Hepatitis A, B, and C

Hepatitis A caused by the hepatitis A virus (HAV) :

How is it spread : HAV is found in the feces (poop) of people with hepatitis A and is usually spread by close personal contact (including sex or living in the same household). It can also be spread by eating food or drinking water contaminated with HAV and by traveling internationally where HAV infection is occurring.

Who should be vaccinated?

• People who wish to be protected from HAV infection

• All children at age 1 year (12–23 months)

• Men who have sex with men

• Users of street drugs (injecting and non- injecting)

• People who travel or work in any area of the world except the U.S., Canada, Western Europe, Japan, New Zealand, and Australia

• People who will have close personal contact with an international adoptee, from a country where HAV infection is common, during the first 60 days following the adoptee’s arrival in the U.S.

• People with chronic liver disease, including HCV

• People working with HAV in a laboratory

• People with clotting factor disorders (e.g., hemophilia)

Symptoms:

Viral hepatitis symptoms are similar no matter which type of hepatitis you have. If symptoms occur, you might experience any or all of the following: jaundice (yellowing of the skin and whites of the eyes), fever, loss of appetite, fatigue, dark urine, joint pain, abdominal pain, diarrhea, nausea, and vomiting. Very rarely, a recently acquired case of viral hepatitis can cause liver failure and death. Sometimes in these instances, a liver transplant (if a liver is available) can save a life. Note: For all types of viral hepatitis, symptoms are less common in children than in adults, and for people of any age with HCV infection, they are less likely to experience symptoms.

Chronic infection:
There is no chronic infection. Once you have had HAV infection, you cannot get it again. About 15 out of 100 people infected with HAV will have prolonged illness or relapsing symptoms over a 6–9 month period.

What treatment helps? :
• There is no treatment for HAV other than
supportive care.

• Avoid alcohol. It can worsen liver disease.

How is it prevented?
• Get vaccinated! Safe and effective vaccines to prevent HAV infection have been available in the U.S. since 1995.
• Always wash your hands with soap and water after using the toilet, changing a diaper, and before preparing or eating food.
• For a recent exposure to someone with

HAV or if travel is soon (leaving in less than 2 weeks) to an area of the world where hepatitis A is common, see your healthcare provider about your need for hepatitis A vaccine or a dose of immune globulin (IG).



Hepatitis B caused by the hepatitis B virus (HBV)
How is it spread?:
HBV is found in blood and certain body fluids. The virus is spread when blood or body fluid from an infected person enters the body of a person who is not immune. HBV is spread through having unprotected sex with an infected person, sharing needles or “works” when shooting drugs, exposure to needlesticks or sharps on the job, or from an infected mother to her baby during birth. Exposure to infected blood in ANY situation can be a risk for transmission.

Who should be vaccinated?
• Any adult who wants to be protected from HBV infection
• Sexually active people who are not in long-term, mutually monogamous relationships
• Men who have sex with men
• People seeking evaluation or treatment for a sexually transmitted disease
• Healthcare or public safety workers who might be exposed to blood or body fluids
• Residents and staff of facilities for developmentally disabled people
• Adults under 60 years of age with diabetes
• Dialysis and pre-dialysis patients
• People infected with HIV
• People in close personal contact (i.e., household or sexual)
with someone who has chronic HBV infection
• Current or recent injection-drug users
• Travelers to regions of the world where hepatitis B is common
(Asia, Africa, the Amazon Basin in South America, the Pacific
Islands, Eastern Europe, or the Middle East);

• People with chronic liver disease

Symptoms
Viral hepatitis symptoms are similar no matter which type of hepatitis you have. If symptoms occur, you might experience any or all of the following: jaundice (yellowing of the skin and whites of the eyes), fever, loss of appetite, fatigue, dark urine, joint pain, abdominal pain, diarrhea, nausea, and vomiting. Very rarely, a recently acquired case of viral hepatitis can cause liver failure and death. Sometimes in these instances, a liver transplant (if a liver is available) can save a life. Note: For all types of viral hepatitis, symptoms are less common in children than in adults, and for people of any age with HCV infection, they are less likely to experience symptoms

Chronic infection
Chronic infection occurs in up to 90% of infants infected at birth; in about 30% of children infected at ages 1–5 years; and less than 5% of people infected after age 5 years. In the U.S., 2,000 to 4,000 people die each year from hepatitis B. Death from chronic liver disease occurs in 15%–25% of chronically infected people People who have chronic HBV infection have a much higher risk of liver failure and liver cancer.

What treatment helps?
• People with chronic HBV infection should have a medical evaluation for liver disease every 6–12 months. Several antiviral medications are currently licensed for the treatment of individuals with chronic HBV. These drugs are effective in preventing serious liver problems in up to 40% of patients, but the drugs do not get rid of the virus. Liver transplant is the last resort, but livers are not always available.
• Avoid alcohol. It can worsen liver disease.
• There is no medication to treat recently acquired HBV

infection.

How is it prevented?
• Get vaccinated! Hepatitis B vaccination is the best protection. Three shots are usually given over a period of six months.
• Whenever a woman is pregnant, she should be tested for
hepatitis B (HBsAg blood test); infants born to HBV-infected mothers should be given HBIG (hepatitis B immune globulin) and vaccine within 12 hours of birth.

• Tell your sex partner(s) to get vaccinated too, and always follow “safer sex” practices (e.g., using condoms).


Hepatitis C caused by the hepatitis C virus (HCV)
How is it spread?
HCV is found in blood and certain body fluids. The virus is spread when blood or body fluid from an HCV-infected person enters another person’s body. HCV is spread through sharing needles or “works” when shooting drugs, through exposure to needlesticks or sharps on the job, or sometimes from an infected mother to her baby during birth. It is possible to transmit HCV during sex, but it is not common.

Who should be vaccinated?
There is no vaccine to prevent HCV.
Testing for HCV is recommended for the following groups of people.
• People born during 1945–1965
• Injecting drug users
• Recipients of clotting factors made before 1987
• Hemodialysis patients
• Recipients of blood or solid organ transplants before 1992
• Infants born to HCV-infected mothers
• People with undiagnosed abnormal liver test results

Although HCV is not commonly spread through sex, Individuals having sex with multiple partners or with an infected steady partner may be at increased risk of HCV infection.

Symptoms:
Viral hepatitis symptoms are similar no matter which type of hepatitis you have. If symptoms occur, you might experience any or all of the following: jaundice (yellowing of the skin and whites of the eyes), fever, loss of appetite, fatigue, dark urine, joint pain, abdominal pain, diarrhea, nausea, and vomiting. Very rarely, a recently acquired case of viral hepatitis can cause liver failure and death. Sometimes in these instances, a liver transplant (if a liver is available) can save a life. Note: For all types of viral hepatitis, symptoms are less common in children than in adults, and for people of any age with HCV infection, they are less likely to experience symptoms.

Chronic infection:
Chronic infection occurs in 75%–85% of newly infected people and 70% of chronically infected people go on to develop chronic liver disease. In the U.S., an estimated 8–10,000 people die each year from HCV. People who have chronic HCV infection have a much higher risk of liver failure and liver cancer. Chronic HCV-related liver disease is the leading cause for liver transplant.

What treatment helps?
• People with chronic HCV infection should have a
medical evaluation for liver disease every 6–12 months. There are drugs licensed for the treatment of individuals with chronic HCV infection. Combination therapy is
currently the treatment of choice and can eliminate the virus in approximately 40–50% of patients with genotype 1 (the most common genotype in the U.S.).
• Get vaccinated against hepatitis A and B.
• Avoid alcohol. It can worsen liver disease.

• There is no medication for the treatment of recently acquired HCV infection.

How is it prevented?
• There is no vaccine to prevent HCV infection.

• HCV can be spread by sex, but this is not common. If you are not in a mutually monogamous relationship, use latex condoms correctly and every time to prevent the spread of sexually transmitted diseases. (The efficacy of latex condoms in preventing HCV infection is unknown, but their proper use may reduce transmission.) In addition to getting hepatitis A vaccine, you should also get hepatitis B vaccine.

Jaundice

Definition = Neonatal jaundice is the term used when a newborn has an excessive amount of bilirubin in the blood. Bilirubin is a yellowish-red pigment that is formed and released into the bloodstream when red blood cells are broken down. Jaundice comes from the French word jaune, which means yellow; thus a jaundiced baby is one whose skin colour appears yellow due to bilirubin.

Predisposing causes of Jaundice:
• A newborn baby has a haemoglobin (Hb) level of 18-19g/dl. This is necessary during fetal life to facilitate oxygen carrying capacity.
• As soon as the baby is born and able to breathe oxygen the high Hb level is not needed and starts to drop.
• In the first week of life the baby’s Hb will drop to about 11g/dl and this breakdown of the foetal RBC’s may cause bilirubin to exceed the plasma carrying capacity of the blood.
• Therefore causing Physiological JAUNDICE

What is BILIRUBEN?
• Bilirubin is a product of haemoglobin break-down. Haemoglobin is contained in the red blood cells and it’s most important function is to carry oxygen to the tissues.
• When a red blood cell reaches the end of it’s life, the reticuloendothial system takes it out of circulation.
• This consists of the liver and spleen.
• The haemoglobin is broken down into it’s two constituents: Haem and Globin. • The globin is a protein which is re-used by the body.
• The Haem is an iron compound and so can’t be re-used. It is broken down to be excreted.
• Biliruben is a product of this last process and the accumulation in the blood causes yellow staining on the skin: JAUNDICE.
• Biliruben can cross the blood/brain barrier and stain the basal ganglia. The staining is permanent, Damage irreversible, which is why high SBR is so dangerous

Types of Jaundice
• Physiological Jaundice
• Pathological Jaundice

Types of Jaundice Physiological
• This occurs in the first few days after birth and will have cleared by day 10
• It occurs because of physiological changes taking place during the transition from intrauterine to neonatal life
• It is the consequence of: immature liver enzymes, high red cell mass

Other Factors which may increase Physiological Jaundice
• Prematurity
• Bruising
• Polycythemia
• Breast feeding

Types of Jaundice Pathological
• This refers to jaundice that arises from factors that alter the usual process involved in biliruben metabolism in the liver
• It is significant in the first 24hrs of life especially if there is Rhesus incompatibility
• It may persist more than 2 weeks in some conditions when the baby will be jaundice all over and may appear a muddy yellow colour

Pathological Jaundice
• This includes :-
• Group incompatibility (Haemolytic Disease of the Newborn) Rhesus factor, ABO incompatibility
• Hypoxemia
• Sepsis
• Endocrine or metabolic disorders and bile duct obstruction
• hypoglycaemia

Management of Jaundice
• The aim of the management of Jaundice is to prevent biliruben encephalopathy (kinicterus) developing as a result of high levels of serum biliruben.
Start investigations if:-
• Jaundice is significant in the first 24hrs
 • Jaundice persists after 10 days
• If the SBR is above 250umol/l or less in preterm babies
• If Jaundice is present in a baby who is already ill
• Ascertain mothers blood group for compatibility and rhesus antibody status. Coombes antibody status should be obtained from mothers notes.
• Check baby’s blood group for Rhesus status, and Hb in case the jaundice is caused by haemolysis causing anaemia
• Check baby for Infection
• If the baby’s SBR is above the treatment line (depending on which charts your unit uses) Photo therapy can commence.
• You may need to increase the baby’s fluid depending on you units policy. (you need to be familiar with unit policy)
• Indomethacin dislodges Biliruben from it’s plasma binding site so increases SBR

Kidney stones

What are kidney stones?

Urine* contains many dissolved minerals and salts. When your urine has high levels of these minerals and salts, you can form stones. Kidney stones can start small but can grow larger in size, even filling the inner hollow structures of the
kidney*. Some stones stay in the kidney, and do not cause any problems. Sometimes, the kidney stone can travel down the ureter*, the tube between the kidney and the bladder*.
If the stone reaches the bladder, it can be passed out of the body in urine. If the stone becomes lodged in the ureter, it blocks the urine flow from that kidney and causes pain.The kidneys are fist-size organs that handle the body’s fluid and chemical levels. Most people have two kidneys, one on each side of the spine behind the liver, stomach, pancreas and intestines. Healthy kidneys clean waste from the blood and remove it in the urine. They control the levels of sodium, potassium and calcium in the blood.
The kidneys, ureters and bladder are part of your urinary
tract*. The urinary tract makes, transports, and stores urine in the body. The kidneys make urine from water and your body’s waste. The urine then travels down the ureters into the bladder, where it is stored. Urine leaves your body through the urethra*.
Kidney stones form in the kidney. Some stones move from the kidney into the ureter. The ureters are tubes leading from the kidneys to the bladder. If a stone leaves the kidney and gets stuck in the ureter, it is called a ureteral stone.

What are the symptoms of kidney stones?
Stones in the kidney often do not cause any symptoms and can go undiagnosed. When a stone leaves the kidney, it travels to the bladder through the ureter. Often the stone can become lodged in the ureter. When the stone blocks the flow of urine out of the kidney, it can cause the kidney to swell (hydronephrosis*), often causing a lot of pain.

Common symptoms of kidney stones are:
• A sharp, cramping pain in the back and side, often moving to the lower abdomen or groin. Some women say the pain is worse than childbirth labor pains. The pain often starts suddenly and comes in waves. It can come and go as the body tries to get rid of the stone.
• A feeling of intense need to urinate.
• Urinating more often or a burning feeling during urination.
• Urine that is dark or red due to blood. Sometimes urine has only small amounts of red blood cells that can’t be seen with the naked eye.
• Nausea and vomiting.
• Men may feel pain at the tip of their penis.

Common Cold

 Common Cold

The term “common cold” refers to a mild upper respiratory viral illness. It is self-limited therefore it will go away without treatment. It is the most frequent acute illness in the United States. It is separate and a distinctly different illness than influenza, throat infection, bronchitis, sinusitis, pertussis, and allergic rhinitis. The average person has two or three colds a year. Colds are caused by many viruses, which cause similar symptoms. The same virus can cause another cold after re-exposure. However, the second illness is usually milder and lasts for a shorter period of time. Seasonal patterns may be seen for some of the viruses

Transmission: 

* Common cold viruses can be spread by three mechanisms: 

o Direct contact – colds are primarily spread from person-to-person via hands. The virus can stay alive on the skin for at least two hours. Thus, if a sick person shakes someone’s hand and that individual then touches his eye, nose, or mouth, the virus can be transmitted and later infect that person. 

o Indirect contact – viruses may survive on surfaces such as countertops for several hours thus can be transmitted from touching that surface and then touching the mouth, nose, or eyes.

  o Inhaling viral particles – droplets containing viral particles can be breathed, coughed, or sneezed into the air and transmitted to others if another person is standing close (within a few feet) and the droplet touches that person’s eye, nose, or mouth. Covering the mouth while coughing or sneezing reduces this risk. 

*  Persons with colds shed viruses the most on the second day of illness, however, low levels of viral shedding may persist for up to two weeks. 

* Saliva generally does not spread the common cold virus as most people with a cold have no detectable virus in their saliva. 

* Studies of using recirculated air in commercial airliners versus fresh air ventilation show no difference in the number of colds reported by persons after the flight.

Risk factors:

 There are some factors that can increase the risk and severity of illness with a cold. There is no scientific basis for the belief that a cold climate increases susceptibility to getting a respiratory illness. 

Increased risks of developing cold symptoms occur with: 

1. Psychological stress 

2. Lack of sleep or sleep disturbances 

3. Exposure to children in daycare settings 

Increased severity of colds is often seen with: 

1. Underlying chronic diseases 

2. Immunodeficiency disorders 

3. Malnutrition 

4. Cigarette smoking

Clinical features: 

Symptoms of the common cold are mostly due to the response of the individual to the infection, rather than to direct damage to the respiratory tract from the virus. Symptoms vary from person to person and include: 

 Rhinitis (runny nose) and congestion are the most common symptoms. 

 Sore throat, sneezing, cough, malaise (feeling ill) 

 Fever is uncommon in adults but may be present in children 

 Purulent (colored, thick drainage containing pus) drainage may be seen with the common cold. The presence of purulence does not distinguish between a cold or sinus infection. 

Incubation period/symptom duration:
 From the time of contact until onset of symptoms is generally 24 to 72 hours but can be as early as 10 to 12 hours after exposure.
 Symptoms usually last 3 to 10 days, but can last up to two weeks in some people.

Diagnosis:
The diagnosis is based on symptoms and observed signs.
 Swelling and congestion of nasal passages  Redness of the throat
 Enlarged lymph nodes in the neck
 Normal lung exam
 Chest x-rays not needed unless chest exam is abnormal Conditions that can mimic a cold include:  Allergic or seasonal rhinitis – a cough or sore throat are usually not seen with allergies.
 Bacterial throat infection or tonsillitis – nasal congestion and drainage are not generally seen with a bacterial throat infection or tonsillitis.
 Bacterial sinus infections – usually associated with significant facial pain and purulent nasal discharge.
 Influenza – usually associated with high fever, headache, and body aches.
 During flu season, obtain nasal swabs for rapid flu testing
 Pertussis – associated with prolonged coughing, sometimes associated with vomiting.

Complications:
 Acute sinus infections are a rare complication in adults with colds. Viral sinusitis occurs more frequently than secondary bacterial sinusitis. Viral sinusitis will resolve within 3 weeks without antibiotic treatment.
 Lower respiratory tract disease:    
      o RSV (respiratory syncytial virus) can cause an infection in the lungs especially in children,                  older adults, and immunocompromised patients.
      o Acute asthma attacks occur with colds thought to be due to changes in airway reactivity which            can last up to four weeks following an infection.
 Ear infections:
      o Because colds cause problems with drainage and pressure regulation of the middle ear, an acute          ear infection (otitis media) can occur.


Prevention:
 Studies have not proven that the use of alcohol gels prevent developing symptoms of a respiratory illness as the virus can be spread by inhaling droplet particles. However general hygienic measures such as hand washing has been shown to prevent the spread of respiratory viruses especially from younger children.
 Decontamination of environmental surfaces with disinfectants that kill viruses may help decrease the rate of transmission. However a study of the effectiveness of antibacterial cleaning products failed to show a difference when compared to standard cleaning products in the incidence of colds.
 Vitamins - regular supplementation with vitamins C, D, and E have not been shown to decrease the incidence of colds.
 Zinc – there have been studies that show that children taking zinc sulfate decreased the rate of development of colds, however studies have not shown this to work for adults. Zinc, especially when found in intranasal products, can lead to the loss of smell. 

Signs and Symptoms of a Stroke

About Stroke

A stroke or cerebrovascular accident occurs when the blood supply to the brain is cut off (an ischemic stroke) or when a blood vessel bursts (a hemorrhagic stroke). Most strokes are of the ischemic type. Without oxygen, brain cells begin to die. Death or permanent disability can result. High blood pressure, smoking, and having had a previous stroke or heart attack increase a person’s chances of having a stroke.

Ischemic Stroke

Are all ischemic strokes the same?

There are two types of ischemic strokes.

• Thrombotic strokes are caused by a blood clot (thrombus) in an artery going to the brain. The clot blocks blood flow to part of the brain. Blood clots usually form in arteries damaged by plaque.

• Embolic strokes are caused by a wandering clot (embolus) that’s formed elsewhere (usually in the heart or neck arteries). Clots are carried in the bloodstream and block a blood vessel in or leading to the brain.

How are ischemic strokes diagnosed?

When someone has shown symptoms of a stroke or a TIA (transient ischemic attack), a doctor will gather information and make a diagnosis. He or she will review the events that have occurred and will:

• get a medical history from you or a family member

• do a physical and neurological examination

• have certain laboratory (blood) tests done

• get a CT or MRI scan of the brain

• study the results of other diagnostic tests that might be needed

SYMPTOMS OF STROKE

The symptoms of stroke depend on what part of the brain is affected and how large an area

is involved. A stroke is a sudden event accompanied by one or more of the following signs:

! Numbness or weakness, especially on one side of the body

! Loss of consciousness or altered consciousness

! Decreased vision in one or both eyes

! Language difficulties, either in speaking or understanding

! Difficulty walking; loss of balance or coordination

! Confusion or loss of memory

! Swallowing difficulties

! Paralysis of any body area, including face

! Sudden, severe headache with no known cause

! Neck pain

! Nausea and vomiting

STROKE TESTS
When a patient presents at the emergency room with a suspected stroke, there are several tests available to the doctor to determine the type, location, and severity of the event. Testing depends on the doctor’s assessment of the patient and is done on a case-by-case basis. Available tests include:
! Head CT or head MRI – Used to determine if a stroke has occurred and, if so, what type, i.e., ischemic or hemorrhagic. Can define the location and extent of the stroke and determine if there have been previous strokes.
! Angiography – Radiographic imaging with dye injected directly into an artery. Can show narrowing of the vessel and detect the location and size of aneurysms and vascular malformations.
! Doppler ultrasound/carotid duplex imaging – Use of high-frequency sound waves to detect blockages in the carotid arteries.
! ECG (electrocardiogram) or echocardiogram – may be used to diagnose underlying heart disease or if a cardiac embolus is suspected.

STROKE TREATMENT
Ischemic Stroke
A person coming to the hospital with stroke symptoms will normally be given a CT scan to determine is he or she has had an ischemic or hemorrhagic stroke. If an ischemic stroke is detected, the standard treatment is the intravenous (IV) administration of a clot-busting (thrombolytic) medication such as t-PA (tissue plasminogen activator). T-PA, however, must be administered within three hours of a stroke onset, necessitating that the patient go to the hospital at the first signs of a stroke event. Data from the National Institute of Neurological Disorders and Stroke (NINDS) indicate that patients treated with t-PA within the three-hour window were at least 33% more likely than untreated patients to recover with little or no disability (11). The NINDS study showed that the average length of stay was shorter (10.9 days) for t-PA treated patients than for nontreated patients
(12.4 days); t-PA treated patients were also more likely than others to return home following discharge rather than to a rehabilitation center or nursing home (12). It is estimated, however, that only about
2% of stroke sufferers, however, get to the hospital in time for t-PA therapy and qualify as candidates for t-PA (13).
The most serious risk associated with IV t-PA is bleeding. An estimated 25% of patients will experience some bleeding (14), mostly minor (such as gum or nose bleeding). The NINDS study found that 6.4% of patients suffered bleeding in the brain (15). Other published studies have found both lower percentages and higher percentages of bleeding in the brain, for example, 3.3% in the FDAmandated
Standard Treatment with Alteplase [t-PA] to Reverse Stroke (STARS) Study and 15.7% in a 1997-98 study of two major Cleveland hospitals (15). Because of the risk of bleeding, not all patients can receive t-PA; some of the contraindications include history of intracranial bleeding, major surgery within the past 14 days, serious head trauma, dental extractions within seven days, and pregnancy. Other thrombolytic agents are currently under investigation that might have fewer contraindications than t-PA.

Hemorrhagic Stroke
If a CT or MRI scan has detected bleeding in or around the brain itself, i.e., a hemorrhagic stroke, immediate treatment is also imperative. Both cerebral and subarachnoid hemorrhages can be more deadly than ischemic strokes. The causes of a hemorrhagic stroke include hypertension, a ruptured or leaking aneurysm, a leaking vascular malformation, or anticoagulation medication.
For patients with anticoagulation-induced bleeding, those medications are immediately stopped, and protamine, vitamin K, or fresh frozen plasma may be given to reduce bleeding. Ruptured aneurysms or arteriovenous malformations are generally treated surgically by the use of detachable microcoils or by microsurgical clipping. Microsurgical clipping is the more well-established and longer-used technique. It involves performing a craniotomy, locating the aneurysm and clipping the ase to stop blood from entering the aneurysm. Microcoils use an endovascular technique, during which a catheter is threaded into the affected artery using a cerebral angiogram to guide its path. The catheter contains tiny platinum coils that are released into the aneurysm, inducing clotting to prevent further bleeding. The technique used depends upon the assessment of the patient’s medical team.

Hayfever

HEYFEVER

Seasonal allergic rhinitis and/or conjunctivitis, more commonly known as hayfever, are allergic hypersensitivity reactions in the nasal mucosa and the conjunctiva of the eye associated with the presence of pollens in the atmosphere in the summer months.

Causes

■■ Hayfever is caused by exposure to pollen or other allergens that only occur at certain times of year. The most common causes are:

–– tree pollens in spring

–– grass pollen in summer

–– mugwort and chrysanthemum pollen and fungal spores in autumn.

■■ Symptoms are the result of a type I allergic reaction in which initial exposure of a sensitive individual to an antigen results in the production of antigenspecific immunoglobulin E (IgE). IgE attaches to mast cells and basophils, which become sensitive to further antigenic material. On further exposure the antigen binds to IgE, causing degranulation of the mast cells and release of chemical mediators, including histamine, leukotrienes and prostaglandins, which produce an inflammatory response. Prolonged exposure to the allergen may result in a sustained response, causing nasal congestion.

Epidemiology

■■ Hayfever is estimated to affect 10–15% of the UK population, and the incidence appears to be rising.

■■ Up to 10% of children and 20–30% of adolescents are thought to suffer. Incidence peaks in the early teens and then diminishes. About two-thirds of adult sufferers are under 30 years old.

■■ Heredity may play a role, and children whose parents suffer from hayfever have

a high chance of suffering themselves.

Signs and symptoms

Nasal symptoms

The development of nasal symptoms over time is described in terms of early and late phases.

Early-phase nasal symptoms

■■ Rhinorrhoea (nasal discharge): discharge is clear and watery, and frequent blowing and wiping can make the nose sore, sometimes leading to infections.

■■ Sneezing: begins within 60 seconds of inhalation of allergen and can result in long bouts of repeated sneezing, which is disruptive and distressing.

■■ Nasal pruritus (itching): may be continuous or intermittent, and is extremely unpleasant and irritating.

■■ Some sufferers also experience an itching sensation in the roof of the mouth.

Late-phase nasal symptoms

■■ Nasal congestion, usually developing after some days of exposure to allergen, when the blood vessels in the nose become dilated. Congestion may be uni- or bilateral, and may shift from one nostril to the other every few hours. Mouthbreathing may result, which can lead to a dry mouth and bad breath, disrupted sleep and anosmia (loss of sense of smell).

■■ Nasal congestion may cause frontal or sinus headaches and give rise to secondary infections such as sinusitis.

■■ The eustachian tubes may become blocked with mucus and infected, and otitis media may result.

■■ In some cases a dark or bluish swelling, like a black eye, develops around the eyes, caused by impaired nasal venous outflow.

Eye symptoms: allergic conjunctivitis

■■ clear, watery ophthalmic discharge

■■ redness caused by dilation of the conjunctival blood vessels

■■ ophthalmic itching, sometimes so severe that the sufferer resorts to scratching the eyelids to relieve it

■■ photophobia

■■ skin folds or pleats develop parallel to the lower lid margin, extending from under the eye to the top of the cheekbone.

Differential diagnosis

Allergic rhinitis and the common cold have several features in common. They may be confused with each other but can be distinguished by the differences shown in

Table 23.1.

Symptoms and circumstances for referral

■■ wheezing or shortness of breath, which could indicate asthma

■■ earache or facial pain, as these may indicate sinusitis or otitis media requiring antibiotics

■■ purulent, rather than clear, discharge from the eyes, indicating the possibility of infection

■■ blood in nasal discharge

■■ no improvement after 1 week of treatment with over-the-counter medication.

COMMON WORMS

COMMON WORMS
Worms are probably the best known of human parasites. Records from ancient civilizations show that worms have been infecting man for centuries. Yet few people like to face the embarrassment of a diagnosis, perhaps because of the myth that having worms means you are dirty.

Where is the prevalence high?
Worms are cosmopolitan but like most other parasitic infections, they prefer the tropica regions of the world where warm, moist conditions prevail in conjunction with poor hygiene and sanitation. Worm eggs and their infective larval stages can survive for many months in stool-contaminated water or soil. Any basic improvement in the disposal of faecal waste will go a long way in reducing the prevalence of worms. In general, cold winter temperatures discourage the survival and transmission of these parasites.

Types of worms
There are three groups of parasitic worms commonly known as roundworms, tapeworms and flukes.

Roundworms
Roundworms are cylindrical and smooth and most of the human roundworms live in the intestine. Intestinal roundworms include the commonest worm of all, Ascaris, as well as hookworm, whipworm (Trichuris) and pinworm or threadworm (Enterobius). Ascaris can reach about a foot in length while pinworms look like tiny white threads. Female roundworms lay eggs that are passed out in the faeces of an infected person. One species called Strongyloides actually gives birth to larval worms that pass out in stools. Faecally  contaminated soil is a feature of all urban and rural areas where sanitation is poor and  worms such as Ascaris and Trichuris are transmitted when soil-contaminated fruits and  vegetables are eaten without washing, or, in the case of hookworms, when larval worms in the soil penetrate the skin of persons walking barefoot.
Pinworm eggs are sticky and the female lays them around the anus of the host at night.
The eggs cause intense “itchy bottom” and inevitable scratching. The eggs can lodge under fingernails or in bedding leading to a vicious cycle of infection and re-infection.
Several members of the same family can be infected at once, especially if they share beds.
Not all the roundworms which parasitize man are intestinal species. The filarial worms, which inhabit blood, tissues or skin, are also roundworms and are transmitted by biting  insects.

Tapeworms
Tapeworms are flat, segmented and ribbon-like. Man is infected with Taenia by eating  the larvae in meat, either beef or pork, which is undercooked or raw. The enjoyment of “rare” meat contributes to transmission in areas where meat inspection is not thorough.Tapeworm eggs and segments are passed in the faeces of infected persons and if they  contaminate pasture, are ingested by cattle or pigs. Once in the animal, the eggs hatch and the larvae settle in the muscles as cysts, which remain infective to man. Only thorough cooking will kill the cysts. Much to the horror of the infected person, the live, active and very visible segments of the tapeworm can exit out of the anus with or without stool and be seen publicly on its long journey down the leg.
Smaller tapeworms also exist, the most exotic being Echinococcus (Hydatid), which lives in the intestine of dogs. If a human (instead of a sheep) accidentally swallows the eggs from the dog faeces, the eggs hatch and become “hydatid cysts” in the infected human, lodging in various organs of the body to disrupt normal functions due to pressure effects. Pastoralists living in close association with their dogs, such as the Turkana of northwestern Kenya, are especially at risk.

Flukes
Flukes are flat and leaf-shaped with the exception of the bilharzia or schistosome flukes, which are cylindrical. All flukes spend part of their life cycle in snails, in which they  multiply. The larvae shed from the snails are infective to man, either directly through the skin, or by eating raw plants, fish (especially in the Far East) or small animals in which  the larval cysts hide. The larval forms of schistosomes are found in water and penetrate the skin of persons through water contact. The adult schistosome flukes live inside blood  vessels feeding on blood. Their eggs escape from the human body in faeces or urine where they reach by digging burrows in body tissues causing bleeding and pain. Some eggs never complete their journey and lie trapped in body tissues where they cause slow damage, pain and bleeding. These injuries can progress quietly for over 15 years before major complaints arise.

What do people infected with worms complaint about?
Many healthy individuals will harbour worms without having symptoms. In general Though, infection with intestinal worms will cause disturbances such as tummy aches, abdominal discomfort, nausea, bloating, indigestion, acidity, tiredness, coughing, occasional vomiting and diarrhoea. Bloody diarrhoea can be a symptom of early bilharzia. Headaches, dizziness, irritability, muscle pains, skin rashes and even backache may occur. Filarial worms can lead to elephantiasis, blindness and skin damage in  addition to allergic manifestations in the lungs and blood. Some people with worms end  up being treated wrongly for asthma.

Do worms cause death?

Sometimes death may occur when worms such as Ascaris coil up together blocking the intestinal lumen, especially in children. Death may also occur as an indirect result of worm infection due to exhaustion, incapacitation, blindness, anaemia, pressure in the brain or lungs and vomiting.
While fatality is rare, studies have shown that a heavy worm load consistently lowers the performance of children in schools and can lead to nutritional deficiencies including  anemia

How to detect worm infection
Simple laboratory tests on stool and urine can diagnose most common intestinal worms  by identification of eggs and larvae. Filarial worms are identified by examining blood or  skin microscopically. More complicated tests can also be performed on blood.
Radiological methods such as ultrasound and x-rays are useful for certain infections.
Advice to travellers in the tropics
• Avoid consuming contaminated or suspicious food or drink.
• Avoid eating raw or undercooked meat and fish.
• Avoid walking bare-feet on soil which might be faecally contaminated.
• Try to prevent insect bites by using repellents or bed nets.
• Avoid swimming in fresh water lakes or rivers.
• Peel fruits when there is no clean water to wash them.
• Wash hands with soap and water before eating.
• De-worm yourself regularly (every six months) using self-administered
Albendazole or Mebendazole, especially if you are far from medical facilities.
In conclusion, it is wise to take precautions but when they fail there is effective treatment
for all worm infections.

Rheumatoid arthritis

Rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic inflammatory disease that can affect multiple joints in the body. Although its cause is still unknown, RA is believed to be the result of a malfunctioning immune system. With RA, inflammation manifests in the lining of the joints, causing pain, swelling, joint damage and deformity. It can occasionally involve other internal organs, such as the nerves, eyes, lungs or heart.

ARTHRITIS AND JOINT PAIN
Aching or pain in the joints (without swelling) in inflammatory bowel disease (IBD) is called arthralgia. Between 10% to 20% of people with IBD have joint pain at some point. Arthralgia can occur in various joints of the body, such as the knees, ankles, and hands. IBD-associated arthralgias do not damage the joint. Arthralgia is often relieved by treating the active symptoms in the gastrointestinal (GI) tract. Arthritis, or inflammation (pain with swelling) of the joints, is the most common extraintestinal complication of IBD. It may affect as many as 30% of people with Crohn’s disease or ulcerative colitis. Although arthritis is typically associated with advancing age, in IBD it often strikes younger patients as well. In addition to joint pain, arthritis also causes swelling of the joints and a reduction in flexibility. It is important to point out that people with arthritis may experience arthralgia, but many people with arthralgia may not have arthritis.

Early Signs of RA:
The onset of RA usually starts over a period of weeks to months, with more joints affected over time. You should see your doctor if you experience one or more of the following symptoms for more than six weeks:
• pain and stiffness in multiple joints, sometimes affecting the same joints on both sides of your body
• stiff joints in the morning lasting 60 minutes or more
• reduced range of motion, such as difficulty making a fist
• joint swelling, sometimes feeling hot to touch
• fever, fatigue, weight loss or decreased appetite
• nodules (growth that forms under your skin), most commonly on the elbows, hands and feet; this occurs in 20 per cent of people

Treatment
In the general population, people with peripheral arthritis may use nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and swelling of the joints. However, as a rule, these medications—which include aspirin and ibuprofen—are not a good option for everyone with IBD because they can irritate the intestinal lining and increase the inflammation. (It should be noted, though, that some people with IBD can tolerate NSAIDs and find these medications helpful in relieving symptoms of arthritis. It is important to discuss medication usage with your doctor.) Corticosteroids also may be used to treat the arthritis symptoms as well as IBD.
In most cases, doctors manage the symptoms of peripheral arthritis by controlling the inflammation within the colon.
Only axial arthritis seems not to improve as the intestinal inflammation resolves. Once inflammation has decreased, possibly after a course of a medication such as prednisone or sulfasalazine (or other 5-aminosalicylates), joint pain generally disappears. Because they take months to work, the immunomodulators azathioprine and/or 6-mercaptopurine are not used specifically to control joint inflammation. However, the immunomodulator methotrexate can be an effective treatment for IBD-associated joint pain. Similarly, the newer biologic agents such as infliximab (Remicade®), adalimumab (Humira®), and certolizumab (Cimzia®) have all been shown to be very effective in reducing joint inflammation and swelling. Infliximab and adalimumab have even shown good results as a primary treatment for ankylosing spondylitis, preventing joint damage and destruction.
In addition to medication, doctors may recommend resting the affected joint, occasional use of moist heat, or range of motion exercises, as demonstrated by a physical therapist.

डेंगू बुखार क्या है?

डेंगू बुखार क्या है?

डेंगू बुखार एक संक्रामक रोग मच्छरों द्वारा किया जाता है और चार से संबंधित डेंगू वायरस के किसी भी कारण होता है। इस रोग में इस्तेमाल किया "तोड़ने की हड्डी" बुखार कहा जा सकता है क्योंकि यह कभी कभी गंभीर जोड़ों और मांसपेशियों का दर्द महसूस होता है कि हड्डियों को तोड़ रहे हैं जैसे कारण बनता है। स्वास्थ्य विशेषज्ञों का डेंगू बुखार के बारे में 200 से अधिक वर्षों के लिए जाना जाता है। डेंगू बुखार के ज्यादातर दौरान और शीघ्र ही कैरेबियन और मध्य और दक्षिण अमेरिका, अफ्रीका, दक्षिण पूर्व एशिया और चीन, भारत, मध्य पूर्व, ऑस्ट्रेलिया और दक्षिण और मध्य प्रशांत के उष्णकटिबंधीय और उपोष्णकटिबंधीय क्षेत्रों में बरसात के मौसम के बाद पाया जाता है। दुनिया भर में, डेंगू संक्रमण के 50 से 100 मिलियन करने के मामले हर साल होती है। यह संयुक्त राज्य अमेरिका में 100 से 200 मामलों, ज्यादातर लोग हैं, जो हाल ही में विदेश यात्रा की है में भी शामिल है। कई मामलों संभावना unreported जाने के कारण कुछ स्वास्थ्य सेवा प्रदाताओं के रोग को पहचान नहीं है।

कारण :

डेंगू बुखार डेंगू वायरस के किसी भी प्रकार के चार में से एक कारण हो सकता है: DEN-1, डेन -2, डेन-3, और डेन-4। आप अपने जीवनकाल के दौरान कम से कम दो नहीं तो अलग अलग समय पर सभी चार प्रकार से संक्रमित हो सकता है, लेकिन केवल एक बार में एक ही प्रकार से।

संचरण :
डेंगू वायरस एक संक्रमित एडीज मच्छर के काटने से प्रेषित किया जा कर सकते हैं। मच्छरों संक्रमित हो गया जब वे संक्रमित मनुष्यों काटने, और बाद में अन्य लोगों को संक्रमण संचारित कर सकते हैं। दो मुख्य प्रजाति के मच्छर, एडीज aegypti और एडीज albopictus, मेक्सिको में फैलता डेंगू के सभी मामलों के लिए जिम्मेदार किया गया है। डेंगू से व्यक्ति में एक मच्छर बिना मध्यवर्ती सदिश रूप में प्रेषित किया जा नहीं कर सकता।

 लक्षण:
ठेठ सीधी (क्लासिक) डेंगू के लक्षण आमतौर पर 4 से 7 दिनों के भीतर बुखार के साथ शुरू करने के बाद आप एक संक्रमित मच्छर ने काट लिया गया है। इन लक्षणों में शामिल हैं: तेज बुखार, 105ºF अप करने के लिए गंभीर सिर दर्द, रेट्रो कक्षीय दर्द, गंभीर जोड़ों और मांसपेशियों में दर्द, मतली और उल्टी, और दाने (आंख के पीछे)। 3 से 4 दिनों के बाद शुरू होता है बुखार दाने शरीर के सबसे अधिक दिखाई देते हैं, और उसके बाद 1 से 2 दिनों के बाद उतरे। वहाँ एक दूसरे दाने कुछ दिनों के बाद हो सकता है। डेंगू रक्तस्रावी बुखार के लक्षण क्लासिक डेंगू के लक्षणों के सभी प्लस नाक से खून बह रहा शामिल हैं, मसूड़ों, या त्वचा के नीचे, बैंगनी चोट के निशान है, जो रक्त वाहिकाओं को नुकसान का परिणाम हो सकता है। डेंगू रोग के फार्म का यह मौत का कारण बन सकता है।

कैसे डेंगू का निदान और इलाज किया जाता है?
डेंगू के दो रक्त परीक्षण, के अलावा 2 से 3 सप्ताह ऐसा करने से निदान किया जा सकता है। परीक्षण दिखा सकते हैं अपने खून का एक नमूना वायरस के लिए एंटीबॉडी शामिल है। हालांकि, महामारी, एक स्वास्थ्य देखभाल प्रदाता अक्सर प्रयोगशाला के परिणाम का इंतजार किए बिना निदान डेंगू "presumptively" ठेठ संकेत और लक्षण द्वारा।

इलाज:
वहाँ क्लासिक डेंगू बुखार के लिए कोई विशेष उपचार है, और ज्यादातर लोगों को 2 सप्ताह के भीतर ठीक हो। वसूली के साथ मदद करने के लिए, स्वास्थ्य देखभाल के विशेषज्ञों का सुझाव है:
रोग नियंत्रण के लिए केंद्र को अमेरिकी सलाह देता डेंगू बुखार के साथ लोगों को एस्पिरिन लेने के लिए नहीं। सदमे और कोमा, जल्दी और आक्रामक आपातकालीन उपचार तरल पदार्थ और इलेक्ट्रोलाइट प्रतिस्थापन के साथ सहित गंभीर डेंगू के लक्षण, के लिए संजीवनी जा सकता है।

जटिलताओं:
ज्यादातर लोग हैं जो डेंगू बुखार का विकास 2 सप्ताह के भीतर पूरी तरह से ठीक हो। कुछ विशेष रूप से वयस्कों, वायरस से संक्रमित होने के बाद महीनों के लिए कई हफ्तों के लिए थक गया और / या उदास हो सकता है। अधिक चिकित्सकीय गंभीर डेंगू रक्तस्रावी बुखार और डेंगू के झटके सिंड्रोम नाड़ी (रक्त वाहिनियों) और जिगर की क्षति में परिणाम कर सकते हैं, और जीवन के लिए खतरा हो सकता है।

मैं डेंगू कैसे रोक सकते हैं?
डेंगू वायरस के संक्रमण को रोकने के लिए सबसे अच्छा तरीका विशेष सावधानी बरतने के लिए मच्छरों ने काटा जा रहा से बचने के लिए है। कई डेंगू के टीके विकसित किए जा रहे हैं, लेकिन कोई भी अगले कुछ वर्षों में खाद्य एवं औषधि प्रशासन द्वारा लाइसेंस प्राप्त होने की संभावना है। एक क्षेत्र में सड़क पर जहां डेंगू बुखार पाया गया है, एक मच्छर नींबू नीलगिरी की DEET, Picaridin युक्त बचाने वाली क्रीम, और तेल का उपयोग करते हैं तो जब तक वहाँ एक एलर्जी या DEET या इसे करने के लिए एक contraindication है एक विकल्प के रूप में सिफारिश नहीं कर रहे DEET से कम प्रभावी हैं अनुपलब्ध है। सुरक्षात्मक कपड़ों के लंबे बाजू की शर्ट, लंबी पैंट, मोजे, और जूते में ड्रेस है। एडीज मच्छरों को आम तौर पर दिन के दौरान काटने के कारण, विशेष रूप से भोर से पहले सुबह घंटों के दौरान और अंधेरा होने से पहले देर से दोपहर में सावधानियों का उपयोग करने के लिए सुनिश्चित हो। अन्य सावधानियों में शामिल हैं:
ओ मुक्त खड़े पानी से मुक्त आसपास के क्षेत्रों में रखें।
ओ लंबी आस्तीन और हल्के रंग के कपड़े पहनें।
ओ कीट से बचाने वाली क्रीम का प्रयोग करें जब बाहर।
ओ Unscreened खिड़कियों रखा जाना चाहिए प्रवेश करने से मच्छरों को रोकने के लिए बंद कर दिया।
ओ ध्यान से पता लगाने के लिए अपने पर्यावरण का निरीक्षण किया और पानी जहां मच्छरों इस तरह के फूल के बर्तन, कंटेनर, birdbaths, बेकार पड़े टायरों, आदि के रूप में, नस्ल कर सकते हैं के साथ खड़े सभी क्षेत्रों को समाप्त

HEALTH:

WHO definition of Health: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (1946).

Health is not an easy term to define. ‘Health’ is an elusive word. Most people who consider themselves healthy are not healthy. And many people who are suffering from some known disease may be relatively healthy. Health is a concept which does not merely relate to the absence of disease, of the healthy working of organs, or having good thoughts. Health is a holistic concept. It relates to a person as a whole. Not just the person you see, but also the person you ‘feel’. Health is a united by four parts:

–      Social health

–      Physical Health

–       Mental Health

–      Emotional Health

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