new medical articles

What causes acne

2011-08-21T15:26:00.000-07:00

What causes acne

ACNE

Almost everyone gets acne. Most people have some acne between the ages of 10 to 20.

Almost all teens worry about how their skin looks, but acne is a very common problem that can be well controlled with proper treatment.

Causes of Acne

Acne is caused by an obstruction, or plugging, of the sebaceous follicle (oil gland).

Plugging of the skin opening of the gland causes a blackhead. A plug that occurs below the surface of the skin causes a whitehead. These can become inflamed or infected, which results in small bumps or cysts.

Acne is not caused by foods, or by poor hygiene, as is commonly believed. Excessive face washing or scrubbing with abrasive pads can actually make acne worse!

What causes acne

Develop a Written Asthma Management Plan

2011-08-05T16:29:00.000-07:00

Develop a Written Asthma Management Plan

As part of the overall management of patients with asthma, the health-care provider, in consultation with the patient or the parent or guardian of a child with asthma, should develop a written plan as part of educating patients regarding self management, especially for patients with moderate or severe persistent asthma and those with a history of severe exacerbation.

The National Heart, Lung, and Blood Institute provides more specific advice on asthma management plans, emphasizing the provider/patient partnership (available at http://www.

nhlbi.nih.gov/health/public/lung/asthma/asthma.htm#plan).

Writing the management plan helps clarify expectations for treatment (Box 4) and provides patients with an easy reference for remembering how to manage their asthma. The action plan should include written instructions on recognizing symptoms and signs of worsening asthma; taking appropriate medicines (type, dose, and frequency); recognizing when to seek medical care; and monitoring response to medications.

Symptom-based plans may be equally effective as plans based

on peak flow monitoring, although some patient preferences and circumstances (e.g., inability to recognize or report signs and symptoms of worsening asthma) may warrant a choice of peak flow monitoring. The management plan should be reviewed and adjusted, as needed, at every visit. For children, a copy of the plan should be given to each care giver and the child’s school.

Develop a Written Asthma Management Plan

Classify Severity of Asthma

2011-08-05T16:18:00.000-07:00

Classify Severity of Asthma

Because asthma is characterized by varying signs and symptoms, for appropriate treatment and monitoring, the severity of such signs and symptoms must be classified at the initial and all subsequent visits. Initially and before treatment has been optimized, clinical signs, symptoms, and peak flow monitoring or spirometry are used to classify severity (Table 2)

(Box 2). After the patient’s asthma is stable, severity is subsequently classified according to the level of medication required to maintain treatment goals.

Health-care providers should have the knowledge, equipment, staff or access to needed resources to aid in classification and proper management of all patients with asthma.

Classify Severity of Asthma

how get rid of acne - ways to get rid of acne

2011-08-02T07:12:00.000-07:00

how get rid of acne - ways to get rid of acne

way how to get rid of acne fast&pimples overnight

10 methods to obtain Rid of acne breakouts at Home

If you have acne, but you are fortunate in that it is mild or occasional, you possess the option of successfully stopping and treating acne breakouts at home. understanding how to obtain rid of acne utilizing home-based techniques is safe, effective, and inexpensive. numerous of those methods do not price you something at all, as they are merely methods to modify your behaviors and wellbeing habits. for individuals who wish to obtain a far better knowing of how to obtain rid of acne, there are numerous methods by which to make an try to do it.

First, understanding how to obtain rid of acne breakouts suggests understanding easy methods to carry great treatment of your skin, regardless of whether or not you have acne breakouts or not. whilst acne breakouts is frustrating, resist the temptation to make an try to do something that may irritate your skin. rather than washing your confront with ordinary cleaning soap along with a hard washcloth, use your fingertips along with a mild cleanser formulated for acne breakouts prone skin.

how get rid of acne - ways to get rid of acne

Furthermore, knowing how to obtain rid of acne breakouts most successfully will depend upon whether your skin tone is oily, or whether or not it is dried out or sensitive. If your skin tone is oily, you will most probable wish to use a water-based, alcohol-free, non-comedogenic cleanser. If your skin is dried out or sensitive, you will wish to use a medicated moisturizer following washing your face. this can soothe your skin tone if it gets red-colored or irritated.

While it may possibly not be obvious, limiting your sunshine coverage is an additional method to avoid acne breakouts outbreaks. additionally to becoming an excellent method to avoid skin tone cancer, staying out with the sunshine is an excellent method to avoid acne breakouts as well. numerous men and women maintain the misconception that sunshine exposure can avoid and deal with acne, but this really is not the case.

Knowing how to obtain rid of acne breakouts by adhering to some sensible skin tone treatment program will not do you any great for individuals who do not maintain your arms away of your face. Do not make an effort to get rid of pimples by picking at them or popping them, and do not make an effort to get rid of blackheads or whiteheads by squeezing them. It is not suggested that you just use any instruments to remove blackheads or whiteheads, either. Finally, maintain aside from resting your chin or the aspect of your confront in your hands.

ways to get rid of acne - how to get get rid of acne

In addition, you will not wish to undo the results of the sensible skin tone treatment program by sleeping on sheets and pillowcases which have not been washed regularly. Oils out of your face and system can create up on towels, clothing, and bed sheets, and will possess the impact of clogging your pores.

You may possibly wish to learn how to obtain rid of acne breakouts with over-the-counter medications.

Fortunately, over-the-counter drugs are simple to find, as they are usually available at your regional medicine shop or supermarket plus they are fairly inexpensive.

of one of the most typical elements in this type of drugs is benzoyl peroxide. To begin, you may wish to think about utilizing an over-the-counter item using a minimal concentration of benzoyl peroxide, that include 2.5% or 5%. If this does not function in inclusion to you would like, you may possibly wish to think about a item using a greater concentration, that include 10%.

If you are curious about how to obtain rid of acne breakouts utilizing ingredients other than over-the-counter medications, you may possibly come across what you choose within your refrigerator, cupboard, or

medicine cabinet. Some folk treatments for treating acne breakouts consist of placing little quantities of toothpaste in your pimples, rubbing your confront with lemon or lime juice, or creating a

mask from cooked oatmeal.

Fortunately, understanding how to obtain rid of acne breakouts is not difficult. It merely needs a little of adjustment for your everyday routine, in inclusion to becoming conscious of and eliminating any poor routines

you have that contribute to acne breakouts outbreaks.

How to get rid of acne permanently - ways to get rid of acne scars

Donating bone marrow stem cells

2011-07-30T11:33:00.000-07:00

Donating bone marrow stem cells

There are two ways of collecting stem cells from donors for a transplant:

• peripheral blood stem cell (PBSC) harvest: where donor stem cells are collected from the circulating blood using a process called leukapheresis (see below)

• bone marrow harvest: where bone marrow is collected from bone while the donor is under general anaesthetic.

Most transplants from related donors use PBSC, while transplants from unrelated donors use either PBSC or bone marrow harvest depending on a number of factors, including the patient’s disease and donor preference.

Collecting peripheral blood stem cells

Many donors prefer this method because they don’t need an anaesthetic and won’t have pain after it is done. They need to be injected with a drug called granulocyte colony stimulating factor (G-CSF) for a few days before the procedure, which may have some temporary side effects.

Pre-treatment with G-CSF

The transplant team will prescribe G-CSF. The donor takes it home, and has it injected under the skin once or twice a day for about four days before stem cells are collected on the fifth, and occasionally the sixth day. Some donors choose to inject themselves, but others have someone else – a relative, a nurse or their local doctor – inject the drug.

G-CSF is a synthetic copy of a naturally occurring bone marrow hormone. The hormone is not usually detectable in the body, but the immune system makes it in response to infection. Its natural action is to stimulate the growth of bone marrow stem cells, which can become white cells to fight infection. It also causes the release of stem cells from the marrow into the blood. When enough G-CSF is given, large numbers of stem cells are released into the blood, which can be collected for the transplant.

Side effects

Most donors experience some side effects from G-CSF. These are mostly flu-like symptoms, such as aches and pains, fatigue and generally feeling a “bit off.” The symptoms usually are mild and controlled by paracetamol, but occasionally donors can feel more unwell and need stronger painkillers.

Severe side effects are rare but there have been rare reports of a ruptured spleen in donors, as G-CSF enlarges the spleen (a large organ under the left side of the rib cage). However, many thousands of normal donors have been treated with G-CSF without any serious short- or long-term side effects.

Donating bone marrow stem cells

Harvesting the cells – leukapheresis

On the day of collection, the donor is attached to a machine that collects or ‘harvests’ stem cells from the blood. The collection process, which is called leukapheresis, is usually done at the transplant centre if the donor is related, but always at another collection centre if the donor is unrelated, on an outpatient basis over 3-6 hours.

The donor is awake throughout the procedure. At the beginning, a needle is put into a large vein in the crook of each elbow, and connected by tubes to the apheresis machine. This is basically a big centrifuge, which spins the blood and separates it into white blood cells, red cells and plasma.

The blood is withdrawn from one arm of the donor, passed through the machine, and the portion of the white blood cells that includes the stem cells are collected – a bit like skimming cream off milk. The rest of the blood is then returned to the donor through the other arm. About 12L of blood is processed through the machine.

The donor usually notices no side effects, but occasionally changes in the calcium level in the blood, caused by the anticoagulant solution (citrate) used to stop the blood clotting in the machine, may cause a tingling feeling. Calcium treatment will reverse this. More rarely, donors can feel faint during the procedure because of low blood pressure. The collection will be stopped if this happens.

Some donors don’t have accessible veins in their arms and may need to have the needle put into a large vein in the groin. The insertion of this needle is less pleasant and has a greater risk of bruising, so is only used if there is no alternative.

Most donors can go home within a few hours of the collection. The side effects of G-CSF usually go away within a few days of the drug being stopped.

Most donor leukapheresis procedures collect enough stem cells for a successful transplant. The cells are collected in a bag, usually in a volume of 150-200mL, and the stem cells are counted in the laboratory. About one in three donors will need to have a second collection the next day, after another dose or two of G-CSF.

Donating bone marrow stem cells

Bone marrow harvest

A bone marrow harvest is done in a hospital operating room, usually under general anaesthesia. It is a low-risk procedure, but the donor will feel sore afterwards. While the donor is under anaesthesia, a needle is put inside the rear hipbone (the iliac crest), which contains a lot of bone marrow.

The bone marrow is a thick, red liquid and is extracted with needles and syringes. Several skin punctures on each hip and multiple bone punctures are usually needed to extract the required amount of bone marrow. No surgical cuts or stitches are involved – only skin punctures where the needle was inserted.

The amount of bone marrow harvested depends on the size of the patient. Usually 1L of marrow and blood is harvested. Although this may sound like a lot, it is only about 2% of a person’s bone marrow and the body replaces it in four weeks.

When the anaesthesia wears off, the donor will feel some discomfort at the harvest site, as if they have had a hard fall. It can usually be relieved with paracetamol. There may be some colourful bruising at the back of the hips in the week after the harvest.

Donors can usually go home after an overnight stay in hospital and can resume their normal activities in a few days. Regular blood donors will probably need to wait a while before giving blood, at least until they have their haemoglobin level checked after the harvest.

Sometimes the bone marrow may be treated to remove T cells (T cell depletion) to reduce the risk of graft-versus-host disease.

Donating bone marrow stem cells

Key points

• Most transplants from related donors use stem cells collected from the circulating blood using a process called leukapheresis.

• Most transplants from unrelated donors use bone marrow cells, which are collected from bone while the donor is under general anaesthetic.

• Before the harvest donors will be injected with a drug called G-CSF, which stimulates bone marrow stem cells to grow and multiply.

• G-CSF often causes mild side effects, such as flu-like symptoms. The side effects of G-CSF usually go away within a few days of the drug being stopped. Severe side effects are rare.

• Leukapheresis is a relatively painless procedure. Almost all donors can go home within a few hours of it being done.

• Bone marrow harvest is done in a hospital operating room, usually under general anaesthesia. It is a low-risk procedure, but the donor will feel sore afterwards.

Donating bone marrow stem cells

The basics of bone marrow transplants

2011-07-30T11:03:00.000-07:00

The basics of bone marrow transplants

A bone marrow transplant (BMT) is a fairly new treatment for diseases that until recently could not be cured. Since it was first used with good results in 1968, this treatment has been used for patients with immune system diseases and blood diseases such as leukaemia, lymphoma and multiple myeloma.

In Australia each year, around 1,000 children and adults have a BMT. More than 300 people have a BMT each year in New South Wales.

What is bone marrow?

Bone marrow is the soft, spongy part in the centre of your bones where blood cells are produced. The bone marrow makes stem cells, which are early-stage cells that produce other cells. Each tissue in the body contains stem cells that renew and replace that tissue when needed due to damage or wear and tear. Stem cells generate all blood cells in the human body, including red cells, white cells and platelets.

Types of BMT

Allogeneic transplant

This type of transplant uses stem cells donated by another person (a donor) and is the focus of this book. It is called a syngeneic transplant if the donor is an identical twin.

The two types of allogeneic transplants are:

• Myeloablative or full allo: the aim is to destroy the patient’s marrow and kill the cancer cells.

• Non-myeloablative (“mini” allo): the aim is to suppress the patient’s marrow and allow the donor cells to grow and attack the cancer cells. This is the graft-versus-tumour effect.

There are two ways to collect or harvest the donor’s stem cells:

�� A peripheral blood stem cell harvest: this is used for most adult transplants and collects stem cells from the donor’s circulating blood.

�� A bone marrow harvest: this collects stem cells from the donor’s bone marrow, usually from the hip bones.

The donor’s stem cells must match the genetic make-up of your own cells as closely as possible. Blood tests, called tissue typing, are done to work out if the donor’s cells match.

The most suitable donor is usually a brother or sister whose bone marrow is a close match. There is a 25-35% chance that a patient will have a family member whose stem cells match. But if no matching relative can be found, an unrelated donor may be found in the Australasian/International Bone Marrow Donor Registry. A mismatched or autologous BMT may also be considered.
The basics of bone marrow transplants

The basics of bone marrow transplants

Autologous transplant

An autologous transplant uses your own stem cells. This type of transplant can be done if the disease is in remission or if the illness does not involve the bone marrow (eg, Hodgkin’s disease, non-Hodgkin’s lymphoma).

For an autologous BMT, stem cells are taken from the patient’s blood before the transplant, stored and then given back after high-dose chemotherapy or radiotherapy.

This book does not describe autologous BMT in detail. For more information about autologous transplants, see the BMT Network NSW publication, Autologous Bone Marrow Transplant: A Patient’s Guide.

Preparing for a BMT

The BMT team

An expert team of doctors, nurses and other support staff will care for you. The team can quickly identify and treat any problems or side effects. A good BMT program will also give patients and their families emotional and psychological support before, during and after the transplant.

For a BMT to work well, you must be healthy enough to cope with the procedure. When deciding if you should have a BMT, your doctor will consider your age, general physical condition and the type and stage of your disease.

The work up

Before a BMT, a number of tests are carried out to ensure you are healthy enough for the treatment. You will also have tests of heart, lung and kidney function before and after the BMT so your doctor can check whether these organs are still working as well after the transplant. The pre-BMT tests (also called the work up) are usually done before you are in hospital, but may be done after you are admitted.

You will need to have a dental check-up and all necessary work done before the BMT. If you or your dentist is unsure, please check with your BMT team before any work is started.

The basics of bone marrow transplants

Making informed decisions

Long-term implications

It is important to think about some of the possible long-term effects, such as infertility, and discuss them with your transplant doctor before starting a BMT. See page ?? for more information.

Gathering information

When you are considering a BMT, you will be given a lot of information about the process. Some people do in-depth research and think through every detail, while others just want enough information for the next day or stage. Some people only want to know enough to be informed, and choose not to read or listen to anything negative so they can stay motivated and focused.

A BMT is a serious and complicated procedure so it is vital you are informed and that you clearly understand what the BMT means for you. This requires good communication with your BMT doctor and the rest of the team.

At your first visits to the doctor, you will receive a lot of information about the proposed BMT, its side effects and possible complications. To help you absorb this information, it can help to take notes during the consultation or tape-record the discussion. Many people like to have a relative or friend go with them, to take part in the discussion, take notes or just listen.

If you don’t understand what you’ve been told, don’t be afraid to ask questions or to ask for the information to be repeated as often as you need. Questions are a good sign that you are working in partnership with your medical team. It is very important to be involved in your care and to express your concerns before, during and after a BMT. Your role is crucial, particularly in telling the team about how you are feeling and any symptoms you are having.

In the days before the BMT, you will need to sign a number of consent forms for the treatment or clinical trial.

Finally, remember that not everyone will want to go ahead with a BMT. After thinking about all the possible risks and benefits, some people decide it is not for them. In this case, you need to tell your doctors, and talk to them about other treatments. Your doctor will still give you the best other treatment options available.

How is a BMT done?

Collecting bone marrow stem cells

The stem cells are collected from the donor’s blood or bone marrow. If the donor is related to you, the stem cells will usually be collected from the blood. Cells from unrelated donors are harvested from the either the peripheral blood or the bone marrow, under general anaesthetic, depending on what your doctor believes is best for you and/or donor preference.

The central line

If you don’t already have one, a central venous catheter will be inserted under the skin of your chest into a vein. It is also called a central line or Hickman catheter depending on the type of line.

A central line is a long, hollow tube that usually has two or three passages (called lumens) to allow for a number of uses. It is made of silicone or hard plastic. Your central line will stay in place during the BMT and may be used to collect blood samples and to give you all the medications and fluids you need.

Your central line will usually be inserted into a large vein that runs beneath your collar bone with the tip sitting near to the entry into your heart. The rest of the central line remains outside your body for easy access. A clamp keeps the tube closed when it is not being used. The central line may be put in when you are in the operating theatre, in the x-ray department or on the ward.

Add diagram showing central line in place

Conditioning treatment

You will have several days of chemotherapy and/or radiotherapy, which destroy bone marrow and cancerous cells and make room for the healthy stem cells. This is called the conditioning or preparative regimen.

You may also hear the phrase ‘countdown to transplant’, because this treatment is expressed in your medical notes in terms of the number of days until the transplant. For example, day -5 (minus 5) means that you are five days away from the transplant day, which is called day 0. The type and number of days of chemotherapy and/or radiotherapy vary according to the disease being treated and the protocol or preferred treatment plan of the hospital where the BMT is being done.

For a myeloablative BMT, the dose of chemotherapy and/or radiotherapy given to patients during conditioning is much stronger than doses given to patients with the same disease who are not having a BMT. You may become weak, irritable and nauseous. Anti-nausea medications will help during this period. Don’t be alarmed if your blood results go down at this time, as this is what the chemotherapy or radiotherapy is supposed to do – that is, empty your bone marrow before your transplant.

The transplant

The transplant will take place a day or two after the chemotherapy and/or radiotherapy. The transplant is not a surgical procedure. It takes place in your hospital room, not an operating room.

You may be given medication before the transplant to prevent a reaction to the transplanted cells. This is more likely to occur when the match between the donor marrow and the patient is not exact or the blood groups are different.

The healthy bone marrow stem cells are infused through your central line, in much the same way that any blood product is given. Many patients describe the actual transplant as an anticlimax, as it all over so quickly – usually between 30 minutes and an hour.

You will be checked frequently for signs of fever, chills, hives and chest pains while the bone marrow is being infused. When the transplant is completed, the days and weeks of waiting begin.

The bone marrow begins to grow (engraftment)

Engraftment means new cell growth. It takes place after your bone marrow transplant when there is a sustained rise in new blood cell production. As a general guide, engraftment is said to have happened once the white blood cell count rises above 0.5 x 10 9 /L and the platelet count to above 20 x 103 /L without transfusion.

The 2-4 weeks after the transplant are the most critical. The high-dose chemotherapy and/or radiotherapy given to you during conditioning destroyed your bone marrow, crippling your immune or defence system, leaving your body with no natural defences against infection.

As you wait for the transplanted bone marrow to migrate to the cavities of the large bones, engraft and begin producing normal blood cells, you will be very susceptible to infection and excessive bleeding. You will be given multiple antibiotics and blood transfusions to help prevent and fight infection. You will also have transfusions of platelets to prevent bleeding and additional medications to prevent and control graft-versus-host disease (GVHD), which happens when the white blood cells from the donor marrow attack the cells of the patient’s body. (For detailed information of GVHD, see page?)

While many infections start from within the body, your BMT team will take a number of precautions to minimise your exposure to viruses and bacteria in your environment. These will vary from centre to centre. Visitors and hospital personnel will wash their hands with antiseptic soap and may wear protective gowns, gloves and/or masks while in your room.

Any visitors or relatives will be asked not to visit if they are unwell eg, if they have a sore throat, runny nose, a cold /flu or upset stomach. Fresh fruits, vegetables, plants and cut flowers, which often carry fungi and bacteria that pose a risk of infection, may not be allowed in your room.

When leaving the room, you may wear a mask, gown and gloves as a barrier against bacteria and virus, and also to remind others that you are susceptible to infection.

Blood samples will be taken daily to monitor engraftment and organ function. When the transplanted bone marrow engrafts and begins producing normal blood cells, you will gradually be taken off the antibiotics, and blood and platelet transfusions will generally no longer be required.

Once the bone marrow is producing a sufficient number of healthy red blood cells, white blood cells and platelets, you will be discharged from the hospital, provided no other complications have developed. BMT patients typically spend 4-8 weeks in hospital.

How you may feel physically during the transplant

A BMT is a physically, emotionally and psychologically taxing procedure for you and your family. Seek as much help as you need to cope – toughing it out on your own is not usually the best way to cope with the transplant experience.

At times, you may feel very sick and weak during the transplant. Walking, sitting up in bed for long periods of time, reading books, talking on the phone, visiting with friends or even watching TV may require more energy than you have.

Complications can develop after a bone marrow transplant such as infection, bleeding, GVHD or liver disease, which can create additional discomfort (see page?). Pain is usually controlled with medication, which may include the use of intravenous morphine or other narcotic drugs. In addition, mouth and throat sores can develop that make eating and swallowing uncomfortable and difficult. Temporary mental confusion sometimes occurs and can be frightening for the patient who may not realise it is only temporary. The medical and nursing staff will help you and your carers deal with these problems.

Dealing with emotional and psychological concerns

Being diagnosed with a life-threatening illness can be a traumatic experience. It is common to feel overwhelmed by the amount of information you receive and the need for urgent treatment. Each person feels differently and responds differently. People will find some aspects of the treatment process more stressful than others.

It is important you know that BMT is a team effort and that you are the central and most important person in this team. Understanding your treatment plan and clear communication are essential elements in maintaining your emotional and psychological well-being. People often say it is the unexpected symptom, complication and treatment that upsets or frightens them the most. A BMT already involves a degree of uncertainty. Poor communication can add unnecessary stress to this situation. Don’t hesitate to clarify any aspect of the process.

People will vary in the amount of information they want about the transplant. Some will want to speak to others who have been through a bone marrow transplant. Some will want to be well researched on all aspects of the transplant process. Others will only need to have minimal facts about their proposed treatment. Whichever category you fall into, it will be important for you to have all the information you need about your treatment before the transplant.

You may find that you feel isolated with little control over your day-to-day activity because of the precautions taken to guard against infection while your immune system is not working properly. You will be in a single room and the number of visitors you can have at one time is restricted.

Make your room your own space with your personal effects. Try to stay as independent as you can and talk to your nurses about how you can participate in your care. Lack of privacy is another common issue for people having a BMT – talk to your nurse about allocating times when you will be as undisturbed as possible.

Waiting for the transplanted stem cells to engraft, for blood counts to return to safe levels or for side effects to disappear can be very frustrating and lead to increased stress. Try to remain positive and be realistic in your goals. BMT is an individual process that cannot be predicted all of the time.

You may find that personal relationships with family and friends come under pressure during BMT. This is not uncommon. Relationships within families will change, and it is important to recognise what these changes will be. Talk to the BMT social worker if you need help.

Each family member or close friend will cope with your BMT in their own way and this may, at times, lead to misunderstandings or conflict. Just because a family member or friend is not visiting does not mean they don’t care – they may just be taking some time out as their way of coping.

Psychological discomfort, like physical discomfort, is a normal symptom of the BMT experience. Social workers and psychologists/psychiatrists are also part of your BMT team, so call on them when you need help. There is no right or wrong way to manage all the challenges and stresses that BMT throws at you. There is only the method that works for you.

Going home

Recovering from a BMT continues for some months after you leave hospital. For the first few weeks you may be too weak to do much more than sleep, sit up and walk a bit around the house. You will need to visit the hospital or clinic regularly so your BMT team can monitor your progress and administer any medications and/or blood products needed.

It will take at least six months before you will be ready to return to work or your normal daily activities. You’ll need lots of patience and determination to cope during this period. Some people find that reaching their ‘new normal’ takes longer than others.

Your new marrow is still in its infancy and is not yet able to protect you from some bacteria and viruses encountered in everyday life. The medications you will need to control GVHD only add to this. So it is important to protect yourself from potential sources of infection. Enjoy the outdoors, dine alfresco, keep sick friends and relatives away, see movies and do the shopping at quiet times. You can get back to a normal life; you just have to take a little extra care.

Life after BMT

Life after transplant can be both exhilarating and stressful. On the one hand, it is exciting to be alive after being so close to death, and many people find their quality of life has improved after transplant.

But there is always the worry that a relapse will occur. Also, innocent statements or events can sometimes conjure up unpleasant memories of the transplant experience long after recovery. It can take a long time to come to grips with these difficulties. Tell your BMT team about any difficulties you experience.

Shaded box

Frequently asked questions

What is a bone marrow transplant (BMT)?

A BMT is a standard treatment option for some people who have life-threatening blood or immune system diseases. It is the process of replacing unhealthy bone marrow cells (stem cells) with healthy bone marrow cells. The healthy bone marrow cells are re-infused intravenously after very strong chemotherapy and/or radiotherapy, which kills your unhealthy bone marrow cells. The re-infusion of healthy bone marrow cells essentially rescues you from your chemotherapy and/or radiation by enabling your bone marrow to start producing new red and white blood cells and platelets.

What is the difference between a BMT and a peripheral blood stem cell transplant?

Both transplants aim to do the same thing – replace bone marrow stem cells in a person who has had their bone marrow destroyed by large doses of chemotherapy and or radiotherapy.

Bone marrow is the spongy substance found in the hollow of bones of the hips, legs and arms. It contains stem cells (also called CD34s), which produce all circulating blood cells: red blood cells, white blood cells and platelets.

When the stem cells are collected from circulating blood, the transplant is called a peripheral blood stem cell transplant. A transplant with stem cells collected from the marrow, usually from the hip bone area, is called a bone marrow transplant.

Are there different types of BMT?

Yes, there are two different types of BMT. This book focuses on allogeneic bone marrow transplant, which involves finding a donor whose tissue type closely matches yours. The donor can be related or unrelated. Related donors are usually a brother or sister. If no matching relative is found, your transplant doctor will ask the Australian Bone Marrow Donor registry to start a search (see Finding a donor, page ?). An autologous BMT uses your own blood stem cells, but this type of transplant is not discussed in this book.

If I have a common blood group, will I have a common tissue type?

No, not necessarily. There is no link between your blood type and your tissue type. Tissue type is determined by different sets of genetic proteins called human leukocyte-associated antigens (HLA), which are found on the surface of most cells. A person’s tissue type is identified by a blood test called tissue typing. Therefore, your donor can still be a bone marrow match for you but have a different blood group.

Will I need an operation to have a BMT?

No, the stem cells will simply be re-infused through your central line in the same way you receive transfusions such as platelets or red blood cells (packed cells).

What is engraftment and when will it happen?

Engraftment means new cell growth, and takes place after your bone marrow transplant when there is a sustained rise in new blood cell production. This generally occurs within 2-4 weeks after your transplant. The first obvious sign may be a rise in your white blood cell count above 0.5. This tells us that your new bone marrow cells are starting to produce new blood cells. Until this time, you are at high risk of infection and need to avoid possible sources of infection.

What are the possible side effects of a BMT?

The two main risks from the transplant process are an increase risk of infection and bleeding due to high doses of chemotherapy and/or radiation. Short-term effects may include nausea, vomiting, fatigue, mouth ulcers, weight loss, hair loss and skin reactions. Long-term effects include infertility, cataracts and possible complications in the liver, kidneys, lungs, joints and/or heart.

Allogeneic transplants carry the risk of GVHD. This occurs when the white blood cells from the donor marrow (the graft) identify the cells of the patient’s body (the host) as foreign and attack it. This can be mild in the form of skin rashes on the hands and feet, to very severe affecting liver, gut and/or lung function. (For detailed information about possible BMT complications, see page??)

What are my chances of having a successful BMT?

This is very difficult to answer as so many individual issues come into play. The outcome of your transplant is highly influenced by your original disease, the stage of your disease and your general condition at the time of the transplant. There are many other variables, including how you have responded to treatment and the closeness of the match of your donor. The best person to discuss your possible transplant outcome is your transplant doctor. He/she can discuss your individual factors that may influence your chances of success.

The basics of bone marrow transplants

diabetes overview

2011-07-22T12:14:00.000-07:00

diabetes overview

What is Diabetes?

Diabetes is a disease in which the body does not produce any or enough insulin, or is not able to use insulin effectively. Insulin is a hormone which combines with glucose (sugar) in the blood. It helps glucose or sugar to enter the body’s cells to be used for energy.

The different types of diabetes

Type 1 diabetes

Type 1 accounts for only 5-10% of people with diabetes. People with type 1 diabetes do not produce insulin. This type of diabetes usually begins in childhood or before age 30. A person with type 1 will need to take insulin daily in addition to eating well and being active.

Type 2 diabetes

Type 2 diabetes is the most common type and accounts for 90-95% of people with diabetes. In type 2 diabetes, the body does not make enough insulin or is not able to use it. This type of diabetes is most often found in people over age 45, but is becoming more common in younger people, including children.

In the early stages, people with type 2 can often maintain a normal blood glucose by healthful eating and regular activity. However, as the disease progresses, oral pills or insulin are usually needed to achieve target blood glucose goals.

Gestational diabetes

Gestational diabetes is a special type of diabetes that occurs in a small number of pregnant women. After pregnancy, blood glucose levels usually return to normal. However, a woman who has had gestational diabetes, has a greater chance of developing type 2 diabetes later in life, especially if she is overweight and sedentary.

Pre-diabetes (impaired fasting glucose)

Pre-diabetes is a condition where the fasting blood glucose is higher than normal, but not yet at the level to diagnose diabetes. A person with pre-diabetes can lower the risk of developing diabetes by losing weight, being active, and eating a healthy diet.

diabetes overview

Diabetes Care

Taking care of your diabetes will help you feel better and may help reduce or delay the problems associated with diabetes such as heart attack, stroke, blindness, kidney disease or losing a foot or leg. The management of diabetes focuses on controlling the diabetes ABCs:

• A1C (Pronounced A-one-C): A laboratory blood test that measures your average blood glucose level over

the past three months.

• Blood Pressure: High blood pressure makes your heart work too hard.

• Cholesterol: LDL or bad cholesterol builds up and clogs your arteries and HDL or good cholesterol helps remove cholesterol from your blood vessels.

You and your health care team will need to monitor your ABCs. The chart below lists recommended target numbers.

Diabetes ABCs

diabetes overview

Health care team

Working with your health care team, you can manage your diabetes to achieve your target goals. One of your team members is the pharmacist.

Our pharmacist can answer questions about diabetes products, including blood glucose meters, medications and foot care products. Another member of your health care team is a Registered Dietitian (RD), especially one with Diabetes Education Certification (CDE). Working with a dietitian, you can learn how to balance your food, activity and medication. Together you and your dietitian can develop an individualized meal plan based on your food likes and dislikes as well as your lifestyle that will help you achieve your target ABCs.

But remember, you are the leader of your diabetes care team.

Controlling diabetes

Controlling diabetes is a balance of healthful eating, regular activity and medication. Checking your blood sugar lets you know if you need to adjust any of the components.

• Blood glucose monitoring

To help control your diabetes you may need to check your own blood glucose at home with a meter. It tells you what your blood glucose is at the time you do the test. Checking at different times of the day – before

and after meals, before and after exercise, before bed - allows you to look for patterns. Most meters today read the blood sample results as plasma rather than whole blood glucose values. Make sure you know whether your meter provides plasma or whole blood results.

Goals for blood glucose control

diabetes overview

Diabetes meal planning
Eating right with diabetes is no longer about following a “diet”. It is about making healthy food choices, and the foods that are good for you are also good for everyone in your family.
• The basic principles of diabetic meal planning are:
1. Do not skip meals. Skipping meals can cause your blood glucose to drop if taking certain diabetes medications. And people who skip meals tend to overeat at the next meal which can raise your blood glucose.
2. Control carbohydrate intake. Carbohydrates in foods are what most affect blood glucose levels. That does not mean you should not eat carbohydrates, but rather, control how much is eaten at meals and snacks. Carbohydrates come from many foods:
• Starches, such as bread, rice, cereals, pasta, starchy vegetables (such as potatoes, corn and green peas), dried beans and peas.
• Natural sugars found in milk (lactose) and fruit (fructose).
• Added sugars such as table sugar, corn syrup, molasses, dextrose, honey, high fructose corn syrup, and fruit juice concentrate.
3. Eat a variety of foods. Consume the recommended number of servings from each of the food groups to ensure you get all the nutrients you need on a daily basis. See the Diabetes Food Pyramid on page 10.
4. Eat less saturated fat, trans fat and cholesterol. Saturated fat, trans fat and to a lesser extent, cholesterol in your diet may increase your blood cholesterol level, which in turn may increase your risk of heart disease.
Because there is a strong connection between diabetes and heart disease, it is important to maintain a normal blood cholesterol level.
• Saturated fats are usually solid at room temperature and found mainly in animal foods such as meat fat, poultry skin, lard, butter, cheese, and whole and 2% milk.
• Trans fats are produced when oils (unsaturated fats) are made harder through a process called hydrogenation. Trans fats are found mainly in commercial baked goods, fried foods, and stick margarines.
• Dietary cholesterol is found only in animal foods, and the most concentrated sources are egg yolks, organ meats, shrimp and squid.

5. Eat more fiber. People with diabetes need to eat more fiber just like everyone else. Many people routinely eat only about half the recommended amount of fiber per day. A diet rich in fiber fills you up and helps lower blood cholesterol levels. Fiber comes from many foods:
• Grains and grain products especially whole grain breads and cereals.
• Fruits and vegetables. Fiber is found in all fruits and vegetables including fresh, frozen, canned, and dried. Cooking does not lower the fiber content of the food, but juice has little or no fiber.
• Cooked dried peas and beans such as lima, kidney, black, pinto, and navy beans, and split peas and chick peas are very high in fiber – about 5 grams or more per 1/2 cup serving.
Slowly increase the amount of fiber you eat. Aim for 21-38 gramsper day or 14 grams per 1000 calories consumed. Be sure to consume water and other beverages throughout the day as you increase your fiber
intake. Thirst is the best indicator to drink more fluid.
6. Maintain a healthy body weight. If overweight, aim for a moderate weight loss of 5 to 10% of your current weight. This amount of weight loss can help improve your blood glucose, blood cholesterol and blood pressure.
The government classifies weight by Body Mass Index (BMI). A healthy BMI is 18.5 – 24.9. To lose weight, eat less and move more.

BMI Classification
<18.5 Underweight
18.5 - 24.9 Normal
25.0 - 29.9 Overweight
30.0 - 39.9 Obesity
>40.0 Extreme obesity
This formula can be used to calculate your BMI

How do I set up a meal plan?
A meal plan is a guide that tells you how much and what kinds of food to eat at meals and snacks. A good meal plan should fit in with your eating habits and schedule. You and your dietitian should work together to design a meal plan that’s right for you and includes foods you enjoy.
Understanding your meal plan allows for flexibility so you can eat out, use convenience foods and allow for special events. It will also help you adjust for changes in your schedule, such as days when meals may
be delayed or when you are feeling ill.

diabetes overview
Carbohydrate counting
Carbohydrate counting is a meal planning tool that allows you to eat carbohydrates in amounts that keep your blood glucose in your target range.
A dietitian can help you determine the total amount of daily carbohydrate that is best for your sex, age, and activity level and how to distribute it through the day.
The first step: Know which foods contain carbohydrates. Carbohydrates include both starches and sugars. It is best if most of the carbohydrates you eat come from healthy foods like bread, cereals, grains, cooked dried beans and peas, starchy vegetables, fruits, milk, and yogurt. These foods contain vitamins, minerals and fiber. Sugars and sweets have little nutritional value and are often high in fat. It’s OK to eat sweets once in a while, but when you do eat sweets you must eat less of other carbohydrates, rather than just add the sweets to your meal plan.
The second step: Learn serving sizes. A serving of starch, fruit or milk is the amount of food that provides about 15 grams of carbohydrate and is referred to as 1 carbohydrate choice or serving. See the Diabetes Food Pyramid on p.10 to learn serving sizes for foods in the starch, fruit and milk groups. It will help to measure or weigh foods until you can judge them by looking at a portion on your plate.

The third step: Spread carbohydrate throughout the day. Based on the total amount of carbohydrate in your meal plan, divide your daily carbohydrate up into meals and snacks. To avoid fluctuations in your blood glucose, it is best to eat about the same amount of carbohydrate at each meal and snack and to eat meals and
snacks at about the same time each day.

How many carbohydrates choices do you need? A general guide is:
Women: 45-60 grams (3-4 choices) per meal; 0-30 grams (0-2 choices) per snack
Men: 60-75 grams (4-5 choices) per meal; 0-30 grams (0-2 choices) per snack

Checking your blood glucose levels before and after different meals will help you learn the amount of carbohydrate in meals and snacks that works for you. If you need to lose weight or are very active, you may need fewer or more servings than recommended above.

The Diabetes Food Pyramid
Another approach to meal planning is to use the Diabetes Food Pyramid (above) as a guide of what and how much to eat. This allows for a variety of foods every day and can be used by the whole family.
The Diabetes Food Pyramid groups foods by carbohydrate content so it works better for people with diabetes. It is different from the USDA My Pyramid you may have seen in government publications, pamphlets or on food packaging.

How many servings?
The number of servings needed from each food group in the Pyramid is given in ranges, rather than a single number. For example, the bottom group Grains/Beans/Starchy Vegetables suggests 6 or more servings per day. Why? Because we are very different people. Smaller people and older people need less food than larger people, younger people or very active people. Thus, a small, older woman will need fewer servings per day than a younger, large man.
Individuals may need to make adjustments according to their own needs and blood sugars. Your health care team, particularly your dietitian, may prescribe a slightly different plan for you based on your target goals.
The plate method Another meal planning method is the plate method. With this method, no measuring is required. Instead, your plate determines the correct portion. Divide a plate into quarters. For lunch or dinner, use one quarter of the plate for Meat and Meat Substitutes, one quarter for Grains, Beans & Starchy Vegetables and the remaining half for Vegetables. For breakfast, use one quarter of the plate for Meat & Meat Substitutes if desired, and one half for Grains, Beans & Starchy Vegetables. A glass of milk, or a serving of fruit may be added to any of the meals or reserved for snacks.
Too many people cover their plate with large servings of starch or protein foods and skimp on vegetables. This way of eating can lead to too many calories, too much carbohydrate and too much saturated fat.

How sweet it is
Sugar substitutes or sugar replacers include nonnutritive sweeteners and sugar alcohols. They can both replace sugar sweeteners in foods and drinks.
• Nonnutritive sweeteners – No calories or carbohydrates There are five nonnutritive sweeteners approved by the Food and Drug Administration (FDA) for use in foods and beverages:
• Acesulfame potassium (K)
• Aspartame
• Neotame
• Saccharin
• Sucralose
These nonnutritive sweeteners are calorie-free (except for aspartame which is very low in calories). Products that use these sugar substitutes include diet soft drinks, sugar-free gelatins, powdered drink mixes, chewing
gum, jellies, jams, pancake syrup and light yogurts. They are also available as tabletop sweeteners.
• Are nonnutritive sweeteners safe?
The five nonnutritive sweeteners currently on the market were extensively tested before they were approved by the FDA. They are considered safe for everyone, including children and pregnant women, in amounts that consumers would typically consume of them. However, people with phenylketonuria (PKU), a rare genetic disease, need to limit their intake of aspartame.
• Sugar alcohols (Polyols) – Contain calories and carbohydrates Sugar alcohols are carbohydrates that sweeten with fewer calories per gram than sugar. Also called polyols, sugar alcohols are neither sugars nor alcohols. Sugar alcohols include:
• Sorbitol, mannitol, xylitol, erythritol, D-tagatose
• Isomalt, lactitol, maltitol, trehalose
• Hydrogenated starch hydrolysates (HSH)
Sugar alcohols are often used in sugar-free or no-sugar-added foods such as gum, cookies, and ice cream.

Currently, there are two low-calorie sweeteners made from the sugar alcohol erythritol - ZSweet and Sun Crystals - available as tabletop sweeteners in some stores and on the internet.
• Stevia
Stevia is a calorie-free sweetener made from a plant in South America. FDA has not approved stevia for use as a nonnutritive sweetener in the United States for lack of scientific evidence to assure its safety.
However, stevia is sold as a dietary supplement, which does not require FDA approval. Check with your health professional before using it.
• How do nonnutritive sweeteners or sugar alcohols fit into your meal plan?
Nonnutritive sweeteners and sugar alcohols can help lower the amount of carbohydrate in foods and allow for more flexibility in your meal plan. However, sugar-free or no-sugar-added does not mean carbohydratefree or low-calorie. Sugar-free or no-sugar-added means that no sugar sweeteners such as white sugar, brown sugar, honey, syrup, molasses, high fructose corn syrup or fruit juice concentrate have been used in
the food or drink.
Often times, a sugar-free or no-sugar-added food has as many calories, and grams of fat and carbohydrate as the regular product. Check the Nutrition Facts label to determine how a sugar-free food or drink fits into your meal plan and/or carbohydrate budget. For example, sugar-free gum is calorie-free and carbohydrate-free, and can be consumed as a free food. In contrast, sugar-free cookies contain calories, fat and carbohydrate, and must be counted in your meal plan and/or carbohydrate budget, not eaten in addition to it.

Using the Nutrition Facts label
Serving Size: The serving size is the first thing you should look at. All the numbers in the Nutrition Facts box are based on this serving size.
If you eat more or less than this amount, you must adjust the numbers accordingly. Be aware that the serving size on the food label may not be the same as the serving size in your food plan.
% Daily Value (%DV): %DV is a useful tool for comparing foods.
If the %DV is 5% or less, it is low in that nutrient. If the %DV is
20% or more, it is high in that nutrient.
Total Fat: Look at the grams of total fat as well as the grams
of saturated fat and trans fat.
• A low fat food has 3 grams or less fat per serving.
• A low saturated fat food has 1 or less grams saturated fat per serving and no more than 15% calories from saturated fat.
• Trans fat: Try to eat as little as possible because it increases your risk of heart disease.
Sodium: Limit sodium to help reduce your risk of, or help control, high blood pressure. The recommended intake for healthy adults is 2300 mg sodium per day. For people with high blood pressure, the recommended
intake is 1500-2000 mg sodium per day.
Total Carbohydrate: Look at the grams of total carbohydrate.
It is the grams of total carbohydrate that needs to be counted intoyour meal plan, not the grams of sugar. Remember, 15 grams of carbohydrate is the same as one carbohydrate choice or serving.
The grams of sugar and fiber (and sugar alcohols if present) are indented under total carbohydrate because they are included in the total.
• If a food contains 5 or more grams of dietary fiber, you can
subtract half the fiber from the total carbohydrate grams
to get a more accurate carbohydrate count.
• If a food contains 5 or more grams of sugar alcohols,
you can subtract half the sugar alcohol content from
the total carbohydrate grams to get a more
accurate carbohydrate count.
• A free food is any food that contains less than 20 calories and less than 5 grams of carbohydrate per serving.

Shopping list
The first step to eating well is shopping right. You can find a wide selection of healthful foods at your supermarket.
At Stop & Shop, it is easy to find healthy foods. Just look for the Healthy Ideas symbol on the shelf tag! A Healthy Ideas food must meet strict criteria. A Healthy Ideas food will be low in total fat, saturated fat, and cholesterol and free of artificial trans fat. A Healthy Ideas food is also controlled in sodium and sugar and must provide at least 10% of the Daily Value for either protein, fiber, calcium, iron, vitamin A or vitamin C.
For complete criteria, visit our website, stopandshop.com or pick up a Healthy Ideas brochure at your store.

diabetes overview

Fruits and Vegetables
• All fresh, raw fruits and vegetables are healthy choices.
• Choose canned fruits in light syrup or juice.
• Choose no-salt-added canned vegetables or those with the Healthy Ideas symbol.
• Choose whole fruits over fruit juices.
• When buying juice, look for 100% juice (those with the Healthy Ideas symbol). Limit juice if overweight, because it has as many calories as regular soda.
• Choose plain frozen vegetables over those with sauce.
• Choose more dark green and deep yellow vegetables.
• To save time, buy pre-washed and pre-cut vegetables and fruits.

Meat, Poultry, Seafood and other Protein Sources
For the healthiest choices, look for the Healthy Ideas symbol. Only Extra Lean meats, with less than or equal to 5 grams total fat, 2 grams saturated fat, and 95 mg cholesterol per reference serving* qualify as a
Healthy Ideas food. Lean meats, with less than or equal to 10 grams total fat, 4 grams saturated fat and 95 mg cholesterol per reference serving* are good choices too.
• Choose cuts with the words “loin” or “round” in the name, e.g. top round or pork tenderloin.
• Choose 96% or 93% lean ground beef. Fresh ground turkey breast and 93% lean ground turkey are great choices also.
• Limit high fat meats such as ribs, corned beef, sausage or bacon.
• Buy skinless poultry parts or remove the skin before cooking.
• When buying fish and shellfish, look for fresh, plain frozen or canned in water instead of oil, for fewer calories. Skip the breaded or batter-dipped frozen fish.
• Include at least two seafood meals per week for heart health.
• Canned and dried beans (legumes) are high in fiber and good sources of protein.
• Peanut butter and other nut butters are another good alternative to animal protein. To qualify for the Healthy Ideas symbol, peanut and nut butters must be free of any added sugar.
• Choose egg substitutes for protein without fat and cholesterol.
• Look for soy products with at least 8.25 grams of protein per reference serving*.

Deli
• Look for deli meats with the Healthy Ideas symbol. These meats have less than 3 grams total fat and less than 1 gram saturated fat per serving.
• Look for lower sodium deli meats at the service deli.
• Choose roast beef, turkey, chicken and ham over bologna, salami, or pepperoni.
• Choose hot dogs with 3 grams of fat or less per serving (look for
the Healthy Ideas symbol). Chicken and turkey franks do not always have less fat than beef franks.
Breads, Cereals and Grains
• Choose breads that list whole grain or whole wheat flour as the first ingredient and contain at least 2.5 grams of fiber per serving.
• Look for whole grain cereals with at least 5 grams of fiber, and no more than 12 grams of sugar per serving.
• Choose quick oats or old fashioned oats over instant oatmeal varieties that have more sodium and sugar.
• Choose whole grain crackers. Go easy on cheese crackers, peanut butter crackers, and butter crackers.
• Choose whole grain pastas and whole grain blends.
• Choose brown rice and other whole grains such as bulgur and quinoa.
• Prepare rice and pasta mixes without added fat and salt.

Dairy
• Choose low fat and nonfat dairy products and plain or light yogurts.
• Nonfat milk meets the strict criteria of Healthy Ideas. Low fat milk (1%) has more saturated fat but is a good choice also.
• Limit 2% or whole milk and higher fat dairy products.
• Look for nonfat or light yogurt.
• Look for cheeses with no more than 3 g saturated fat.
• Look for light or diet margarine and cream cheese.
• Buy evaporated skim milk as a substitute for cream in coffee and recipes.
Convenience and Frozen Foods
• Frozen dinners with the Healthy Ideas symbol on the shelf tag are low in fat, saturated fat and cholesterol, and controlled in sodium (less than 600 mg per federal reference serving size*).
• Look for pasta sauces with the Healthy Ideas symbol. All Healthy Ideas pasta sauces are low fat, less than 480 mg sodium per refernce serving and are free from added sugars.
• Select broth or bean based soups over cream soups or Ramen-type soups.

Snacks and Sweets
Snacks and sweets are meant to be extras in your diet and eaten in moderation. Many snacks and sweets do not provide at least 10% of the Daily Value for a Healthy Ideas nutrient and therefore do not qualify for the
Healthy Ideas symbol. However, here are some tips to help you make good choices when you shop for these items.
• For low fat snacks, choose light microwave popcorn, pretzels and rice cakes.
• Look for low fat cookie choices including animal crackers, graham crackers, fig bars, ginger snaps, and vanilla wafers.
• Choose granola and cereal bars with at least 2.5 grams of fiber and no more than 1 gram of saturated fat and 0 grams of trans fat.
• Nuts are a healthy snack, but limit quantities.
• Choose nonfat puddings.
• Select low fat frozen desserts like light ice cream, frozen yogurt, sherbet, sorbet, Italian ice, popsicles, and fruit bars.
• No Sugar Added sweets such as sugar-free gelatin and popsicles can be a good choice, but always read the grams of total carbohydrate on No Sugar Added products.
Fats and Oils
• Choose soft margarines or spreads with 0 grams trans fat.
• Choose light or reduced fat salad dressings.
• Choose canola oil or olive oil for cooking.
• Choose light or reduced fat mayonnaise.

Be active each day
Physical activity is like medicine – but it costs nothing and has no negative side effects. Regular physical activity can help:
• Improve insulin sensitivity and lower blood sugars
• Achieve and maintain a healthy weight
• Improve blood pressure and blood cholesterol levels
• Relieve stress and improve emotional well-being To be physically fit, there are three things you need to work on:
aerobic endurance, muscle strengthening, and flexibility.
Aerobic endurance exercises increase breathing and heart rate, and help burn calories. Aerobic activities should be done most preferably all days of the week, for at least 30 minutes. Work hard enough to elevate
your breathing and heart rate, but not so hard you can’t carry on a conversation. Examples include brisk walking, jogging, bicycling, swimming, and rowing. An alternative to counting minutes is to get a step counter and count steps. For good health, aim for 10,000 steps daily, for weight loss aim for 12,000 – 15,000 steps daily.
Muscle strengthening exercises build muscle, maintain bones, and increase body metabolism, which helps with weight control. You can go to a gym and lift weights or use hand/ankle weights at home. Select a weight you can lift 8 times in good form before you have to stop and rest your muscles. Muscle strengthening exercises should be done 2 to 4 times per week in sets of 1 to 3 with 8 to 12 repetitions per set using arms, legs and trunk, e.g. arm lifts, leg curls and crunches/push-ups.
Flexibility (stretching) exercises help keep your body limber and reduce muscle stiffness. Stretching should be done slowly, without jerking.
Hold the stretched position for at least 10 seconds. Do 4 to 6 stretching exercises per session. Stretch after doing your endurance and muscle strengthening exercises.
diabetes overview

diabetes mellitus

2011-07-22T04:52:00.000-07:00

diabetes mellitus

Diabetes

A condition in which excessive amounts of some substances are excreted from the body. The term may refer to either of two unrelated diseases, diabetes mellitus and diabetes insipidus. The word diabetes derives from the Greek for siphon, a reference to the copious urine excretion that characterizes this affliction. In common usage, the term diabetes is synonymous with diabetes mellitus.

Diabetes Mellitus

Diabetes mellitus is a disease of abnormal carbohydrate metabolism in which glucose cannot enter the body's cells and be utilized, and therefore remains in the blood in high concentrations. Mellitus is the Latin word meaning honey, and is applicable because the urine of patients with diabetes mellitus has a sweet taste, distinguishing this disease from diabetes insipidus, in which large volumes of dilute, almost colorless and tasteless urine are passed. In diabetes mellitus the excess sugar in the blood (hyperglycemia) leads to the excretion of sugar in the urine (glycosuria), a cardinal diagnostic symptom. Glycosuria in turn causes the excretion of large amounts of urine (polyuria), which results in dehydration and intense thirst (polydipsia). Although blood glucose is high, it cannot enter the appetite-regulating cells of the hypothalamus; hunger is therefore great, and the diabetic person tends to eat constantly (polyphagia). But because glucose cannot enter and nourish the cells, body tissues are subjected to the equivalent of starvation; rapid weight loss occurs, part of which is due to the excretion of water in urine. See also: Carbohydrate metabolism

diabetes mellitus

Varieties

Diabetes mellitus appears in two varieties, each with its own cause: diabetes mellitus type I (formerly known as juvenile onset diabetes), caused by deficiency of the pancreatic hormone insulin (whose chief function is to promote the entry of glucose into cells); and diabetes mellitus type II (formerly known as maturity onset diabetes), in which insulin is available but cannot be properly utilized.

Diabetes mellitus type 1

diabetes mellitus type 1

Of the two forms of diabetes, type I is initially the more serious and less common, afflicting approximately 1 in every 600 children. The incidence varies among countries. The highest incidence is seen in Finland and Sweden, and some of the lowest in Korea and Mexico. The United States and Canada are included among the highest. Although it usually appears before the age of 20, type I diabetes can strike at any age. It is caused by a significant shortage or complete lack of insulin secretion. The endocrine cells normally responsible for insulin production are found in the pancreas, but have nothing to do with the ordinary digestive functions of that organ. They occur as islands of endocrine tissue, called islets of Langerhans, scattered throughout the substance of the pancreas. The islets consist of at least three cell types, each of which secretes a different hormone important in regulating carbohydrate metabolism. The alpha cells produce glucagon, which elevates blood glucose; the beta cells produce insulin; and the delta cells produce somatostatin, a hormone that appears to participate in controlling the activity of the alpha and beta cells.

In type I diabetes the beta cells are destroyed, possibly by the attack of the body's own immune system or by virus infection; victims of type I require daily insulin injections to survive. Insulin must be injected rather than taken orally because it is inactivated by the enzymes of the digestive system. Without insulin therapy, a patient with type I diabetes will inevitably deteriorate into a condition of ketosis (presence in the blood of ketone bodies, the metabolic intermediates of fat metabolism) and acidosis (dangerously acidic blood pH). Ketoacidosis, as the combined condition is called, leads rapidly to coma and death in the untreated diabetic.

When Frederick G. Banting and Charles H. Best succeeded in purifying insulin from animal pancreatic tissue in 1921, type I diabetics were given their first chance at living a normal life-span. Today type I diabetics are routinely treated by injections of insulin. Human insulin became increasingly available in the 1980s through the use of recombinant deoxyribonucleic acid (DNA) technology. In this technique the gene specifying human insulin is spliced into the chromosome of a bacterium, and the billions of progeny bacteria then produce insulin as though it were one of their own bacterial proteins, thus serving as minifactories for the hormone. The bacterium used to produce insulin is Escherichia coli. Another DNA technique for producing insulin uses yeast instead of E. coli. Up to the early 1980s, insulin was extracted from cattle and pigs. This “foreign” insulin is still used, but has some unwanted side effects not seen or rarely seen with human insulin, therefore making human insulin the treatment of choice. One of the most important characteristics of insulin produced by genetic engineering, other than its being identical to human pancreatic insulin, is its limitless availability. See also: Genetic engineering; Insulin; Pancreas

Diabetes mellitus type 2

diabetes mellitus type 2

Type II is the more common form of diabetes mellitus, accounting for 8 out of every 10 cases. It usually appears after the age of 30, although an uncommon variant called type II diabetes of the young occasionally occurs in obese children and teenagers. The initial symptoms of type II diabetes are much less noticeable than those of type I, and the characteristic triad of polyuria, polydipsia, and polyphagia may even be entirely absent. For this reason, type II diabetes can exist undetected for dangerously long periods. Victims are not prone to the ketoacidosis and coma that threaten type I patients, and their disease can usually be managed without insulin injections. Thus two other names for type II diabetes are nonketosis-prone diabetes and noninsulin-dependent diabetes.

Whereas type I diabetes is a disease of insulin shortage, victims of type II diabetes usually have insulin in their bloodstream. In fact, insulin levels in type II diabetics are sometimes even higher than those in nondiabetic individuals. However, since the cells of a type II patient do not respond to insulin by taking in and utilizing blood glucose as normal cells would, the type II diabetic may have hyperglycemia in spite of high insulin levels. The probable reason for this defect is that the cells have specific receptor molecules on their surface membranes whose job is to recognize insulin and trigger the biochemical steps leading to glucose uptake and utilization. Interestingly, the number of insulin receptors on cells can be changed by gaining or losing body weight; the more body fat a person carries, the fewer insulin receptors there will be on the cells. This may explain why type II diabetes is mainly a disease of the obese, and why weight reduction is such effective therapy. High glucose levels also decrease the number of insulin receptors; normalizing glucose levels is thus of utmost importance.

The most important treatment for most cases of type II diabetes consists of exercise and weight reduction, which will return glucose metabolism to normal in 9 out of 10 cases. Because the cells of type II diabetics lack responsiveness to their own insulin, insulin injection therapy is used for some of these cases.

Approximately 10% of all type II patients must use insulin. This percentage appears to more than double in Black, Latino, Native American, or other minority patients living in the United States. In addition, a family of drugs known as oral hypoglycemic agents is often used in treating the disease. These drugs, including tolbutamide, chlorpropamide, acetohexamide, and tolazamide, lower blood glucose by stimulating the pancreatic cells to release insulin, and by augmenting insulin's effect on the cells of the body. All of these drugs are known as first-generation sulfonylureas. However, there are other drugs with the same basic molecule but with chemical changes in their structure; these are called second-generation sulfonylureas. This group of drugs is safe if properly used and is effective in many cases if used in conjunction with proper diet and exercise programs.

Amylin

Amylin is a 37-amino-acid peptide hormone that occurs naturally in humans, and has been shown to be in excess in individuals with non-insulin-dependent diabetes mellitus. Amylin has been shown to be deposited in the islets of Langerhans, and may decrease insulin release and insulin production in the pancreas, thus causing a deterioration in glucose control in non-insulin-dependent diabetes.

In insulin-dependent diabetes, amylin appears to slowly decrease with the progression of the disease, and when none is found, individuals may be more prone to have hypoglycemia unawareness (low blood glucose levels without symptoms).

Complications

Both type I and type II diabetes tend to produce a number of debilitating and life-threatening complications despite the use of insulin or oral hypoglycemic agents. It is primarily these complications, not the risk of ketoacidosis, that account for the heavy burden this disease inflicts on society, and make diabetes the third leading cause of death in the United States.

Much evidence indicates that most of the complications of diabetes are caused by the elevated blood glucose levels common in this disease. Even diabetics who take regular insulin injections exhibit wide fluctuations in their blood glucose levels, in marked contrast to the tightly controlled blood glucose levels observed in nondiabetics. According to the prevalent hypothesis, the more diabetics succeed in controlling their blood glucose to near-normal levels, the less risk there will be of developing any complications of the disease.

Thus, careful attention to diet, exercise, regular medication, and monitoring of blood glucose is vitally important for any diabetic.

The most common complications of diabetes are the following.

Eye damage

Diabetes is the leading cause of nontraumatic blindness in young adults. The blood vessels of the diabetic eye

are prone to microaneurysms (small outpouching of the vessel wall), excessive vascular permeability

(leakage from the vessel), growth of newer, more fragile vessels, and ultimately hemorrhage (bleeding).

These events can lead to scarring, fibrosis, and subsequent loss of vision.

Kidney damage

In long-standing diabetes, the smallest blood vessels of nephrons (the functional filtration units of the

kidney) frequently suffer the same type of damage as the blood vessels of the retina; this condition is called

diabetic nephropathy. Severe diabetic nephropathy commonly leads to kidney failure, and such patients

require dialysis in order to survive. The prognosis for individuals with diabetes on dialysis is poor, with only

30% surviving beyond 5 years.

Premature atherosclerosis

Atherosclerosis (often called arteriosclerosis or hardening of the arteries) is a condition in which arteries

become progressively occluded by accumulations of cholesterol-containing plaque. Although atherosclerosis is

common in older nondiabetics, diabetics tend to develop it earlier and in a more severe form. The most

common consequence of atherosclerosis is coronary artery disease and stroke, which result when the blood

supply to the heart or the brain is obstructed by a plaque within an artery. Coronary artery disease is the

leading cause of death in long-term diabetics, accounting for 75% of fatalities. Also, because of

atherosclerosis and restricted blood flow, diabetics are often subject to gangrene, especially of the

extremities. See also: Arteriosclerosis

Nervous system abnormalities

Patients with diabetes may experience a variety of nervous system disturbances, collectively referred to as

diabetic neuropathy. Symptoms may include muscle weakness, pain in the extremities, local paralysis,

urinary incontinence, sexual impotence, and sensations of cold, heat, or tingling in various parts of the body.

There may also be episodes of diarrhea, frequently nocturnal, which is a characteristic of the “diabetic

diarrhea” problems involving the upper intestinal tract. Nervous system involvement of the esophagus and

stomach may cause nausea and even vomiting.

Causes

Three factors that are believed to be important in the causation of this disease are heredity, viral infections,

and immunological damage to the pancreas.

Heredity

Although diabetes is popularly considered a genetic disease, it is not inherited in the sense that one can

inherit curly hair. Heredity does operate in determining one's risk of diabetes, but only as a predisposing

factor, not as an absolute determinant. The two types of diabetes mellitus have entirely different patterns of

inheritance, and the presence of one type in a family does not influence one's risk of developing the other.

Genetic factors play a much more important role in type II diabetes than in type I diabetes. For example, the

identical twin of a person who develops type II diabetes after age 40 is almost 100% certain to develop the

disease, but someone whose identical twin has type I diabetes runs only a 52% risk of becoming a diabetic.

Parents with type I diabetes face only a 2% risk of having a child with the disease, whereas the risk to the

offspring of a type II diabetic is about 10%. Genetic predisposition is apparently stronger in the case of type

II diabetes of the young, with a 50% chance that the child of such a diabetic will also develop the disease.

The environment obviously plays a significant role in type II diabetes. See also: Human genetics

Virus infections

Virus infection is strongly implicated as one causative factor in the beta-cell destruction that characterizes

type I diabetes, but it is not involved in type II diabetes. Some of the viruses that have been implicated are

the agents of mumps and rubella (German measles), whose action seems to be delayed for months or years,

and coxsackievirus B, which is more likely to precipitate diabetes shortly after the person recovers from the

influenzalike infection. Apparently, several factors operate to determine whether or not diabetes will develop

in a person infected with one of these extremely common viruses. They include the organ affinity of the

particular virus strain, the person's susceptibility to viral invasion of the pancreatic tissue, and the individual's

capacity to regenerate islet tissue that has been damaged by a viral infection. See also: Animal virus

Immunological damage to pancreas

Autoimmune reactions, wherein the body's immune defense system attacks its own pancreatic tissue as

though it were a foreign substance, are also suggested as a cause for the beta-cell destruction of type I

diabetes. An autoimmune response may be conducted by T lymphocytes or by soluble antibodies in the blood

or by both. These reactions may arise spontaneously or may be secondary to a viral infection of the pancreas

that leaves the islet tissue modified in some way that marks it for attack. See also: Autoimmunity

Diet

Dietary management has been part of diabetic therapy since preinsulin days, when starvation diets were

used to prolong the life of type I diabetics. More recently, weight reduction for victims of type II diabetes and

complex carbohydrate liberalization for those of both types of diabetes mellitus have been the cornerstone of

therapy.

For obese type II diabetics, weight reduction is certainly appropriate, since it tends to increase the number of insulin receptors on the cells of the body, usually making it possible to normalize blood glucose without

resorting to the use of insulin injections or oral drugs.

Some other dietary measures besides reducing caloric intake are now believed beneficial for type II diabetics.

The ingestion of foods high in fiber content, for example, has been shown to reduce hyperglycemia in type II

diabetics.

For type I diabetics, the traditional diet is high in protein and quite restricted in carbohydrates, with only

about 45% of the total daily caloric intake being carbohydrate-derived. Since most type I diabetics are thin,

weight reduction is not part of their program. Presently, the recommended carbohydrate intake has been

liberalized to 55–60% of the diet, plus 15–20% protein and 20–30% fat. There has been a trend toward

relaxing the carbohydrate restriction for type I diabetics as evidence accumulates that diets containing even

as much as 80% carbohydrates can be compatible with excellent control of diabetes, as long as the

carbohydrates are complex (that is, whole grains, legumes, potatoes, bread) rather than refined (that is,

sugars, candy, soft drinks, desserts, and so on). Artificially sweetened food can be very beneficial for weight

control; however, it is not a necessary component of treatment.

Prospects

The ideal solution is to be able to mimic insulin secretion, with intensive insulin therapy used with either

multiple insulin injections or insulin infusion pump therapy. The insulin pump continuously delivers a small

amount of insulin, and the individual can increase the amount before meals based on his or her glucose level.

Still, this setup is not ideal: in a nondiabetic, insulin is delivered directly into the portal blood system, while

therapy delivers insulin under the skin, where it can be absorbed into the bloodstream. Hooking a glucosemonitoring

device to the insulin pump would allow the system to close, permitting the individual to have an

artificial pancreas implanted (several models are available).

Healthy pancreatic tissue can be transplanted from a donor into a type I diabetic, but there are many

problems related to this method, such as the typing of the pancreatic tissue from the donor, the possibility of

rejection, and the possibility of infections.

diabetes mellitus

Diabetes Insipidus

Diabetes insipidus is caused by a deficiency of, or resistance to the action of, vasopressin, the antidiuretic

hormone produced by the posterior lobe of the pituitary gland. If the pituitary fails to produce vasopressin,

the condition is called central diabetes insipidus. If the kidneys do not respond to the vasopressin and fail to

concentrate urine, the condition is labeled nephrogenic diabetes insipidus. Symptoms include increased thirst

and frequent urination. Permanent damage to the kidneys can result if the condition is not treated.

A low level of vasopressin can be corrected with desmopressin acetate, a synthetic analog of 8-argininevasopressin,

which can be administered in the form of a nasal spray. Desmopressin acetate is ineffective

in the treatment of nephrogenic diabetes insipidus. See also: Neurohypophysis hormone

diabetes mellitus - diabetes mellitus type 2 - diabetes mellitus type 1

What is bone marrow transplant

2011-07-20T05:10:00.000-07:00

What is bone marrow transplantation - what is bone marrow transplant for donor

Bone marrow transplantation is a procedure in which bone marrow cells are taken out from a donor and given to a patient.

Depending on the donor or source of bone marrow, different types of bone marrow transplantation is done.

There are two major ways in which bone marrow cells can be removed from a person or donor. The first is by taking the bone marrow cells directly from the marrow using long needles (called bone marrow harvest needles) to suck out the marrow from the marrow spaces at the large hipbone. This is done under anaesthesia over about 2 hours. The second is a revolutionary method, which have been available only in the last 5-10 years. By giving certain medications, the bone marrow cells can be stimulated to circulate from the marrow into the blood. Using a special machine called an apheresis machine ( also called a cell separator), the cells can be removed from the blood. Blood is drawn out as in a blood donation, into the machine, which then separates out the marrow cells and return blood cells to the donor.

The donor is usually a relative, usually either a brother or sister. However, there are three other sources. They are unrelated match donor, cord blood and autologous.

Unrelated donors are donors that have volunteered to donate bone marrow just like blood donors.

Cord blood is obtained from the cord of newborn babies. It may be used for transplantation of a relative or be used for non-related recipients.

It is also possible for the patient to donate his own marrow cells to be stored first and then returned to him after the chemotherapy has been given as conditioning.

(See autologous BMT section)

What is bone marrow transplant

Figure 22b: Sources of haemopoeitic stem cells for transplantation

Sibling (Brother and sisters) This is commonest form in the allogeneic setting.

Twin An identical twin shares the same ‘marrow type’ as the patient, thus making it very safe.

Extended family Sometimes a family member may share the same ‘marrow type’ as the patient and can donate to the patient.

Unrelated donors Volunteer donors who have the same ‘marrow type’ are able to donate their marrow for needy patients.

Autologous The patient’s own marrow can be used to do a transplant. (See chapter on autologous transplantation)

Thus the different types of transplants are:

Allogeneic bone marrow transplantation Allogeneic peripheral stem cell transplantation Autologous bone marrow transplantation Autologous peripheral stem cell transplantation Cord blood transplantation.

Who should receive a bone marrow transplant?

There are three important conditions limiting the use of bone marrow transplantation:

(i) Age - The older the patient, the more risky the transplant because of a higher incidence of complications. The upper age limit of transplants locally is currently 40 years of age. In some overseas centres, the upper age limit is 55 years of age.

(ii) Suitable disease - Bone marrow transplantation is not suitable for all blood diseases. The results are best for acute myeloid leukaemia if the transplant is done only when the patient has achieved remission. In chronic myeloid leukaemia the results are best when the transplant is performed relatively early i.e. when the patient is still in the chronic phase of the disease. In severe aplastic anaemia, new marrow is required to replace the patient's marrow that has completely failed.

(iii) Suitable donor - Allogeneic bone marrow transplants require a donor with the same tissue type as the patient. There is no age limit for donors. However the donor must be healthy and has not transmissible diseases.

How to find a suitable donor?

Our immune system which protects us from bacteria, viruses and other microorganisms which try to invade our bodies, has to have a way of identifying which cells are our own and which cells (micro-organisms) are ‘enemies’ that has to be destroyed. They are able to recognise our own cells because the cells have antigens (markers) on their surfaces. The antigens that we know are called HLA antigens. (HLA stands for human leucocyte antigens.) An analogy can be made. In war we can recognise each other by the uniforms or badges we wear. The enemy wears different uniforms and thus are easily recognised and attacked. We will not attack our own soldiers who are wearing the same uniforms.

These HLA antigens are unique in that they differ in us from one another. Family members tend to share same antigens. Brothers and sisters have a high chance of having the same antigens.

The process in which we check to see what antigens are carried on our cells is called tissue typing. Thus we are able to find out one’s tissue type using this process. This process is also called ‘HLA typing’.

What is bone marrow transplantation

How is tissue typing done?

A bone marrow test is not required. Only blood is needed because the white cells (mainly lymphocytes) that is in our blood is used. A blood sample is taken and using sophisticated tests the tissue type is determined.

In Malaysia, tissue typing is performed by the Institute of Medical Research, Kuala Lumpur and recently in University Hospital, Kuala Lumpur. Singapore is the nearest centre where this is also done. Only blood samples in special bottles need to be sent and the donors and patients do not need to go to the centres themselves.

The chance of finding a suitable donor is best from a brother or a sister of the patient. There is a one in four chance of a brother or a sister having a complete match. The chances of the rest of the family (parents or children) having the same tissue type are much less (about one in 100). This is because genes inherited from

both parents of the patient determine the tissue or HLA type. The same tissue type is thus most likely to be found among the patient’s brothers and sisters (siblings).

Different ethnic groups have different HLA types just like hair color or facial features.

Thus if it is more likely to find the same tissue type in persons of the same ethnicity.

Figure 23a: Inheritance of HLA antigens

There are four possibilities for the type of HLA inherited from parents. They are inherited in pairs. We obtain one of the pairs from each parent. Thus the chances of having a sibling with the same tissue type is about 25%.

What is bone marrow transplantation

What are the problems associated with bone marrow transplants?

Sterility - the inability to have children is a permanent side effect of bone marrow transplantation. The ability to participate in sexual activity is not affected. In overseas centres, sperm banking is an option for male patients. Also eggs may also be stored for the female.

Skin changes and hair loss- the hair loss is only temporary and the hair will grow back after the transplant but sometimes is a bit thinner than previously. There are skin changes due to the chemotherapy given for the transplant but these are also temporary.

Mucositis - during the transplant, most patients develop a very sore mouth from the chemotherapy and for a while, cannot eat and will depend on nutrition given intravenously. Pain relieve can be achieved usually with medication.

Graft-versus-host-disease - this is a special complication of transplants due to the immune cells (lymphocytes) from the donor present in the donated marrow, which attack the recipient (patient). This is because they recognise the patient’s body cells as foreign like bacteria or micro-organisms. This occurs more often in HLA

mismatched transplants and unrelated donor transplants. It can also occur in fully matched transplants because there are still antigens that we yet cannot tissue type.

Also they may be other factors that change the donated cells resulting in them not recognising the shared HLA antigens as shared.

It can cause rashes, liver damage and damage to the gut. It occurs in about 40% of patients but can usually be treated. It is occasionally fatal.

Infections - During and after transplants, the patient remains at high risk of infections and will be on antibiotics and special medication for about one year. The immunity does not return to normal for a few years.

What does the patient undergo?

Because the procedure is very tedious and also difficult, the donor is counselled at length and allowed to make his or her own mind to go ahead with the transplantation.

The transplant patient is hospitalised for about one month but will require very close follow up at least three times a week for the subsequent two months. During the hospitalisation, a special device called a Hickman catheter is placed (using minor surgery) which serves as a way of giving fluids, chemotherapy, blood transfusion and nutrition directly into the bloodstream. This eliminates the need to use veins on

the arms to take blood samples and give intravenous medication.

The patient undergoes conditioning chemotherapy to prepare the patient to receive the new marrow. Conditioning chemotherapy has side effects including vomiting, diarrhoea and occasional bleeding from the bladder. The new marrow collected from the donor is then transfused into the patient. These cells know how to get to the bone marrow spaces through the bloodstream in a normal process called homing. The blood counts of the patient remain very low for about 2 to 3 weeks before the new marrow grows. The patient will be required to take medications for at least a year.

What does the donor undergo?

The donor is counselled (given advice) about the procedure and how it is useful for the patient. As the procedure is completely voluntary, the donor’s wishes are highly respected.

Depending on the procedure to be used whether conventional bone marrow harvest or peripheral stem cell collection, the donor is selected.

In the conventional bone marrow harvest programmes, the donor undergoes a medical examination to determine fitness for surgery. A unit of blood may be taken a week prior to the harvest and given back to the donor at the time of harvest so as to minimise the need for additional blood transfusion. The harvest is done under general anaesthesia and marrow is aspirated using special needles from the back of the pelvis (hip bone). There is no permanent side effect and the main complication is some discomfort felt at the back for several days after the procedure. The donor is usually hospitalised for three days only.

what is bone marrow transplant for - what is bone marrow transplant for donor - what is bone marrow transplant like

Bone Marrow Transplant

2011-07-20T03:54:00.000-07:00

Bone Marrow Transplant - bone marrow transplant procedure for donor

Conditioning

Chemotherapy or chemotherapy plus radiation destroys bone marrow so there is room for new destroys recipients immune system so it doesn’t destroy transplanted cells destroys diseased cells (leukemic or pre-leukemic) These treatments lead to an increased risk for infections during treatment also nausea, vomiting, hair loss, skin rash, mouth sores Long term these treatments lead to an increased risk for:sterility endocrinopathies cancer rarely - vessels in liver swell shut, juandice, liver damage rarely - lung damage or cardiomyopathy FA patients have impaired DNA repair, and thus these treatments are less well tolerated and more risky for them

Affected child in this case was treated with cyclophosphamide total body irradiation also needed due to MDS (preleukemia)

Introduction of new cells

Bone marrow or cord blood is put into the blood of the transplant recipient.

The bone marrow cells will travel to their proper locations in the recipient’s bones and establish themselves there.

Treatments to prevent infection during immunosuppression

Granulocyte colony stimulating factor to increase white cell production Anti-fungal (prevent candida and aspergillus) Cefazolin (prevent Streptococcal infection) Acyclovir (prevent herpes infection) Cotrimoxazole (prevent pneumocystis infection)

Additional Treatments

Cyclosporin A to prevent graft versus host (GVH) (the transplanted cells attack the recipient)

Long-term

Affected child in this case No acute or chronic GVH (she had a matched sibling donor) Mild adenovirus gastroenteritis resolved by 3 mos No other opportunistic infections developed Mild drug related toxicity developed in the liver All medications were discontinued by 24 months post transplant.

Molly Nash

Molly still needs treatment for some of her congenital defects (intestinal and spinal abnormalities) Her risk of developing cancer other than leukemia remains high since the other cells in her body still contain mutations in FANCC.

Bone Marrow Transplant

Engraftment

Usually donor bone marrow cells begin to function in the recipient within 30 days.

Affected child in this case Neutrophils were to target levels by day 17 Platelets were to target levels by day 30

Importance of a Matched Donor

2 year survival rates vary for FA patients who have received BMTs matched sibling donor - 66 - 85%

match from bank 22 - 40%

What does a matched donor mean?

Our cells have molecules on their surface called human leukocyte antigens (HLA).

Our immune system uses to these molecules to distinguish between our cells and invaders.

These molecules enable infected cells to signal and initiate an immune response.

In a matched donor, the molecules on the surface of the donor cells would be the same as those found on the surface of the recipient.

Bone Marrow Transplant

Why is it important for HLA type to match?

If the HLA antigens are the same between the donor and the recipient, neither with recognize the other as foreign.

If the HLA antigens are different…

Possibility 1

The donor bone marrow cells may recognize the recipient cells as foreign and attack the recipient.

This can range from mild to fatal.

It is known as Graft versus Host or GVH GVH is a major risk in all BMT.

Possibility 2

Any remaining bone marrow cells in the recipient may recognize the transplant as foreign and destroy it.

For transplant purposes

HLA-A, HLA-B and HLA-DR antigens are the most important.

Since you have two copies of the genes for each of these antigens (one from your mother, one from your father), there are 6 antigens that need to be matched.

They are all co-dominant, meaning they are all expressed on the surface of cells.

A bone marrow transplant will not usually be done unless 5 out of 6 of these antigens match, and 6 out of 6 is considered best.

Matching of additional HLA antigens (beyond HLA-A, HLA-B and HLADR is optimal and reduces chances of long-term complications.

For transplant purposes

HLA-A, HLA-B and HLA-DR antigens are the most important.

Since you have two copies of the genes for each of these antigens (one from your mother, one from your father), there are 6 antigens that need to be matched.

They are all co-dominant, meaning they are all expressed on the surface of cells.

A bone marrow transplant will not usually be done unless 5 out of 6 of these antigens match, and 6 out of 6 is considered best.

Matching of additional HLA antigens (beyond HLA-A, HLA-B and HLADR is optimal and reduces chances of long-term complications.

Chances of finding a matched donor

Bone Marrow Transplant

There are two type of HLA:

Major Histocompatilbility Classes I and II MHC Class I antigens. These antigens are found on the surface

of all nucleated cells in our body. In humans the MHC Class I antigens are called HLA-A, HLA-B and HLA-C.

Bone Marrow Transplant

MHC Class II Antigens

These antigens are found on B-cells and macrophages.

In humans these antigens are HLA-D, HLA-DR, HLA-DP and HLA-DQ

HLA variability HLA genes are highly variable in humans. This polymorphism represents a species response to maximize protection against diverse microorganisms.

This diversity in HLA antigens makes finding a transplant donor difficult.

Chances of creating an HLA-matched sibling

All HLA genes are located on chromosome 6 Recombination between the HLA loci is relatively rare So, chances of any given sibling being a matched donor are just under 25% In addition, the sibling will be matched

at other HLA loci as well.

To create a sibling who could serve as a donor

The case we are discussing goes beyond just HLA matching, we need to find an embryo that is FA-free and is HLA-matched.

HLA matching is on chromosome 6 FANCC is on chromosome 9 So, we are looking at 2 chromosomes rather than one.

The genotypes of the family members are shown below.

What are the chances of creating an HLA-matched, FA-free embryo?

Bone Marrow Transplant - bone marrow transplant procedure for donor

what is diabetes

2011-07-19T06:08:00.000-07:00

what is diabetes - what are diabetes - what are diabetes types

Q: What is diabetes?

A: Diabetes means that your blood glucose (sugar) is too high. Your blood always has some glucose in it because the body uses glucose for energy; it’s the fuel that keeps you going. But too much glucose in the blood is not good for your health.

Your body changes most of the food you eat into glucose. Your blood takes the glucose to the cells throughout your body. The glucose needs insulin to get into the body’s cells. Insulin is a hormone made in the pancreas, an organ near the stomach. The pancreas releases insulin into the blood. Insulin helps the glucose from food get into body cells. If your body does not make enough insulin or the insulin does not work right, the glucose can’t get into the cells, so it stays in the blood. This makes your blood glucose level high, causing you to have diabetes.

If not controlled, diabetes can lead to blindness, heart disease, stroke, kidney failure, amputations (having a toe or foot removed, for example), and nerve damage. In women, diabetes can cause problems during pregnancy and make it more likely that your baby will be born with birth defects.

what is diabetes

Q: What is pre-diabetes ?

A: Pre-diabetes means your blood glucose is higher than normal but lower than the diabetes range. It also means you are at risk of getting type 2 diabetes and heart disease. There is good news though: You can reduce the risk of getting diabetes and even return to normal blood glucose levels with modest weight loss and moderate physical activity. If you are told you have pre-diabetes, have your blood glucose checked again in 1 to 2 years.

Q: What are the different types of diabetes?

A: The three main types of diabetes are:

• Type 1 diabetes is commonly diagnosed in children and young adults, but it’s a lifelong condition. If you have this type of diabetes, your body does not make insulin, so you must take insulin every day. Treatment for type 1 diabetes includes taking insulin shots or using an insulin pump, making healthy food choices, getting regular physical activity, taking aspirin daily (for many people), and controlling blood pressure and cholesterol levels.

what are diabetes - what is diabetes insipidus

• Type 2 diabetes is the most common type of diabetes — about 9 out of 10 people with diabetes have type 2 diabetes. You can get type 2 diabetes at any age, even during childhood. In type 2 diabetes, your body makes insulin, but the insulin can’t do its job, so glucose is not getting into the cells. Treatment includes taking medicine, making healthy food choices, getting regular physical activity, taking aspirin daily (for many people), and controlling blood pressure and cholesterol levels. If you have type 2 diabetes, your body generally produces less and less insulin over time. This means that you may need to increase your medications or start using insulin in order to keep your diabetes in good control.

• Gestational (jess-TAY-shun-ul) diabetes occurs during pregnancy. This type of diabetes occurs in about 1 in 20 pregnancies. During pregnancy your body makes hormones that keep insulin from doing its job. To make up for this, your body makes extra insulin. But in some women this extra insulin is not enough, so they get gestational diabetes. Gestational diabetes usually goes away when the pregnancy is over. Women who have had gestational diabetes are very likely to develop type 2 diabetes later in life.

Q: Who gets diabetes?

A: About 24 million Americans have diabetes, about half of whom are women. As many as one quarter do not know they have diabetes.

Type 1 diabetes occurs at about the same rate in men and women, but it is more common in Caucasians than in other ethnic groups.

Type 2 diabetes is more common in older people, mainly in people who are overweight. It is more common in African Americans, Hispanic Americans/Latinos, and American Indians.

Q: What causes diabetes?

A: Type 1 and type 2 diabetes —The exact causes of both types of diabetes are still not known. For both types, genetic factors make it possible for diabetes to develop. But something in the person’s environment is also needed to trigger the onset of diabetes. With type 1 diabetes, those environmental triggers are unknown. With type 2 diabetes, the exact cause is also unknown, but it is clear that excess weight helps trigger the disease. Most people who get type 2 diabetes are overweight.

Gestational diabetes — Changing hormones and weight gain are part of a healthy pregnancy, but these changes make it hard for your body to keep up with its need for insulin. When that happens, your body doesn’t get the energy it needs from the foods you eat.

Q: Am I at risk for diabetes?

A: The risk factors for type 1 diabetes are unknown. Things that can put you at risk for type 2 diabetes include:

• Age — being older than 45

• Overweight or obesity

• Family history — having a mother, father, brother, or sister with diabetes

• Race/ethnicity — your family background is African American, American Indian/Alaska Native, Hispanic American/Latino, Asian American/Pacific Islander and Native Hawaiian

• Having a baby with a birth weight more than 9 pounds

• Having diabetes during pregnancy (gestational diabetes)

• High blood pressure — 140/90 mmHg or higher. Both numbers are important. If one or both numbers are usually high, you have high blood pressure.

• High cholesterol — total cholesterol over 240 mg/dL

• Inactivity — exercising less than 3 times a week

• Abnormal results in a prior diabetes test

• Having other health conditions that are linked to problems using insulin, like Polycystic Ovarian Syndrome (PCOS)

• Having a history of heart disease or stroke

Q: Should I be tested for diabetes?A: If you’re at least 45 years old, you should get tested for diabetes, and then you should be tested again every 3 years. If you’re 45 or older and over-weight (Calculate your Body Mass Index) you may want to get tested more often. If you’re younger than 45, over-weight, and have one or more of the risk factors listed in “Am I at Risk for Diabetes?” you should get tested now. Ask your doctor for a blood glucose or A1c test. Your doctor will tell you if you have normal blood glucose (blood sugar), pre-diabetes, or diabetes.

Q: What are the signs of diabetes?

A: • being very thirsty • urinating a lot • feeling very hungry • feeling very tired • losing weight without trying • having sores that are slow to heal • having dry, itchy skin • losing feeling in or having tingling in the hands or feet • having blurry vision • having more infections than usual If you have one or more of these signs, see your doctor.

Q: How can I take care of myself if I have diabetes?

A: Taking care of yourself when you have gestational diabetes is very much like taking care of yourself when you have other types of diabetes. But it can be a little scary when you’re pregnant and you also have a new condition to take care of. Don’t worry. Many women who’ve had gestational diabetes have gone on to have healthy babies. Here are the things you’ll need to do:

• Follow your meal plan — You will meet with a dietitian or diabetes educator who will help you design a meal plan full of healthy foods for you and your baby. You will be advised to:

• limit sweets

• eat often — three small meals and one to three snacks every day

• be careful about the carbohydrates you eat —your meal plan will tell you when to eat carbohydrates and how much to eat at each meal and snack

• eat lots of whole grain foods, fruits, and vegetables

• Get moving — try to be active for at least 2 hours and 30 minutes each week. If you’re already active, your doctor can help you make an exercise plan for your pregnancy. If you haven’t been active in the past, talk to your doctor. Your doctor can suggest activities, such as swimming or walking, to help keep your blood glucose on track.

suggest activities, such as swimming or walking, to help keep your blood glucose on track.

what is diabetes - what is diabetes symptoms - numbers

• Each time you check your blood glucose, write down the results in a record book. Take the book with you when you visit your health care team. If your results are often out of range, your health care team will suggest ways you can reach your targets.

• Take your diabetes medicine exactly as your doctor tells you. You may need to take insulin to keep your blood glucose at the right level. If so, your health care team will show you how to give yourself insulin shots. Insulin will not harm your baby—it cannot move from your bloodstream to your baby’s.

Q: Is there a cure for diabetes?

A: There is no cure for diabetes at this time, but there is a great deal of research going on in hopes of finding cures for both type 1 and type 2 diabetes. Many different approaches to curing diabetes are being studied, and researchers are making progress.

Q: Is there anything I can do to prevent type 2 diabetes?

A: Yes. The best way to prevent diabetes is to make some lifestyle changes:

• Maintain a healthy weight. Being overweight raises your risk for diabetes. Calculate your Body Mass Index (BMI) to see if you’re at a healthy weight. If you’re overweight, start making small changes to your eating habits by adding more whole grain foods, fruits, and vegetables. Start exercising more, even if taking a short walk is all you can do for now. If you’re not sure where to start, talk to your doctor. Even a relatively small amount of weight loss – 10 to 15 pounds – has been proven to delay or even prevent the onset of type 2 diabetes.

• Eat healthy

• Eat lots of whole grains (such as whole wheat or rye bread, whole grain cereal, or brown rice), fruits, and vegetables.

• Choose foods low in fat and cholesterol. Read food labels. If you eat 2,000 calories per day, you should eat no more than 56 grams of fat each day.

• If you drink alcohol, limit it to no more than one or two drinks (one 12-ounce beer, one 5-ounce glass of wine, or one 1.5-ounce shot of hard liquor) a day.

• Get moving. Health benefits are gained by doing the following each week:

• 2 hours and 30 minutes of moderate intensity aerobic physical activity

• 1 hour and 15 minutes of vigorous-intensity aerobic physical activity

• A combination of moderate and vigorous-intensity aerobic physical activity

and

• Muscle strengthening activities on 3 days

Some suggestions for fitting activity in:

• Take the stairs instead of the elevator.

• Take a brisk walk on your lunch break.

• Park at the far end of the parking lot and walk.

• Get off the bus or subway a few stops early and walk the rest of the way.

• Walk or bicycle whenever you can.

what are diabetes types

what is diabetes - what is diabetes mellitus - what is diabetes type 1 - what is diabetes type 2

How are Environmental Factors Linked to Asthma

2011-07-11T14:22:00.000-07:00

How are Environmental Factors Linked to Asthma? (Lucas Neas - ORD)

Genetic factors, viral and parasitic infections, diet, lifestyle, air pollution, and allergen sensitization are all linked in some way to asthma. However, none of them alone can be considered the source of the recent upward trend in asthma cases. While genetics are certainly a factor, they do not change quickly enough for a genetic shift to be the cause of the trend. However, genetic factors predispose people to asthma, who are then forced over to active asthma by an increasingly “adverse” environment.
The decrease in infections, due to vaccination and smaller families, means that there has been an overall decrease in the necessity for an immune response to certain diseases. This may sensitize the body to asthma-related allergens. However, this decrease has occurred since the 1960s while the asthma trend is more recent. With regard to diet, it has been found that antioxidants are more protective and an increase in trans-fatty acids, salt, and sugar in the diet due to junk food may be a risk factor. There has certainly been an increase in the consumption of junk food in the United States since the 1960s, but there is a question as to whether this would explain the worldwide trends. The levels of exposures due to indoor and outdoor antigens may have increased, including on an occupational and even community-wide level. Early childhood exposures to dust mites, humidified homes, cockroaches, cat dander, mold spores, and pollen may have increased. However, this does not explain why asthma incidence seems to increase after moving from an urban poor environment to a rich environment. This phenomenon has been seen in Ghana. Other research has looked at lifestyle causes, such as the lack of general time outdoors, particularly spent engaging in vigorous activity. Data have shown that living on a farm provides protection from asthma; this may mean that today’s children spend too much time on indoor activities which increases their exposure to indoor pollutants over time. In addition, pulmonary “exercise” results from general time outdoors. However, if outdoor activity is promoted, it is necessary to ensure that the ambient environment is not polluted.

Air pollutants have been considered as asthma triggers. However, air pollution has decreased over the past decade while asthma cases and severity have increased. For example, the dramatically cleaner air that resulted from the shutdown of many plants in the former East Germany did not result in changes of asthma rates. In fact, while eastern Germany has more bronchitis and wheeze associated with airborne irritants, they also experience lower rates of asthma and hay fever than in western Germany. In addition, New South Wales, Australia has high rates of asthma but a clean environment.

The Harvard Six-Cities Study and 24-City Study in the United States and Canada looked at the prevalence of respiratory illness in children vs. air pollution. Bronchitis was associated with air pollutants but asthma was not. A study performed in Kanawha County, West Virginia showed an association between volatile organic compounds (VOCs) and other traffic-related pollution and asthma on a city-wide scale.

Based on these studies, it appears that air pollutants may play a greater role as a trigger or exacerbation of asthma but not as a cause, although they may increase the possibility of sensitization to antigens and bioaerosols. Air toxics, such as those associated with traffic, present an area needing further study.

Environmental Factors Linked to Asthma

the Basic Aspects of Asthma

2011-07-11T14:11:00.000-07:00

What are the Basic Aspects of Asthma? (Hillel Koren - ORD)

There are almost 15 million asthmatics in the United States, resulting in 15.5 million outpatient visits and 415,000 hospitalizations per year. Approximately 5,000 people in the United States die each year from an asthma attack. Asthma also causes a significant economic impact, not only from the direct health care costs associated with treatment but also substantial indirect costs, such as absenteeism from work and lost productivity. The incidence and severity of asthma is increasing worldwide, despite the fact that ambient air pollution levels have dropped over the past ten years. This increase has occurred disproportionately among African Americans and other minorities in the United States. Poverty has been suggested as the reason for this; however, asthma is relatively lower in Africa, where poverty is quite high. It has also been considered that the answer lies in lifestyle changes, where changing to a less “traditional,” more Western lifestyle marks an increase in asthma incidence. In Australia, however, higher rates of asthma are found in the rural, rather than the urban, parts of the country. These examples illustrate the complexity of the asthma issue.

Asthma is a complex, multi-factorial disease characterized by reversible airway obstruction, non-specific airway hyperresponsiveness, and mucus hypersecretion; it is a chronic airway inflammatory disease with episodes of acute exacerbation. A complex network of immune cells, effector cells, cytokines, and other mediators interact to produce the asthmatic response. Asthma can vary widely in severity, both between and within individuals, but common symptoms include wheezing, shortness of breath, cough, chest tightness, and mucus production. Typical features of asthma include an increased level of immunoglobulin E, a positive reaction to inhaled allergens, and exaggerated bronchoconstriction in response to airway cooling or drying, exercise, and chemical or pharmacologic bronchoconstrictors (e.g., histamine or methacholine). The disease can be divided into two general categories, e.g., extrinsic and intrinsic. Extrinsic allergic asthma involves hereditary factors and allergens and is detected by the presence of serum IgE. Most childhood asthma falls into this category. Intrinsic asthma, which is more common in adults, does not involve these factors but results in similar pathobiology and treatment as extrinsic asthma.

Asthma is triggered by many factors in the environment, including house dust, pet dander, fungi, and cold air. Food allergens and stress can also trigger the condition. Genetic risk factors play a significant role in determining which people show signs of asthma, given similar exposure scenarios. The presence of atopy is a risk factor for developing overt asthma. If one parent is atopic, half of the children will have atopy. If both parents are atopic, 75 percent of the children will have atopy. If neither parent is atopic, there is a 15 percent chance of having an atopic child, which means that the potential for asthma exists. While there is certainly genetic control of asthma, there is no single gene responsible for its expression. The interaction between the environmental and genetic risk factors results in clinical asthma and the pathologic abnormalities of asthma, including bronchospasms, mucosal edema, airway inflammation, increased mucosal secretion, and a thickening of the basement membrane. While a normal airway has a well-organized epithelium, an asthmatic airway has a disrupted epithelium, is constricted, has a mucus hypersecretion plug, enlarged smooth muscle cells, and an inflamed basement membrane.

During the first hour after asthma attack, there is an initial drop in lung function and then an oscillation in function which decreases in a few days. Repeated episodes of airway inflammation can cause long-term structural damage and weakness, making the airways more prone to damage during the next attack. For this reason, it is important to control asthma so that the condition does not worsen.

Airways hyperresponsiveness alone is not necessarily diagnostic of asthma. Airway inflammatory cells in asthmatics characteristically include eosinophils, other polymorphonuclear granulocytes, and lymphocytes. Injury of the airway epithelium is present to varying extents, even in individuals with mild asthma. Evaluation of a patient with suspected asthma includes family, exposure, and social history. Tests for IgE antibody, pulmonary function, and allergy skin tests are conducted. The severity of asthma is different for any asthmatic and can range from mild, moderate, to severe persistent asthma, depending on the degree of exacerbation, activity levels, and compromise of pulmonary function (peak air flow).

The management and treatment of asthma involves working with the patient to develop treatment goals and an action strategy. Goals might be to prevent chronic and troublesome symptoms, prevent acute attacks, and continue all activities. The patient is provided with written, individualized instructions, a daily plan for management, and the long-term benefits of following the plan are discussed. The patient is taught how and when to use the peak lung flow meter, which can predict some asthma attacks. Medications are also helpful for control and include a regime of beta-agonist inhalers and steroids.

Poor disease management, lack of accessibility to medical services, inadequate advanced planning, and lack of outdoor exercise may contribute to the increased incidence and severity of asthma. In addition, it is possible that the decreased prevalence of infectious diseases has had an affect on the immune system, enhancing the response to allergens. ETS and other indoor air quality issues may also play a role. In summary, asthma appears to be a disease of modern, industrialized, affluent societies.

the Basic Aspects of Asthma

OBESITY IN AMERICA

2011-07-11T13:37:00.000-07:00

OBESITY IN AMERICA

PREVALENCE

• Obesity is a life-threatening disease affecting 34% of adults in the U.S.; 68% of adults are either overweight or obese

• Between 2000 and 2005, obesity (BMI ≥30) increased by 24%, morbid obesity (BMI ≥ 40) increased by 50% and super obesity (BMI ≥ 50) increased by 75%3

• In 2008, only one state (Colorado) had a prevalence of obesity less than 20%. Thirty-two states had a prevalence equal to or greater than 25%; six of these states (Alabama, Mississippi, Oklahoma, South Carolina, Tennessee and West Virginia) had a prevalence of obesity equal to or greater than 30%4 COSTS ASSOCIATED WITH OBESITY

• Obesity-related health spending costs the U.S. healthcare system an estimated $147 billion annually, double what it was a decade ago and amounting to nearly 10% of medical spending

• Obese individuals spend 40% more on health care than individuals of normal weight

• Lost productivity related to obesity among Americans ages 17 to 64 costs $3.9 billion a year

• Diseases associated with obesity account for 27% of the increases in medical costs since 1987;8 spending related to diabetes alone totals $190 billion a year

OBESITY IN CHILDREN/TEENS

• As of 2007, 32% of children aged 10-17 in the U.S. are overweight and 16% are obese; childhood obesity has more than tripled in the past 30 years1

• As of 2006, 11% of preschoolers ages 2 to 5, 15% of children ages 6 to 11 and 18% of adolescents ages 12 to 19 are overweight;1 as of 2004, 4% of children age 2-19 are considered severely obese1

• Overweight adolescents have a 70% chance of becoming overweight or obese adults. This increases to 80% if a parent is overweight or obese

• One in five American 4-year-olds are considered obese and the rate is higher among American Indian children, with nearly a third of them obese

• A study of 5- to 17-year-olds found that 70% of obese children had at least one risk factor for cardiovascular disease and 39% of obese children had at least two risk factors

CONTRIBUTING FACTORS TO OBESITY

• Genetics: According to the National Institute of Health, several studies have shown that adopted children have weights closer to their biological parents than to their adoptive parents

• Metabolism: The resting metabolic rate (RMR) – the energy needed to keep the body functioning at rest – can vary substantially from one person to another, which may help explain why some people gain weight quicker than others and find it more difficult to lose weight

• Culture: Foods specific to certain cultures can contribute to obesity. Research also shows that individuals

originally from other countries have difficulty adjusting to the calorie-rich foods offered in the U.S.

• Illness: Hypothyroidism, Cushing’s Syndrome and Polycystic Ovary Syndrome are a few of the medical conditions that are associated with weight gain

• Environment: Lifestyle, dietary habits and physical activity have a particularly strong influence on the likelihood of being or becoming obese

• Psychological issues: Many people overeat or binge to suppress emotions or escape from problems

RISKS ASSOCIATED WITH OBESITY

• Morbid obesity is associated with more than 30 illnesses and medical conditions including: Type 2 diabetes,

coronary heart disease, stroke, hypertension and cancer. Other conditions include: asthma, osteoarthritis, joint

degeneration, cirrhosis of the liver, venous stasis disease, infertility, pregnancy complications, gastroesophageal

reflux disease (GERD), chronic headaches, liver disease, sleep apnea, lower back pain and urinary incontinence

• Obesity is associated with 112,000 excess U.S. deaths each year;14 obese individuals have a 10 to 50% increased

risk of death compared to individuals of healthy weight7

WEIGHT CLASSIFICATIONS FOR ADULTS

• Body Mass Index (BMI) is the most common measurement tool to assess body fat, calculated by dividing weight in kilograms by height in meters, squared:

Weight in kilograms

Height in meters

• Super obese: A person with a BMI of 50 or more o 50,000 adults are super obese in the U.S.

• Morbidly obese: A person with a BMI of 40 or more, or a BMI of 35 or more with an obesity-related disease, such as Type 2 diabetes, heart disease or sleep apnea

o 15 million adults are morbidly obese in the U.S.

• Obese: A person with a BMI of 30 – 39.9

o 64 million adults are obese in the U.S.

• Overweight: A person with a BMI of 25 – 29.9

o 134 million adults are overweight or obese in the U.S.

OBESITY IN AMERICA

Childhood Obesity in America

2011-07-11T12:59:00.000-07:00

Childhood Obesity in America

Overview

Childhood obesity in America has been on the rise and has reached a level higher than elsewhere in the world. Obesity is defined as an excessive accumulation of body fat. Fast food, food high in fat or sugar, processed foods, or just poor diets are contributing factors to this problem; genetic or hormonal causes may also be a factor. Children and adolescents that are obese face serious health and social issues that may impact their self-esteem or future well being as an adult.

In the United States between 5-25% of children and teenagers are obese. Children that are obese as a child will most likely be overweight or obese as an adult (as high as 80%). As with adult-onset obesity, childhood obesity has multiple causes that center around an imbalance between energy consumed (calories obtained from food) and energy expended (calories expended in the basal metabolic rate and physical activities). Childhood obesity most likely results from an interaction

of nutritional, psychological, familial, and physiological factors (ERIC Digest 1990 ED.328506).

It is my strong belief that obesity would be easier to prevent than to treat, so the main focus of this unit will be educating students to make healthy food choices, build self-esteem and exercise on a daily basis. Diet management, heredity, metabolic factors, social and emotional disorders will be explored.

This unit will be taught at Dimner Beeber Middle School, located in the Wynnefield section of the city, to 6th, 7th, and 8th grade students during their Science Lab classes. The periods are seventy five minutes long and the students come once a week. The lessons from this unit may be adapted for classes of different lengths.

Childhood Obesity in America

Rationale

Acknowledging and evaluating the current rise in obesity in the United States and throughout the world is important for many reasons. Scientifically, when a problem is clearly defined, its solutions or remedies etc. may have dramatic effects on the targeted population. The benefits may be long or ever-lasting.

Raising self-esteem, making healthy food choices and exercising on a regular basis may be the rewards of attention given to the health problem of childhood obesity today. The main focus of this unit will be to raise awareness of the problem of childhood obesity and present possible ways of preventing this problem through maintaining a healthy lifestyle.

Prevention is recognized as the primary, and most efficient, means to combat obesity. However, many children and adolescents who are already overweight or obese require assistance both to prevent further weight gain and to prevent development of obesity-related co-morbidities in adulthood (Hills, King and Byrne 2007).

In this unit suggestions will be made, strategies developed and lessons planned to address this problem of obesity at Beeber Middle School. There are 507 students currently enrolled, and I have the Body Mass Indexes of 440 of the students that were screened by the school nurse.

Body Mass Index

Beeber Middle School Students

1% of the students fall into the underweight percentile, 68% of the students fall into the normal or average percentile, 3% of the students fall into the at risk of becoming obese and 28% of the students are obese. The majority of the students fall into the normal range, however, 31% of the students fall into the ‘at risk’ or obese range.

BMI is calculated as weight(kg)/height(m2) or weight(lb)/height(in2)

x 703. The result is plotted against age on a gender-specific BMI curve(Fig. 5.1and 5.2).

BMI will help identify children who are obese (BMI >95th percentile), overweight (BMI between the 85th and 95th percentiles), normal weight (BMI between the 5th and 85th percentiles), or underweight(BMI under the 5th percentile for age and gender).

When applied to an individual child, the calculation of BMI allows for classification and prompts further evaluation of individual risk factors for obesity and obesity-related co morbidities. (Hassink 2007)

The BMI classification method is still deemed to be contentious by some researchers. For example, some argue that BMI standards apply mainly to the populations whose data were used to determine the cutoff points (Fu et al., 2003; Misra, 2003). Others defend the present cutoffs and contend that they are simple, uniform definitions of overweight and obesity that hold across populations (Stevens, 2003). Despite the ongoing debate regarding cutoff points to define obesity, in agreement with Cole et al. (2000), the choice to use the BMI cutoff percentiles passing through the adult BMI cutoff point of 30 seems to be reasonable (Luciano et al., 2003). However, the use of population-specific cutoff points would clearly be the preferable choice, where available. In contemporary children, fat-free mass (FFM) and fat may contribute in the same way to the values of BMI as for the reference child (Wells et al., 2002). BMI also correlates with other parameters. For example, there is a slightly higher correlation between BMI and subscapular skin fold than weight-for-height index and the same parameter. This is also true for other cardiovascular risk factor variables (blood pressure, serum lipids, and lipoproteins) regardless of age-for-sex groups. However, weight-for-height measures are not superior to BMI as an indicator of obesity (Frontini et al., 2001).A study by Wright et al., (2001) found BMI at age 9 was significantly correlated with BMI at 50, but not with percentage of body fat. After adjustment, BMI correlated with selected health risks. (Parizkova and Hills)

The current rise in the attention given to the increase in childhood obesity has been accompanied by a growing body of literature investigating the relationship between potential risks of obesity and body fatness and the associated preventative measures. We know that there are some risk factors that affect some children more than others. However, there are certain risk factors that can predict a child’s chance of becoming obese. A systematic review (Parsons et al., 1999) identified seven risk factors: parental fatness, social factors, birth weight, timing or rate of maturation, physical activity, dietary factors and other behavioral or psychological factors. (Cameron, Norgan, Ellison)

With these factors in mind, the lessons of this unit will address making healthy choices for maintaining a health lifestyle.

Objectives

Most children, given information about making healthy food choices, will see a reduction in overweight or obesity, or not become at risk of gaining excess body fat, if they maintain a rigorous physical regimen or increase daily exercise. The goal of this unit is to help children maintain a healthy body weight by making healthy food choices while

exercising daily. The students will be taught to recognize the importance of physical activity, the importance of a balanced diet, understand the importance of adequate relaxation and sleep and develop or maintain a positive self-image.

Strategies

Students will use a variety of resources, instructional input and hands-on activities. They will evaluate web sites, compare nutrional values and calculate BMI to help them maintain a healthy lifestyle.

Classroom Activities

Lesson One

What Factors Affect a Healthy Lifestyle? -1

Pre-class -Students will discuss in small groups the factors they think will affect a healthy lifestyle. 5-7 minutes.

Classwork: Students will read “What Factors Affect a Healthy Lifestyle?” worksheet. (www.worldteacherspress.com) page 9. After reading the information, students will respond to and answer questions from the worksheet “What Factors Affect a Healthy Lifestyle?”(www.worldteacherspress.com) page 11 - 2 20 -minutes

Assessment: Students can discuss and compare what they have learned from the lesson. 10 -minutes

Lesson Two

What is Exercise and Its Benefits?

Pre-class - Have students list all the activities that they consider to be exercise. 5-7 minutes.

Classwork: Have students go to http//familydoctor.org/online/famdocen/home/healthy/physical/basic/059.html (google -exercise benefits of #2)

Students will research the benefits of exercise using a website.

In small groups students will plan exercise activities that can be used during 10, 20, or 30 minute periods (jumping jacks, sit-ups etc). Students can compile activities to be done in a circuit, rotating every 2 or 3 minutes, depending on the time period and the amount of activities to be done.

Assessment: Encourage students to use what they have created on a daily basis. Have them write about any changes or new ideas.

Lesson Three

Self–Management / Self-Esteem

Pre-class - Have students brainstorm various aspects of his/her life which may need changing. 5-7 minutes

Classwork: Students will develop a self-management system that can be used in everyday life.

Part 1 - Have students list at least five strategies for maintaining a healthy or a balanced lifestyle. (Example - healthy diet, exercise, proper amount of sleep, release of stress, relaxation etc). 10-20 minutes

Part 2 - Students will make a chart utilizing the strategies for self-management, diet and exercise. The chart should allow them to record, on a daily basis for at least a week, information including amount of time spent exercising, sleeping and pursuing leisure time. The chart should also include space to record the amount of food and drink consumed. 10-20 minutes

Assessment: Have students set goals for themselves and maintain a daily diary/log on the strategies they felt were important for a balanced, healthy lifestyle. Students should share what they have written periodically.

Annotated Bibliography/Resources

Teachers list

A Clinical Guide to Pediatric Weight Management and Obesity

Sandra Gibson, Lippincott, Williams & Williams Phila. Pa. 2007

This book’s purpose is to increase understanding of the epidemiology, pathophysiology, and effects of childhood obesity.

Childhood Obesity and Health Research

Richard K. Flamenbaum Editor, Nova Science Publishers Inc. New York, 2006

This book focuses on clinical issues, preventions and interventions of childhood obesity.

Childhood Obesity - Prevention and Treatment

Jana Parizkova and Andrew Hill, Second Edition, CRC Press. Boca Raton, Fl. 2005

This book highlights recent research on aspects related to the prevention and management of childhood obesity.

Evaluation and Treatment of Childhood Obesity

Rebecca Moran MD,American Family Physicans >vol. 59. No. 4 (Feb. 15, 1999)

This article focuses on maintaining a healthy weight and gives information about losing weight.

Child and Adolescent Obesity - Causes and Consequences, Prevention and Management

Edited by Walter Burniat, 2002

This book addresses the ever increasing problem of

obesity, long term health and social problems that arise.

Underage & Overweight: America’s Childhood Obesity Crisis- What

Every Family Needs to Know

Frances M Berg, Haiheriegh Press Long Island City, NY, 2004

This is a research, evidence-based book that emphazies the importance of a multifaceted approach to alleviating the childhood crisis of obesity.

Students and Teachers

Children, Obesity and Exercise: Prevention, treatment and management of

childhood and adolescent obesity.

Edited by Andrew P. Hills, Neil A. King and Nuala M. Byrne, Routledge NY. 2007

Through sports and exercise this book provides an accessible and practical guide to understanding and managing childhood and adolescent obesity.

Childhood Obesity - Contempory Issues.

Edited by N. Cameron, N.G.Norgan and G.T.H. Ellison, Taylor and Frances Group, Boca Raton, Fl. 2006 This book provides an up to date account of the increase of obesity in children, its causes and its preventions.

Healthy Choices - Diet -Exercise - Self-Management

World Teachers Press, www.worldteacherspress.com, Didax Inc., Rowley MA. 2006

This book provides teachers and students with practical and content- rich materials to address three levels of instruction; self-management, diet and exercise.

Deciphering Food Labels http:/www.kidshealth.com/parent/nutrition_fit/nutrition/food_labels.html

Nutritional facts are explained and suggestions are given for creating a well balanced diet.

How to Understand and Use the Nutrition Fact Label

http:/www.cfsan.fda.gov~dms/lab-gen.html

Label-building skills are used to make it easier for understanding nutrition labels to make quick informed food choices that contribute to a healthy diet.

Healthy Eating

http:/www.kidshealth.org/parent/nutrition_fit/nutrition/habits.html

Base around the idea that good nutrition and a balanced diet help kids grow up healthy. Gives strategies to improve nutrition and encourage smart eating habits.

Childhood Obesity on the Rise, Carol Torgan Ph.D

http:/www.nih.gov/news/WordonHealth/jun2002/childhoodobesity.html

Gives advice and suggestions for helping children maintain healthy body weight.

Appendices-Standards

Standards

Health Education Standard 1

Students will comprehend concepts related to health promotions and disease prevention to enhance health.

6-8 1.8.1 Analyze the relationship between healthy

behaviors and personal health.

1.8.2 Describe the interrelationships of emotional, intellectual, physical, and social health in adolescence

1.8.3 Analyze how the environment affects personal health.

1.8.4 Describe how family history affects personal health.

1.8.7 Describe the benefits of and barriers to practicing healthy behaviors.

Health Education Standard 2 Students will analyze the influence of family, peers, culture, media, technology and other factors on health behaviors.

2.8.1 Examine how the family influences the health of adolescence.

2.8.3 Describe the influence of culture on health beliefs, practices and behaviors.

2.8.4 Analyze how the school and community can

affect personal health behaviors.

Health Education Standard 3 Students will demonstrate the ability to access valid information and products and services to enhance health.

3.8.1 Analyze the validity of health information, products and services.

3.8.2 Access valid health information from home, school, and community.

3.8.5 Locate valid and reliable health products and services.

Health Education Standard 4 Students will demonstrate the ability to use interpersonal communication skills to enhance health and avoid or reduce health risks.

4.8.1 Apply effective and verbal and nonverbal

communication skills to enhance health.

4.8.2 Demonstrate refusal and negotiation skills to avoid or reduce health risks.

4.8.4 Demonstrate how to ask for assistance to

enhance the health of self or others.

Health Educations Standard 5 Students will demonstrate the ability to use decision-making skills to enhance health.

5.8.1 Identify circumstances that can help or hinder healthy decision making.

5.8.4 Distinguish between healthy and unhealthy

alternatives to health-related issues or

problems.

5.8.7 Analyze the outcomes of a health related

decision.

Health Education Standard 6 Students will demonstrate the ability to use goal-setting skills to enhance health.

6.8.1 Assess personal health practices.

6.8.2 Develop a goal to adopt, maintain, or improve a personal health practice.

6.8.3 Apply strategies and skills needed to attain a personal health goal.

6.8.4 Describe how personal health goals can vary with changing abilities, priorities and responsibilities.

Health Education Standard 7 Students will demonstrate the ability to practice health-enhancing behaviors and avoid or reduce health risks.

7.8.1 Explain the importance of assuming responsibility for personal health behaviors.

7.8.2 Demonstrate healthy practices and behaviors that will maintain or improve the health of self or others.

7.8.3 Demonstrate behaviors that avoid or reduce health risks to self and others.

Health Education Standard 8 Students will demonstrate the ability to

advocate for personal, family and community health.

8.8.2 Demonstrate how to influence and support

others to make positive health choices.

8.8.3 Work cooperatively to advocate for healthy individuals, families, and schools.

Appendices

Governors Fitness Challenge

Governor Edward Rendell has issued a challenge for Pennsylvania’s school children to make life-long healthy food choices. Specifically the Governor wants the children to maintain good nutrition with daily activity in an attempt to reduce overweight and obesity in our state. This unit will support the Governor;s initiative by offering opportunities for our children and their families by providing information to help them make healthy food choices while exercising daily. The 5-2-1 rule will be promoted.

5-2-1 Rule

The 5-2-1 rule is a suggested guideline for healthy living:

”5” Eat 5 servings of fruits or vegetables a day.

“2” Spend no more than 2 hours a day watching TV or playing video games or on the computer

“1” Spend one or more hours a day being physically

active.

Childhood Obesity in America

Acne Pimples

2011-03-28T10:15:00.000-07:00

Acne Pimples

What is acne (pimples)?
Acne (pimples) is a very common skin condition that affects most secondary school students at some stage. Because acne is so common, many people refer to it as a normal part of growing up. Even though acne is a common problem, it can have serious effects on the way a young person performs at school and acts socially.
A pimple begins as a blockage to a sebaceous (oil) gland duct. This usually starts at puberty when certain hormones are released. The hormones cause the sebaceous glands to overproduce sebum (oil). We normally have dead skin cells and bacteria on the surface of our skin, which can combine with the sebum to form a plug in the hair follicles. These plugs are known as closed comedones (white heads) or open comedones (blackheads).
What happens then all takes place under the skin. Even though the sebaceous gland duct is blocked, oil continues to be produced and the gland keeps getting bigger and bigger, a bit like a balloon. Bacteria grow in the blocked gland and produce fatty acids and other very irritating substances.
Eventually the balloon bursts and releases the irritating material. This causes
intense inflammation which is what we see as the pimple.

There are several different types of spots (pimples) including blackheads, white heads, papules, pustules, nodules and cysts. A person with acne will often have a mixture of different types of spots, although one type may be more common. Acne usually occurs on the face, neck, chest, back and shoulders where there are large numbers of sebaceous glands.

What causes acne?

Some advice on caring for the skin for people with acne

Myths about Acne

How can acne be managed and treated ?

Mild Acne - Moderate Acne

Severe Acne

Severe Acne

2011-03-28T09:30:00.000-07:00

Severe Acne
The most severe forms of acne characterised by many nodules, cysts and deep scarring on the face, neck and/or back, require treatment to prevent further acne and to prevent scarring. Oral retinoids (isotretinoin) are used to treat severe acne and can only be prescribed by a skin specialist (dermatologist). Treatment with isotretinoin generally lasts 5-7 months.
It requires careful follow-up by the dermatologist to make sure that no side effects occur with the medication.
The following table gives details of the various products available for the treatment of acne, whether they need a prescription, and the type of acne they may be used for.

Acne Treatment

Severe Acne
Source: Department of Dermatology, St. Vincent’s Hospital Melbourne, Victoria Parade,
Fitzroy, Victoria 3065 Australia.

Mild Acne - Moderate Acne

2011-03-28T09:13:00.000-07:00

Mild Acne
Topical preparations which may be in the form of creams, lotions and gels,are applied directly to the skin. They are designed to remove the comedones,i.e. the block in the gland, so that normal sebum flow can occur. They alsoreduce the bacterial content of skin and within the sebaceous gland.
The topical preparations most commonly used are available over the counterwithout a prescription. If the acne becomes more extensive or more active, a topical preparation available by prescription from a doctor may be required. Topical preparations need to be used on all the areas where acne tends tooccur, not just on the inflamed spots present today. In this way, they will prevent future spots appearing.

Moderate Acne
For more moderate acne, oral antibiotics may be required in addition to topical preparations. Oral antibiotics must be prescribed by a doctor. Once the acne is under control, oral antibiotics will no longer be necessary. However, the use of a topical preparation should be continued for some time. Oral anti-androgen drugs which are also used as oral contraception may be used by females to treat moderate acne. They are available only on prescription by a doctor.

How can acne be managed and treated ?

2011-03-28T08:57:00.000-07:00

How can acne be managed and treated ?
There are some very effective treatments for the management of acne.
Virtually all of them are directed at preventing acne, rather than treating the spots that exist today.
Treatment for acne usually needs to be used for at least one to two years.
The treatment used varies between individuals and depends on the type of acne. Some young people with minimal acne (a small number of blackheads and whiteheads) may not require any treatment at all.

How can acne be managed and treated
Mild Acne - Moderate Acne
Severe Acne

Myths about Acne

2011-03-28T08:50:00.000-07:00

Myths about Acne
Most people have been given advice on how to avoid acne or treat acne, such as "get plenty of sun", or "don't worry about it - everyone gets it and it's a normal part of growing up".

While those providing the advice are trying to help, there are many myths about acne that have been passed down through generations.

Some common myths are:

* Eating chocolate causes acne
* Acne is related to a bad diet
* Acne is the result of a bacterial infection and can be spread from one person to another, or from one part of the face to another in the same person
* Acne is an allergic reaction to something
* All types of make-up cause acne
* Acne is due to poor personal hygiene
* Acne is caused by oily hair
* Blackheads are dirt trapped in the skin and are a result of poor personal hygiene
* Squeezing pimples will make them spread
* Lying in the sun or using a sun lamp will clear acne

Some advice on caring for the skin for people with acne

2011-03-28T08:32:00.000-07:00

What about diet ?
"I ate too much chocolate on the weekend and now I have a pimple!!” Most of us have heard statements like this or perhaps said it ourselves. But there is actually proof that chocolate, fatty or fried foods, dairy products, cakes or sweets can cause acne or make acne worse. This does not mean that a person can exist solely on a diet of chocolate and cake and expect no acne to develop! But for most people on a healthy balanced diet, eating the occasional chocolate or sweet does not seem to make any difference to acne.

Some advice on caring for the skin for people with acne

Some people with acne can spend many years trying to work out a good method of caring for their skin. The best advice is to keep some basic principles in mind. Remember that even though a product is expensive, has an exclusive brand name and is in an attractive bottle, it does not mean that it is better than many of the products you can buy from the supermarket.
Washing your face with a mild soap morning and night will help to keep your skin clean and remove the excess oil. Washing your face more frequently than this can cause excessive dryness of the skin. It is not really necessary to use an antibacterial face wash or a special soap, although some believe they may be useful in the prevention of minimal acne only.
Application of toners or skin fresheners is unnecessary, and products of this type can be very expensive. It is also unnecessary to apply a moisturiser to skin affected by acne, and some products may add to the problem. Remember - many products available on the market are claimed to be essential for acne sufferers and can cost large sums of money. Much of their
marketing targets those who are very concerned about their condition and will try anything, even if the claims made about the product are not entirely accurate.

What causes acne ?

2011-03-28T08:13:00.000-07:00

What causes acne?
Although we do not know the exact cause of acne, there are many factors which can lead to acne and these can vary from person to person. Occasionally, there may be a history of members of a family, such as one parent and several of the children, with severe acne. But in general, the tendency to acne is not inherited.
Going through puberty
Acne does not usually develop until a person reaches puberty when the hormones which stimulate sebaceous glands are first produced. These hormones include testosterone. Acne usually appears earlier in females than males, because females tend to start puberty earlier. Males often have more severe acne than females, as they have much higher levels of testosterone.
Having a period (menstruation)
Many females experience a worsening of their acne in the few days before their menstrual period. This is associated with the changing levels of hormones. The changing hormone levels can also cause some females to feel anxious and irritable. Some find that they tend to pick and squeeze their spots more at this time, which can also make acne worse.

Applying makeup
Acne can be made worse by certain cosmetics. Some cosmetics contain oils which can increase the blockage in the sebaceous glands. Those with acne should avoid using oil-based cosmetics and try preparations that are water-based and less likely to cause problems. Some sunscreens can also increase blockages in the sebaceous glands. This does not mean that someone with acne should avoid using a sunscreen. But it would be best to check the ingredients in the sunscreen and use a preparation that is not oil-based.
Stress
Stress can cause people to feel worried and anxious. Many say that their acne is worse in times of increased anxiety such as before going out for a special occasion. Nevertheless, there is little evidence that stress can cause acne in someone who has never been affected by it. Some people tend to make their acne worse by picking and squeezing spots more often when they
are worried or anxious.

What causes acne

did you know?
When somebody has acne, it does not mean that they lack hygiene or cleanliness. A "blackhead" does not have a black appearance as a result of dirt being trapped in the skin. The black colour is due to a chemical reaction when the sebum or oil comes into contact with the air.
نادي السيارات السياحة في تركيا سيارات مستعملة للبيع

all about acne

2011-03-27T15:32:00.000-07:00

all about acne

Many of us complain at times about our ‘acne’. But what most of us are experiencing is simply an annoying pimple or two. Real acne can be a debilitating problem that can leave a sufferer emotionally and physically scarred.
Dermatologist Charles Crutchfield MD, Clinical Associate Professor at the University of Minnesota Medical School, describes acne as a complicated disease process that is
driven by both genetic and hormonal influences.
He says that acne is, essentially, a disorder of the pilosebaceous unit. ‘What this means is that the human body, through evolution, is covered with millions and millions of hairs. These hairs come out of a follicle. Over time, these hairs have become miniaturized. Some are so small you can’t see them, but you certainly can see the follicles in the skin where the hairs protrude. These are commonly referred to as pores.
At the bottom of the pore, there is an oil gland called a sebaceous gland. The pore itself is like a tube, and the hair comes out of it. Sebaceous glands are found in high concentrations on the face, chest, shoulders, and back. These are the most common areas where acne
can occur.’ Over time, he explains, the cells that line the follicular tubes where the hairs come out don’t behave properly.

This usually occurs under hormonal influence. Hormonal changes occur during adolescence, and that’s the reason why acne tends to occur at the beginning of adolescence.
‘The skin cells in the pores will stick together and form clumps. These are often known as comedones, or white-heads. Sometimes the material in the clump will oxidize and become dark. These are known as blackheads. When the oil tries to escape from the follicle but can’t because
there is a plug in the way, it will build up and form a nodule.
Bacteria that live in the skin migrate into the area and use the sebum as a food source. By-products of this bacterial presence will often cause inflammation. Inflammation brings in white cells that eventually die and turn into pus,’ explains Dr . Crutchfield. ‘This is why acne is really a wide variety of disease states, from small bumps to nodules to red inflammatory nodules and pustules,’ he says. ‘As you can see, acne is a very sophisticated disease and different components of the pathway are present to different degrees in different people. That’ s why there’s rarely a one-size-fits-all approach to the treatment of acne.’
Many of the treatments used to treat acne are designed specifically to address different stages in this pathway, causing the skin cells to mature properly, addressing the bacterial component with antibiotics, addressing the anti-inflammatory component, and addressing the production
of oil in the skin.

‘I tend to be very aggressive in my acne treatments.
My philosophy is, if you are going to spend the time, effort, energy, and money to treat a condition, let’s use the best possible tools to get the best results,’ he says. ‘I tend to have the best results when I design an overall program that encompasses many smaller treatments that will work together in a synergistic manner. I use a combination of these treatments that normalize the way the skin matures under the influence of hormones. I also use treatments that will break up any of the newly forming plugs and comedones, attack the bacterial presence in the area,address the inflammation, and sometimes treatments that will calm down the oil production in the patient’s skin.’
In designing an individual’s acne treatment program, Dr. Crutchfield looks at patient distress, how long they have had the acne, what effective treatments they have tried in the past, whether they are starting to form acne scars and whether they have a family history of acne. ‘I also evaluate the type of acne that they have, be it comedonal, papular, inflammatory/pustular, or nodulocystic.
This will assist me in selecting the right combination of therapies to treat them.’ He adds that because everyone’s skin chemistry is different, it’s important that a board-certified dermatologist manages the treatment of complicated acne. ‘Patients’ responses need to be monitored carefully and medicines need to be adjusted accordingly. Because medications
can have side effects, it is important to balance the positive and negative to make sure that the benefits of acne therapy and the results outweigh the risks of treatment. Some of the common side effects with these treatments can be irritation, sun sensitivity, mild stomach upset, yeast infections and dry skin.’

Dr. Crutchfield recommends the Aramis laser for acne treatment. ‘This is a glass erbium laser that has FDA approval to treat mild to moderate acne. The mechanism of action is to interact with the oil glands in the skin and suppress oil production. Usually treatments can take place anywhere from once a week to once a month, usually with six to 10 treatments needed to be effective. I find this works in the vast majority of patients and I use it as a component in our
overall acne treatment program,’ he says. ‘Patients have responded well to the Aramis. I also like it because it is completely painless as opposed to some of the other laser options that tend to hurt quite a bit. I think the Aramis is far superior to any other light or laser system that is designed to treat acne.’

What can be done about acne scarring? Dr . Crutchfield says he is often confronted with distressed patients who ask for help with their acne scarring. ‘Unfortunately, when I look at their face, in addition to seeing acne scarring, I will often find active inflammatory acne. I explain that my approach is to first clear up any acne; otherwise, we will end up chasing our tail. If we treat the scars and the patient develops new ones at the same time because their acne is not addressed, our efforts will have minimal results,’ he explains. Dr. Crutchfield’s protocol in such a case would be to start with an aggressive anti-acne treatment program and then address any residual scars. He says that it is also important to note that many patients believe they have acne ‘scars’ when really what they have is what is called post-inflammatory hyperpigmentation.
‘To me, a scar is a permanent change in the skin with fibrosis. I explain to patients that a scar can never be changed back into normal skin. The approach is to make the scar look as close to normal skin as possible so the contrast is not as great. The best way I can treat acne
scarring is to prevent it.’ As for future treatment options, Dr. Crutchfield expects to see combination products that will include both a benzoyl peroxide and topical antibiotic. ‘This is great for addressing both the bacteria and the anti-inflammatory component of acne with a mild ability to break up the comedonal plug’. The experience of the physician in treating acne and the extensive range of treatments that are now available are having a significant impact on the quality of life for many acne sufferers. cbm

new study reveals fda approved laser acne scar and acne treatment

2011-03-26T07:32:00.000-07:00

new study reveals fda approved laser acne scar and acne treatment:

treating and preventing acne be a distressing and frustrating experience. even after acne has been successfully treated, many patients are left with unsightly scaring from inflamed acne. these scars have a devastating psychological impact on both teenagers and adults.

A recent study conducted by DR. david goldberg, board-certified dermatologist, director of the skin laser et surgery specialists of new york et new jersey , and director of skin laser research at nys mount sinai school of medicine, represents a radical new approach to acne scar treatment. DR. goldbergs research has demonstrated that acne scars can be improved without surgery and what it means for patients who are afflicted with acne scars.

Q:DR.goldberg, what does this study mean for those who suffer from acne scarring؟

A: until now acne sufferers have had no non-invasive, cosmetically elegant option
for residual scarring.
traditional methods of acne scar tretment have been surgical in nature.commonly used techniques include skin grafting, skin excisions or dermabrasion. although these approaches do lead to some type of improvement in acne scarring, they are noted by their 1-2 week post-surgical recovery time (dermabrasion), or the replacement of one scar with another scar (skin grafting or acne scar excisione). my study indicates that the cooltouch laser, a highly popular laser in the treatment of early aging skin, can also vastly improve acne scarring.

Q: how does this treatment work
A: this new study was based on previously published research in the journal dermatologic surgery and the journal of cutaneous laser surgery. in those studies, l exhibited that the cooltouch laser, could not only help to improve aging patients. in the current study, because the laser produced new collagen at the depth of the treated acne scars, both treated patients and independent observers noted improvement in the depth and appearance of the treated scars.
Q: what does the procedure entail
A: the skin is treated with the laser and the treatment is approximately 15 minutes in length. the procedure results in no perceptible wound. because treatments do not involve any breakage in the lasered skin, there is little potential for complications. the procedure is not onlynon-invasive, but is safe and effective. in fact, based in part upon this study and its findings, the FDA approved the use of the cooltouch laser for the treatment of both acne scars in may of 2003.

Acne ..The Long Story

2011-03-22T10:16:00.000-07:00

Acne (The Long Story)
If you are old enough to read this article you have had first-hand experience with acne. What follows is a rational approach to the treatment of acne. Defined terms are italicized and can be found in Table I. Acne is an all-encompassing term for skin blemishes, on the face, chest, and back. The location of acne directly corresponds to areas where sebaceous follicles are found in high density. The battleground of acne is within the sebaceous follicle, which is basically a hair follicle with attached oil glands. However, the hair is often absent or underdeveloped. The gland produces oil which is called sebum. Androgens (masculinizing hormones produced by both men and women) increase sebum production markedly. It is no coincidence that
acne begins at puberty when sebum production accelerates in response to hormonal changes.
Sebaceous oil would not be a problem if it flowed freely onto the surface as it does on the scalp. However, a second key event in the formation of acne occurs; this event is the formation of an oil-duct plug, known as a microcomedone. Cells lining the duct of the sebaceous follicle peel off the side and combine with the oil to form a tight little plug. Behind this plug acne bacteria proliferate, metabolize the sebum, and create an inflammatory reaction. Rupture of the plugged gland causes the classic pustule (known as a "zit"), and occasionally, if the reaction is more vigorous, larger papules and nodules. So it takes three elements--sebum, a plug, and the ensuing proliferation of acne bacteria--to create acne lesions. Treatment of acne is predicated
on the elimination of one or more of these pathogenic elements.
THE "DIRT" MYTH
Since acne is not due to dirt, excess washing will not be beneficial. You cannot scrub away what is under the skin, and scouring your face usually makes acne worse rather than better. Washing once or twice a day with a mild soap is okay--just do not overdo it.

THE "DIET' MYTH
Although sebum is an oil, it is not produced in excess by dietary intake of various fats such as chocolate or French fries. Dietary restrictions, while good for your arteries, will not alter acne problems. The oil that causes a problem with acne is not on the face. Drying the oil off your face using astringents (drying agents) will not eliminate acne, although you might like the way your face looks or feels after using such a product. This also goes for facials. They are not particularly harmful, although in some cases acne can flare in a delayed fashion following a facial. A facial treatment does not "clean out" the keratin plug described earlier.

THE HORMONAL CONTRIBUTION
Hormones do indeed affect sebum production, so there may be benefit for women who take oral
contraceptives that are predominantly estrogenic. For a few the benefit is unmistakable. For the majority the benefit is modest. For theoretical reasons, some oral contraceptive pills, such as Ortho-Tri-Cyclen, Yasmin and Yaz are preferred for acne sufferers. However, no one has been able to predict which one works best and how you will respond to the pill. Typically it takes two to four months to see the therapeutic benefits from the oral contraceptive pill.
ACNE THERAPIES
Step one therapy for acne has traditionally comprised tretinoin (Retin-A). The rationale for using this vitamin-A derivative is simple: It is comedolytic. It thins the outer layer of skin (the stratum corneum), and slowly over months reverses the formation of the keratin-sebum plugs, which lead to rupture of the sebaceous follicle. That is the good news. The bad news is that it is generally irritating to all but the toughest oilier skin. Newer preparations, such as Avita Cream and Retin-A Micro Gel, seem to be better tolerated but are more expensive. Furthermore, a persistent red flush is seen in many patients on Retin-A. Certain areas of the face, such as the chin, are easily irritated with tretinoin and the frequency of use might be limited to every two or three days until your skin gets used to it. Tretinoin cream can be diluted half-and-half with a moisturizer, such as Eucerin cream. Excess Washing tends to make tretinoin therapy more irritating. It is also frequently forgotten that it may takes months before you see the full benefit of tretinoin.

Step two therapy for mild to moderate acne with simple pimples (known as pustules) and small red bumps (known as acne papules) usually means adding an anti-inflammatory medication to the regimen. The OTC benzoyl peroxides are such medications. Benzoyl peroxide in 2.5%, 5%, and 10% seem to be equally effective, but the 10% is more drying and irritating than the 2.5%. We recommend the 5% lotion used once or twice a day. Benzoyl peroxide works as an antibiotic, suppressing acne bacteria. The drying and peeling effec may seem therapeutic, but it is a side effect. Benzoyl peroxide should NEVER be used at the same time as Retin-A products because it will neutralize the benefit of the Retin-A. Practically this means that you apply the benzoyl peroxide in the morning and the Retin-A before bed. Other useful antibiotic (anti-inflammatory) solutions/lotions include erythromycin, sulfur preparations, and clindamycin (Cleocin-T). These are less irritating but more expensive than benzoyl peroxide. Also, if you have sensitive skin you may need to use a lotion form of the antibiotic. For very sensitive skin, topical sulfur based antibiotics such as sulfacetamide (Klaron, Sulfacet R, etc.) may be the least irritating.

If your acne is more severe, including painful lumps, or if you do not respond to medicines applied on the skin (topical medications), the next step is to consider oral antibiotics. These are especially useful for individuals with severe back acne, which is hard to treat with topical products. Oral antibiotics like tetracycline, doxycycline, minocycline, erythromycin, and Septra (sulfamethoxazole-trimethoprim), all have a place in the treatment of the more severe grades of acne. It takes up to 6-8 weeks to see the full benefit of oral antibiotics. Unfortunately the benefits rarely persist if oral antibiotics are stopped. Some individuals initially improve over
months, only to relapse with severe acne. When this type of resistance, or tolerance, is seen, we often switch to different antibiotics or stop them for a while. The most common side effect of antibiotics is usually some form of stomach discomfort in perhaps 10% to 20% of people, and they will need to try something different. About one in ten to one in twenty women will develop a vaginal yeast infection if they are on prolonged antibiotic therapy. Also allergic rashes can occur to antibiotics, particularly with Septra. If this happens with any antibiotic it should be stopped and reported to your provider immediately. Minocycline (Minocin) can be effective for severe acne and has some peculiar side effects: Occasionally it causes dizziness, darkening of the skin or nails, and very rarely, graying of the teeth.

Below is a ranking of oral antibiotics and a few comments.
1. Minocycline is taken once a day with food.
2. Septra (also known as sulfamethoxazole trimethoprim generically) is cheap and causes the most allergic reactions, but is often effective when other drugs fail.
3. Doxycycline is inexpensive but must be taken with food to minimize indigestion.
4. Erythromycin is very safe (even in pregnancy) but stomach problems are common.
5. Tetracycline is safe and inexpensive, but must be taken on an empty stomach.

NEWER TOPICAL PREPARATIONS

1. Azelex and Finacea are azelaic acid which is a naturally-produced organic acids that has antibiotic properties and some benefit in reducing keratin plug formation. A touted benefit is that it gradually diminishes acne blemishes over three to six months.

2. Differin cream/gel, also known as adapalene, is a new vitamin-A-like product which seems to be about as effective or slightly more effective than Retin-A, but it may be less irritating.
3. Tazorac cream/gel is an agent that works similar to tretinoin (Retin A).
4. Salicylic acid (a beta hydroxy acid) can be found in products such as Neutrogena acne pore treatment. Beta-hydroxy acids and Alpha-hydroxy acids, such as glycolic acid or lactic acid, are widely available in drug stores, and may be useful for mild acne. A program that combines several different topicals that we have discussed is Proactive. The alpha and beta hydroxy acids are keratolytic acids which have a peeling effect on the skin. They unseat some blackheads and whiteheads, but can be irritating to sensitive skin. They can be used in combination with other drugs like topical erythromycin or clindamycin. I do not usually use these with retinoids, such as Retin-A or Avita, because the combination is particularly irritating.

ANSWERS TO FREQUENTLY-ASKED QUESTIONS

Is there an important antibiotic/birth control pill interaction?
Most of the commonly-used oral antibiotics (for example, tetracycline, erythromycin, Septra, minocycline) do not negate the birth control effect of oral contraceptives, although the Physician's Desk Reference (PDR) makes statements to the contrary. There are some theoretical reasons why the oral contraceptive effectiveness might be reduced, but when this has been studied, oral contraceptive failure when antibiotics areused at the same time is extremely rare. Of course, using a backup method can eliminate any concern and has its own benefits. There is a large literature base on this particular subject and you should discuss it further with your practitioner.
Can I change my pores?
Your pore size is inherited and cannot be changed permanently by acne medicines. However, physical treatments such as deep peels, surgery, and laser treatment may smooth the skin surface and make pores less noticeable.

What do we do for the really bad (scarring) acne that responds poorly, if at all, to oral antibiotics?
The remedy for this group of patients is Accutane (isotretinoin). A typical candidate for this includes someone who has tried topicals and at least one or two different oral antibiotics without success. There are individuals who are physically and emotionally scarred by their acne, and they should be afforded a potential cure. Accutane in long-term studies seems to cure 60%-80% of severe acne types. Typically, it is used for sixteen to twenty weeks and may be repeated two or three times. It may fail to provide lasting benefit to teenagers and they may need one or two additional courses years later. Also, it fails more often in those with very severe
back acne. A separate detailed account of the side effects associated with this medication can be found under "Accutane" in the Skin Problem List.

CONCLUSION
If you have been able to wade through this discussion of acne, you realize there is a logic to the various
treatments. Depending on your skin type and grade of acne, we can help you choose a regimen that will work
for you. One area that was not discussed under "Acne" but is discussed further under "Scars" is what to do
about acne blemishes, marks, and scars.