Shortly after the discovery of antibiotics, infectious disease and public health authorities proposed that infectious agents had been "tamed." Not so .the combination of antibiotic-resistance, "new" bacteria and viruses, neglected or deteriorating public health measures, poverty, malnutrition, immune-deficient patients, and bioterrorism have combined to render the previously stated optimism incorrect and create continuing new and fearful challenges.
Piet Hein, the Danish writer/cartoonist put it well: Problems worthy of attack prove their worth by striking back.
Human papillomavirus is the most prevalent STD in the world, occurring at some point in up to 75% of sexually active women. Nearly all cervical cancers are directly linked to previous infection with one or more of the oncogenic types of HPV. Other risk factors for cervical cancer include sexual activity at a young age, multiple sexual partners, immunosuppression and HIV infection.
Can a vaccine prevent infection and, therefore, cervical (and other) cancers? If so, who should get the vaccine? When? Males as well
as females? How long does vaccination last? Are there dangers to vaccination?
HPV is the most prevalent sexually transmitted infection in the world. And, unlike other STDs such as gonorrhea or HIV/AIDS, use of
condoms and other safe-sex practices may not be nearly as effective in preventing infection. This is because the papilloma virus
lives in the skin (squamous) cells covering the pubic area (vulva and shaft of the penis) as well as the interior cells lining the
vagina and cervix in women, and urethra and anus in both sexes. Condoms do not cover the entire shaft of the penis nor do they block
contact with pubic skin. Therefore, during intercourse, even with a condom, skin cells containing HPV can come in contact with a
woman's vulva or vagina, enabling the virus ultimately to reach the cervix. In addition, the friction of sexual intercourse is believed
to cause tiny, microscopic tears in the vaginal wall, making transmission far more likely. Moreover, even dead cells shed during
intercourse can contain the virus and remain infective for days (Roden, Lowy and Schiller 1997).
The most effective way to prevent cervical and other genital cancers would be a vaccine. Individuals would need to be immunized at an early age before they are sexually active. The benefits of such a vaccine would be particularly significant in developing countries, where women's healthcare services are minimal. Designing a vaccine, however, will not be easy because people's immune response appears to be specific to the type of HPV. For example, a person protected against type 16 would still be at risk of infection with other cancer-inducing types, such as 18 or 33. There also appear to be subtypes or variants within type 16, and perhaps with other types as well. Finally, as mentioned above, the types of HPV associated with cervical disease vary by geographical area. With the increase in international travel, the various carcinogenic types soon will be spread throughout the world. Therefore, a vaccine with a mixture of several types would have to be created (Groopman 1999; Stewart et al 1996).
Despite these problems, safety testing of at least two vaccines that could protect women from cancer-linked papilloma viruses is underway. Estimates are, however, that it will be several years before either would be available, and many more years before they would be affordable in developing countries. Finally, there also are attempts to produce a therapeutic vaccine, one which would boost the immune system of someone who is already infected and cause the cancer to regress or even disappear. These vaccines are targeted to inactivate the E6 and E7 proteins, those viral proteins that block the action of the cell growth regulating proteins (Rb and p53) (Massimi and Banks1997).
Until such time that a protective vaccine is widely available, primary prevention must focus on continuing to change sexual practices and
other behaviors that increase a person's risk of becoming infected. Just as with the fight against HIV/AIDS, risk reduction counseling
related to the risk factors listed above (Table 1) must be incorporated into all levels of the healthcare system, especially those dealing
with young people. The messages must include alerting teenagers that practices designed to minimize the risk of STD or HIV/AIDS exposure
(i.e., the use of male or female condoms) may not be as effective for HPV prevention.1 In addition, vigorous efforts to
discourage adolescents, especially young girls, from starting smoking and initiating sexual activity must be widely and continuously
Although at present prevention of HPV infection is difficult, for women already infected the immediate need is:
Since 1989, JHPIEGO has been exploring the feasibility of several low-cost alternatives for cervical cancer detection. Prominent among these is unmagnified (naked eye) visual inspection using a dilute solution of acetic acid (VIA). In March 1999, researchers from JHPIEGO and the University of Zimbabwe reported in The Lancet that the sensitivity (77%) and specificity (64%) of VIA are comparable to those of good quality Pap smears. This large-scale study, which involved more than 10,000 women attending primary healthcare clinics in Zimbabwe, confirmed the findings of similar studies in South Africa and India (Sankaranarayanan et al 1998). A second major finding from the Zimbabwe study was that nurse-midwives, who did all the VIA tests, quickly learned to competently perform them. This finding is important because the vast majority of developing country women who need to be tested live in areas where there are no doctors and where Pap smears may never be available. Furthermore, unlike Pap smears that require several days to a week to get the results back, with VIA the results are available immediately. As a consequence, these nurse-midwives were able to quickly and easily identify women with no disease, those with abnormal findings suitable for immediate treatment and those with very large lesions or advanced disease requiring referral.
With the establishment of VIA as an acceptable alternative to Pap smears (Kitchener and Symonds 1999), it is now possible to offer VIA with outpatient treatment of precancerous lesions at the same visit. For example, cryotherapy, which involves freezing the cervix with a liquid coolant such as carbon dioxide to destroy the abnormal cervical tissue, is highly effective.
And cryotherapy has been used extensively throughout the world for more than 20 years (Cox 1999; Mitchell et al 1998; Olatunbosun, Okonofua and Ayangade 1992). Cryotherapy is also one of the easiest methods to learn and can be performed by nurses and other healthcare workers. In light of these promising epidemiologic studies and the availability of a simple, low-cost outpatient method of treatment, the opportunity to markedly reduce the incidence of cervical cancer globally is at hand. As the first step (Phase 1) in this process, JHPIEGO is conducting several safety, acceptability, feasibility and program effectiveness (SAFE) demonstration projects in separate regions of the world. These SAFE projects are needed to:
We anticipate the results of these studies will show that well-trained nurses and midwives can quickly and easily identify patients who are appropriate for immediate treatment with cryotherapy or refer those requiring more aggressive treatment (or those with advanced disease). We also expect to learn that a test, treat or referral program is a safe, acceptable and feasible approach for preventing cervical cancer in low-resource settings. Finally, we anticipate identifying ways in which large-scale Cervical Cancer Prevention (CECAP) programs can be implemented nationally through a combination of individual and community education, participation by local nongovernmental organizations and women's groups, and sponsorship by indigenous service organizations and clubs.
This practical approach to preventing cervical cancer has the potential to reduce disease progression and death in a majority of women who
currently do not have access to Pap smears and physician-staffed services. Also, it has the potential to reduce referrals of women with early
lesions to higher levels of the healthcare system as well as increase the chance of detecting invasive cancer at an earlier stage when it can
be treated successfully. Finally, once a precancerous lesion is treated, a woman's risk of developing an infection with other HPV types may
be reduced for several years, while those women found to be normal may not need retesting for 5 or more years (Lonky et al 1997; Lonky et al
Human papillomavirus is the most prevalent STD in the world, occurring at some point in up to 75% of sexually active women. Nearly all cervical cancers are directly linked to previous infection with one or more of the oncogenic types of HPV. Other risk factors for cervical cancer include sexual activity at a young age, multiple sexual partners, immunosuppression and HIV infection. Lacking an appropriate vaccine for HPV, primary prevention of cervical cancer must focus on condom use and changing sexual practices as well as other behaviors that increase a person's risk of becoming infected with HPV.
For women already infected with HPV, the immediate need is to identify those with early, easily treatable precancerous lesions and to treat these
women cost-effectively before the lesions progress to cancer. Visual inspection using a dilute solution of acetic acid (VIA) has been established
as an acceptable alternative to Pap smears. Therefore, it is now possible to offer VIA with cryotherapy, an outpatient treatment that uses a
liquid coolant to destroy abnormal cervical tissue. Cryotherapy is highly effective and has been used extensively throughout the world for more
than 20 years. Once a precancerous lesion is treated, a woman's risk of developing an infection with other HPV types may be reduced for several
years, while those women found to be normal may not need retesting for 5 or more years.
1 A recent case-control study, however, has shown that male condom use, which significantly decreases the amount of infectious virus
deposited in the vagina during sexual intercourse, offers substantial protection (Wen et al 1999).
Dementia (from Latin de- "apart, away" + mens (genitive mentis ) "mind") is the progressive decline in cognitive function due to damage or disease in the brain beyond what might be expected from normal aging. Particularly affected areas may be memory, attention, language and problem solving, although particularly in the later stages of the condition, affected persons may be disoriented in time (not knowing what day of the week, day of the month, what month or even what year it is), place (not knowing where they are) and person (not knowing who they are). Symptoms of dementia can be classified as either reversible or irreversible depending upon the etiology of the disease. Less than 10% of all dementias are reversible. Dementia is a non-specific term that encompasses many disease processes, just as fever is attributable to many etiologies.
Without careful assessment, delirium can easily be confused with dementia and a number of other psychiatric disorders because
many of the signs and symptoms are conditions present in dementia (as well as other mental illnesses including depression and
The prevalence of dementia in the global community is rising as the global life expectancy is rising. Particularly in Western
countries, there is increasing concern about the economic impact that dementia will have in future, older populaces. In Australia,
the 2006 estimated prevalence of dementia is 1.03% of the population as a whole. It is a disease which is strongly associated with
age; 1% of those aged 60-65, 6% of those aged 75-79, and 45% of those aged 95 or older suffer from the disease.
Proper differential diagnosis between the types of dementia (see below) will require, at the least, referral to a specialist, e.g. a geriatric internist, geriatric psychiatrist, neurologist, neuropsychologist or geropsychologist. However, there are some brief (5-15 minutes) tests that have good reliability and can be used in the office or other setting to evaluate cognitive status. Examples of such tests include the abbreviated mental test score (AMTS) and the mini mental state examination (MMSE).
An AMTS score of less than six and an MMSE score under 24 suggests a need for further evaluation. Of course, this must be interpreted in the context of the person's educational and other background, and particular circumstances. Routine blood tests are usually performed to rule out treatable causes. These tests include vitamin B12, folic acid, thyroid-stimulating hormone (TSH), C-reactive protein, full blood count, electrolytes, calcium, renal function and liver enzymes. Abnormalities may suggest vitamin deficiency, infection or other problems that commonly cause confusion or disorientation in the elderly. Chronic use of substances such as alcohol can also predispose the patient to cognitive changes suggestive of dementia.
A CT scan or magnetic resonance imaging (MRI scan) is commonly performed. This may suggest normal pressure hydrocephalus, a potentially reversible cause of dementia, and can yield information relevant to other types of dementia, such as infarction (stroke) that would point at a vascular type of dementia. Sometimes neuropsychological testing is helpful as well.
The final diagnosis of dementia is made on the basis of the clinical picture. For research purposes, the diagnosis depends on both
a clinical diagnosis and a pathological diagnosis (ie, based on the examination of brain tissue, usually from autopsy).
The most common types of dementia are as follows and vary according to the history and the presentation of the disease: (Where
available the ICD-10 codes are provided. The first code refers to the dementia, and the second to the underlying condition.
It can also be a consequence of:
Less than 5% of a sample of dementia cases have a potentially treatable cause. These include:
Except for the treatable types listed above, there is no cure to this illness, although scientists are progressing in making a
type of medication that will slow down the process. Cognitive and behavioral interventions may also be appropriate. Educating
and providing emotional support to the caregiver [or carer] is of importance as well.
[Original article: http://www.mayoclinic.com/health/coronary-artery-disease/DS00064]
Coronary artery disease
How healthy are your coronary arteries? If you eat healthy foods, get physical activity every day and don't smoke, you're well on your way to preventing symptoms of coronary artery disease a leading type of heart disease.
The coronary arteries supply your heart with blood, oxygen and nutrients. When blood flow through the coronary arteries becomes obstructed, it's known as coronary artery disease.
Coronary artery disease is caused by the gradual buildup of fatty deposits in your coronary arteries (atherosclerosis). As the deposits slowly narrow your coronary arteries, your heart receives less blood. Eventually, diminished blood flow may cause chest pain (angina), shortness of breath or other symptoms. A complete blockage can cause a heart attack.
Since coronary artery disease often develops over decades, it can go virtually unnoticed until it produces a heart attack. But there's plenty you can do to prevent coronary artery disease. Start by committing to a healthy lifestyle.
Signs and symptoms
If your coronary arteries become narrowed, they can't supply enough oxygenated blood to your heart especially when it's beating hard, such as during physical activity. At first, the restricted blood flow may not cause any symptoms. As the fatty deposits continue to accumulate in your coronary arteries, however, you may have:
Coronary artery disease is thought to begin with damage or injury to the inner layer of a coronary artery, sometimes as early as childhood. The damage may be caused by various factors, including:
Once the inner wall of an artery is damaged, fatty deposits (plaques) accumulate. If the surface of these fatty deposits breaks or ruptures, blood cells called platelets will clump at the site to try to repair the artery. This clump can block the artery, leading to a heart attack.
Men are generally at greater risk of coronary artery disease than are women. However, the risk for women increases after menopause. A family history of heart disease and simply getting older increases the risk as well.
Other risk factors for coronary artery disease include:
Risk factors often occur in clusters and may feed one another, such as obesity leading to diabetes and high blood pressure. When grouped together, certain risk factors put you at an ever greater risk of coronary artery disease. For example, metabolic syndrome a cluster of conditions that includes elevated blood pressure, high triglycerides, elevated insulin levels and excess body fat around the waist greatly increases the risk of all types of heart disease.
Sometimes coronary artery disease develops without any classic risk factors. Researchers are studying other possible factors, including:
When to seek medical advice
If you have risk factors for coronary artery disease, talk to your doctor. He or she may want to test you for the condition especially if you have signs or symptoms of narrowed arteries. Even if you don't have evidence of coronary artery disease, your doctor may recommend aggressive treatment of your risk factors. Early diagnosis and treatment may stop progression of coronary artery disease and help prevent a heart attack.
Screening and diagnosis
The doctor will ask questions about your medical history, do a physical exam and order routine blood tests. He or she may suggest one or more diagnostic tests as well, including:
Some stress tests are done using an echocardiogram. These are known as stress echos. For example, your doctor may do an ultrasound before and after you exercise on a treadmill or bike. Or your doctor may use medication to stimulate your heart during an echocardiogram.
Another stress test known as a nuclear stress test helps measure blood flow to your heart muscle at rest and during stress. It's similar to a routine exercise stress test but with images in addition to an ECG. Trace amounts of radioactive material such as thallium or a compound known as sestamibi (Cardiolite) are injected into your bloodstream. Special cameras can detect areas in your heart that receive less blood flow.
When your coronary arteries narrow, your heart may not receive enough blood when demand is greatest particularly during physical activity. This can cause chest pain or shortness of breath. If a cholesterol plaque ruptures, complete blockage of your heart artery may trigger a heart attack.
The lack of blood flow to your heart during a heart attack leads to irreversible damage to your heart muscle. The amount of damage depends in part on how quickly you receive treatment. If your heart has been damaged and can't pump enough blood to meet your body's needs, you may experience heart failure.
Lifestyle changes can promote healthier arteries. If you smoke, quitting is the most important thing you can do. Eat healthy foods, and exercise regularly. Sometimes medication or procedures to improve blood flow are recommended as well.
Various drugs can be used to treat coronary artery disease, including:
Procedures to restore and improve blood flow
Sometimes more aggressive treatment is needed. Here are a few options:
On the research front
Researchers are exploring new techniques for treating coronary artery disease, such as gene therapy. In this experimental procedure, genes and growth factor proteins may be injected through a catheter or directly into the heart to stimulate growth of new blood vessels and restore blood flow to the heart. Gene-coated stents that could encourage the repair of coronary arteries are being studied as well.
Lifestyle changes can help you prevent or slow the progression of coronary artery disease.
In addition to healthy lifestyle changes, remember the importance of regular medical checkups. Some of the main risk factors for coronary artery disease high cholesterol, high blood pressure and diabetes have no symptoms in the early stages. Early detection and treatment can set the stage for a lifetime of better heart health.
Also ask your doctor about a yearly flu vaccine. Coronary artery disease and other cardiovascular disorders increase the risk of
complications from the flu.
There is much excellent literature regarding bioterrorism. The following are for general reading for those who are not expert in the field.
Alibek, K. and S. Handelman. Biohazard: The Chilling True Story of the Largest Covert Biological Weapons Program in the World - Told from Inside by the Man Who Ran it. 1999. Delta (2000) ISBN 0-385-33496-6
Alibek was the Director of the USSR biological weapons program.
Judith Miller, Stephen Engelberg, William Broad. Germs: Touchstone/Simon and Schuster 2001.
Jonathan Tucker. War of nerves. Pantheon Press, 2006
Richard Preston. The Hot Zone (history of Ebola and discovery of Ebola Reston)
Richard Preston. The Demon in the Freezer (smallpox eradication and emergence)
Anthrax: Emerging Infectious Diseases (EID) Journal , a peer-reviewed CDC journal tracking trends and analyzing new and reemerging infectious disease issues around the world.
[Original article: http://www.ninds.nih.gov/disorders/multiple_sclerosis/multiple_sclerosis.htm]
What is Multiple Sclerosis?
An unpredictable disease of the central nervous system, multiple sclerosis (MS) can range from relatively benign to somewhat disabling to devastating, as communication between the brain and other parts of the body is disrupted. Many investigators believe MS to be an autoimmune disease -- one in which the body, through its immune system, launches a defensive attack against its own tissues. In the case of MS, it is the nerve-insulating myelin that comes under assault. Such assaults may be linked to an unknown environmental trigger, perhaps a virus.
Most people experience their first symptoms of MS between the ages of 20 and 40; the initial symptom of MS is often blurred or double vision, red-green color distortion, or even blindness in one eye. Most MS patients experience muscle weakness in their extremities and difficulty with coordination and balance. These symptoms may be severe enough to impair walking or even standing. In the worst cases, MS can produce partial or complete paralysis. Most people with MS also exhibit paresthesias, transitory abnormal sensory feelings such as numbness, prickling, or "pins and needles" sensations. Some may also experience pain. Speech impediments, tremors, and dizziness are other frequent complaints. Occasionally, people with MS have hearing loss. Approximately half of all people with MS experience cognitive impairments such as difficulties with concentration, attention, memory, and poor judgment, but such symptoms are usually mild and are frequently overlooked. Depression is another common feature of MS.
Is there any treatment?
There is as yet no cure for MS. Many patients do well with no therapy at all, especially since many medications have serious side effects and some carry significant risks. However, three forms of beta interferon (Avonex, Betaseron, and Rebif) have now been approved by the Food and Drug Administration for treatment of relapsing-remitting MS. Beta interferon has been shown to reduce the number of exacerbations and may slow the progression of physical disability. When attacks do occur, they tend to be shorter and less severe. The FDA also has approved a synthetic form of myelin basic protein, called copolymer I (Copaxone), for the treatment of relapsing-remitting MS. Copolymer I has few side effects, and studies indicate that the agent can reduce the relapse rate by almost one third. An immunosuppressant treatment, Novantrone (mitoxantrone), is approved by the FDA for the treatment of advanced or chronic MS.
One monoclonal antibody, natalizumab (Tysabri), was shown in clinical trials to significantly reduce the frequency of attacks in people with relapsing forms of MS and was approved for marketing by the U.S. Food and Drug Administration (FDA) in 2004. However, in 2005 the drugs manufacturer voluntarily suspended marketing of the drug after several reports of significant adverse events. In 2006, the FDA again approved sale of the drug for MS but under strict treatment guidelines involving infusion centers where patients can be monitored by specially trained physicians.
While steroids do not affect the course of MS over time, they can reduce the duration and severity of attacks in some patients. Spasticity, which can occur either as a sustained stiffness caused by increased muscle tone or as spasms that come and go, is usually treated with muscle relaxants and tranquilizers such as baclofen, tizanidine, diazepam, clonazepam, and dantrolene. Physical therapy and exercise can help preserve remaining function, and patients may find that various aids -- such as foot braces, canes, and walkers -- can help them remain independent and mobile. Avoiding excessive activity and avoiding heat are probably the most important measures patients can take to counter physiological fatigue. If psychological symptoms of fatigue such as depression or apathy are evident, antidepressant medications may help. Other drugs that may reduce fatigue in some, but not all, patients include amantadine (Symmetrel), pemoline (Cylert), and the still-experimental drug aminopyridine. Although improvement of optic symptoms usually occurs even without treatment, a short course of treatment with intravenous methylprednisolone (Solu-Medrol) followed by treatment with oral steroids is sometimes used.
What is the prognosis?
A physician may diagnose MS in some patients soon after the onset of the illness. In others, however, doctors may not be able to readily identify the cause of the symptoms, leading to years of uncertainty and multiple diagnoses punctuated by baffling symptoms that mysteriously wax and wane. The vast majority of patients are mildly affected, but in the worst cases, MS can render a person unable to write, speak, or walk. MS is a disease with a natural tendency to remit spontaneously, for which there is no universally effective treatment.
What research is being done?
The National Institute of Neurological Disorders and Stroke (NINDS) and other institutes of the National Institutes of Health (NIH) conduct research in laboratories at the NIH and also support additional research through grants to major medical institutions across the country. Scientists continue their extensive efforts to create new and better therapies for MS. One of the most promising MS research areas involves naturally occurring antiviral proteins known as interferons. Beta interferon has been shown to reduce the number of exacerbations and may slow the progression of physical disability. When attacks do occur, they tend to be shorter and less severe. In addition, there are a number of treatments under investigation that may curtail attacks or improve function. Over a dozen clinical trials testing potential therapies are underway, and additional new treatments are being devised and tested in animal models.
In 2001, the National Academies/Institute of Medicine, a Federal technical and scientific advisory agency, prepared a strategic
review of MS research. To read or download the National Academies/Institute of Medicine report, go to:
"Multiple Sclerosis: Current Status and Strategies for the