MEDICAL CORRESPONDENCE - CORRESPONDANCE MEDICALE:

(Letters or information sent to friends and families - informations et lettres envoyees a des amis et parents). Most of the text is not original. It is just a compilation of information collected in different places. It is only there temporarily till I debate the cases further

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About Neurotoxicity

Journal 01/26/2005

Dear comrade, Saturday night I was brought to the emergency room of St. Vincent Hospital by an emergency team. I has almost passed out at home when I suddenly began to feel an insupportable vertigo and nausea and had to leave my desk to lie on the belly on my bed. Because of my heart problem, it could have potentially be fatal since I was making a huge effort to vomit only sputum and gastric fluid but no food since the stomach has been empty for more than 8 hours. At the hospital and even before reaching it, I began to feel better when I put on a fan and got to open air; there, the doctor thought I might have pancreatitis or was, in any case, a pateint who needed urgent care and supervision, since my blood amylase was high, my potassium was also high and my heart rate was low (47/mn.). We began to disagree when I told him that my heart rate has always been low, due to increased vagal tone, caused by athletic sport, now by a heart medication (Toprol which is a long acting lopressor) and very recently by Kelp (organic iodide) that I might have taken in excess to replace table salt (those people of the over-the-counter vitamin industry are really "machoket". I thought also that the pattern of the belly pain (on the upper right quadrant) was more suggestive of a liver injury and also because I thought that my problem was also due to a combination of effects of my medication (Toprol + Vasotec + Prevacid) and of an inhalant brougth by the obsolete heating and ventilation system in building where I live; Prevacid (Lansoprazole), in particular, was introduced very recently, in my medication. Finally, an I.v. (Ringer Lactate and Dextrose) was in place and helped to recuperate but was left too long after it has run out of liquid; that could have jeopardize my prosthetic heart valve. So, I signed out. Now, I am again well and almost certain that the problems was caused by the agents I thought, with Prevacid having been the major offender. .

Bye, take care.

Roger

P.S.- www.geocities.com/rogerqualo/MA_PAGE_UNIVERSITAIRE

1) Aliphatic hydrocarbons: Dizziness, syncope, giddiness, hypotension, cerebral ischemia, headache, tachycardia (n-butyl, isobutyl, amyl nitrite), increased intraocular pressure, confusion, sudden death, methemoglobinemia, convulsion, myocardial ischemia, coma, cardiovascular collapse, asphyxia

2) Naphtha: kerosene Irritation of mucous membranes, nausea, ataxia, dizziness, hallucinations, narcoses, cardiac arrhythmias including ventricular fibrillation

3) Gasoline Respiratory arrest, syncope, death, myoclonia, chorea, encephalopathy, tremor, pulmonary hemorrhage and edema, pneumonitis, plumbism, anemia, lead encephalopathy, confusion, dementia, cerebral edema, peripheral and cranial neuropathies, paresthesias, proteinuria, hematuria

4) etc..

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About Cancer in the Old Age

Cancer in the Old Age: An Issue

Controversy continues over whether cancer is less aggressive in the elderly. Growth and metastasis of several types of cancer (breast, colon, lung, prostate) appear to be slower in the elderly. Yet, death occurs with smaller tumor burdens. Reasons for the difference in mortality appear to be complex: Diagnosis is often made later, treatment tends to be less aggressive, and competing causes of death are more likely; all of these factors result in shorter survival in older patients.

Risk Factors and Prevention

Although cancer occurs in persons of every age, it is fundamentally a disease of aging. Sixty percent of new cancer cases and two thirds of cancer deaths occur in persons > 65 years. The incidence of common cancers (eg, breast, colorectal, prostate, lung) increases with age. However, incidence of many cancers levels off after age 80, suggesting the possibility of intrinsic resistance to the development of cancer in late life or some selection bias

Screening

Because cancer is more common in the elderly than in younger populations, screening is more likely to detect cancer in older populations. Cancers for which screening has proved beneficial in reducing mortality include breast, cervical, and colon cancer.

Treatment

• Research that focuses on cancer in younger populations may not be applicable to the elderly, the segment of the population at highest risk for cancer, leaving us with a paucity of knowledge on how best to manage cancer in the age group that experiences it most.
• Treatment goals must be individualized based not only on treatability of the cancer, but also on comorbid conditions, functional status (one of the best predictors of response and social situation (which may preclude treatments involving travel or expense), and willingness of the patient to tolerate side effects of treatment. Surgery, chemotherapy, radiation therapy, and hormonal therapy are the mainstays of treatment. However, symptomatic and supportive therapy with analgesics, antidepressants, anxiolytics, and antiemetics, as well as support groups and individual and family counseling, must be integrated into treatment programs. Access to support services and to trained health care practitioners varies depending on the patient's geographic location, financial resources, mobility, and support of family and friends. Referral to major cancer centers may prolong survival but may not be the most humane course of action for debilitated and relatively immobile patients.
• Age per se is not usually the deciding factor as to whether aggressive treatment is warranted: that decision must assess the likelihood that the cancer will respond to treatment, the extent of spread, comorbid conditions that could limit therapy, and the patient's wishes. Chemotherapy or radiation therapy should be strongly considered in clinical situations in which cure, prolonged survival, or definable palliation can be achieved with these modalities.

End-of-Life Issues

• It must not be forgotten that cancer is often fatal. Sometimes treatment becomes futile, exposing an elderly patient to suffering that outweighs any potential benefit. Even at the time of initial diagnosis, treatment is not always warranted. An honest discussion of what is likely to be gained and what the side effects of treatment are likely to be is the best course of action. Most patients understand when it is time to make a transition to more palliative goals of care (palliative care is defined by the World Health Organization as the active total care of patients whose disease is not responsive to treatment). This understanding can be fostered by direct and forthright discussions regarding prognosis and benefits and risks of therapy and is enhanced by a trusting physician-patient relationship.
• Involvement of hospice services early in the course of palliative care can be helpful.. The financial benefits alone of switching to the Medicare hospice benefit may be substantial. Hospice personnel have expertise in preparing patients and families spiritually, financially, and legally for the end of life.
• Most patients wish to remain at home. Every effort should be made to accommodate this wish, but attention needs to be paid to caregiver burden. Short stays in a hospital or nursing home, which are covered by Medicare, may be necessary for respite to caregivers. Interventions and clinic visits should be kept to the minimum necessary for palliation. Although Medicare reimburses physicians for time spent on hospice issues, the reimbursement is rarely adequate and does not compensate for the amount of documentation required.
• (The Merck Manual of Geriatrics)

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About Cholesterol:

AMERICAN HEART ASSOCIATION

1. Cholesterol, Fiber and Oat Bran American Heart Association Recommendation

• Dietary fiber is the term for several materials in the parts of plants that your body can't digest. Fruits, vegetables, whole-grain foods, beans and legumes are all good sources of dietary fiber. Fiber is classified as soluble or insoluble. The American Heart Association Eating Plan suggests that you eat foods high in both types of fiber. When regularly eaten as part of a diet low in saturated fat and cholesterol, soluble fiber has been shown to help lower blood cholesterol. Foods high in soluble fiber include oat bran, oatmeal, beans, peas, rice bran, barley, citrus fruits, strawberries and apple pulp.
• Insoluble fiber doesn't seem to help lower blood cholesterol. But it's an important aid in normal bowel function. Foods high in insoluble fiber include whole-wheat breads, wheat cereals, wheat bran, cabbage, beets, carrots, Brussels sprouts, turnips, cauliflower and apple skin.
• Many commercial oat bran and wheat bran products (muffins, chips, waffles) actually contain very little bran. They may also be high in sodium, total fat and saturated fat. We recommend reading the labels on all packaged foods.

2. Drug therapy can be considered for patients who, in spite of adequate dietary therapy, regular physical activity and weight loss, need further treatment for elevated blood cholesterol levels. “Signification des sigles”: Signification ofd the acronyms: CAD: coronary artery disease; CHD: coronary heart disease; LDL: low density lipoprotein or bad cholesterol; HDL: high density lipoprotein or good cholesterol; TC: total cholesterol;

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About Genital Disorders

GENITAL DISORDERS (SOME)

Some Benign Disorders

Urogenital atrophy

Urogenital atrophy due to hypoestrogenism predisposes postmenopausal women to common skin disorders of the vulva. Vulvar pruritus is the primary symptom. Evaluation involves direct examination and, often, biopsy.

Vulvitis

Various agents (eg, deodorants and soaps used to mask the odor associated with urinary incontinence) can cause superficial irritation and dermatitis, with pruritus, edema, and burning. Treatment involves removal of the cause of irritation and topical use of a corticosteroid cream.

Candidal vulvovaginitis

Candidal vulvovaginitis is especially common among elderly women who are diabetic or obese. The most common symptoms are vulvovaginal pruritus and discharge. Candidal vulvovaginitis is diagnosed by physical examination and the use of a wet preparation, in which a cotton-tipped applicator is used to obtain a sample of the discharge from the posterior vaginal fornix. Microscopic examination of the sample reveals the presence of yeast pseudohyphae or spores. Treatment involves use of topical antifungal drugs and, to relieve symptoms, local corticosteroids.

Vulvar Non-Neoplastic Epithelial Disorders

Vulvar Dystrophies

Lichen sclerosus, a dermatosis of unknown etiology, is characterized by epithelial thinning, edema and fibrosis of the dermis, and labial shrinkage. It typically involves the vulvar vestibule and especially the labia minora, where the affected skin resembles thin, white parchment paper. Vulvar pruritus is the most common symptom. Diagnosis is made by biopsy. A high-potency topical corticosteroid, such as clobetasol propionate cream 0.05%, is applied twice daily for 2 to 3 weeks and then nightly until symptoms and findings subside. The dosage can be tapered to 1 to 3 times weekly depending on response.

Squamous hyperplasia

Squamous hyperplasiamay occur anywhere on the vulva and may be localized to a small area. Squamous hyperplasia produces vulvar pruritus; the skin appears thickened and raised. When squamous hyperplasia affects more than one site, the involved areas are typically asymmetric. The diagnosis is usually one of exclusion. However, biopsy may be necessary to establish the diagnosis. A topical medium-strength corticosteroid, such as triamcinolone acetonide cream 0.1%, is applied twice daily and decreased to once daily until symptoms resolve (usually 2 to 3 weeks). Eliminating local irritants (eg, detergents, dyes, perfumes) and practicing good perineal hygiene (eg, wiping front to back after bowel movements and voiding), with emphasis on keeping the area dry, often cures squamous hyperplasia.

Other dermatoses

Other dermatoses (eg, lichen simplex chronicus, lichen planus, psoriasis, chronic eczematous dermatitis) can often be diagnosed on clinical grounds alone. However, if the patient has seen other physicians or has been treated previously, biopsy is usually indicated.

Fistulas: Abnormal communicating tracts between two internal organs or between an internal organ and the external body surface.

• Vesicovaginal and ureterovaginal fistulas usually occur in women who have had a hysterectomy for a benign condition. Patients leak urine continuously or intermittently and have some vulvar excoriation and erythema. Vesicovaginal fistulas occasionally occur many years after radiation therapy for gynecologic cancer; patients typically present with total urinary incontinence. In these cases, recurrent cancer is a strong possibility. A vesicovaginal fistula can be diagnosed by infusing dye colored with water into the bladder and observing the flow of dye into the vagina, where a tampon had been previously placed. It may also be diagnosed by cystoscopy, pelvic examination, or vaginography; a negative test result does not rule out a fistula.
• A ureterovaginal fistula is diagnosed by intravenous or retrograde urography. Fistulas caused by hysterectomy are best treated surgically. Those caused by radiation therapy usually require a diversionary procedure (ie, a urinary conduit).
• Urethrovaginal fistulas are very rare but may occur after surgery for stress incontinence or urethral diverticula. Postvoiding incontinence is the usual symptom. Diagnosis is made by endoscopy, urethrography, or both, sometimes using a double-balloon catheter to occlude the internal and external urethral orifices. Many fistulas are missed on the first diagnostic attempt. Treatment involves surgical closure of the fistula and often requires interposition of some vascularized tissue (eg, a labial subcutaneous flap).
• Colovesical (enterovesical) fistulas in the elderly may be caused by diverticulitis or, less commonly, by malignant neoplasms. Symptoms include lower abdominal pain, cystitis, pneumaturia (ie, passage of gas in the urine), and hematuria. Colovesical fistulas should be sought promptly in a patient who has recurrent or refractory urinary tract infections, especially when multiple bowel flora are cultured from the urine. Diagnosis is often difficult because the fistulas may intermittently seal, making them difficult to find. Diagnostic methods include barium enema, sigmoidoscopy, cystography, and oral ingestion of charcoal with subsequent examination of the urine for charcoal particles. The treatment of colovesical fistulas caused by diverticulitis depends on the extent and activity of the diverticulitis. In some cases, the involved segment of sigmoid colon can be resected, with immediate reanastomosis and closure of the opening in the bladder. In other cases, a proximal diverting colostomy is safer than immediate resection, because it allows active diverticulitis to subside before the involved segment of colon is definitively repaired and resected. Fistulas caused by colon cancer usually require excision with proximal diversion and concurrent treatment of the tumor.

Some Malignancies

Endometrial Cancer

• Endometrial cancer is the most common gynecologic malignancy in the USA; it is the fourth most common malignancy in women after breast, colorectal, and lung cancer. About 36,000 new cases of endometrial cancer occur per year. Peak incidence occurs in women aged 50 to 60, and the incidence appears to be increasing. Risk factors include obesity, nulliparity, and prolonged use of unopposed exogenous estrogen. (Error! Reference source not found.)
• The most common symptom is postmenopausal vaginal bleeding. (Error! Reference source not found.) Diagnosis requires endometrial biopsy, although it is sometimes suggested by Pap smear. Early diagnosis and treatment have made the prognosis for endometrial cancer better than that for other gynecologic malignancies. However, prognosis is influenced by the stage of the tumor (Error! Reference source not found.); 5-year survival rates range from 75 to 90% for those with stage I disease to 10% for those with stage IV disease. The combined 5-year survival rate for all stages is about 65%. Older women have a poorer prognosis.
• Optimal treatment is hysterectomy, bilateral oophorectomy, and retroperitoneal lymph node dissection in the pelvic and para-aortic areas. Upper vaginal or pelvic radiation therapy, chemotherapy, or both may be required for advanced cancer based on stage, the patient's comorbidities, and the results of a thorough discussion of risks and benefits.

Ovarian Cancer

• Ovarian cancer is the second most common gynecologic malignancy after endometrial cancer. The peak incidence occurs in women in their 50s and 60s. Risk factors include uninterrupted ovulation (ie, no pregnancies or oral contraceptive use) and inherited genetic mutations (BRCA1 mutations).
• Symptoms develop late and are usually nonspecific; vague abdominal or gastrointestinal discomfort is common. As a result, 75% of patients present with stage III or stage IV disease. Large abdominopelvic masses, ascites, or both may be detected during routine pelvic examination. Ovaries in postmenopausal women are small and normally not palpable; thus, any palpable ovary in a postmenopausal patient suggests ovarian cancer, and prompt evaluation is warranted. If cancer is suggested by pelvic ultrasound, the mass is surgically resected for definitive diagnosis, staging, and treatment.
• Initial treatment involves surgical removal of visible tumor. The decision to recommend chemotherapy is based on the tumor stage, the patient's comorbidities, and the results of a discussion of the risks and benefits of therapy. Although chemotherapy may be well tolerated, cure rates for advanced stage disease are low.
• Combination chemotherapy is given IV over several months, except to patients with early-stage disease or histologically borderline tumors. Treatment rarely includes radiation therapy. The serum CA 125 marker is useful for monitoring treatment response and disease status in many women, especially those with serous tumors. For patients with recurrent disease, modalities such as new generation chemotherapeutic drugs, monoclonal antibody therapy, and gene therapy are being investigated.
• Platinum-based chemotherapy given after surgery results in clinical remission in 70% of patients, with median survival of 3 years. Because most ovarian cancer is diagnosed at an advanced stage, the long-term prognosis is poor. A majority of patients experience a recurrence, and the 5-year survival rate seldom exceeds 20%.

Cervical Cancer

• Cervical cancer is the third most common gynecologic malignancy after endometrial cancer and ovarian cancer; it is the eighth most common malignancy among women in the USA. The peak incidence occurs in patients in their 40s or 50s. However, it occurs in women of all ages, including the elderly.
• Human papillomavirus (HPV) is thought to play a role in the etiology of cervical cancer. Although HPV is a common component of the biologic flora of the vagina, certain subtypes may have the ability to integrate into the DNA of cervical cells and induce genetic alterations, leading to malignant transformation; HPV types 16 and 18 are present in > 75% of cervical cancers. Prevention strategies that use Pap tests for early detection of HPV types 16 and 18 are being investigated.
• Cervical histopathology is classified as mild cervical dysplasia, in which abnormal cells proliferate in the lower third of the epithelium; moderate cervical dysplasia, in which abnormal cells involve the middle third of the epithelium; severe dysplasia (carcinoma in situ), in which a full thickness of epithelium contains abnormal cells; or invasive carcinoma, in which cancer cells penetrate the basement membrane and invade the stroma. About 85% of cervical cancers are squamous cell carcinomas and 15% are adenocarcinomas, although the incidence of adenocarcinomas may be increasing.
• Symptoms depend on the stage of the tumor. Some patients have postcoital or postmenopausal vaginal bleeding, although many patients with premalignant or small lesions are asymptomatic. Routine Pap testing is the best screening method. Technologic advances in slide preparation and automated rescreening devices have improved the accuracy rate of the Pap test, so that it can detect about 90% of early-stage neoplasias. In elderly women with no previous history of abnormal Pap smears under routine surveillance and with no outstanding risk factors, the need for frequent Pap tests decreases. Elderly women who have had consistently normal Pap smears need to be tested only every 5 years. Those who have had cancer or dysplasia, regardless of age, should continue to undergo annual Pap tests.
• If the Pap test result is positive, colposcopy-directed biopsies and endocervical curettage are used diagnostically; if biopsy results do not exclude invasive carcinoma or if the cervical transformation zone is not visible, subsequent cervical conization may be required. Conization can often be accomplished using diathermy loops under local anesthesia in an office setting.
• The combined cure rate for all cervical cancers is 50 to 60%. The cure rate for early-stage cancers treated with radical hysterectomy or radiation therapy approaches 85%. Locally advanced disease is treated with radiation and chemotherapy; the 5-year survival rate in these cases is about 70%. Radiation or chemotherapy can provide palliation for patients with distant metastases; however, the prognosis in these cases is very poor.

Vulvar cancer

• Vulvar cancer, the fourth most common gynecologic malignancy, accounts for about 3 to 4% of all gynecologic malignancies in the USA. The average age at diagnosis is about 70 years, and the incidence increases with age.
• Vulvar pruritus is the most common presenting symptom, but many patients are asymptomatic. Lesions may appear erythematous and flat, condylomatous, or ulcerated; discharge or local discomfort is often present.
• Vulvar dystrophy and other vulvar lesions (Error! Reference source not found.) must be differentiated from malignant lesions. Premalignant lesions may appear as white patches, brown pigmented areas, or granular red lesions. These lesions and all raised or ulcerated lesions should undergo biopsy. Dystrophic lesions (lichen sclerosus) or inflammatory lesions that do not respond within a few weeks to topical corticosteroid therapy should also undergo biopsy. Flat or slightly raised ulcerative lesions should undergo biopsy if they stain blue when swabbed with toluidine blue or if they turn white when swabbed with 3% acetic acid.
• Prognosis is generally good for patients with early-stage lesions. The 5-year survival rate is 80 to 90% if lymph node metastasis is absent and 16 to 30% if lymph node metastasis is present.
• Treatment of premalignant and malignant lesions is primarily surgical. Most women, even those who are debilitated, can have skin lesions removed under local anesthesia. Extensive condylomatous or in situ lesions are amenable to treatment with wide local excision or laser therapy. Minimally invasive lesions (< 1 mm) can be treated with partial vulvectomy alone.
• Topical therapy with cytotoxic drugs (eg, 5% 5-fluorouracil cream) may be useful for some in situ lesions. Although treatment with 5-fluorouracil cream results in complete response in 50% of cases, it often causes vulvar irritation and painful superficial ulceration.
• Radical vulvectomy, with unilateral or bilateral inguinal lymphadenectomy, is required for the staging and treatment of larger or deeply invasive tumors. Radiation therapy occasionally has an adjunctive role; preoperative chemotherapy or radiation therapy may make extensive tumors resectable.

Vaginal Cancer

• Vaginal cancer is relatively rare; it accounts for 1% of gynecologic malignancies in the USA. The average age at diagnosis is 60 to 65 years. Most (95%) vaginal cancer is squamous cell carcinoma, although adenocarcinoma and melanoma may occur.
• An early symptom is vaginal bleeding or discharge. Usually, nodules or ulcers develop on the vaginal mucosa; biopsy is necessary for definitive diagnosis.
• Prognosis depends on the size and location of the tumor. Five-year survival rates vary from 25 to 48%. Primary treatment usually consists of radiation therapy, although surgery or chemotherapy can be used in select cases. For example, tumors in the upper third of the vagina near the cervix may be surgically resectable.

Ovarian Cysts

1. An ovarian cyst is a sac filled with liquid or semiliquid material arising in an ovary. The number of diagnoses of ovarian cysts has increased with the widespread implementation of regular physical examinations and ultrasound technology. The finding of an ovarian cyst causes considerable anxiety for women because of the fear of malignancy, but the vast majority of ovarian cysts are benign.
2. In the US: Ovarian cysts are found on transvaginal ultrasound images in nearly all premenopausal women and in up to 14.8% of postmenopausal women. The majority of these cysts are functional in nature and benign The incidence of epithelial ovarian cystadenocarcinomas, sex cord stromal tumors, and mesenchymal tumors rises exponentially with age until the sixth decade of life, at which point incidence plateaus. Tumors of low malignant potential occur at a mean age of 44 years, with a span from adolescence to senescence. The average age is more than a decade less than that for invasive cystadenocarcinoma. Germ cell tumors are most common in adolescence and rarely occur in those older than 30 years.
3. Lab Studies: · No laboratory tests are diagnostic for ovarian cysts.
4. Imaging Studies: · Ultrasound · This is the primary imaging tool for a patient considered to have an ovarian cyst. Findings can help define morphologic characteristics of ovarian cysts
5. Histologic Findings: The definitive diagnosis of all ovarian cysts is made based histological analysis. Each type has characteristic findings.
6. Surgical Care: · Persistent simple ovarian cysts larger than 5 cm and complex ovarian cysts should be removed surgically. ·
   1. Reserve a laparoscopic approach for patients who have undergone a thorough workup and are thought to not have malignant disease. Such patients include those considered to have a dermoid or endometrioma, those with functional or simple cysts that are causing symptoms and have not resolved with conservative management, and those presenting with acute symptoms. In all cases, one should be able to remove the cyst intact. · A laparotomy should be performed on patients thought to have a significant risk for malignant disease and on patients with benign-appearing cysts that cannot be removed intact laparoscopically. ·
   2. Whether performing a laparoscopy or laparotomy, the goals are as follows: ·
   3. Confirm the diagnosis of an ovarian cyst. ·
   4. Assess whether the cyst appears malignant. ·
   5. Obtain fluid from peritoneal washings for cytologic assessment.
   6. · Remove the entire cyst intact for pathologic analysis, including frozen section. This may mean removing the entire ovary.
   7. · Assess the other ovary and other abdominal organs.
   8. · Excision of the cyst alone, with conservation of the ovary, may be performed in patients who desire retention of their ovaries for future fertility or other reasons. Included are endometrioma, dermoid, and functional cysts.
   9. · If the ovarian cyst is benign, removal of the opposite ovary should be considered in postmenopausal women, in perimenopausal women, and in premenopausal women older than 35 years who have completed their family and are considered at increased risk for subsequent development of ovarian carcinoma. These issues should be discussed with the patient preoperatively.
   10. · A gynecologic cancer specialist should be available to help with any patient who undergoes surgery for a potentially malignant ovarian cyst. This allows the appropriate surgery to be performed on patients found to have cancer. Whenever possible, the patient should have consulted with the specialist prior to the surgery to allow all issues to be addressed. Medical/Legal Pitfalls:
   11. · Any pelvic mass should be assumed to be a cancer until proven otherwise, particularly in a patient with a prior history of breast cancer or a family history of breast/ovarian cancer.
   12. · An ultrasound analysis of the pelvis should always be obtained if a patient is thought to have a pelvic mass after clinical examination.
   13. · If a patient has large fibroids, missing concomitant ovarian pathology, both clinically and on ultrasound findings, is possible. · Always be vigilant about patients with an increased risk of ovarian cancer, and arrange appropriate counseling. (emedicine.com)

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On Hysterectomy

• Epidemiology of fibroids Fibroids, or leiomyomas, account for one third of hysterectomies and one fifth of gynecological visits, and they create an annual cost of $1.2 billion (Lepine, 1997; Zhao, 1999). They are benign uterine tumors that increase in size and frequency as women age but revert in size postmenopausally (Goodwin, 2001; Kjerulff, 1996). Factors that have proven to contribute to fibroid growth include estrogen, progesterone, insulinlike growth factors I and II, epidermal growth factor, and transforming growth factor-beta (Guarnaccia, 2001
• Currently, surgical procedures are not recommended for fibroids based on uterine size alone in the absence of symptoms. According to Reiter et al (1992), no increased incidence in perioperative morbidity existed posthysterectomy in those women with a fibroid uterus larger than 12 weeks' gestational size compared to those women with a fibroid uterus smaller than 12 weeks' gestational size. They concluded that hysterectomy for a large asymptomatic fibroid uterus may not be needed as a means of preventing increased operative morbidity associated with future growth, unless a sarcomatous change is observed.
• In patients who experience symptoms with fibroids, the symptoms are related to the size, location, and number of fibroids within the uterus. As many as one third of patients with symptomatic uterine fibroids experience abnormal bleeding and prolonged and heavy menstrual periods, which can result in anemia. The growth of fibroids to large sizes may cause pressure on local organs; thus, presenting symptoms may include pelvic pain or pressure, pain during sexual intercourse, reduced urinary capacity due to increased bladder pressure, constipation due to increased colon pressure, and infertility or late miscarriages (Guarnaccia, 2001).
• Reasons for choosing hysterectomy are treatment of uterine cancer and various common noncancerous uterine conditions that lead to disabling levels of pain, discomfort, uterine bleeding, and emotional stress.

COMPLICATIONS

• Possible complications of hysterectomy include surgical wound infection; excessive bleeding; injury to the bowel, bladder, or ureter; or urinary tract infection.
• Although hysterectomy often is the definitive treatment for many pelvic pathologies, nonsurgical alternatives always should be attempted in elective cases. Hormone suppression, gonadotropin-releasing hormone antagonists, and uterine artery embolization have been used with success. As more pharmacological and invasive radiological interventions become available, the number of hysterectomies performed not only in the United States but also abroad will continue to decrease. Not only will surgical techniques continue to be updated and improved, but preoperative and postoperative interventions, such as the use of epoetin alfa (Procrit), will improve morbidity, mortality, and quality of life when this surgical procedure is performed. (emedicine.com)

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On The Lungs:

TABLE 64-1. PULMONARY FUNCTION ABBREVATIONS

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On the Over the Counter Supplements:

• Some supplements may interact with prescription and over-the-counter medicines.
• Taking a combination of supplements or using these products together with medications (whether prescription or OTC drugs) could under certain circumstances produce adverse effects, some of which could be life-threatening. Be alert to advisories about these products, whether taken alone or in combination. For example: Coumadin (a prescription medicine), ginkgo biloba (an herbal supplement), aspirin (an OTC drug) and vitamin E (a vitamin supplement) can each thin the blood, and taking any of these products together can increase the potential for internal bleeding. Combining St. John's Wort with certain HIV drugs significantly reduces their effectiveness. St. John's Wort may also reduce the effectiveness of prescription drugs for heart disease, depression, seizures, certain cancers or oral contraceptives.
• Some supplements can have unwanted effects during surgery: It is important to fully inform your doctor about the vitamins, minerals, herbals or any other supplements you are taking, especially before elective surgery. You may be asked to stop taking these products at least 2-3 weeks ahead of the procedure to avoid potentially dangerous supplement/drug interactions -- such as changes in heart rate, blood pressure and increased bleeding - that could adversely affect the outcome of your surgery.
• Adverse effects from the use of dietary supplements should be reported to MedWatch: by calling FDA at 1-800-FDA-1088, by fax at 1-800-FDA-0178 or reporting on-line at: Error! Reference source not found..
• There is currently no systematic evaluation of the safety of products marketed as dietary supplements. Dietary supplements routinely enter the marketplace without undergoing a safety review by FDA Despite the lack of any system for gaining information about the risks of dietary supplements, an increased number of reports of adverse reactions to dietary supplement products has recently been recognized
• FDA has begun to identify dietary supplements for which serious adverse reactions have been documented. This list is not intended to include all hazardous ingredients in dietary supplements.
• The Federation of American Societies for Experimental Biology (FASEB) warned that consuming amino acids in dietary supplement form posed potential risks for several subgroups of the general population, including women of childbearing age (especially if pregnant or nursing), infants, children, adolescents, the elderly, individuals with inherited disorders of amino acid metabolism, and individuals with certain diseases.

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On Ovarian Cancer:

On Varicella: