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Pulmonary Embolism

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Definition:-
Pulmonary embolism (PE) is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (embolism). Usually this is due to embolism of a thrombus (blood clot) from the deep veins in the legs, a process termed venous thromboembolism. A small proportion is due to the embolization of air, fat or amniotic fluid. The obstruction of the blood flow through the lungs and the resultant pressure on the right ventricle of the heart leads to the symptoms and signs of PE. The risk of PE is increased in various situations, such as cancer and prolonged bed rest..

You may click to see more pictures of Pulmonary Embolism
Pulmonary embolism is a condition that occurs when one or more arteries in your lungs become blocked. In most cases, pulmonary embolism is caused by blood clots that travel to your lungs from another part of your body — most commonly, your legs.

Symptoms:-
Symptoms of PE are sudden-onset dyspnea (shortness of breath), tachypnea (rapid breathing), chest pain of a “pleuritic” nature (worsened by breathing), cough and hemoptysis (coughing up blood). More severe cases can include signs such as cyanosis (blue discoloration, usually of the lips and fingers), collapse, and circulatory instability. About 15% of all cases of sudden death are attributable to PE.

On physical examination, a pleural rub may be audible by stethoscope over affected areas of the lung. Strain on the right ventricle may be detected as a left parasternal heave, a loud pulmonary component of the second heart sound, raised jugular venous pressure, and more rarely leg swelling.

A fever though usually low grade is present in 14% of people with pulmonary embolism.

Symptoms of pulmonary embolism include difficulty breathing, chest pain on inspiration, and palpitations. Clinical signs include low blood oxygen saturation and cyanosis, rapid breathing, and a rapid heart rate. Severe cases of PE can lead to collapse, abnormally low blood pressure, and sudden death.

Pulmonary embolism occurs when a clump of material, most often a blood clot, gets wedged into an artery in your lungs. These blood clots most commonly originate in the deep veins of your legs, but they can also come from other parts of your body. This condition is known as deep vein thrombosis (DVT).

Occasionally, other substances can form blockages within the blood vessels inside your lungs. Examples include:

*Fat from within the marrow of a broken bone
*Part of a tumor
*Air bubbles

It’s rare to experience a solitary pulmonary embolism. In most cases, multiple clots are involved. The lung tissue served by each blocked artery is robbed of fuel and may die. This makes it more difficult for your lungs to provide oxygen to the rest of your body.

Because pulmonary embolism almost always occurs in conjunction with deep vein thrombosis, some doctors refer to the two conditions together as venous thromboembolism (VTE).

Causes:-

In 9 out of 10 cases, pulmonary embolism (PE) begins as a blood clot in the deep veins of the leg (a condition known as deep vein thrombosis). The clot breaks free from the vein and travels through the bloodstream to the lungs, where it can block an artery.Click to see to learn more

Diagnosis:-
The diagnosis of PE is based primarily on validated clinical criteria combined with selective testing because the typical clinical presentation (shortness of breath, chest pain) cannot be definitively differentiated from other causes of chest pain and shortness of breath. The decision to do medical imaging is usually based on clinical grounds, i.e. the medical history, symptoms and findings on physical examination, followed by an assessment of clinical probability.

The most commonly used method to predict clinical probability, the Wells score, is a clinical prediction rule, whose use is complicated by multiple versions being available. In 1995, Wells et al. initially developed a prediction rule (based on a literature search) to predict the likelihood of PE, based on clinical criteria. The prediction rule was revised in 1998 This prediction rule was further revised when simplified during a validation by Wells et al. in 2000. In the 2000 publication, Wells proposed two different scoring systems using cutoffs of 2 or 4 with the same prediction rule. In 2001, Wells published results using the more conservative cutoff of 2 to create three categories. An additional version, the “modified extended version”, using the more recent cutoff of 2 but including findings from Wells’s initial studies were proposed. Most recently, a further study reverted to Wells’s earlier use of a cutoff of 4 points to create only two categories.

There are additional prediction rules for PE, such as the Geneva rule. More importantly, the use of any rule is associated with reduction in recurrent thromboembolism.

The Wells score:–
*Clinically suspected DVT – 3.0 points
*Alternative diagnosis is less likely than PE – 3.0 points
*Tachycardia – 1.5 points
*Immobilization/surgery in previous four weeks – 1.5 points
*History of DVT or PE – 1.5 points
*Hemoptysis – 1.0 points
*Malignancy (treatment for within 6 months, palliative) – 1.0 points

Traditional interpretation

*Score >6.0 – High (probability 59% based on pooled data)
*Score 2.0 to 6.0 – Moderate (probability 29% based on pooled data)
*Score <2.0 – Low (probability 15% based on pooled data)

Alternate interpretation.
:-
*Score > 4 – PE likely. Consider diagnostic imaging.
*Score 4 or less – PE unlikely. Consider D-dimer to rule out PE.

Blood tests:-
In low/moderate suspicion of PE, a normal D-dimer level (shown in a blood test) is enough to exclude the possibility of thrombotic PE.

When a PE is being suspected, a number of blood tests are done, in order to exclude important secondary causes of PE. This includes a full blood count, clotting status (PT, APTT, TT), and some screening tests (erythrocyte sedimentation rate, renal function, liver enzymes, electrolytes). If one of these is abnormal, further investigations might be warranted.

Non-invasive imaging:-
CT pulmonary angiography (CTPA) is a pulmonary angiogram obtained using computed tomography (CT) with radiocontrast rather than right heart catheterization. Its advantages are clinical equivalence, its non-invasive nature, its greater availability to patients, and the possibility of identifying other lung disorders from the differential diagnosis in case there is no pulmonary embolism. Assessing the accuracy of CT pulmonary angiography is hindered by the rapid changes in the number of rows of detectors available in multidetector CT (MDCT) machines.[14] A study with a mixture of 4 slice and 16 slice scanners reported a sensitivity of 83% and a specificity of 96%. This study noted that additional testing is necessary when the clinical probability is inconsistent with the imaging results.[15] CTPA is non-inferior to VQ scanning, and identifies more emboli (without necessarily improving the outcome) compared to VQ scanning

Ventilation/perfusion scan (or V/Q scan or lung scintigraphy), which shows that some areas of the lung are being ventilated but not perfused with blood (due to obstruction by a clot). This type of examination is used less often because of the more widespread availability of CT technology, however, it may be useful in patients who have an allergy to iodinated contrast or in pregnancy due to lower radiation exposure than CT

Ventilation/perfusion scan (or V/Q scan or lung scintigraphy), which shows that some areas of the lung are being ventilated but not perfused with blood (due to obstruction by a clot). This type of examination is used less often because of the more widespread availability of CT technology, however, it may be useful in patients who have an allergy to iodinated contrast or in pregnancy due to lower radiation exposure than CT.

Low probability diagnostic tests/non-diagnostic tests:-

Tests that are frequently done that are not sensitive for PE, but can be diagnostic.

*Chest X-rays are often done on patients with shortness of breath to help rule-out other causes, such as congestive heart failure and rib fracture. Chest X-rays in PE are rarely normal,[18] but usually lack signs that suggest the diagnosis of PE (e.g. Westermark sign, Hampton’s hump).

*Ultrasonography of the legs, also known as leg doppler, in search of deep venous thrombosis (DVT). The presence of DVT, as shown on ultrasonography of the legs, is in itself enough to warrant anticoagulation, without requiring the V/Q or spiral CT scans (because of the strong association between DVT and PE). This may be valid approach in pregnancy, in which the other modalities would increase the risk of birth defects in the unborn child. However, a negative scan does not rule out PE, and low-radiation dose scanning may be required if the mother is deemed at high risk of having pulmonary embolism.

Electrocardiogram findings:-
Electrocardiogram of a patient with pulmonary embolism showing sinus tachycardia of approximately 150 beats per minute and right bundle branch block.An electrocardiogram (ECG) is routinely done on patients with chest pain to quickly diagnose myocardial infarctions (heart attacks). An ECG may show signs of right heart strain or acute cor pulmonale in cases of large PEs – the classic signs are a large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III (“S1Q3T3”). This is occasionally (up to 20%) present, but may also occur in other acute lung conditions and has therefore limited diagnostic value. The most commonly seen signs in the ECG is sinus tachycardia, right axis deviation and right bundle branch block. Sinus tachycardia was however still only found in 8 – 69% of people with PE.

Echocardiography findings:-
In massive and submassive PE, dysfunction of the right side of the heart can be seen on echocardiography, an indication that the pulmonary artery is severely obstructed and the heart is unable to match the pressure. Some studies  suggest that this finding may be an indication for thrombolysis. Not every patient with a (suspected) pulmonary embolism requires an echocardiogram, but elevations in cardiac troponins or brain natriuretic peptide may indicate heart strain and warrant an echocardiogram.

The specific appearance of the right ventricle on echocardiography is referred to as the McConnell sign. This is the finding of akinesia of the mid-free wall but normal motion of the apex. This phenomenon has a 77% sensitivity and a 94% specificity for the diagnosis of acute pulmonary embolism.

Combining tests into algorithms:-
Recent recommendations for a diagnostic algorithm have been published by the PIOPED investigators; however, these recommendations do not reflect research using 64 slice MDCT.[12] These investigators recommended:

*Low clinical probability. If negative D-dimer, PE is excluded. If positive D-dimer, obtain MDCT and based treatment on results.

*Moderate clinical probability. If negative D-dimer, PE is excluded. However, the authors were not concerned that a negative MDCT with negative D-dimer in this setting has an 5% probability of being false. Presumably, the 5% error rate will fall as 64 slice MDCT is more commonly used. If positive D-dimer, obtain MDCT and based treatment on results.

*High clinical probability. Proceed to MDCT. If positive, treat, if negative, additional tests are needed to exclude PE.

Pulmonary Embolism Rule-out Criteria:-
The Pulmonary Embolism Rule-out Criteria, or PERC rule, helps assess patients in whom pulmonary embolism is suspected, but unlikely. Unlike the Wells Score and Geneva score, which are clinical prediction rules intended to risk stratify patients with suspected PE, the PERC rule is designed to rule-out risk of PE in patients when the physician has already stratified them into a low-risk category.

Patients in this low risk category without any of these criteria may undergo no further diagnostic testing for PE: Hypoxia – Sa02 <95%, unilateral leg swelling, hemoptysis, prior DVT or PE, recent surgery or trauma, age >50, hormone use, tachycardia. The rationale behind this decision is that further testing (specifically CT angiogram of the chest) may cause more harm (from radiation exposure and contrast dye) than the risk of PE.[24] The PERC rule has a sensitivity of 97.4% and specificity of 21.9% with a false negative rate of 1.0% (16/1666).

Treatment:-
In most cases, anticoagulant therapy is the mainstay of treatment. Acutely, supportive treatments, such as oxygen or analgesia, are often required.

Anticoagulation:-
In most cases, anticoagulant therapy is the mainstay of treatment. Heparin, low molecular weight heparins (such as enoxaparin and dalteparin), or fondaparinux is administered initially, while warfarin, acenocoumarol, or phenprocoumon therapy is commenced (this may take several days, usually while the patient is in hospital). It however may be possible to treat low risk patients as outpatients. An ongoing study is looking into the safety of this practice. Warfarin therapy often requires frequent dose adjustment and monitoring of the INR. In PE, INRs between 2.0 and 3.0 are generally considered ideal. If another episode of PE occurs under warfarin treatment, the INR window may be increased to e.g. 2.5-3.5 (unless there are contraindications) or anticoagulation may be changed to a different anticoagulant e.g. low molecular weight heparin. In patients with an underlying malignancy, therapy with a course of low molecular weight heparin may be favored over warfarin based on the results of the CLOT trial. Similarly, pregnant women are often maintained on low molecular weight heparin to avoid the known teratogenic effects of warfarin, especially in the early stages of pregnancy. People are usually admitted to hospital in the early stages of treatment, and tend to remain under inpatient care until INR has reached therapeutic levels. Increasingly, low-risk cases are managed on an outpatient basis in a fashion already common in the treatment of DVT.

Warfarin therapy is usually continued for 3–6 months, or “lifelong” if there have been previous DVTs or PEs, or none of the usual risk factors is present. An abnormal D-dimer level at the end of treatment might signal the need for continued treatment among patients with a first unprovoked pulmonary embolus.

Thrombolysis:-
Massive PE causing hemodynamic instability (shock and/or hypotension, defined as a systolic blood pressure <90 mmHg or a pressure drop of 40 mmHg for>15 min if not caused by new-onset arrhythmia, hypovolemia or sepsis) is an indication for thrombolysis, the enzymatic destruction of the clot with medication. It is the best available medical treatment in this situation and is supported by clinical guidelines.

The use of thrombolysis in non-massive PEs is still debated. The aim of the therapy is to dissolve the clot, but there is an attendant risk of bleeding or stroke. The main indication for thrombolysis is in submassive PE where right ventricular dysfunction can be demonstrated on echocardiography, and the presence of visible thrombus in the atrium.

Surgical management:-
Surgical management of acute pulmonary embolism (pulmonary thrombectomy) is uncommon and has largely been abandoned because of poor long-term outcomes. However, recently, it has gone through a resurgence with the revision of the surgical technique and is thought to benefit selected patients

Chronic pulmonary embolism leading to pulmonary hypertension (known as chronic thromboembolic hypertension) is treated with a surgical procedure known as a pulmonary thromboendarterectomy.

Inferior vena cava filter:-
If anticoagulant therapy is contraindicated and/or ineffective, or to prevent new emboli from entering the pulmonary artery and combining with an existing blockage, an inferior vena cava filter may be implanted.

Prognosis:-
Mortality from untreated PE is said to be 26%. This figure comes from a trial published in 1960 by Barrit and Jordan,[38] which compared anticoagulation against placebo for the management of PE. Barritt and Jordan performed their study in the Bristol Royal Infirmary in 1957. This study is the only placebo controlled trial ever to examine the place of anticoagulants in the treatment of PE, the results of which were so convincing that the trial has never been repeated as to do so would be considered unethical. That said, the reported mortality rate of 26% in the placebo group is probably an overstatement, given that the technology of the day may have detected only severe PEs.

Prognosis depends on the amount of lung that is affected and on the co-existence of other medical conditions; chronic embolisation to the lung can lead to pulmonary hypertension. After a massive PE, the embolus must be resolved somehow if the patient is to survive. In thrombotic PE, the blood clot may be broken down by fibrinolysis, or it may be organized and recanalized so that a new channel forms through the clot. Blood flow is restored most rapidly in the first day or two after a PE. Improvement slows thereafter, and some defects may remain permanently. There is controversy over whether or not small subsegmental PEs need to be treated at all[40] and some evidence exists that patients with subsegmental PEs may do well without treatment.

Predicting mortality:-
The PESI and Geneva prediction rules can estimate mortality and so may guide selection of patients who can be considered for outpatient therapy.

Underlying causes:-
After a first PE, the search for secondary causes is usually brief. Only when a second PE occurs, and especially when this happens while still under anticoagulant therapy, a further search for underlying conditions is undertaken. This will include testing (“thrombophilia screen”) for Factor V Leiden mutation, antiphospholipid antibodies, protein C and S and antithrombin levels, and later prothrombin mutation, MTHFR mutation, Factor VIII concentration and rarer inherited coagulation abnormalities.

Epidemiology:-

Risk factors:-
The most common sources of embolism are proximal leg deep venous thrombosis (DVTs) or pelvic vein thromboses. Any risk factor for DVT also increases the risk that the venous clot will dislodge and migrate to the lung circulation, which happens in up to 15% of all DVTs. The conditions are generally regarded as a continuum termed venous thromboembolism (VTE).

The development of thrombosis is classically due to a group of causes named Virchow’s triad (alterations in blood flow, factors in the vessel wall and factors affecting the properties of the blood). Often, more than one risk factor is present.

*Alterations in blood flow: immobilization (after surgery, injury or long-distance air travel), pregnancy (also procoagulant), obesity (also procoagulant)

*Factors in the vessel wall: of limited direct relevance in VTE

*Factors affecting the properties of the blood (procoagulant state):

*Oestrogen-containing hormonal contraception
*Genetic thrombophilia (factor V Leiden, prothrombin mutation G20210A, protein C deficiency, protein S deficiency, antithrombin deficiency, hyperhomocysteinemia and plasminogen/fibrinolysis disorders).
*Acquired thrombophilia (antiphospholipid syndrome, nephrotic syndrome, paroxysmal nocturnal hemoglobinuria)

Prognosis:-
Once anticoagulation is stopped, the risk of a fatal pulmonary embolism is 0.5% per year

Prevention:-
If you are in hospital for surgery or because of illness, your doctor will suggest some leg exercises you can do, to ensure you keep your legs moving. You will be encouraged to drink plenty of fluids (or may have fluids via a drip if you are unable to drink).

If you are having major surgery, you may be given injections of heparin before your surgery to reduce your risk of getting a DVT or pulmonary embolism. You may also be given elastic compression stockings to wear or a device called an intermittent compression pump to keep the blood flowing through your legs.

*Compression stockings (also called TED or thrombo-embolic deterrent stockings) are usually worn to help maintain circulation and reduce the risk of blood clots forming in the veins of your legs. They come in different sizes and will be checked by nursing staff every day to make sure that they’re the correct size and fit for you. You might be asked to wear them after you have had surgery.

*Intermittent compression pumps help to dissolve blood clots by compressing the calf and/or thigh muscles of your leg. They are usually used straight before or during surgery.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:-

Researchers May Have Found an Efficient Way to Detect Pulmonary Embolisms


http://en.wikipedia.org/wiki/Pulmonary_embolism
http://www.mayoclinic.com/health/pulmonary-embolism/DS00429/DSECTION=causes

http://hcd2.bupa.co.uk/fact_sheets/html/Pulmonary_embolism.html

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Cancer Prevention

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Cancer conjures up images of mutilating surgery, chemotherapy, radiation, years with doctors and in hospitals, and — most terrible — death. It comes in many avatars and can attack any part of the body. The risk factors for the ailment are many. It has been found to have associations with infections, lifestyle, genetic factors and heredity. If an injection is available to prevent cancer, it is hard to imagine anyone opting not to take it!

Viruses have long been known to cause infections that can progress to cancer. Previously, the association was suspected but not proven. Today, with electron microscopes, DNA sequencing and other advanced techniques, the association between certain viral infections and cancer has been conclusively proven. Of these, two types of cancer — of the cervix and some cancers of the liver — can be prevented with timely immunisation.a

The statistics speak for themselves. Cervical cancer (or cancer of the neck of the uterus) accounts for 25 per cent of all cancers in women. It is commoner than breast cancer (14 per cent). Around 1,30,000 cases are detected annually in India and half of these women eventually succumb to the disease.

Cervical cancer has long been associated with certain risk factors. It is more likely to occur if the woman smokes, does not have a healthy diet with plenty of fruits and vegetables, is exposed to multiple male sexual partners, has her first sexual contact before the age of 17 years, or has multiple pregnancies. A higher incidence is also noted if the woman has other sexually transmitted infections like Chlamydia or infection with HIV.

Recently, the association between infection with HPV (Human Papilloma Virus) and cervical cancer has been conclusively established. More than 95 per cent of the women with cervical cancer have evidence of HPV infection. Although 75 per cent of normal women have evidence of HPV infection, the virus persists and goes on to cause cancer in 5-10 per cent.

There are 130 identified types of HPV. Some cause infection but produce no symptoms like fever or pain, and are harmless. The patient may remain totally unaware of the infection. Other subtypes of HPV may cause warts on the skin. Around 30-40 types of the virus is transmitted through sexual contact. They may produce no symptoms when the infection first occurs. The virus can persist in the surface mucosa of the moist ano-genital areas. It can produce disfiguring warts in these areas. It can extend into the vaginal areas and cervix. Cancerous changes occur 20-30 years after the initial infection, when the woman is in her 40s and 50s.The progression depends on the type of virus and is more likely to occur if the infection occurred with the subtypes 15-20.

Once the association between cervical cancer and HPV was established, the scientific community got to work and produced a vaccine. It has been extensively studied and is now marketed in India by two companies under the trade names “Gardasil” and “Cervarix”. This is a major scientific breakthrough and cervical cancer can now be prevented in future generations of women.

The dosage schedule advised for HPV vaccine is as follows. The first dose is given between nine and 11 years of age. The second dose is administered two months later, and the third six months after that. No booster doses are advised at present. Women who have not been immunised can have the first dose at any time up to the age of 26 years. If they have already been exposed to HPV, the vaccine will only protect them against the strains to which they have not been exposed. Immunisation is not advised in pregnancy but can be given to breast-feeding mothers. Side effects are rare and include fever and rash.

For those of us who are older and have not had access to the vaccine, a screening test called “pap smear” (Papanicolaou test) can be done to detect cervical cancer in its early stages. The test is widely used and is effective. Screening should ideally be done three years after sexual activity has started and then continued every three years after that. Many Indian women do not have access to this test or are unaware of it.

Liver cancer and chronic liver disease can occur in people who develop hepatitis B infection. This too is a viral disease which is spread by contact with infected body fluids (blood transfusions, sexual intercourse). Infection can be prevented by three doses of hepatitis B vaccine. The second dose is given a month after the first and the third six months later.

Men and women should receive immunisation against Hepatitis B. At present, HPV vaccine is advised only for girls. Perhaps we have forgotten that women get the infection from their infected male partners, making a case for non-gender specific universal immunisation of all children.

Source: The Telegraph (Kolkata, India)

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Yoga

Practice Yoga & Sleep Well

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Nothing can make you more refreshed and energised for a long day than a night of sound sleep. Whether you are a corporate professional, a student or a housewife, all of us experience some form of stress in our day to day lives. There is no end to the number of worries and the anxiety that can plague one’s happiness; especially when we go to sleep. For some of us, depending on our lifestyle, this may be the only time that we get in the whole day, to relax our body and mind. This however, becomes difficult when you try too hard to relax. It only makes your body tenser.

There are numerous benefits of a night of good, sound sleep. It is when you sleep that your body repairs the damaged cells in it. It also helps increase your concentration and retention power because your mind is relaxed. When you do not get this dose of sleep, you feel tired, drained out and unable to concentrate on work at hand. Worse, if this continues, it leads to disorders like insomnia and sometimes people even start hallucinating.

While there are drugs and chemicals to superficially cure you of such disorders and make you sleep, nothing can replace the benefits of a natural remedy. Yoga is such an experimental science. Through yoga, you learn to experiment and understand your own body. It automatically tells you what is good for your body and what is not, what relaxes your body and what does not. The external environment around you will then no longer matter, because you know that you can calm your body down no matter where you are and give it the relaxation it needs. You will not need to depend on anything else to get that night’s sleep.

Shavasana is a relatively common relaxation yogasana but its benefits are innumerous. It relaxes your entire being. This asana should be practiced before sleep as it will take away all your physical and mental fatigue and make you aware of your own body. Ujjayi Pranayama when done in Shavasana helps in inducing sleep. It is a tranquilising  pranayama and a perfect cure for insomnia. It has an enormous soothing effect on the nervous system and calms down your nerves. Matsya Kridasana is another relaxation asana that can be practiced before going to sleep. It is especially helpful in calming down. Source

Source: Yoga.am Dec 13.’09

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High-Flow Oxygen Can Reduce Headaches

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Fifteen minutes of treatment with high flow oxygen significantly eased cluster headaches, according to a new study:-

Cluster headache attacks, characterised by bouts of excruciating pain usually near the eye or temple, typically last for 15 minutes to three hours if untreated and have a frequency of up to eight attacks a day on alternate days.

High flow oxygen is given at a rate of six to seven litres per minute for 10 to 20 minutes at the start of a cluster headache.

Attacks usually occur in bouts, or clusters, lasting for weeks or months, separated by remissions lasting months or years, according to the study.

The current treatment for acute attacks of cluster headache is injection with the drug sumatriptan, but frequent dosing is not recommended because of adverse effects.

Another treatment option is the inhalation of high-dose, high-flow oxygen, but its use may be limited because of the lack of a good quality controlled trial.

Anna S. Cohen, of the National Hospital for Neurology and Neurosurgery, and colleagues conducted a randomised, placebo-controlled trial of high-flow oxygen for the treatment of acute attacks of cluster headache.

The study included 109 adults (aged 18-70 years). Patients treated four cluster headache episodes alternately with high-flow oxygen (inhaled oxygen at 100 percent, or 12 litres per minute, delivered by face mask, for 15 minutes at the start of an attack) or placebo (high-flow air).

Patients were recruited and followed up between 2002 and 2007. The final analysis included 57 patients with episodic cluster headache and 19 with chronic cluster headache.

The researchers found that 78 percent of the patients who received oxygen reported being pain-free or to have adequate relief within 15 minutes of treatment, compared to 20 percent of patients who received air.

For other outcomes, such as being pain-free at 30 minutes or a reduction in pain up to 60 minutes, treatment with oxygen was superior to air. There were no serious adverse events related to the treatments, says a National Hospital release.

“To our knowledge, this is the first adequately powered trial of high-flow oxygen compared with placebo, and it confirms clinical experience and current guidelines that inhaled oxygen can be used as an acute attack therapy for episodic and chronic cluster headache,” the authors write.

Source: The study appeared in the Wednesday issue of JAMA

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Ailmemts & Remedies

Kaposi’s Sarcoma (KS)

Definition:
Kaposi’s sarcoma (KS) is a type of cancer. It causes growths under the skin, although they can grow in the lining of the mouth, nose, throat and other organs. It is different from other cancers as it starts in several areas of the body at once. Most cancers start in one place and then spread.

KS causes abrasions or tumors (growths). They most commonly appear on the skin as small, flat, colored lesions that can be brown, blue, red or deep purple. Lesions can also develop on the internal organs, such as the lymph nodes (part of the immune system), the lungs, and the digestive system, including the bowel, liver and spleen.

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It was originally described by Moritz Kaposi, a Hungarian dermatologist practicing at the University of Vienna in 1872. It became more broadly known as one of the AIDS defining illnesses in the 1980s. The viral cause for this cancer was discovered in 1994.

According to Medilexicon’s medical dictionary:
Kaposi’s sarcoma is: “A multifocal malignant neoplasm of primitive vasoformative tissue, occurring in the skin and sometimes in the lymph nodes or viscera, consisting of spindle cells and irregular small vascular spaces frequently infiltrated by hemosiderin-pigmented macrophages and extravasated red blood cells. Clinically manifested by cutaneous lesions consisting of reddish-purple to dark-blue macules, plaques, or nodules; seen most commonly in men older than 60 years of age and in AIDS patients, as an opportunistic disease associated with human herpes virus-8 infection.”

There are four types of Kaposi’s sarcoma (KS):

1.HIV– or AIDS-related KS…….>AIDS-related KS
2.Classic KS…………………………
3.Endemic or African KS………..>Endemic or African KS
4.Transplant-related KS…………>ks_1

1.HIV- or AIDS-related KS: KS can develop in people whose immune system has been severely weakened by HIV or AIDS. Gay men with HIV or AIDS are mostly affected. It is thought that the virus that causes KS is spread during unprotected anal sex.

In the past, HIV- or AIDS-related KS used to be the most common complication affecting gay men living with HIV and was a leading cause of death. This is no longer the case due to anti-HIV medications that were developed in the 1990s, known as highly active antiretroviral therapy (HAART).

The outlook for HIV- or AIDS-related KS is variable and depends on a person’s age and the state of their immune system. In an older person with a weakened immune system, the cancer often spreads aggressively to other parts of the body (metastasis).

The estimated survival rate for HIV- or AIDS-related KS is five years, although many people live a lot longer. The improvement of survival rate is directly linked to the improvement in medication for treating HIV.

2.Classic KS: It is a rare condition, usually only affecting men between 50 and 70 years of age who are of Mediterranean or eastern European descent. It is thought that people who develop classic KS were born with a pre-existing genetic vulnerability to the virus that causes it.

The outlook for classic KS is good. The cancer tends to spread slowly and does not usually spread to other parts of the body. Classic KS primarily affects older people.

3.Endemic or African KS: It is common in parts of Africa. It is one of the most widespread types of cancer in that region. As with classic KS, endemic KS is thought to develop due to a pre-existing genetic vulnerability to the virus that causes it.

Many people may now be more vulnerable to the virus because of the HIV epidemic in Africa and a weakened immune system due to HIV or AIDS.

The outlook for endemic KS is poor. In addition, access to treatment such as chemotherapy is often limited in parts of the world where endemic KS is widespread.

4.Transplant-related KS: It is an uncommon complication of organ transplants. People who have had an organ transplant usually take medication to weaken their immune system (immunosuppressant) to prevent their body rejecting the new organ. The weakening of their immune system makes them more vulnerable to the virus that causes KS.

The outlook for transplant-related KS is generally good because the condition can usually be successfully treated by reducing or stopping a person’s course of immunosuppressant. However, there is a higher risk of rejection of the donated organ.
Symptoms:
A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign.

The symptoms of KS depend on where the lesions or growths develop.

Skin

Any part of the skin, including the inside of the mouth, can be affected. KS usually appears as small, painless flat lesions or lumps. They can be of different colors (brown, red, blue and purple). They often look like bruises but do not lose their color when pressed like a bruise does.

…….images……images-1…..KS

KS growths may start in one place and then can develop in more than one area. The growths often eventually merge into each other to form a larger tumor.

Internal organs :

The lymph nodes, lungs and organs of the digestive system are most commonly affected. The symptoms of KS depend on which organs are affected.
*Lymph nodes: There may be swelling in the arms and legs. It can be very painful and uncomfortable. This is known as lymphedema and is caused by the KS cells blocking the flow of fluid through the lymph nodes. As a result, the tissue fluid backs up. This causes swelling in the body’s tissues.

LUMPS..lymph

*Lungs: symptoms may include breathlessness.

lymph-nodes-of-pulmonary-system

*Organs in the digestive system: symptoms include nausea, vomiting and bleeding.

..stomach cancer stages

Causes :-

Cancer

Cancer initiates with a change in the structure of DNA, which is found in all human cells. DNA provides our cells with a basic set of instructions such as when to grow and reproduce. A change in its structure, called a genetic mutation, can cause the cells to reproduce uncontrollably. This produces a lump of tissue known as a tumor.

Left untreated, cancer can quickly grow and spread to other parts of the body. It usually spreads through the lymphatic system. Once the cancer reaches the lymphatic system, it can spread to any other part of the body, including the bones, blood and organs.

The human herpes virus 8 (HHV-8)

Kaposi’s sarcoma (KS) is caused by a virus called the human herpes virus 8 (HHV-8). It is also known as the Kaposi’s sarcoma-associated herpes virus (KSHV).

It is thought that HHV-8 contains genetic material that interferes with the normal working of cells. This causes them to reproduce in an uncontrollable manner.

However, HHV-8 does not cause Kaposi’s sarcoma in everyone who contracts the virus. It only seems to cause Kaposi’s sarcoma in:
*people who have an inherited (genetic) vulnerability to HHV-8
*people with a weakened immune system
*HHV-8 was first identified in 1994. There is no firm evidence as to how the virus is spread.

However, there is indication that HHV-8 can be spread during unprotected anal sex. The rates of HHV-8 in specific countries reveal that the virus is almost always more widespread in the gay community. There is circumstantial evidence that HHV-8 can be passed on through saliva. This means the virus could also be spread by kissing.

Diagnosis: –
Before diagnosing Kaposi’s sarcoma (KS), the patient´s general health is reviewed and there is a careful examination of the skin.

If KS is suspected, further testing may be required. People with HIV or AIDS, will usually have their tests carried out at a specialist centre where staff are experienced in treating complications of HIV and AIDS.

*Biopsy: It is the most effective way to confirm a diagnosis of KS. This involves taking a small sample of cells from an affected area of skin. The sample is then checked at a laboratory for the presence of KS cells.

*Endoscopy: It may be carried out if KS is suspected in the digestive system. The procedure involves inserting a thin, flexible tube called an endoscope down the throat. It allows looking inside parts of the digestive system, such as the bowel, liver and spleen, for any abnormalities or signs that KS is present. A biopsy may be taken.

A mild sedative may be given. A local anesthetic will be sprayed on to the throat to prevent discomfort as the tube is passed down.

A similar method can be used to look at the lungs (bronchoscopy) if KS in the lungs is suspected.

*Computerized tomography scan (CT): In the case it is suspected that KS has spread to the lymph nodes or other parts of the body.

A CT scan works by taking a series of X-rays which build up a three-dimensional picture of the inside of the body. A radioactive dye may be given to drink before the CT scan, to allow particular areas of the body to been seen in greater detail.

Treatment :-
The treatment of KS depends on:
*the severity of the symptoms
*the size and location of the lesions
*the type of KS
*the patient´s general health
Treatment plans can vary from person to person, but the usual plan for each type of KS is outlined below.

HIV- or AIDS-related KS

Patients with HIV- or AIDS-related KS will usually be given a course of highly active antiretroviral therapy (HAART) to help strengthen their immune system. HAART may be followed by courses of radiotherapy and/or chemotherapy.

Classic KS

As classic KS spreads slowly, immediate treatment is not usually required. Doctors may recommend waiting and closely monitor the evolution. Treatment will be delayed to see if any symptoms of progressive cancer develop. This is often recommended for older people when it is unlikely that the cancer will affect their natural life span. If treatment is required, radiotherapy is normally used to treat classic KS.

Endemic KS

Usually, endemic KS is treated using a combination of radiotherapy and chemotherapy.

Transplant-related KS

Transplant-related KS is usually treated by reducing or stopping the immunosuppressants. The goal is to strengthen the immune system in order to fight off the humanherpes virus 8 (HHV-8) while ensuring that the body does not reject the transplanted organ. It may be difficult to find the best balance between these two treatment goals.

HAART

It involves using a combination of medicines that interrupt the reproductive cycle of the HIV virus. This helps to prevent the virus from spreading quickly. It also protects and strengthens the immune system.

HIV can quickly adapt and become resistant to a single medicine, therefore a combination of medicines is required. In some people, the medicines used to treat HIV will cause side effects. Usually, there is improvement after a few weeks as the body gets used to the medicines.

Common side effects of HIV medication include:
*diarrhea
*mood changes
*nausea
*skin rashes
*tiredness
*gaining fat on one part of your body while losing it on another (lipodystrophy)

Surgery:-

If the lesion is small, surgery may be used to remove KS from the skin. Cryotherapy may also be given. This freezes the lesions using liquid nitrogen.

Chemotherapy

Chemotherapy uses medicines to treat cancer. The medicines destroy rapidly growing cancer cells. The medicines can either be given intravenously or as a tablet that is taken orally. If the lesion is small, chemotherapy may be injected directly into it. This is called intralesional chemotherapy.

Chemotherapy can cause side effects including vomiting, hair loss, tiredness, and increased vulnerability to infection.

Often, liposomal chemotherapy is used to treat KS. The medicines used in chemotherapy are covered in a fat-based coating called liposome. The extra coating means reduces the side effects and the medication works more efficiently.

Radiotherapy

Radiotherapy uses high-energy rays to locate and destroy the KS cells. It can be very effective in reducing symptoms of internal KS, such as swelling, pain and bleeding.

Possible side effects of radiotherapy include: tiredness, sore skin (particularly for people with HIV or AIDS), stiff joints and muscles, nausea, temporary hair loss, loss of appetite, loss of libido (interest in sex), early menopause, and temporary impotence in men. Once the course of treatment is over, most side effects gradually disappear.

Immunotherapy

Immunotherapy is also known as biological therapy. It is often used in combination with other treatments such as HAART. Immunotherapy uses special proteins that have been genetically developed in a laboratory.

Generally, the body does not consider the cancerous cells as foreign objects. As a result, the immune system does not attack them. In immunotherapy, special antibodies are created in a laboratory. They change the composition of cancerous cells so that the immune system regards them as foreign objects. The immune system then starts to attack the cells in the same way that it would normally attack an infection.

Interferon is one of the most common types of medicines used in immunotherapy. It is usually given by daily injections into the skin over a number of weeks.

Side effects of immunotherapy include:
*back ache
*aching joints and muscles
*chills
*headaches
*high temperature (fever) of 38°C (100.4°F) or above
*loss of appetite
*nausea
*tiredness

Prevention:-
It is not clear how HHV-8 spreads. It might be spread through sexual activity and deep kissing. As with other opportunistic infections, a healthy immune system can control HHV-8 infection. The best way to prevent KS is by using strong anti-HIV medications to keep your immune system strong.

The following are being studed for KS :-

Anti-cytokine approaches: There is a lot of research on cytokines, proteins that the immune system uses to sti mulate cells to grow. Researchers think that substances that can inhibit these (and similar) growth factors can also slow down the growth of KS.

Monoclonal antibodies: These drugs are produced through genetic engineering. Their names end in “-mab,” such as bevacizumab.

Other drugs: Scientists are studying several drugs that slow down the development of new blood vessels (angiogenesis.)

The bottom line is :-
KS is a disease that affects up to 20% of people with AIDS who are not taking ART. It is partly caused by a herpes virus called HHV-8.

The best treatment for KS is strong antiretroviral therapy (ART.) KS in the skin can be treated in several ways and is not a serious problem. KS in internal organs can be life threatening. Internal KS is usually treated with anti-cancer drugs.

If you notice new dark spots on your skin, have your health care provider look at them to see if you might have KS.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:

http://www.aids.org/factSheets/511-Kaposis-Sarcoma-KS.html
http://www.medicalnewstoday.com/articles/173259.php
http://www.dentistry.leeds.ac.uk/oralpath/viruses/viral%20infections/HHV8.htm

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