with IBS have symptoms similar to lactose intolerance with excess gas. A trial of a lactose-free diet and avoidance of foods that produce excess gas such as beans, brussels spouts, pretzels, bagels, wheat germ, raisins, and celery may help reduce symptoms.

3. Stress and Anxiety Triggers for IBS

Stress and anxiety can exacerbate IBS symptoms such as constipation, diarrhea, stomach pain, and bloating. Different things cause stress for different people. Stress can include:

• Problems at work
  
• Commutes
  
• Problems at home
  
• Financial problems
  
• A sense that things are beyond your control

Prevention Strategies:

• Practice healthy living. Eat a well-balanced diet that is appropriate for your IBS. Get regular exercise and enough sleep.
  
• Do something fun. Listen to music, read, shop, or take a walk.
  
• Try behavioral therapy. Learn how to calm yourself down with the help of techniques such as relaxation therapy, biofeedback, hypnotherapy, cognitive behavioral therapy, and psychotherapy.
  
• Talk to people. If you feel comfortable doing so, tell your family members, close friends, boss, and co-workers about your IBS. They may provide vital support. Plus, the conversation may prevent any misunderstandings when your symptoms flare up and you are not able to meet expectations.
  
• Plan ahead. Ease worries about going out lest your symptoms flare up. Get up earlier if you know IBS makes you late for work. If you are driving, map your route so that you know locations of bathrooms. At social events, choose aisle seats close to the facilities. Know what's on the menu so you can eat beforehand if the food will not be agreeable to you.

4. Drugs That Can Trigger IBS

Some drugs can trigger spasms of the colon and symptoms of IBS. These spasms can lead to constipation or diarrhea.

• Antibiotics, especially after prolonged use
  
• Antidepressants
  
• Medicine containing sorbitol, such as cough syrup

Prevention Strategies:

• Talk with your doctor about switching to a drug that won't worsen your IBS symptoms. Don't stop taking a drug without consulting with your doctor.
  
• If an antidepressant is worsening your diarrhea or constipation, talk with your doctor about switching medicine. Older antidepressants (called tricyclic antidepressants) can cause constipation. One type of newer antidepressant (called selective serotonin reuptake inhibitors, which include Prozac and Zoloft) can cause diarrhea. Your doctor can help you find an antidepressant that will not worsen your IBS symptoms.

5. Menstrual Triggers for IBS

Studies show that women with IBS tend to have worse symptoms during their periods. There's not a lot of information about preventing this type of trigger, but doctors may recommend certain strategies to ease pain and discomfort during your period.
Prevention Strategies:

• Oral contraceptives. Some brand names are Ortho Tri-Cyclen, Lo/Ovral, and Alesse. These drugs can regularize periods. Side effects may include upset stomach, vomiting, stomach cramps or bloating, diarrhea, and constipation. Work with your doctor to find a pill that works for you without causing side effects.
  
• Premenstrual dysphoric disorder (PMDD) drugs. These include drugs also used to treat depression, such as Sarafem, Paxil CR, and Zoloft. PMDD is a severe form of PMS. These drugs adjust levels of serotonin, a brain chemical thought to be out of balance during certain phases of a woman's cycle.

HPV Test (Cervista Human Papillomavirus Infection Test in Women)

Cervista HPV Test Facts

• A subgroup of the human papillomaviruses (HPVs) are known to cause cancers of the uterine cervix and other genital areas, the so-called "high risk" HPVs.
  
• The Cervista test is used to diagnose the presence of DNA from the "high-risk" HPVs in cervical samples.
  
• The sample for the test is taken in the same way that a Pap smear test is performed.
  
• There are two Cervista tests available, Cervista HPV 16/18, which identified the two HPV types most likely to cause cancer, and Cervista HPV HR, which identifies all "high-risk" HPV types.
  
• Cervista testing is not recommended for routine screening; rather, it is used in combination with physical examination, medical history, and other testing to help make decisions about management and follow-up on a case-by-case basis.

What is human papillomavirus (HPV)?

Of the more than 100 types of papillomaviruses (HPVs) that infect humans, more than 40 types can infect the anogenital tract (genital tract and anus) of men and women and cause genital warts (known as condylomata acuminata or venereal warts). A subgroup of the HPVs that infect the anogenital tract (genital tract and anus) can lead to precancerous changes in the uterine cervix and cause cervical cancer or other genital cancers in women. The HPV types that cause cervical cancer also have been linked with both anal and penile cancer in men.
The most common HPV types that infect the anogenital tract are HPV types 6, 11, 16, and 18 (HPV-6, HPV-11, HPV-16, and HPV-18), although other HPV types can also infect the anogenital tract. Among these, HPV-6 and HPV-11 are most commonly associated with benign lesions such as genital warts and mild dysplasia of the cervix (potentially precancerous changes in the appearance of cervical cells under a microscope) and are termed "low-risk" HPV types. In contrast, HPV-16 and HPV-18 are the types found in the majority of cervical and anogenital cancers as well as severe dysplasia of the cervix. These belong to the so-called "high-risk" group of HPVs. Twelve other HPV types have also been identified as causes of cervical and other genital cancers, although these are less common that HPV-16 and -18.
HPV infections are transmitted primarily by sexual intimacy, and the risk of infection increases as the number of sexual partners increase.

What is the Cervista HPV test?

The Cervista HPV test, manufactured by Hologic, is a test that is used to identify the presence of human papillomavirus (HPV) genetic material, or DNA, in cervical samples, such as samples taken during Pap screening or colposcopy. The Cervista test was approved by the U.S. Food and Drug Administration in March of 2009 and was the first DNA test approved by the FDA for detection of HPV in women.
Two different tests are available, known as Cervista HPV 16/18 and Cervista HPV HR. Cervista HPV 16/18 is used to diagnose the presence of DNA from the two most common HPV types associated with cancer, HPV 16 and 18, while Cervista HPV HR is used to diagnose all 14 "high risk" or cancer-associated HPV types. The choice for which test to use depends on what information the patient's physician wants to collect.

How is the HPV test done?

For the Cervista test, a sample is taken from the cervix in the same way that a sample for Pap testing is obtained. It can be performed at the same time as Pap testing or colposcopy. There is no special preparation needed for the test, although women should try to schedule Cervista and other screening tests about two weeks after their last menstrual period and try to avoid having the test performed during the menstrual period. Results are typically ready in about the same time as normal Pap screening results.

Who should be tested for HPV?

The Cervista test is not used for routine screening of all women and is not intended to be a stand-alone test. It is not recommended for testing in women under 30 years of age who have normal cytology (Pap) results. Cervista is designed for use in women age 30 and older or women with unclear or borderline Pap screening results, such as ASC-US (atypical squamous cells of unknown significance) or low grade squamous intraepithelial lesions (LSIL). It can provide more information about the risk of cervical cancer for women who may have precancerous changes of the cervix.
According to the manufacturer, the Cervista test "should be used in conjunction with clinical information derived from other diagnostic and screening tests, physical examinations, and full medical history in accordance with appropriate patient management procedures."

How are the results of an HPV test interpreted?

A positive test result does not mean that a woman will definitely get cervical cancer.
The results of the test are used to help estimate a woman's risk of developing cervical cancer or to estimate the severity or risk of findings that may not be clear from physical examination and Pap screening. As discussed previously, the results of the Cervista HPV test are not interpreted alone but in combination with Pap testing, medical history, and physical examination. The test gives one more piece of information to help the health care practitioner make the best decisions about further monitoring and management for each woman on a case-by-case basis.