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UNIT 06
CLINICAL PHARMACY ASPECTS

CONTENTS
PEPTIC ULCER
ANGINA PECTORIS
HYPERTENSION
ASTHMA
TUBERCULOSIS
DIABETES
ACUTE RENAL FAILURE
AIDS
HEPATITIS
RHEUMATOID ARTHRITIS

4/28/16

PEPTIC ULCER
A peptic ulcer is a sore on the inner lining of the stomach or duodenum
the first part of the small intestine. Less commonly, a peptic ulcer may

develop just above the stomach in the esophagusthe organ that


connects the mouth to the stomach.
Causes of peptic ulcer disease include
1
an infection with the bacteria Helicobacter pylori (H. pylori)
2
long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs),
such as aspirin and ibuprofen
3
rarely, cancerous or noncancerous tumors in the stomach,
duodenum, or pancreas
4

Types of Peptic Ulcers


There are two different types of peptic ulcers. They are:

Gastric ulcers, which form in the lining of the stomach.


Duodenal ulcers, which form in the upper small intestine.
Both types of peptic ulcers are most commonly caused either by infection with Helicobacter
pylori (H. pylori) bacteriaHelicobacter pyloriH. pylori or by frequent use of nonsteroidal
anti-inflammatory drugs (NSAIDs).
EPIDEMIOLOGY
The time trends in the epidemiology of peptic ulcer disease (PUD) reflect complex,
multifactorial etiologies. Peptic ulcers were rare before the 1800s. The pathology of gastric
ulcers (GUs) was first described in 1835 [2]; during the late 1800s the prominent form was
GUs in young women. Duodenal ulcers (DUs) were rare until about 1900 and then became a
prevalent condition during the first half of the 20thcentury. However, in developed countries
the mortality from peptic ulcer disease has fallen dramatically for birth cohorts born after the
turn of the 20th century [3].The influence of environmental factors on the pattern of gastritis
may be a key variable in these birth-cohort effects. At the end of the 19thcentury (and
currently in many developing countries) H. pylori infection was characterized by pangastritis
involving the gastric antrum and body and leading to acid hyposecretion, which predisposed
to gastric cancer and GUs [4-7]. In contrast, DUs are associated with antral-predominant
gastritis that spares the acid-secreting body, but is negatively associated with more or severe
body gastritis and with gastric cancer [8]. The reason is that DUs require acid secretion to be
preserved, which cannot be achieved in the face of moderate body gastritis, whereas gastric
cancer is associated with hypochlorhydria.
RISK FACTORS
Risk factors you can control
The following things can increase your chance of getting a peptic ulcer and may slow the
healing of an ulcer you already have:

Taking nonsteroidal anti-inflammatory drugs (NSAIDs). These


include aspirin, ibuprofen(such as Advil), and naproxen (such as Aleve).
Smoking.

Drinking too much alcohol. This is more than 2 drinks a day for men and more than 1
drink a day for women.
In the past, spicy foods, caffeine, and moderate amounts of alcohol were thought to increase
ulcer risk. This is no longer believed to be true.
Risk factors you cannot control
Some things that you cannot control may increase your risk of getting an ulcer. These
include:

A Helicobacter pylori (H. pylori) infection, the most common cause of ulcers.
Physical stress caused by a serious illness or injury (such as a major trauma, surgery,
or the need to be on a ventilator to assist breathing).
Hyper secretory condition, in which your stomach produces too much acid.
A personal or family history of ulcers.
PATHO PHISYOLOGY

SIGNS AND SYMPTOMS


A dull or burning pain in the stomach is the most common symptom of
peptic ulcer disease. A person can feel this pain anywhere between the
navel and the breastbone. The pain usually occurs when a persons
stomach is emptysuch as between meals or during the night lessens
briefly after eating food or taking antacids lasts for minutes to hours
comes and goes for several days, weeks, or months Other, less common
symptoms include

1
bloating
2
burping
3
changes in appetite
4
nausea
5
vomiting
6
weight loss
COMPLICATIONS
Complications of peptic ulcer disease include
1
internal bleedingwhen gastric acid or a peptic ulcer breaks a blood
vessel
2
obstructionwhen a peptic ulcer blocks the path of food trying to
leave the stomach
3
perforationwhen a peptic ulcer grows deeper and breaks
completely through the stomach or duodenal wall
4
peritonitiswhen infection or inflammation develops in the
peritoneum, or lining of the abdominal cavity
DIAGNOSIS
A health care provider diagnoses peptic ulcer disease based on
1
2
3
4
5
6

a medical history
a physical exam
lab tests
upper gastrointestinal (GI) endoscopy
upper GI series
computerized tomography (CT) scan

Medical History
Taking a medical history may help a health care provider determine the cause of a
peptic ulcer. If a patient has peptic ulcer disease symptoms, the health care provider
will ask about the patients use of over-the-counter and prescription NSAIDs.

Physical Exam
A physical exam may help the health care provider diagnose the cause of peptic
ulcer disease. During a physical exam, a health care provider usually
1
2
3

checks for abdominal bloating


listens to sounds within the abdomen using a stethoscope
taps on the abdomen checking for tenderness or pain

Lab Tests
A health care provider will look to see if H. pylori are present using one of three
simple tests:
1

blood test

urea breath test , stool test

TREATMENT
It includes
Antibiotics

Proton pump inhibitors


omeprazole (Prilosec, Zegerid)
lansoprazole (Prevacid)
pantoprazole (Protonix)

Antacids
H2 blockers
Bismuth sub salicylate
PREVENTION
No one knows for sure how H. pylori infection spreads, so prevention is difficult.
However, to reduce the chances of infection, health care providers generally advise
people to
1
wash their hands with soap and water after using the bathroom and before
eating
2
make sure that they or those who prepare the food they eat have washed and
cooked it properly
3
drink water from a clean, safe source

ANGINA PECTORIS
Angina pectoris is the result of myocardial ischemia caused by an imbalance between
myocardial blood supply and oxygen demand. It is a common presenting symptom (typically,
chest pain) among patients with coronary artery disease (CAD). Approximately 9.8 million
Americans are estimated to experience angina annually, with 500,000 new cases of angina
occurring every year.
TYPES
Five different kinds of angina have been identified, with the two most common being stable
angina and unstable angina. Stable angina occurs when the heart has to work harder than
normal, during exercise, for example. It has a regular pattern, and if you already know that
you have stable angina, you will be able to predict the pattern. Once you stop exercising, or
take medication (usually nitroglycerin) the pain goes away, usually within a few minutes.
Unstable angina is more serious, and may be a sign that a heart attack could happen soon.
There is no predictable pattern to this kind of angina; it can just as easily occur during
exercise as it can while you are resting. It should always be treated as an emergency. People
with unstable angina are at increased risk for heart attacks, cardiac arrest, or severe cardiac
arrhythmias (irregular heartbeat or abnormal heart rhythm).
Less common kinds of angina include:
variant angina microvascular angina atypical angina
Variant angina is also known as Prinzmetals angina. It often occurs while someone is
resting (usually between midnight and 8:00 in the morning), and it has no predictable pattern
that is, it is not brought on by exercise or emotion. This kind of angina may cause severe
pain, and is usually the result of a spasm in a coronary artery. Most people who have variant
angina have severe atherosclerosis (hardening of the arteries), and the spasm is most likely to
occur near a buildup of fatty plaque in an artery.

Microvascular anginasometimes referred to as Syndrome Xoccurs when tiny vessels in


the heart become narrow and stop functioning properly, even if the bigger arteries are not
blocked by plaque. Usually it is treated with common angina medications.
Atypical angina often doesnt cause pain, but you may feel a vague discomfort in your chest,
experience shortness of breath, feel tired or nauseous, have indigestion, or pain in your back
or neck. Women are more likely than men to have feelings of vague chest discomfort.
In order to understand what causes angina, it might be helpful to first understand a little bit
about how your heart works.
EPIDEMIOLOGY
United States statistics
Approximately 9.8 million Americans are estimated to experience angina annually, with
500,000 new cases of angina occurring every year. In 2009, an estimated 785 000 Americans
will have a new coronary attack, and about 470 000 will have a recurrent attack. Only 18% of
coronary attacks are preceded by angina. An additional 195,000 silent first myocardial
infarctions are estimated to occur each year.[13]
Race-related demographics
The annual rates per 1000 population of new episodes of angina for those aged 45-54 years
are as follows[13] :

8.5 for nonblack men


10.6 for nonblack women
11.8 for black men
20.8 for black women
The annual rates per 1000 population of new episodes of angina for those aged 55-64 years
are as follows[13] :

11.9 for nonblack men


11.2 for nonblack women
10.6 for black men
19.3 for black women
The annual rates per 1000 population of new episodes of angina for those aged 65-74 years
are as follows[13] :

13.7 for nonblack men


13.1 for nonblack women
8.8 for black men
10.0 for black women
Sex-related demographics
Angina pectoris is more often the presenting symptom of coronary artery disease in women
than in men, with a female-to-male ratio of 1.7:1. It has an estimated prevalence of 4.6
million in women and 3.3 million in men. In one analysis, this female excess was found
across countries and was particularly high in the American studies and higher among
nonwhite ethnic groups than among whites.[14] The frequency of atypical presentations is also
more common among women compared with men. Women have a slightly higher rate of
mortality from coronary artery disease compared with men, in part because of an older age at
presentation and a frequent lack of classic anginal symptoms. The estimated age-adjusted
prevalence of angina is greater in women than in men.

ETIOLOGY
Causes of angina pectoris include the following:

Decrease in myocardial blood supply due to increased coronary resistance in large and
small coronary arteries
Increased extravascular forces, such as severe LV hypertrophy caused by
hypertension, aortic stenosis, or hypertrophic cardiomyopathy, or increased LV diastolic
pressures
Reduction in the oxygen-carrying capacity of blood, such as elevated
carboxyhemoglobin or severe anemia (hemoglobin, < 8 g/dL)
Congenital anomalies of the origin and/or course of the major epicardial coronary
arteries
Risk factors
Precipitating factors
Preventive factors
Decrease in myocardial blood supply due to increased coronary resistance in large and small
coronary arteries
Causes of such decreases in myocardial blood supply include the following:

Significant coronary atherosclerotic lesion in the large epicardial coronary arteries (ie,
conductive vessels) with at least a 50% reduction in arterial diameter
Coronary spasm (ie, Prinzmetal angina)
Abnormal constriction or deficient endothelial-dependent relaxation of resistant
vessels associated with diffuse vascular disease (ie, microvascular angina) [12]
Syndrome X
Systemic inflammatory or collagen vascular disease, such as scleroderma, systemic
lupus erythematous, Kawasaki disease, polyarteritis nodosa, and Takayasu arteritis
RISK FACTORS
Major risk factors for atherosclerosis include a family history of premature coronary artery
disease, cigarette smoking, diabetes mellitus, hypercholesterolemia, or systemic
hypertension.
Other risk factors include LV hypertrophy, obesity, and elevated serum levels of
homocysteine, lipoprotein (a), plasminogen activator inhibitor, fibrinogen, serum
triglycerides, or low high-density lipoprotein (HDL).
PATHO PHYSIOLOGY

SIGNS AND SYMPTOMS


Patients should be asked about the frequency of angina, severity of pain, and number of
nitroglycerin pills used during episodes. Symptomatology reported by patients with angina
commonly includes the following:
Retrosternal chest discomfort (pressure, heaviness, squeezing, burning, or choking
sensation) as opposed to frank pain

Pain localized primarily in the epigastrium, back, neck, jaw, or shoulders

Pain precipitated by exertion, eating, exposure to cold, or emotional stress, lasting for
about 1-5 minutes and relieved by rest or nitroglycerin

Pain intensity that does not change with respiration, cough, or change in position
Angina decubitus (a variant of angina pectoris that occurs at night while the patient is
recumbent) may occur.

The following should be taken into account in the physical examination:

For most patients with stable angina, physical examination findings are normal
A positive Levine sign suggests angina pectoris
Signs of abnormal lipid metabolism or of diffuse atherosclerosis may be noted
Examination of patients during the angina attack may be more helpful
Pain produced by chest wall pressure is usually of chest wall origin
COMPLICATIONS
angina lead to
heart failure , acute renal failure , myocardial infarction , cardiac arrest , death .

Diagnosis
Diagnostic studies that may be employed include the following:
Chest radiography: Usually normal in angina pectoris but may show cardiomegaly in
patients with previous MI, ischemic cardiomyopathy, pericardial effusion, or acute
pulmonary edema

Graded exercise stress testing: This is the most widely used test for the evaluation of
patients presenting with chest pain and can be performed alone and in conjunction with
echocardiography or myocardial perfusion scintigraphy

Coronary artery calcium (CAC) scoring by fast CT: The primary fast CT methods for
this application are electron-beam CT (EBCT) and multidetector CD (MDCT)
Other tests that may be useful include the following:

ECG (including exercise with ECG monitoring and ambulatory ECG monitoring)
Selective coronary angiography (the definitive diagnostic test for evaluating the
anatomic extent and severity of CAD)

Management
General treatment measures include the following:

Encouragement of smoking cessation


Treatment of risk factors (eg, hypertension, diabetes mellitus, obesity, hyperlipidemia)
In patients with CAD, efforts should be made to lower the low-density lipoprotein (LDL)
level (eg, with a statin). Current Adult Treatment Panel III (ATP III) guidelines are as
follows[1] :

In high-risk patients, a serum LDL cholesterol level of less than 100 mg/dL is the goal
In very high-risk patients, an LDL cholesterol level goal of less than 70 mg/dL is a
therapeutic option

In moderately high-risk persons, the recommended LDL cholesterol level is less than
130 mg/dL, but an LDL cholesterol level of 100 mg/dL is a therapeutic option

Non-high-density lipoprotein (HDL) cholesterol level is a secondary target of therapy


in persons with high triglyceride levels (>200 mg/dL); the goal in such persons is a nonHDL cholesterol level 30 mg/dL higher than the LDL cholesterol level goal
Patients with established CAD and low HDL levels are at high risk for recurrent events and
should be targeted for aggressive nonpharmacologic and pharmacologic treatment. The
currently accepted management approach is as follows:

In all persons with low HDL cholesterol levels, the primary target of therapy is to
achieve the ATP III guideline LDL cholesterol level goals with diet, exercise, and drug
therapy as needed

After the targeted LDL level goal is reached, emphasis shifts to other issues; in
patients with low HDL and high triglyceride levels, the secondary priority is to achieve the
non-HDL cholesterol level goal (30 mg/dL higher than the LDL goal); in patients with
isolated low HDL cholesterol levels and triglyceride levels below 200 mg/dL, drugs to raise
HDL can be considered
Other pharmacologic therapies that may be considered include the following:

Enteric-coated aspirin
Clopidogrel
Hormone replacement therapy

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Sublingual nitroglycerin
Beta blockers
Calcium channel blockers
Angiotensin-converting enzyme (ACE) inhibitors
Injections of autologous CD34+ cells [2]
Revascularization therapy (ie, coronary revascularization) can be considered in the following:

Patients with left main artery stenosis greater than 50%


Patients with 2- or 3-vessel disease and left ventricular (LV) dysfunction
Patients with poor prognostic signs during noninvasive studies
Patients with severe symptoms despite maximum medical therapy
The 2 main coronary revascularization procedures are (1) percutaneous transluminal coronary
angioplasty, with or without coronary stenting, and (2) coronary artery bypass grafting.
Considerations for choosing a procedure include the following:

Patients with 1- or 2-vessel disease and normal LV function who have anatomically
suitable lesions are candidates for percutaneous transluminal coronary angioplasty and
coronary stenting.

Drug-eluting stents can remarkably reduce the rate of in-stent restenosis

Patients with significant left main coronary artery disease, 2- or 3-vessel disease and
LV dysfunction, diabetes mellitus, or lesions anatomically unsuitable for percutaneous
transluminal coronary angioplasty have better results with coronary artery bypass grafting
Other procedures that may be considered include the following:

Intra-aortic balloon counterpulsation (in patients who continue to have unstable


angina pectoris despite maximal medical treatment): This should be followed promptly by
coronary angiography with possible coronary revascularization [3]
Enhanced external counterpulsation (in patients whose angina is refractory to medical
therapy and who are not suitable candidates for either percutaneous or surgical
revascularization) [4]
Laser transmyocardial revascularization (experimental) [5]
Use of the Coronary Sinus Reducer (Neovasc Medical, Inc, Or Yehuda, Israel), a
percutaneous implantable device designed to establish coronary sinus narrowing and elevate
coronary sinus pressure (further studies needed)

HYPERTENSION
Hypertension (HTN or HT), also known as high blood pressure, is a long term medical
condition in which the blood pressure in the arteries is persistently elevated. High blood
pressure usually does not cause symptoms. Long term high blood pressure; however, is a
major risk factor for coronary artery disease, stroke, heart failure, peripheral vascular
disease, vision loss, and chronic kidney disease.
TYPES
There are two major types of hypertension and four less frequently found types.
The two major types are:

Primary or essential hypertension, that has no known cause, is diagnosed in the


majority of people.

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Secondary hypertension is often caused by reversible factors, and is sometimes


curable.

The other types include:

Malignant Hypertension.
Isolated Systolic Hypertension

White Coat Hypertension

Resistant Hypertension

Primary Hypertension
This type is also called essential hypertension, and it is by far the most common type of
hypertension, and is diagnosed in about 95% of cases. Essential hypertension has no obvious
or yet identifiable cause.
Secondary Hypertension:
This may be caused by:

Kidney damage or impaired function (This accounts for most secondary forms of
hypertension.)
Tumours or overactivity of the adrenal gland

Thyroid dysfunction

Coarctation of the aorta

Pregnancy-related conditions

Sleep Apnea Syndrome

Medication, recreational drugs, drinks & food

Malignant Hypertension
This, the most severe form of hypertension, is severe and progressive. It rapidly leads to
organ damage. Unless properly treated, it is fatal within five years for the majority of
patients. Death usually comes from heart failure, kidney damage or brain haemorrhage.
However, aggressive treatment can reverse the condition, and prevent its
complications. Malignant hypertension is becoming relatively rare, and is not caused by
cancer or malignancy.
Isolated Systolic Hypertension
In this case the systolic blood pressure, (the top number), is consistently above 160 mm Hg,
and the diastolic below 90 mm Hg. This may occur in older people, and results from the agerelated stiffening of the arteries. The loss of elasticity in arteries, like the aorta, is mostly due
to arteriosclerosis. The Western lifestyle and diet is believed to be the root cause.

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Latest studies confirm the importance of treating ISH, as it significantly reduces the incidence
of stroke and heart disease. Treatment starts with lifestyle modification, and if needed, added
drugs.
White coat hypertension
Also called anxiety-induced hypertension, it means blood pressure is only high when tested
by a health professional. If confirmed, with repeat readings outside of the clinical setting, or
a 24-hour monitoring device, it does not need to be treated. However, regular follow-up is
recommended to ensure that persistent hypertension has not developed.
Lifestyle changes like more exercise, less salt and alcohol, no nicotine and weight loss, would
be wise. A low fat, high fibre diet, with increased fruit and vegetable intake, will be
beneficial.
Resistant Hypertension
If blood pressure cannot be reduced to below 140/90 mmHg, despite a triple-drug regime,
resistant hypertension is considered
EPIDEMIOLOGY
Overall, approximately 20% of the worlds adults are estimated to have hypertension, when
hypertension is defined as BP in excess of 140/90 mm Hg. The prevalence dramatically
increases in patients older than 60 years: In many countries, 50% of individuals in this age
group have hypertension. Worldwide, approximately 1 billion people have hypertension,
contributing to more than 7.1 million deaths per year.[5]
National health surveys in various countries have shown a high prevalence of poor control of
hypertension.[6] These studies have reported that prevalence of hypertension is 22% in
Canada, of which 16% is controlled; it is 26.3% in Egypt, of which 8% is controlled; and it is
13.6% in China, of which 3% is controlled.
ETIOLOGY
The exact causes of high blood pressure are not known, but several factors and conditions
may play a role in its development, including:

Smoking
Being overweight or obese
Lack of physical activity
Too much salt in the diet
Too much alcohol consumption (more than 1 to 2 drinks per day)
Stress
Older age
Genetics
Family history of high blood pressure
Chronic kidney disease

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Adrenal and thyroid disorders


Sleep apnea
RISK FACTORS
Although the exact cause of high blood pressure is unknown, there are several factors and
conditions that may increase risk.

Being overweight or obese


Smoking
Little or no exercise
Too much salt in the diet
Drinking too much alcohol
Stress
Ethnic background
History of high blood pressure in the family
PATHO PHYSIOLOGY

SIGNS AND SYMPTOMS


One of the most dangerous aspects of hypertension is that you may not know that you have it.
In fact, nearly one-third of people who havehigh blood pressure don't know it. The only way
to know if your blood pressure is high is through regular checkups. This is especially
important if you have a close relative who has high blood pressure.

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If your blood pressure is extremely high, there may be certain symptoms to look out
for, including:

Severe headache
Fatigue or confusion
Vision problems
Chest pain
Difficulty breathing
Irregular heartbeat
Blood in the urine
Pounding in your chest, neck, or ears
COMPLICATIONS
High blood pressure (hypertension) puts extra strain on your heart and blood vessels.
If untreated, over time this extra pressure can increase your risk of a heart attack, stroke,
kidney disease and vascular dementia.
Cardiovascular disease
High blood pressure can cause many different diseases of the heart and blood vessels
(medically known as cardiovascular diseases), including:
stroke when the blood supply to part of the brain is cut off
heart attack when the supply of blood to the heart is suddenly blocked
embolism when a blood clot or air bubble blocks the flow of blood in a vessel
aneurysm when a blood vessel wall bursts causing internal bleeding
vascular dementia when blood flow to the brain is reduced, causing parts of the
brain to become damaged
Kidney disease
High blood pressure can also damage the small blood vessels in your kidneys and stop them
from working properly. Mild to moderate chronic kidney disease does not usually cause any
symptoms.
Kidney disease may need treatment with a combination of medication and dietary changes.
More serious cases may require dialysis (a treatment where waste products are artificially
removed from the body) or a kidney transplant.
DIAGNOSIS
For most patients, health care providers diagnose high blood pressure when blood pressure
readings are consistently 140/90 mmHg or above.
Confirming High Blood Pressure

15

A blood pressure test(link is external) is easy and painless and can be done in a health care
providers office or clinic. To prepare for the test:

Dont drink coffee or smoke cigarettes for 30 minutes prior to the test.
Go to the bathroom before the test.

Sit for 5 minutes before the test.


To track blood pressure readings over a period of time, the health care provider may ask you
to come into the office on different days and at different times to take your blood pressure.
The health care provider also may ask you to check readings at home or at other locations
that have blood pressure equipment and to keep a written log of all your results.
TREATMENT
Healthy Lifestyle Changes
Healthy lifestyle habits can help you control high blood pressure. These habits include:

Healthy eating
Being physically active

Maintaining a healthy weight

Limiting alcohol intake

Managing and coping with stress


To help make lifelong lifestyle changes, try making one healthy lifestyle change at a time and
add another change when you feel that you have successfully adopted the earlier changes.
When you practice several healthy lifestyle habits, you are more likely to lower your blood
pressure and maintain normal blood pressure readings.
Healthy Eating
To help treat high blood pressure, health care providers recommend that you limit sodium and
salt intake, increase potassium, and eat foods that are heart healthy.
Limiting Sodium and Salt
A low-sodium diet can help you manage your blood pressure. You should try to limit the
amount of sodium that you eat. This means choosing and preparing foods that are lower in
salt and sodium. Try to use low-sodium and no added salt foods and seasonings at the table
or while cooking. Food labels tell you what you need to know about choosing foods that are
lower in sodium. Try to eat no more than 2,300 mg sodium a day. If you have high blood
pressure, you may need to restrict your sodium intake even more.
Your health care provider may recommend the Dietary Approaches to Stop Hypertension
(DASH) eating plan if you have high blood pressure. The DASH eating plan focuses on
fruits, vegetables, whole grains, and other foods that are heart healthy and low in fat,
cholesterol, and salt.

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The DASH eating plan is a good heart-healthy eating plan, even for those who dont have
high blood pressure. Read more about the DASH eating plan.
Heart-Healthy Eating
Your health care provider also may recommend heart-healthy eating, which should include:

Whole grains
Fruits, such as apples, bananas, oranges, pears, and prunes

Vegetables, such as broccoli, cabbage, and carrots

Legumes, such as kidney beans, lentils, chick peas, black-eyed peas, and lima beans

Fat-free or low-fat dairy products, such as skim milk

Fish high in omega-3 fatty acids, such as salmon, tuna, and trout, about twice a week
When following a heart-healthy diet, you should avoid eating:

A lot of red meat


Palm and coconut oils

Sugary foods and beverages


In the National Heart, Lung, and Blood Institute (NHLBI)-sponsored Hispanic Community
Health Study/Study of Latinos, which studied Hispanics living in the United States, Cubans
ate more sodium and Mexicans ate less sodium than other Hispanic groups in the study. All
Hispanic Americans should follow these healthy eating recommendations even when cooking
traditional Latino dishes. Try some of these popular Hispanic American heart-healthy recipes.
Being Physically Active
Routine physical activity can lower high blood pressure and reduce your risk for other health
problems. Talk with your health care provider before you start a new exercise plan. Ask him
or her how much and what kinds of physical activity are safe for you.
Everyone should try to participate in moderate-intensity aerobic exercise at least 2 hours and
30 minutes per week, or vigorous-intensity aerobic exercise for 1 hour and 15 minutes per
week. Aerobic exercise, such as brisk walking, is any exercise in which your heart beats
harder and you use more oxygen than usual. The more active you are, the more you will
benefit. Participate in aerobic exercise for at least 10 minutes at a time, spread throughout the
week.
Read more about physical activity:

Physical Activity and Your Heart


U.S. Department of Health and Human Services' 2008 Physical Activity Guidelines
for Americans

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Maintaining a Healthy Weight


Maintaining a healthy weight can help you control high blood pressure and reduce your risk
for other health problems. If youre overweight or obese, try to lose weight. A loss of just 3 to
5 percent can lower your risk for health problems. Greater amounts of weight loss can
improve blood pressure readings, lower LDL cholesterol, and increase HDL cholesterol.
However, research shows that no matter your weight, it is important to control high blood
pressure to maintain good health.
A useful measure of overweight and obesity is body mass index (BMI). BMI measures your
weight in relation to your height. To figure out your BMI, check out NHLBIs online BMI
calculator or talk to your health care provider.
A BMI:

Below 18.5 is a sign that you are underweight.


Between 18.5 and 24.9 is in the healthy range.

Between 25 and 29.9 is considered overweight.

Of 30 or more is considered obese.


A general goal to aim for is a BMI below 25. Your health care provider can help you set an
appropriate BMI goal.
Measuring waist circumference helps screen for possible health risks. If most of your fat is
around your waist rather than at your hips, youre at a higher risk for heart disease and type 2
diabetes. This risk may be high with a waist size that is greater than 35 inches for women or
greater than 40 inches for men. To learn how to measure your waist, visit Assessing Your
Weight and Health Risk. For more information about losing weight or maintaining your
weight, go to Aim for a Healthy Weight.
Limiting Alcohol Intake
Limit alcohol intake. Too much alcohol will raise your blood pressure and triglyceride levels,
a type of fat found in the blood. Alcohol also adds extra calories, which may cause weight
gain.
Men should have no more than two drinks containing alcohol a day. Women should have no
more than one drink containing alcohol a day. One drink is:

12 ounces of beer
5 ounces of wine

1 ounces of liquor
Managing and Coping With Stress
Learning how to manage stress, relax, and cope with problems can improve your emotional
and physical health and can lower high blood pressure. Stress management techniques
include:

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Being physically active


Listening to music or focusing on something calm or peaceful

Performing yoga or tai chi

Meditating
Medicines
Blood pressure medicines work in different ways to stop or slow some of the bodys
functions that cause high blood pressure. Medicines to lower blood pressure include:

Diuretics (Water or Fluid Pills): Flush excess sodium from your body, which
reduces the amount of fluid in your blood and helps to lower your blood pressure. Diuretics
are often used with other high blood pressure medicines, sometimes in one combined pill.
Beta Blockers: Help your heart beat slower and with less force. As a result, your
heart pumps less blood through your blood vessels, which can help to lower your blood
pressure.

Angiotensin-Converting Enzyme (ACE) Inhibitors: Angiotensin-II is a hormone


that narrows blood vessels, increasing blood pressure. ACE converts Angiotensin I to
Angiotensin II. ACE inhibitors block this process, which stops the production of Angiotensin
II, lowering blood pressure.

Angiotensin II Receptor Blockers (ARBs): Block angiotensin II hormone from


binding with receptors in the blood vessels. When angiotensin II is blocked, the blood vessels
do not constrict or narrow, which can lower your blood pressure.

Calcium Channel Blockers: Keep calcium from entering the muscle cells of your
heart and blood vessels. This allows blood vessels to relax, which can lower your blood
pressure.

Alpha Blockers: Reduce nerve impulses that tighten blood vessels. This allows blood
to flow more freely, causing blood pressure to go down.

Alpha-Beta Blockers: Reduce nerve impulses the same way alpha blockers do.
However, like beta blockers, they also slow the heartbeat. As a result, blood pressure goes
down.

Central Acting Agents: Act in the brain to decrease nerve signals that narrow blood
vessels, which can lower blood pressure.

Vasodilators: Relax the muscles in blood vessel walls, which can lower blood
pressure.

ASTHMA

Asthma is a chronic disease involving the airways in the lungs. These airways, or
bronchial tubes, allow air to come in and out of the lungs.

19

If you have asthma your airways are always inflamed. They become even more
swollen and the muscles around the airways can tighten when something triggers
your symptoms. This makes it difficult for air to move in and out of the lungs,
causing symptoms such as coughing, wheezing, shortness of breath and/or chest
tightness.
For many asthma sufferers, timing of these symptoms is closely related to physical
activity. And, some otherwise healthy people can develop asthma symptoms only
when exercising. This is called exercise-induced bronchoconstriction (EIB) , or
exercise-induced asthma (EIA). Staying active is an important way to stay healthy,
so asthma shouldn't keep you on the sidelines. Your physician can develop a
management plan to keep your symptoms under control before, during and after
physical activity.
People with a family history of allergies or asthma are more prone to developing
asthma. Many people with asthma also have allergies . This is called allergic
asthma .
Occupational asthma is caused by inhaling fumes, gases, dust or other potentially
harmful substances while on the job.
Childhood asthma impacts millions of children and their families. In fact, the
majority of children who develop asthma do so before the age of five.
There is no cure for asthma, but once it is properly diagnosed and a treatment plan
is in place you will be able to manage your condition, and your quality of life will
improve.
EPIDEMIOLOGY
The recent substantial increase in the reported prevalence of asthma worldwide (Figure 1) has
led to numerous studies of the prevalence and characteristics of this condition.2 Foremost
among these are 2 major international initiatives that have collected data using validated
questionnaires, one among children, the International Study of Asthma and Allergies in
Childhood,3 and the other among young adults, the European Community Respiratory Health
Survey.4 Follow-up investigations for both of these studies5,6 have examined temporal trends
within and across populations. During a mean of 7 years following phase I of the
International Study of Asthma and Allergies in Childhood, which in most participating
countries was conducted between 1991 and 1993, the prevalence of asthma was stable or
decreased in some areas of the world but increased substantially in many other areas,
especially among children 1314 years of age
ETIOLOGY
Allergies (Allergic Asthma)

20

Substances that cause allergies (allergens) can trigger asthma. If you inhale something you
are allergic to, you may experience asthma symptoms. It is best to avoid or limit contact with
known allergens to decrease or prevent asthma episodes.
Common allergens that cause allergic asthma include:

dust mites
cockroach

pollens

molds

pet dander

rodents

Irritants in the Air


Irritants in the environment can also bring on an asthma episode. Although people are not
allergic to these items, they can bother inflamed, sensitive airways:

smoke from cigarettes


air pollution such as smog, ozone, and others

wood fires

charcoal grills

strong fumes, vapors, or odors (such as paint, gasoline, perfumes and scented soaps)

dusts and particles in the air

chemicals

Respiratory Illness

colds
flu (influenza)

sore throats

sinus infections

pneumonia

Respiratory infections are the most common asthma trigger in children.


Exercise
Exercise and other activities that make you breathe harder can affect your asthma. Exercise
especially in cold airis a frequent asthma trigger. Exercise-induced
bronchoconstriction (EIB) is a form of asthma that is triggered by physical activity. It is also
known as exercise-induced asthma (EIA). Symptoms may not appear until after several

21

minutes of sustained exercise. (If symptoms appear sooner than this, it usually means you
need to adjust your treatment.) With proper treatment, you do not need to limit your physical
activity.
Weather
Dry wind, cold air or sudden changes in weather can sometimes bring on an asthma episode.
Feeling and Expressing Strong Emotions

anger
fear

excitement

laughter

yelling

crying

Medicines
Some medicines can also trigger asthma:

If you are sensitive to aspirin and NSAIDs (nonsteroidal anti-inflammatory drugs)


If you take medicines known as beta blockers they can also make asthma harder to
control

Other Asthma Triggers


Other triggers to consider and discuss with your healthcare provider are:

sulfites in food
hormonal changes during the menstrual cycle

other medical problems like reflux

PATHOPHISYOLOGY

22

SIGNS AND SYMPTOMS


According to the leading experts in asthma, the symptoms of asthma and best
treatment for you or your child may be quite different than for someone else with
asthma.
The most common symptom is wheezing. This is a scratchy or whistling sound when
you breathe. Other symptoms include:

Shortness of breath

Chest tightness or pain

Chronic coughing

Trouble sleeping due to coughing or wheezing

Asthma symptoms, also called asthma flare-ups or asthma attacks, are often caused
by allergies and exposure to allergens such as pet dander, dust mites, pollen or
mold. Non-allergic triggers include smoke, pollution or cold air or changes in
weather.

23

DIAGNOSIS AND TREATMENT


Personal and medical history. Your doctor will ask you questions to understand your
symptoms and their causes. Bring notes to help jog your memory. Be ready to answer
questions about your family history, the medicines you take and your lifestyle. This includes
any current physical problems. Shortness of breath, wheezing, coughing and tightness in your
chest may show asthma. This also includes all previous medical conditions. A history of
allergies or eczema increases your chance of asthma. A family history of asthma, allergies or
eczema increases your chance of having asthma, too. Tell your doctor about any home or
work exposure to environmental factors that can worsen asthma. For example, these might
include pet dander, pollen, dust mites and tobacco smoke. The doctor may also ask if you get
chest symptoms when you get a head cold.
Physical examination. If your doctor thinks you have asthma, they will do a physical exam.
They will look at your ears, eyes, nose, throat, skin, chest and lungs. This exam may include a
lung function test to detect how well you exhale air from your lungs. You may also need an
X-ray of your lungs or sinuses. A physical exam then allows your doctor to review your
health.
Lung function tests. To confirm asthma, your doctor may have you take one or more
breathing tests known as lung function tests. These tests measure your breathing. Lung
function tests are often done before and after inhaling a medication known as a
bronchodilator (bron-co-DIE-a-later), which opens your airways. If your lung function
improves a lot with use of a bronchodilator, you probably have asthma. Your doctor may also
prescribe a trial with asthma medication to see if it helps. Common lung function tests used to
diagnose asthma include:
Spirometry. This is the recommended test to confirm asthma. During this test, you
breathe into a mouthpiece thats connected to a device. It is called a spirometer. The
spirometer measures the amount of air youre able to breathe in and out and its rate of
flow. You will take a deep breath and then exhale forcefully.
Peak airflow. This test uses a peak flow meter. It's a small, handheld device that you
breathe into to measure the rate at which you can force air out of your lungs. During
the test you breathe in as deeply as you can and then blow into the device as hard and
fast as possible. If you're diagnosed with asthma, you can use a peak flow meter at
home to help track your condition.
Trigger tests. If your other results are normal, but youve been experiencing signs
and symptoms of asthma, your doctor may use known asthma triggers to try and
provoke a mild reaction. If you dont have asthma, you wont react. But if you do
have asthma, you likely will develop asthma symptoms.
Long-Term Control Medicines
Long-term control medicines help you prevent and control asthma symptoms. You may need
to take this type of medicine every day for best results. There are several kinds of long-term
control medicines:

24

Inhaled corticosteroids prevent and reduce airway swelling. They also reduce mucus
in the lungs. They are the most effective long-term control medicines available.
Corticosteroids are not the same as anabolic steroids that are taken by some athletes
and banned in many athletic events.

Inhaled long-acting beta agonists open the airways by relaxing the smooth muscles
around the airways. If used, this type of medicine should always be taken in
combination with an inhaled corticosteroid.

Combination inhaled medicines contain both an inhaled corticosteroid and a longacting beta agonist. If you need both of these medicines, this is a convenient way to
take them together.

Omalizumab (anti-IgE) is given every 2 or 4 weeks as a shot. This medicine prevents


you from reacting to allergic triggers. It does this by blocking the antibody that causes
allergies. Anti-IgE is a very expensive medicine. It usually is only prescribed if other
asthma medicines have not controlled your asthma.

Leukotriene modifiers are taken in pill or liquid form. This type of medicine reduces
swelling inside the airways and relaxes smooth muscles.

Cromolyn sodium is an inhaled non-steroid medicine. It prevents airways from


swelling when they come into contact with an asthma trigger.

Theophylline comes as a tablet, capsule, solution and syrup to take by mouth. This
medicine helps open the airways by relaxing the smooth muscles.

Oral corticosteroids are taken in pill or liquid form. This medicine may be
prescribed for the treatment of asthma attacks that dont respond to other asthma
medicines. They also are used as long-term therapy for some people with severe
asthma. Corticosteroids are not the same as anabolic steroids taken by some athletes
and banned in many athletic events.

Quick-Relief Medicines
You use quick-relief medicines to help relieve asthma symptoms when they happen. These
medicines act fast to relax tight muscles around your airways. This allows the airways to
open up so air can flow through them. You should take your quick-relief medicine when you
have asthma symptoms. If you use this medicine more than 2 days a week, talk with your
doctor about your asthma control. You may need to make changes to your treatment plan.

Short-acting beta agonists are inhaled and work quickly to relieve asthma
symptoms. These medicines relax the smooth muscles around the airways and
decrease swelling that blocks airflow. These medicines are the first choice for quick

25

relief of asthma symptoms.

Anticholinergics are inhaled but act slower than the short-acting beta agonist
medicines. These medicines open the airways by relaxing the smooth muscles around
the airways. They also reduce mucous production.

Combination quick relief medicines contain both an anticholinergic and a shortacting beta agonist. This combination comes either as an inhaler or nebulizer for
inhalation.

TUBERCULOSIS
Tuberculosis, or TB, is an infectious bacterial disease caused by Mycobacterium tuberculosis,
which most commonly affects the lungs. It is transmitted from person to person via droplets
from the throat and lungs of people with the active respiratory disease.
TYPES
Active TB Disease
Active TB is an illness in which the TB bacteria are rapidly multiplying and invading
different organs of the body .The typical symptoms of active TB variably include cough,
phlegm, chest pain, weakness, weight loss, fever, chills and sweating at night. A person with
active pulmonary TB disease may spread TB to others by airborne transmission of infectious
particles coughed into the air.
Miliary TB
Miliary TB is a rare form of active disease that occurs when TB bacteria find their way into
the bloodstream. In this form, the bacteria quickly spread all over the body in tiny nodules
and affect multiple organs at once. This form of TB can be rapidly fatal.
Latent TB Infection
Many of those who are infected with TB do not develop overt disease. They have no
symptoms and their chest x-ray may be normal. The only manifestation of this encounter may
be reaction to the tuberculin skin test (TST) or interferon gamma release assay (IGRA).
However, there is an ongoing risk that the latent infection may escalate to active disease. The
risk is increased by other illnesses such as HIV or medications which compromise the
immune system. To protect against this, the United States employs a strategy of preventive
therapy or treatment of latent TB infection .
EPIDEMIOLOGY
More than two billion people (about one-third of the world population) are estimated to be
infected with M. tuberculosis [2,3]. The global incidence of tuberculosis (TB) peaked around
2003 and appears to be declining slowly [4]. According to the World Health Organization
(WHO), in 2014, 9.6 million individuals became ill with TB and 1.5 million died [4].
ETIOLOGY
TB is initiated by the infection of a host with Mycobacterium tuberculosis following the
inhalation of droplets (aerosols) containing the bacilli. Once in the lung, the bacilli are
internalized through phagocytosis by the resident macrophages of the lung the AMs.
Belonging to the mononuclear phagocytic system (MPS), AMs are of extreme importance in

26

lung defense, keeping the alveoli clean and sterile.[11] AMs activated by the appropriate
stimuli can effectively transfer the phagocytosed M. tuberculosis to the destructive
environment of lysosomes. However, some bacilli are able to escape lysosomal delivery and
survive and multiply inside AMs.[12,13] Then, the infected AMs can remain in the lung, where
the number of pathogens increases exponentially by killing host cells and by spreading
through lymphatic circulation to regional lymph nodes. This stage occurs 38 weeks after
infection and is termed pulmonary TB, for which the lung is the main organ infected, and the
MPS, particularly the AMs, are the major targets. Later on (3 months after infection) infected
AMs can be disseminated to distant highly irrigated organs (e.g., CNS, spongy bone, liver,
kidneys and genitalia).[11,14,15] At this stage of extrapulmonary TB, acute TB meningitis or
disseminated TB can sometimes result in death (Figure 1). Finally, extrapulmonary
manifestations (e.g., lesion in bones and joints) can appear.
RISK FACTORS & PATHO PHISYOLOGY
SILICOSIS
HIV
NUTRITION
DIABETES MELLITUS
GENETIC FACTORS

27

SIGNS AND SYMPTOMS , COMPLICATIONS

SIGNS AND SYMPTOMS , COMPLICATIONS


Symptoms of TB
The symptoms of active TB are very variable and depend on which part of the body has been
infected, that is which type of TB it is. It is very difficult to diagnose TB just from the
symptoms, as the symptoms are not usually ones that are just for TB. This means that the
symptoms can often be the symptoms of another disease as well. So to diagnose TB it is
always necessary to do at least one TB test.
General symptoms of active TB include weakness or feeling very tired, losing weight without
trying, lack of appetite, chills, fever (a high temperature of 38C or above) and night sweats.1
Symptoms of Pulmonary TB
Pulmonary TB is TB in the lungs. The specific symptoms of pulmonary TB are having a bad
cough that lasts longer than three weeks, having pain in the chest, and coughing up blood or
phlegm from deep inside the lungs.2

28

Symptoms of Extrapulmonary TB
Extrapulmonary TB, which is also known as disseminated or miliary TB, refers to all the
different types of TB other than pulmonary TB.3 Generally it is the types of TB that do not
affect the lungs. The main exception to this is the type of extrapulmonary TB known as
Pleural TB.
The general symptoms of extrapulmonary TB are the same as for pulmonary TB, but there
can then be specific symptoms relating to the particular site or sites in the body that are
infected.
Hemoptysis
Pleurisy
Pleural effusion
Empyema
Pneumothorax
Aspergilloma
Endobronchitis
Brochiectasis
Laryngitis
Cor pulmonale
Ca bronchus
Enteritus
Miliary Tuberculosis
HIV related opportunistic infections
DIAGNOSIS
These are TB tests which can be used to determine if someone has latent TB, which means
that they are infected with TB bacteria. There are also TB tests, which when considered
alongside other factors, such as whether someone has TB symptoms, can confirm a diagnosis
of active TB or TB disease.
Even if a person has symptoms, TB is often difficult to diagnose, and is particularly difficult
to diagnose rapidly. Rapid diagnosis is what is needed to provide effective TB
treatment for drug resistant TB.
Evidence of TB bacteria
The development of TB disease is a two stage process. In the first stage, known as latent TB,
a person is infected with TB bacteria. In the second stage, known as active TB or TB disease,
the bacteria have reproduced sufficiently to usually cause the person to have become sick.
A diagnosis of active TB can only be confirmed when there is definite evidence of TB
bacteria in the persons body. Some of the diagnostic TB tests look directly for TB bacteria.

29

Others such as the chest X-ray look for the effect of the bacteria on the person suspected of
having TB.
Current TB tests some problems
Some of the current TB tests take a long time to obtain a result, and some TB tests are not
very accurate. The TB tests either have low sensitivity (the ability to correctly detect people
with TB) and/or low specificity (the ability to correctly detect people who havent got TB).
If a TB test has low sensitivity, it means that there will be a significant number of false
negatives, meaning that the test result is suggesting that a person has not got TB when they
actually have. Similarly, a low specificity means that there will be a significant number of
false positives suggesting that a person has TB when they actually havent.
Chest X-ray as a TB test
If a person has had TB bacteria which have caused inflammation in the lungs, an abnormal
shadow may be visible on a chest x-ray.1 Also, acute pulmonary TB can be easily seen on an
X-ray. However, what it shows is not specific. A normal chest X-ray cannot exclude extra
pulmonary TB.
Also, in countries where resources are more limited, there is often a lack of X-ray facilities.
The TB skin test
The TB skin test is a widely used test for diagnosing TB. In countries with low rates of TB it
is often used to test for latent TB infection. The problem with using it in countries with high
rates of TB infection is that the majority of people may have latent TB.
The TB skin test involves injecting a small amount of fluid (called tuberculin) into the skin in
the lower part of the arm. Then the person must return after 48 to 72 hours to have a trained
health care worker look at their arm. The health care worker will look for a raised hard area
or swelling, and if there is one then they will measure its size. They will not Include any
general area of redness.2
The TB skin test result depends on the size of the raised hard area or swelling. The larger the
size of the affected area the greater the likelihood that the person has been infected with TB
bacteria at some time in the past. But interpreting the TB skin test result, that is whether it is a
positive result, may also involve considering the lifestyle factors of the person being tested
for TB.3 The TB skin test also cannot tell if the person has latent TB or active TB disease.
The Mantoux TB test is the type of TB test most often used, although the Heaf and Tine tests
are still used in some countries. None of these TB tests though will guarantee a correct
result. False positive results happen with the TB skin test because the person has been

30

infected with a different type of bacteria, rather than the one that causes TB. It can also
happen because the person has been vaccinated with the BCG vaccine. This vaccine is widely
used in countries with high rates of TB infection. False negative results particularly happen
with children, older people and people with HIV.
TB Interferon gamma release assays (IGRAs)
The Interferon Gamma Release Assays (IGRAs), are a new type of more accurate TB test. In
this context referring to an assay is simply a way of referring to a test or procedure.
IGRAs are blood tests that measure a persons immune response to the bacteria that cause
TB. The immune system produces some special molecules called cytokines. These TB tests
work by detecting a cytokine called the interferon gamma cytokine. In practice you carry out
one of these TB tests by taking a blood sample and mixing it with special substances to
identify if the cytokine is present.
Two IGRAs that have been approved by the U.S. Food and Drug Administration (FDA), and
are commercially available in the U.S., are the QuantiFERON TB Gold test, and the TSPOT TB test.
The advantages of an IGRA TB test includes the fact that it only requires a single patient visit
to carry out the TB test. Results can be available within 24 hours, and prior BCG vaccination
does not cause a false positive result. Disadvantages include the fact that the blood sample
must be processed fairly quickly, laboratory facilities are required, and the test is for latent
TB. It is also thought that the IGRAs may not be as accurate in people who have HIV.4 In low
prevalence resource rich settings, IGRAs are beginning to be used in place of the TB skin
test.5
Serological tests for TB
Serological tests for TB are tests carried out on samples of blood, and they claim to be able to
diagnose TB by detecting antibodies in the blood. However, testing for TB by looking for
antibodies in the blood is very difficult.
As a result serological TB tests, sometimes called serodiagnostic tests, for TB are inaccurate
and unreliable, and the World Health Organisation has warned that these tests should not be
used to try and diagnose active TB. Some countries have banned the use of serological or
serodiagnostic tests for TB.
Serological tests for TB are very different from the IGRA tests described above.
Sputum smear microscopy as a test for TB
Smear microscopy of sputum is often the first TB test to be used in countries with a high
rate of TB infection. Sputum is a thick fluid that is produced in the lungs and the

31

airways leading to the lungs. A sample of sputum is usually collected by the person
coughing.
To test for TB several samples of sputum will normally be collected.6 In 2012 it was
suggested that two specimens can be collected on the same day without any loss of
accuracy.7 8
To do the TB test a very thin layer of the sample is placed on a glass slide, and this is called a
smear. A series of special stains are then applied to the sample, and the stained slide is
examined under a microscope for signs of the TB bacteria.9
Sputum smear microscopy is inexpensive and simple, and people can be trained to do it
relatively quickly and easily. In addition the results are available within hours. The sensitivity
though is only about 50-60%.10 In countries with a high prevalence of both pulmonary TB
and HIV infection, the detection rate can be even lower, as many people with HIV and TB coinfection have very low levels of TB bacteria in their sputum, and are therefore recorded as
sputum negative.
TREATMENT

Isoniazid

Rifampicin

Pyrazinamide

Ethambutol

and Streptomycin

DIABETES
Diabetes, often referred to by doctors as diabetes mellitus, describes a group of metabolic
diseases in which the person has high blood glucose (blood sugar), either because insulin
production is inadequate, or because the body's cells do not respond properly to insulin, or
both. Patients with high blood sugar will typically experience polyuria (frequent urination),
they will become increasingly thirsty (polydipsia) and hungry (polyphagia).
TYPES & EPIDEMIOLOGY
Type 1 diabetes
The body does not produce insulin. Some people may refer to this type as insulin-dependent
diabetes, juvenile diabetes, or early-onset diabetes. People usually develop type 1 diabetes
before their 40th year, often in early adulthood or teenage years.

32

Type 1 diabetes is nowhere near as common as type 2 diabetes. Approximately 10% of all
diabetes cases are type 1.
Patients with type 1 diabetes will need to take insulin injections for the rest of their life. They
must also ensure proper blood-glucose levels by carrying out regular blood tests and
following a special diet.
Between 2001 and 2009, the prevalence of type 1 diabetes among the under 20s in the USA
rose 23%, according to SEARCH for Diabetes in Youth data issued by the CDC (Centers for
Disease Control and Prevention).
2) Type 2 diabetes
The body does not produce enough insulin for proper function, or the cells in the body do not
react to insulin (insulin resistance). Some people may be able to control their type 2 diabetes
symptoms by losing weight, following a healthy diet, doing plenty of exercise, and
monitoring their blood glucose levels. However, type 2 diabetes is typically a progressive
disease - it gradually gets worse - and the patient will probably end up have to take insulin,
usually in tablet form. Overweight and obese people have a much higher risk of developing
type 2 diabetes compared to those with a healthy body weight. People with a lot of visceral
fat, also known as central obesity, belly fat, or abdominal obesity, are especially at risk. Being
overweight/obese causes the body to release chemicals that can destabilize the body's
cardiovascular and metabolic systems. The risk of developing type 2 diabetes is also greater
as we get older. Experts are not completely sure why, but say that as we age we tend to put on
weight and become less physically active. Those with a close relative who had/had type 2
diabetes, people of Middle Eastern, African, or South Asian descent also have a higher risk of
developing the disease. Men whose testosterone levels are low have been found to have a
higher risk of developing type 2 diabetes. Researchers from the University of Edinburgh,
Scotland, say that low testosterone levels are linked to insulin resistance.

Gestational diabetes
This type affects females during pregnancy. Some women have very high levels of glucose in
their blood, and their bodies are unable to produce enough insulin to transport all of the
glucose into their cells, resulting in progressively rising levels of glucose. Diagnosis of
gestational diabetes is made during pregnancy. The majority of gestational diabetes patients
can control their diabetes with exercise and diet. Between 10% to 20% of them will need to
take some kind of blood-glucose-controlling medications. Undiagnosed or uncontrolled
gestational diabetes can raise the risk of complications during childbirth. The baby may be
bigger than he/she should be. Scientists from the National Institutes of Health and Harvard
University found that women whose diets before becoming pregnant were high in animal fat

33

and cholesterol had a higher risk for gestational diabetes, compared to their counterparts
whose diets were low in cholesterol and animal fats.
ETIOLOGY
Type 1 diabetes is caused by a lack of insulin due to the destruction of insulin-producing beta
cells in the pancreas. In type 1 diabetesan autoimmune diseasethe bodys
immune system attacks and destroys the beta cells. Normally, the immune system
protects the body from infection by identifying and destroying bacteria, viruses, and
other potentially harmful foreign substances. But in autoimmune diseases, the
immune system attacks the bodys own cells. In type 1 diabetes, beta cell destruction
may take place over several years, but symptoms of the disease usually develop over a
short period of time. Type 1 diabetes typically occurs in children and young adults,
though it can appear at any age. In the past, type 1 diabetes was called juvenile
diabetes or insulin-dependent diabetes mellitus. Genetic Susceptibility
Heredity plays an important part in determining who is likely to develop type 1 diabetes.
Genes are passed down from biological parent to child. Genes carry instructions for making
proteins that are needed for the bodys cells to function. Many genes, as well as interactions
among genes, are thought to influence susceptibility to and protection from type 1 diabetes.
The key genes may vary in different population groups. Variations in genes that affect more
than 1 percent of a population group are called gene variants.
Autoimmune Destruction of Beta Cells
In type 1 diabetes, white blood cells called T cells attack and destroy beta cells. The process
begins well before diabetes symptoms appear and continues after diagnosis. Often, type 1
diabetes is not diagnosed until most beta cells have already been destroyed. At this point, a
person needs daily insulin treatment to survive. Finding ways to modify or stop this
autoimmune process and preserve beta cell function is a major focus of current scientific
research.
Environmental Factors
Environmental factors, such as foods, viruses, and toxins, may play a role in the development
of type 1 diabetes, but the exact nature of their role has not been determined. Some theories
suggest that environmental factors trigger the autoimmune destruction of beta cells in people
with a genetic susceptibility to diabetes. Other theories suggest that environmental factors
play an ongoing role in diabetes, even after diagnosis.
Type 2 diabetes develops most often in middle-aged and older people who are also
overweight or obese. The disease, once rare in youth, is becoming more common in
overweight and obese children and adolescents. Scientists think genetic susceptibility and
environmental factors are the most likely triggers of type 2 diabetes.
Genetic Susceptibility
Genes play a significant part in susceptibility to type 2 diabetes. Having certain genes or
combinations of genes may increase or decrease a persons risk for developing the disease.
The role of genes is suggested by the high rate of type 2 diabetes in families and identical
twins and wide variations in diabetes prevalence by ethnicity. Type 2 diabetes occurs more
frequently in African Americans, Alaska Natives, American Indians, Hispanics/Latinos, and
some Asian Americans, Native Hawaiians, and Pacific Islander Americans than it does in
non-Hispanic whites.
Obesity and Physical Inactivity
Physical inactivity and obesity are strongly associated with the development of type 2
diabetes. People who are genetically susceptible to type 2 diabetes are more vulnerable when
these risk factors are present.

34

Insulin Resistance
Insulin resistance is a common condition in people who are overweight or obese, have excess
abdominal fat, and are not physically active. Muscle, fat, and liver cells stop responding
properly to insulin, forcing the pancreas to compensate by producing extra insulin. As long as
beta cells are able to produce enough insulin, blood glucose levels stay in the normal range.
But when insulin production falters because of beta cell dysfunction, glucose levels rise,
leading to prediabetes or diabetes.
RISK FACTORS
Several risk factors have been associated with type 2 diabetes and include:

Family history of diabetes

Overweight

Unhealthy diet

Physical inactivity

Increasing age

High blood pressure

Ethnicity

Impaired glucose tolerance (IGT)*

History of gestational diabetes

Poor nutrition during pregnancy


PATHOPHISYOLOGY

35

SIGNS AND SYMPTOMS

36

COMPLICATIONS

Eye complications - glaucoma, cataracts, diabetic retinopathy, and some others.

Foot complications - neuropathy, ulcers, and sometimes gangrene which may require
that the foot be amputated

Skin complications - people with diabetes are more susceptible to skin infections and
skin disorders

Heart problems - such as ischemic heart disease, when the blood supply to the heart
muscle is diminished

Hypertension - common in people with diabetes, which can raise the risk of kidney
disease, eye problems, heart attack and stroke
Mental health - uncontrolled diabetes raises the risk of suffering from depression,
anxiety and some other mental disorders

Hearing loss - diabetes patients have a higher risk of developing hearing problems

37

Gum disease - there is a much higher prevalence of gum disease among diabetes
patients
Gastroparesis - the muscles of the stomach stop working properly

Ketoacidosis - a combination of ketosis and acidosis; accumulation of ketone bodies


and acidity in the blood.

Neuropathy - diabetic neuropathy is a type of nerve damage which can lead to


several different problems.

HHNS (Hyperosmolar Hyperglycemic Nonketotic Syndrome) - blood glucose


levels shoot up too high, and there are no ketones present in the blood or urine. It is an
emergency condition.
Nephropathy - uncontrolled blood pressure can lead to kidney disease

PAD (peripheral arterial disease) - symptoms may include pain in the leg, tingling
and sometimes problems walking properly

Stroke - if blood pressure, cholesterol levels, and blood glucose levels are not
controlled, the risk of stroke increases significantly
Erectile dysfunction - male impotence.

Infections - people with badly controlled diabetes are much more susceptible to
infections
Healing of wounds - cuts and lesions take much longer to heal

DIAGNOSIS
Blood tests are used to diagnosis diabetes and prediabetes because early in the disease type 2
diabetes may have no symptoms. All diabetes blood tests involve drawing blood at a health
care providers office or commercial facility and sending the sample to a lab for analysis. Lab
analysis of blood is needed to ensure test results are accurate. Glucose measuring devices
used in a health care providers office, such as finger-stick devices, are not accurate enough
for diagnosis but may be used as a quick indicator of high blood glucose.
Testing enables health care providers to find and treat diabetes before complications occur
and to find and treat prediabetes, which can delay or prevent type 2 diabetes from developing.
Any one of the following tests can be used for diagnosis:*

an A1C test, also called the hemoglobin A1c, HbA1c, or glycohemoglobin test
a fasting plasma glucose (FPG) test

an oral glucose tolerance test (OGTT)

*Not all tests are recommended for diagnosing all types of diabetes. See the individual test
descriptions for details.

38

Another blood test, the random plasma glucose (RPG) test, is sometimes used to diagnose
diabetes during a regular health checkup. If the RPG measures 200 milligrams per deciliter or
above, and the individual also shows symptoms of diabetes, then a health care provider may
diagnose diabetes.
Symptoms of diabetes include

increased urination
increased thirst

unexplained weight loss

Other symptoms can include fatigue, blurred vision, increased hunger, and sores that do not
heal.
Any test used to diagnose diabetes requires confirmation with a second measurement unless
clear symptoms of diabetes exist.
The following table provides the blood test levels for diagnosis of diabetes for nonpregnant
adults and diagnosis of prediabetes.

Source: Adapted from American Diabetes Association. Standards of medical care in diabetes
2012. Diabetes Care. 2012;35(Supp 1):S12, table 2.
A1C Test
The A1C test is used to detect type 2 diabetes and prediabetes but is not recommended for
diagnosis of type 1 diabetes or gestational diabetes. The A1C test is a blood test that reflects
the average of a persons blood glucose levels over the past 3 months and does not show daily
fluctuations. The A1C test is more convenient for patients than the traditional glucose tests
because it does not require fasting and can be performed at any time of the day.
The A1C test result is reported as a percentage. The higher the percentage, the higher a
persons blood glucose levels have been. A normal A1C level is below 5.7 percent.

39

An A1C of 5.7 to 6.4 percent indicates prediabetes. People diagnosed with prediabetes may
be retested in 1 year. People with an A1C below 5.7 percent maystill be at risk for diabetes,
depending on the presence of other characteristics that put them at risk, also known as risk
factors. People with an A1C above 6.0 percent should be considered at very high risk of
developing diabetes. A level of 6.5 percent or above means a person has diabetes.
Laboratory analysis. When the A1C test is used for diagnosis, the blood sample must be
sent to a laboratory using a method that is certified by the NGSP to ensure the results are
standardized. Blood samples analyzed in a health care providers office, known as point-ofcare tests, are not standardized for diagnosing diabetes.
Abnormal results. The A1C test can be unreliable for diagnosing or monitoring diabetes in
people with certain conditions known to interfere with the results. Interference should be
suspected when A1C results seem very different from the results of a blood glucose test.
People of African, Mediterranean, or Southeast Asian descent or people with family members
with sickle cell anemia or a thalassemia are particularly at risk of interference.
However, not all of the A1C tests are unreliable for people with these diseases. The NGSP
provides information about which A1C tests are appropriate to use for specific types of
interference and details on any problems with the A1C test atwww.ngsp.orgExternal Link
Disclaimer.
False A1C test results may also occur in people with other problems that affect their blood or
hemoglobin such as chronic kidney disease, liver disease, or anemia.
More information about limitations of the A1C test and different forms of sickle cell anemia
is provided in the NIDDK health topic, For People of African, Mediterranean, or Southeast
Asian Heritage: Important Information about Diabetes Blood Tests, or by calling 1800860
8747.
Changes in Diagnostic Testing
In the past, the A1C test was used to monitor blood glucose levels but not for diagnosis. The
A1C test has now been standardized, and in 2009, an international expert committee
recommended it be used for diagnosis of type 2 diabetes and prediabetes.2
More information about the A1C test is provided in the NIDDK health topic, The A1C Test
and Diabetes, or by calling 18008608747.
2

The International Expert Committee. International Expert Committee report on the role of
the A1C assay in the diagnosis of diabetes. Diabetes Care.2009;32(7):13271334.
Fasting Plasma Glucose Test
The FPG test is used to detect diabetes and prediabetes. The FPG test has been the most
common test used for diagnosing diabetes because it is more convenient than the OGTT and
less expensive. The FPG test measures blood glucose in a person who has fasted for at least 8
hours and is most reliable when given in the morning.

40

People with a fasting glucose level of 100 to 125 mg/dL have impaired fasting glucose (IFG),
or prediabetes. A level of 126 mg/dL or above, confirmed by repeating the test on another
day, means a person has diabetes.
Oral Glucose Tolerance Test
The OGTT can be used to diagnose diabetes, prediabetes, and gestational diabetes. Research
has shown that the OGTT is more sensitive than the FPG test, but it is less convenient to
administer. When used to test for diabetes or prediabetes, the OGTT measures blood glucose
after a person fasts for at least 8 hours and 2 hours after the person drinks a liquid containing
75 grams of glucose dissolved in water.
If the 2-hour blood glucose level is between 140 and 199 mg/dL, the person has a type of
prediabetes called impaired glucose tolerance (IGT). If confirmed by a second test, a 2-hour
glucose level of 200 mg/dL or above means a person has diabetes.
TREATMENT
Treatment for diabetes requires keeping close watch over your blood sugar levels (and
keeping them at a goal set by your doctor) with a combination of medications, exercise, and
diet. By paying close attention to what and when you eat, you can minimize or avoid the
"seesaw effect" of rapidly changing blood sugar levels, which can require quick changes in
medication dosages, especially insulin. If you have type 1 diabetes, you rpancreas no longer
makes the insulin your body needs to use blood sugar for energy. You will need insulin in the
form of injections or through use of a continuous pump. Learning to give injections to
yourself or to your infant or child may at first seem the most daunting part of managing
diabetes, but it is much easier that you think.
Some people with diabetes use a computerized pump -- called an insulin pump -- that gives
insulin on a set basis. You and your doctor program the pump to deliver a certain amount of
insulin throughout the day (the basal dose). Plus, you program the pump to deliver a certain
amount of insulin based on your blood sugar level before you eat (bolus dose).
Insulin comes in four types:

Rapid-acting (taking effect within a few minutes and lasting 2-4 hours)
Regular or short-acting (taking effect within 30 minutes and lasting 3-6 hours)
Intermediate-acting (taking effect in 2-4 hours and lasting up to 18 hours)
Long-acting (taking effect in 6-10 hours and lasting beyond 24 hours)

ACUTE RENAL FAILURE


Acute kidney injury (AKI) is the abrupt loss of kidney function, resulting in the retention of
urea and other nitrogenous waste products and in the dysregulation of extracellular volume
and electrolytes. The term AKI has largely replaced acute renal failure (ARF), reflecting the
recognition that smaller decrements in kidney function that do not result in overt organ failure
are of substantial clinical relevance and are associated with increased morbidity and

41

mortality. The term ARF is now reserved for severe AKI, usually implying the need for renal
replacement therapy. The loss of kidney function that defines AKI is most easily detected by
measurement of the serum creatinine, which is used to estimate the glomerular filtration rate
(GFR).
TYPES

Incidence of Acute Renal Failure


ARF affects approximately 1 percent of patients on admission to the hospital, 2 to 5 percent
during hospitalization, and 4 to 15 percent after cardiopulmonary bypass surgery.
Signs and Symptoms of ARF
Acute renal failure does not produce a classic set of symptoms. The most common symptom
is decreased urine output, which occurs in 70 percent of patients.
ARF Diagnosis
ARF is most easily diagnosed by an increase in blood levels of creatinine (Cr) and blood
urea nitrogen (BUN). The blood level of creatinine typically increases by 0.5 milligrams per
tenth of a liter (mg/dL) every day.
Treatment for Acute Renal Failure (ARF)
There are several modalities of renal replacement therapy (RRT) for patients with acute renal
failure:
Intermittent hemodialysis
Continuous hemodialysis (used in critically ill patients)

42

Peritoneal dialysis (rarely used)


ETIOLOGY
People who are most at risk for kidney failure usually suffer from one or more of the
following causes:

Loss of Blood Flow to the Kidneys


A sudden loss of blood flow to your kidneys can prompt kidney failure. Some diseases and
conditions that cause loss of blood flow to the kidneys include:

a heart attack

heart disease

scarring of the liver or liver failure

dehydration

a severe burn

an allergic reaction

a severe infection, such as sepsis


Blood pressure and anti-inflammatory medications can also limit blood flow.

Urine Elimination Problems


When your body cant eliminate urine, toxins build up and overload the kidneys. Some
cancers can block the urine passageways. These include prostate (most common type in men),
colon, cervical, and bladder cancers. Other conditions can interfere with urination and
possibly lead to kidney failure, including:

kidney stones

an enlarged prostate

blood clots within your urinary tract

damage to the nerves that control your bladder


Other Causes
Some diseases and conditions may lead to kidney failure, including:

a blood clot in or around your kidneys

43

infection

an overload of toxins from heavy metals

drugs and alcohol

vasculitis, which is an inflammation of blood vessels

lupus, which is an autoimmune disease that can cause inflammation of many body
organs

glomerulonephritis, which is an inflammation of the small blood vessels of the


kidneys

hemolytic uremic syndrome, which involves the breakdown red blood cells following
a bacterial infection, usually of the intestines

multiple myeloma, which is a cancer of the plasma cells in your bone marrow

scleroderma, which is an autoimmune disease that affects your skin

thrombotic thrombocytopenic purpura, which is a disorder that causes blood clots in


small vessels

chemotherapy drugs, which are medications that treat cancer and some autoimmune
diseases

dyes used in some imaging tests


certain antibiotics
EPIDEMIOLOGY
In the United States, approximately 1% of patients admitted to hospitals have AKI at the time of admission.
The estimated incidence rate of AKI during hospitalization is 2-5%. AKI develops within 30 days
postoperatively in approximately 1% of general surgery cases [8] and arises in up to 67% of intensive care
unit (ICU) patients.[9] In recipients of solitary kidney transplants, 21% developed AKI within the first 6 months
after transplantation.[10]
Approximately 95% of consultations with nephrologists are related to AKI. Feest and colleagues calculated
that the appropriate nephrologist referral rate is approximately 70 cases per million population. [11]

PATHOPHISYOLOGY

44

AIDS
AIDS (Acquired immune deficiency syndrome or acquired immunodeficiency syndrome) is a
syndrome caused by a virus called HIV (Human Immunodeficiency Virus). The illness alters
the immune system, making people much more vulnerable to infections and diseases. This
susceptibility worsens as the syndrome progresses. HIV is found in the body fluids of an
infected person (semen and vaginal fluids, blood and breast milk). The virus is passed from
one person to another through blood-to-blood and sexual contact. In addition, infected
pregnant women can pass HIV to their babies during pregnancy, delivering the baby during

45

childbirth, and through breast feeding. HIV can be transmitted in many ways, such as vaginal,
oral sex, anal sex, blood transfusion, and contaminated hypodermic needles.
TYPES
HIV-1 and HIV-2
HIV type 1 and HIV type 2 are two distinct viruses. Worldwide, the predominant virus is
HIV-1, and generally when people talk about HIV without specifying the type of virus they
are referring to HIV-1.
The relatively uncommon HIV-2 virus is concentrated in West Africa, but has been seen in
other countries. It is less infectious and progresses slower than HIV-1. While commonly used
antiretroviral drugs are active against HIV-2, optimum treatment is poorly understood.
EPIDEMIOLOGY
The HIV prevalence rate in South and South-East Asia is less than 0.35 percent, with total of
4.2 4.7 million adults and children infected. More AIDS deaths (480,000) occur in this
region than in any other except sub-Saharan Africa. The geographical size and human
diversity of South and South-East Asia have resulted in HIV epidemics differing across the
region. The AIDS picture in South Asia is dominated by the epidemic in India.
In South and Southeast Asia, the HIV epidemic remains largely concentrated in injecting drug
users, men who have sex with men, sex workers, and clients of sex workers and their
immediate sexual partners.[22] In the Philippines, in particular, sexual contact between males
comprise the majority of new infections. An HIV surveillance study conducted by Dr. Louie
Mar Gangcuangco and colleagues from the University of the Philippines-Philippine General
Hospital showed that out of 406 MSM tested for HIV in Metro Manila, HIV prevalence was
11.8% (95% confidence interval: 8.7- 15.0).[23][24]
Migrants, in particular, are vulnerable and 67% of those infected in Bangladesh and 41%
in Nepal are migrants returning from India.[22] This is in part due to human trafficking and
exploitation, but also because even those migrants who willingly go to India in search of
work are often afraid to access state health services due to concerns over their immigration
status.
ETIOLOGY
HIV is a retrovirus that infects the vital organs of the human immune system. The virus
progresses in the absence of antiretroviral therapy. The rate of virus progression varies widely
between individuals and depends on many factors (age of the patient, body's ability to defend
against HIV, access to health care, existence of coexisting infections, the infected person's
genetic inheritance, resistance to certain strains of HIV).

46

HIV can be transmitted through:

Sexual transmission. It can happen when there is contact with infected sexual
secretions (rectal, genital or oral mucous membranes). This can happen while having
unprotected sex, including vaginal, oral and anal sex or sharing sex toys with someone
infected with HIV.

Perinatal transmission. The mother can pass the infection on to her child during
childbirth, pregnancy, and also through breastfeeding.

Blood transmission. The risk of transmitting HIV through blood transfusion is


nowadays extremely low in developed countries, thanks to meticulous screening and
precautions. Among drug users, sharing and reusing syringes contaminated with HIVinfected blood is extremely hazardous.
Thanks to strict protection procedures the risk of accidental infection for healthcare
workers is low.
Individuals who give and receive tattoos and piercings are also at risk and should be very
careful.
RISK FACTORS

Have unprotected sex. Unprotected sex means having sex without using a
new latex or polyurethane condom every time. Anal sex is more risky than is
vaginal sex. The risk increases if you have multiple sexual partners.
Have another STI. Many sexually transmitted infections (STIs) produce open
sores on your genitals. These sores act as doorways for HIV to enter your body.

Use intravenous drugs. People who use intravenous drugs often share
needles and syringes. This exposes them to droplets of other people's blood.

Are an uncircumcised man. Studies indicate that lack of circumcision


increases the risk of heterosexual transmission of HIV.

PATHOPHISYOLOGY

47

SIGNS AND SYMPTOMS

Primary infection (Acute HIV)


The majority of people infected by HIV develop a flu-like illness within a month or two
after the virus enters the body. This illness, known as primary or acute HIV infection,
may last for a few weeks. Possible signs and symptoms include:

Fever
Headache

Muscle aches and joint pain

Rash

Sore throat

Swollen lymph glands, mainly on the neck

Although the symptoms of primary HIV infection may be mild enough to go


unnoticed, the amount of virus in the bloodstream (viral load) is particularly high at
this time. As a result, HIV infection spreads more efficiently during primary infection
than during the next stage of infection.

48

Clinical latent infection (Chronic HIV)


In some people, persistent swelling of lymph nodes occurs during clinical latent HIV.
Otherwise, there are no specific signs and symptoms. HIV remains in the body,
however, and in infected white blood cells.
Clinical latent infection generally lasts around 10 years if you're not receiving
antiretroviral therapy. This phase can last for decades in people taking antiretroviral
medications. But some people progress to more severe disease much sooner.

Early symptomatic HIV infection


As the virus continues to multiply and destroy immune cells, you may develop mild
infections or chronic signs and symptoms such as:

Fever

Fatigue

Swollen lymph nodes often one of the first signs of HIV infection

Diarrhea

Weight loss

Oral yeast infection (thrush)

Shingles (herpes zoster)

Progression to AIDS
If you receive no treatment for your HIV infection, the disease typically progresses to
AIDS in about 10 years. By the time AIDS develops, your immune system has been
severely damaged, making you susceptible to opportunistic infections diseases
that wouldn't usually trouble a person with a healthy immune system.
The signs and symptoms of some of these infections may include:

Soaking night sweats


Recurring fever

Chronic diarrhea

Persistent white spots or unusual lesions on your tongue or in your mouth

Persistent, unexplained fatigue

Weight loss

49

Skin rashes or bumps

COMPLICATIONS

Infections common to HIV/AIDS

Tuberculosis (TB). In resource-poor nations, TB is the most common opportunistic


infection associated with HIV and a leading cause of death among people with AIDS.
Cytomegalovirus. This common herpes virus is transmitted in body fluids such as
saliva, blood, urine, semen and breast milk. A healthy immune system inactivates the
virus, and it remains dormant in your body. If your immune system weakens, the virus
resurfaces causing damage to your eyes, digestive tract, lungs or other organs.

Candidiasis. Candidiasis is a common HIV-related infection. It causes inflammation


and a thick, white coating on the mucous membranes of your mouth, tongue, esophagus
or vagina.

Cryptococcal meningitis. Meningitis is an inflammation of the membranes and fluid


surrounding your brain and spinal cord (meninges). Cryptococcal meningitis is a common
central nervous system infection associated with HIV, caused by a fungus found in soil.

Toxoplasmosis. This potentially deadly infection is caused by Toxoplasma gondii, a


parasite spread primarily by cats. Infected cats pass the parasites in their stools, and the
parasites may then spread to other animals and humans.

Cryptosporidiosis. This infection is caused by an intestinal parasite that's commonly


found in animals. You contract cryptosporidiosis when you ingest contaminated food or
water. The parasite grows in your intestines and bile ducts, leading to severe, chronic
diarrhea in people with AIDS.

Cancers common to HIV/AIDS

Kaposi's sarcoma. A tumor of the blood vessel walls, this cancer is rare in
people not infected with HIV, but common in HIV-positive people.
Kaposi's sarcoma usually appears as pink, red or purple lesions on the skin and
mouth. In people with darker skin, the lesions may look dark brown or black.
Kaposi's sarcoma can also affect the internal organs, including the digestive tract
and lungs.

Lymphomas. This type of cancer originates in your white blood cells and usually first
appears in your lymph nodes. The most common early sign is painless swelling of the
lymph nodes in your neck, armpit or groin.

50

Other complications

Wasting syndrome. Aggressive treatment regimens have reduced the number of

cases of wasting syndrome, but it still affects many people with AIDS. It's defined as a
loss of at least 10 percent of body weight, often accompanied by diarrhea, chronic
weakness and fever.
Neurological complications. Although AIDS doesn't appear to infect the nerve
cells, it can cause neurological symptoms such as confusion, forgetfulness, depression,
anxiety and difficulty walking. One of the most common neurological complications is
AIDS dementia complex, which leads to behavioral changes and diminished mental
functioning.

Kidney disease. HIV-associated nephropathy (HIVAN) is an inflammation of


the tiny filters in your kidneys that remove excess fluid and wastes from your
bloodstream and pass them to your urine. Because of a genetic predisposition,
the risk of developing HIVAN is much higher in blacks.

DIAGNOSIS
HIV is most commonly diagnosed by testing your blood or saliva for antibodies to the
virus. Unfortunately, it takes time for your body to develop these antibodies usually
up to 12 weeks.
A newer type of test that checks for HIV antigen, a protein produced by the virus
immediately after infection, can quickly confirm a diagnosis soon after infection. An
earlier diagnosis may prompt people to take extra precautions to prevent
transmission of the virus to others.

Home test
A Food and Drug Administration-approved home test is available. To do the test, you
swab fluid from your upper and lower gums. If the test is positive, you need to see
your doctor to confirm the diagnosis and discuss your treatment options. If the test is
negative, it needs to be repeated in three months to confirm the results.

Tests to tailor treatment


If you receive a diagnosis of HIV/AIDS, several types of tests can help your doctor
determine what stage of the disease you have. These tests include:

CD4 count. CD4 cells are a type of white blood cell that's specifically targeted and
destroyed by HIV. Even if you have no symptoms, HIV infection progresses to AIDS when
your CD4 count dips below 200.

51

Viral load. This test measures the amount of virus in your blood. Studies have shown
that people with higher viral loads generally fare more poorly than do those with a lower
viral load.

Drug resistance. This blood test determines whether the strain of HIV you have will
be resistant to certain anti-HIV medications.

TREATMENT
There's no cure for HIV/AIDS, but a variety of drugs can be used in combination to
control the virus. Each class of anti-HIV drugs blocks the virus in different ways. It's
best to combine at least three drugs from two classes to avoid creating strains of HIV
that are immune to single drugs.
The classes of anti-HIV drugs include:

Non-nucleoside reverse transcriptase inhibitors (NNRTIs).NNRTIs disable a


protein needed by HIV to make copies of itself. Examples include efavirenz (Sustiva),
etravirine (Intelence) and nevirapine (Viramune).
Nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs). NRTIs are
faulty versions of building blocks that HIV needs to make copies of itself. Examples
include Abacavir (Ziagen), and the combination drugs emtricitabine-tenofovir (Truvada),
and lamivudine-zidovudine (Combivir).

Protease inhibitors (PIs). PIs disable protease, another protein that HIV needs to
make copies of itself. Examples include atazanavir (Reyataz), darunavir (Prezista),
fosamprenavir (Lexiva) and indinavir (Crixivan).

Entry or fusion inhibitors. These drugs block HIV's entry into CD4 cells. Examples
include enfuvirtide (Fuzeon) and maraviroc (Selzentry).

Integrase inhibitors. These drugs work by disabling integrase, a protein that HIV
uses to insert its genetic material into CD4 cells. Examples include raltegravir (Isentress),
elvitegravir (Vitekta) and dolutegravir (Tivicay).

When to start treatment


Everyone with HIV infection, regardless of CD4 count, should be offered antiviral
medication.
HIV therapy is particularly important for the following situations:

You have severe symptoms.


You have an opportunistic infection.

Your CD4 count is under 350.

52

You're pregnant.

You have HIV-related kidney disease.

You're being treated for hepatitis B or C.

Treatment can be difficult


HIV treatment regimens may involve taking multiple pills at specific times every day
for the rest of your life. Side effects can include:

Nausea, vomiting or diarrhea


Heart disease

Weakened bones or bone loss

Breakdown of muscle tissue (rhabdomyolysis)

Abnormal cholesterol levels

Higher blood sugar levels

HEPATITIS
Hepatitis is an inflammation of the liver. The condition can be self-limiting or can
progress to fibrosis (scarring), cirrhosis or liver cancer. Hepatitis viruses are the most
common cause of hepatitis in the world but other infections, toxic substances (e.g. alcohol,
certain drugs), and autoimmune diseases can also cause hepatitis.
TYPES

53

EPIDEMIOLOGY
It is estimated that approximately 2 billion people worldwide have evidence of past or present
infection with hepatitis B virus (HBV), and 248 million individuals are chronic carriers (ie,
positive for hepatitis B surface antigen [HBsAg]) [2,3]. The overall prevalence of HBsAg is
reported to be 3.6 percent; however, it varies depending upon the geographic area. The
prevalence of chronic HBV ranges from <2 percent in low prevalence areas (eg, United
States, Canada, Western Europe) to 2 to 7 percent in intermediate prevalence areas (eg,
Mediterranean countries, Japan, Central Asia, Middle East, and parts of South America) to 8
percent in high prevalence areas (eg, Western Africa, South Sudan) (table 1) [2-4].
The wide range in the prevalence of patients with chronic HBV in different parts of the world
is largely related to differences in the age at infection, which is inversely related to the risk of
chronicity. The rate of progression from acute to chronic HBV infection is approximately 90
percent for perinatally-acquired infection [5], 20 to 50 percent for infections between the age
of one and five years [6,7], and less than 5 percent for adult-acquired infection [6].
ETIOLOGY
The type of virus that's causing your hepatitis affects how severe your disease is and how
long it lasts.

54

Hepatitis A. You usually get it when you eat or drink something that's got the virus in it. It's
the least risky type because it almost always gets better on its own. It doesn't lead to longterm inflammation of yourliver
Even so, about 20% of people who get hepatitis A get sick enough that they need to go to the
hospital. There's a vaccine that can prevent it.
Hepatitis B. This type spreads in several ways.You can get it from sexwith someone who's
sick or by sharing a needle when using street drugs. The virus also can pass from a mother to
her newborn child at birth or soon afterward.
Most adults with hepatitis B get better, but a small percentage can't shake the disease and
become carriers, which means they can spread it to others even when their own symptoms
disappear.
Hepatitis C. You get this type if you have contact with contaminatedblood or needles used to
inject illegal drugs or draw tattoos.
Sometimes you don't get any symptoms, or just mild ones. But in some cases hepatitis
C leads to cirrhosis, a risky scarring of your liver.
Hepatitis D happens only if you're already infected with hepatitis B. It tends to make that
disease more severe.
It's spread from mother to child and through sex.
Hepatitis E mainly spreads in Asia, Mexico, India, and Africa. The few cases that show up in
the U.S. are usually in people who return from a country where there are outbreaks of the
disease.
Like hepatitis A, you usually get it by eating or drinking something that's been contaminated
with the virus.
RISK FACTORS
You're at increased risk of hepatitis A if you:

Travel or work in regions with high rates of hepatitis A


Attend child care or work in a child care center

Are a man who has sexual contact with other men

Are HIV positive

Have a clotting-factor disorder, such as hemophilia

Use injected or noninjected illicit drugs

55

Live with another person who has hepatitis A

Have oral-anal contact with someone who has hepatitis A

PATHOPHISYOLOGY

SIGNS AND SYMPTOMS


Signs and symptoms of acute hepatitis appear quickly. They include:

fatigue

flu-like symptoms

dark urine

pale stool

abdominal pain

loss of appetite

unexplained weight loss

yellow skin and eyes, which may be signs of jaundice


Since chronic hepatitis develops slowly, these signs and symptoms may be too subtle to
notice.
COMPLICATIONS

56

Chronic hepatitis B or C can often lead to more serious health problems. Because the virus
primarily affects the liver, people with chronic hepatitis B or C are at risk for:

chronic liver disease

cirrhosis (scarring of the liver)

cancer of the liver (in rare cases)


When the liver stops functioning normally, liver failure can occur. Complications of liver
failure include:

bleeding disorders

a buildup of fluid in the abdomen

increased blood pressure in portal veins that enter the liver

kidney failure

hepatic encephalopathy, which can involve fatigue, memory loss, and diminished
mental abilities due to the build up of toxins that affect the brain (especially ammonia)

hepatocellular carcinoma, which is a form of liver cancer


People with chronic hepatitis C are encouraged to avoid alcohol because it can accelerate
liver disease and failure. Certain supplements, prescription, and over-the-counter medications
can also affect liver function. If you have chronic hepatitis C, check with your doctor before
taking any new medications.
DIAGNOSIS
Physical Exam
During a physical examination, your doctor may press down gently on your abdomen to see if
theres pain or tenderness. Your doctor may also feel to see if your liver is enlarged. If your
skin or eyes are yellow, your doctor will note this during the exam.

Liver Biopsy
A liver biopsy is an invasive procedure that involves the doctor taking a sample of tissue from
your liver. This is a closed procedure. In other words, it can be done through the skin with a
needle and doesnt require surgery. This test allows your doctor to determine if an infection or
inflammation is present or if liver damage has occurred.

57

Liver Function Tests


Liver function tests use blood samples to determine how efficiently the liver works. These
tests check how the liver clears blood waste, protein, and enzymes. High liver enzyme levels
may indicate that the liver is stressed or damaged.
Ultrasound
An abdominal ultrasound uses ultrasound waves to create an image of the organs within the
abdomen. This test will reveal fluid in the abdomen, an enlarged liver, or liver damage.

Blood Tests
Blood tests used to detect the presence of hepatitis virus antibodies and antigen in the blood
will indicate or confirm which virus is the cause of the hepatitis.
Viral Antibody Testing
Further viral antibody testing may be needed to determine if a specific type of the hepatitis
virus is present.

Treatments
Treatment options are determined by which type of hepatitis you have and whether the
infection is acute or chronic.

Hepatitis A
Hepatitis A isnt usually treated. Bed rest may be recommended if symptoms cause a great
deal of discomfort. If you experience vomiting or diarrhea, you will be put on a special diet
created by your doctor to prevent malnutrition or dehydration. Vaccination can also prevent
hepatitis A infections by helping your body produce the antibodies that fight this type of
infection. Most children receive the vaccination between ages 12 and 18 months. Vaccination
is also available for adults.

58

Hepatitis B
Acute hepatitis B doesnt require specific treatment. Chronic hepatitis B is treated with
antiviral medications. This form of treatment can be costly because it must be followed for
several months or years. Treatment for chronic hepatitis B also requires regular medical
evaluations and monitoring to determine if the virus is progressing. The CDC recommends
hepatitis B vaccinations for all newborns. The vaccine is also recommended for all healthcare
and medical personnel.
Hepatitis C
Antiviral medications are used to treat both acute and chronic forms of hepatitis C. People
who develop chronic hepatitis C are typically treated with a combination of antiviral drug
therapies. They may also need further testing to determine the best form of treatment. People
who develop cirrhosis (scarring of the liver) or liver disease as a result of chronic hepatitis C
may be candidates for a liver transplant.

Hepatitis D
Hepatitis D is treated with a medication called alpha interferon. According to the Public
Health Agency of Canada, between 60 to 97 percent of people develop hepatitis D again even
after treatment.
Hepatitis E
There are currently no specific medical therapies to treat hepatitis E. Because the infection is
often acute, it typically resolves on its own. People with this type of infection are often
advised to get adequate rest, drink plenty of fluids, get enough nutrients, and avoid alcohol.
Prevention
Hygiene
Practicing good hygiene is one key way to avoid contracting hepatitis. If youre traveling to a
developing country, you should avoid:

drinking local water

ice

seafood

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raw fruit and vegetables


Hepatitis contracted through contaminated blood can be prevented by:

not sharing drug needles

not sharing razors

not using someone elses toothbrush

not touching spilled blood


Vaccines
The utilization of vaccines is a second key to preventing hepatitis. Vaccinations are available
to prevent the development of hepatitis A and B. Experts are currently developing vaccines
against hepatitis C, D, and E.

RHEUMATOID ARTHRITIS
Rheumatoid arthritis is a chronic inflammatory disorder that can affect more than just your
joints. In some people, the condition also can damage a wide variety of body systems,
including the skin, eyes, lungs, heart and blood vessels.
An autoimmune disorder, rheumatoid arthritis occurs when your immune system mistakenly
attacks your own body's tissues.
Unlike the wear-and-tear damage of osteoarthritis, rheumatoid arthritis affects the lining of
your joints, causing a painful swelling that can eventually result in bone erosion and joint
deformity.
The inflammation associated with rheumatoid arthritis is what can damage other parts of the
body as well. While new types of medications have improved treatment options dramatically,
severe rheumatoid arthritis can still cause physical disabilities.
EPIDEMIOLOGY
Studies of the descriptive epidemiology of RA indicate a population prevalence of 0.5% to 1% and a
highly variable annual incidence (12-1200 per 100,000 population) depending on gender,
race/ethnicity, and calendar year. Secular trends in RA incidence over time have been shown in
several studies, supporting the hypothesis of a host-environment interaction. People with RA have a
significantly increased risk of death compared with age- and sex-matched controls without RA from
the same community. The determinants of this excess mortality remain unclear; however, reports
suggest increased risk from gastrointestinal, respiratory, cardiovascular, infectious, and hematologic
diseases among RA patients compared with controls. Despite extensive epidemiologic research, the
etiology of RA is unknown. Several risk factors have been suggested as important in the development

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or progression of RA. These include genetics, infectious agents, oral contraceptives, smoking, and
formal education. Epidemiologic research is an essential contributor to our understanding of RA.

CAUSES AND SYMPTOMS


Signs and symptoms of rheumatoid arthritis may include:

Tender, warm, swollen joints

Joint stiffness that is usually worse in the mornings and after inactivity

Fatigue, fever and weight loss

Early rheumatoid arthritis tends to affect your smaller joints first particularly the joints
that attach your fingers to your hands and your toes to your feet.
As the disease progresses, symptoms often spread to the wrists, knees, ankles, elbows, hips
and shoulders. In most cases, symptoms occur in the same joints on both sides of your body.
About 40 percent of the people who have rheumatoid arthritis also experience signs and
symptoms that don't involve the joints. Rheumatoid arthritis can affect many nonjoint
structures, including:

Skin

Eyes

Lungs

Heart

Kidneys

Salivary glands

Nerve tissue

Bone marrow

Blood vessels

Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go.
Periods of increased disease activity, called flares, alternate with periods of relative remission
when the swelling and pain fade or disappear. Over time, rheumatoid arthritis can cause
joints to deform and shift out of place.

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Causes

Rheumatoid arthritis vs. osteoarthritis


Rheumatoid arthritis occurs when your immune system attacks the synovium the lining of
the membranes that surround your joints.
The resulting inflammation thickens the synovium, which can eventually destroy the cartilage
and bone within the joint.
The tendons and ligaments that hold the joint together weaken and stretch. Gradually, the
joint loses its shape and alignment.
Doctors don't know what starts this process, although a genetic component appears likely.
While your genes don't actually cause rheumatoid arthritis, they can make you more
susceptible to environmental factors such as infection with certain viruses and bacteria
that may trigger the disease.
Risk factors
Factors that may increase your risk of rheumatoid arthritis include:

Your sex. Women are more likely than men to develop rheumatoid arthritis.

Age. Rheumatoid arthritis can occur at any age, but it most commonly begins between
the ages of 40 and 60.

Family history. If a member of your family has rheumatoid arthritis, you may have
an increased risk of the disease.

Smoking. Cigarette smoking increases your risk of developing rheumatoid arthritis,


particularly if you have a genetic predisposition for developing the disease. Smoking
also appears to be associated with greater disease severity.

Environmental exposures. Although uncertain and poorly understood, some


exposures such as asbestos or silica may increase the risk for developing rheumatoid
arthritis. Emergency workers exposed to dust from the collapse of the World Trade
Center are at higher risk of autoimmune diseases such as rheumatoid arthritis.

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Obesity. People who are overweight or obese appear to be at somewhat higher risk of
developing rheumatoid arthritis, especially in women diagnosed with the disease when
they were 55 or younger.

Complications
Rheumatoid arthritis increases your risk of developing:

Osteoporosis. Rheumatoid arthritis itself, along with some medications used for
treating rheumatoid arthritis, can increase your risk of osteoporosis a condition that
weakens your bones and makes them more prone to fracture.

Rheumatoid nodules. These firm bumps of tissue most commonly form around
pressure points, such as the elbows. However, these nodules can form anywhere in the
body, including the lungs.

Dry eyes and mouth. People who have rheumatoid arthritis are much more likely to
experience Sjogren's syndrome, a disorder that decreases the amount of moisture in
your eyes and mouth.

Infections. The disease itself and many of the medications used to combat rheumatoid
arthritis can impair the immune system, leading to increased infections.

Abnormal body composition. The proportion of fat compared to lean mass is often
higher in people who have rheumatoid arthritis, even in people who have a normal body
mass index (BMI).

Carpal tunnel syndrome. If rheumatoid arthritis affects your wrists, the


inflammation can compress the nerve that serves most of your hand and fingers.

Heart problems. Rheumatoid arthritis can increase your risk of hardened and blocked
arteries, as well as inflammation of the sac that encloses your heart.

Lung disease. People with rheumatoid arthritis have an increased risk of


inflammation and scarring of the lung tissues, which can lead to progressive shortness
of breath.

Lymphoma. Rheumatoid arthritis increases the risk of lymphoma, a group of blood


cancers that develop in the lymph system.

Diagnosis
Rheumatoid arthritis can be difficult to diagnose in its early stages because the early signs
and symptoms mimic those of many other diseases. There is no one blood test or physical
finding to confirm the diagnosis.

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During the physical exam, your doctor will check your joints for swelling, redness and
warmth. He or she may also check your reflexes and muscle strength.
Blood tests
People with rheumatoid arthritis often have an elevated erythrocyte sedimentation rate (ESR,
or sed rate) or C-reactive protein (CRP), which may indicate the presence of an inflammatory
process in the body. Other common blood tests look for rheumatoid factor and anti-cyclic
citrullinated peptide (anti-CCP) antibodies.
Imaging tests
Your doctor may recommend X-rays to help track the progression of rheumatoid arthritis in
your joints over time. MRI and ultrasound tests can help your doctor judge the severity of the
disease in your body.
PATHOPHISYOLOGY

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TREATMENT
There is no cure for rheumatoid arthritis. But recent discoveries indicate that remission of
symptoms is more likely when treatment begins early with strong medications known as
disease-modifying antirheumatic drugs (DMARDs).
Medications
The types of medications recommended by your doctor will depend on the severity of your
symptoms and how long you've had rheumatoid arthritis.

NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and


reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin IB)
and naproxen sodium (Aleve). Stronger NSAIDs are available by prescription. Side

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effects may include ringing in your ears, stomach irritation, heart problems, and liver
and kidney damage.

Steroids. Corticosteroid medications, such as prednisone, reduce inflammation and


pain and slow joint damage. Side effects may include thinning of bones, weight gain
and diabetes. Doctors often prescribe a corticosteroid to relieve acute symptoms, with
the goal of gradually tapering off the medication.

Disease-modifying antirheumatic drugs (DMARDs). These drugs can slow the


progression of rheumatoid arthritis and save the joints and other tissues from permanent
damage. Common DMARDs include methotrexate (Trexall, Otrexup, Rasuvo),
leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine).
Side effects vary but may include liver damage, bone marrow suppression and severe
lung infections.

Biologic agents. Also known as biologic response modifiers, this newer class of
DMARDs includes abatacept (Orencia), adalimumab (Humira), anakinra (Kineret),
certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab
(Remicade), rituximab (Rituxan), tocilizumab (Actemra) and tofacitinib (Xeljanz).
These drugs can target parts of the immune system that trigger inflammation that causes
joint and tissue damage. These types of drugs also increase the risk of infections.
Biologic DMARDs are usually most effective when paired with a nonbiologic
DMARD, such as methotrexate.

Therapy
Your doctor may send you to a physical or occupational therapist who can teach you
exercises to help keep your joints flexible. The therapist may also suggest new ways to do
daily tasks, which will be easier on your joints. For example, if your fingers are sore, you
may want to pick up an object using your forearms.
Assistive devices can make it easier to avoid stressing your painful joints. For instance, a
kitchen knife equipped with a saw handle helps protect your finger and wrist joints. Certain
tools, such as buttonhooks, can make it easier to get dressed. Catalogs and medical supply
stores are good places to look for ideas.

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Surgery
If medications fail to prevent or slow joint damage, you and your doctor may consider
surgery to repair damaged joints. Surgery may help restore your ability to use your joint. It
can also reduce pain and correct deformities.
Rheumatoid arthritis surgery may involve one or more of the following procedures:

Synovectomy. Surgery to remove the inflamed synovium (lining of the joint).


Synovectomy can be performed on knees, elbows, wrists, fingers and hips.

Tendon repair. Inflammation and joint damage may cause tendons around your joint
to loosen or rupture. Your surgeon may be able to repair the tendons around your joint.

Joint fusion. Surgically fusing a joint may be recommended to stabilize or realign a


joint and for pain relief when a joint replacement isn't an option.

Total joint replacement. During joint replacement surgery, your surgeon removes the
damaged parts of your joint and inserts a prosthesis made of metal and plastic.

Surgery carries a risk of bleeding, infection and pain. Discuss the benefits and risks with your
doctor.
Alternative medicine
Some common complementary and alternative treatments that have shown promise for
rheumatoid arthritis include:

Fish oil. Some preliminary studies have found that fish oil supplements may reduce
rheumatoid arthritis pain and stiffness. Side effects can include nausea, belching and a
fishy taste in the mouth. Fish oil can interfere with medications, so check with your
doctor first.

Plant oils. The seeds of evening primrose, borage and black currant contain a type of
fatty acid that may help with rheumatoid arthritis pain and morning stiffness. Side
effects may include nausea, diarrhea and gas. Some plant oils can cause liver damage or
interfere with medications, so check with your doctor first.

Tai chi. This movement therapy involves gentle exercises and stretches combined
with deep breathing. Many people use tai chi to relieve stress in their lives. Small
studies have found that tai chi may reduce rheumatoid arthritis pain. When led by a
knowledgeable instructor, tai chi is safe. But don't do any moves that cause pain.

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