Psoriasis

What is psoriasis?
Psoriasis (say "sor-eye-ah- sus") is a condition that affects your skin and causes thick red marks that look like scales to form. The thick scaling is due to an increase in the number of skin cells. Sometimes pus-filled blisters form. Most of the time, the skin on the elbows and knees is
affected, but psoriasis can occur anywhere on the body, including the scalp, fingernails and mouth, and even the skin over the joints. Psoriasis tends to run in families and it usually appears between the ages of 15 and 35.
Doctors now believe that psoriasis starts with the immune system. T cells, a type of white blood cell, usually protect the body against infection and disease by attacking bacteria and viruses. However, when you have psoriasis, your T cells mistakenly attack your skin cells instead. Your body then produces other immune system responses, leading to swelling and rapid production of of skin cells.
Certain things that can cause the psoriasis to get worse include:

• Infections
• Disease that weaken the immune system
• Stress
• Certain medications
  

Is psoriasis contagious?
No. You can't catch psoriasis from another person or give it to someone by touching them, and you can't spread it to other parts of your body.

How is psoriasis treated?
There are various treatments for psoriasis. Your doctor will decide which one is right for you. Keeping your skin moisturized with an over-the-counter product is a good first step. Body lotion can help to remove the scales. Prescription creams, ointments, lotions and gels (also called topical medicines) that you put on the affected areas are often used to treat psoriasis. Your doctor may tell you to put your medicine on the areas of psoriasis before you go to bed and then cover the areas with plastic wrap (such as Saran Wrap). If you don't respond to any of these treatments, your doctor may prescribe a new medicine that is given as an injection. This new
medication is used for moderate to severe cases of psoriasis.
Special shampoos are used for psoriasis on the scalp. In more severe cases, medicines are taken in pill form. Other treatments include a special type of ultraviolet light therapy. Sunlight can help psoriasis, but be careful not to stay in the sun too long. A sunburn can make your psoriasis worse. You should use a sunscreen on the parts of your skin that aren't affected by psoriasis. It's especially important to put sunscreen on your face.

Will psoriasis go away with treatment?
The scales of psoriasis should improve almost immediately after you begin treatment. It may take 2 to 6 weeks for the affected areas of your skin to return to a more normal thickness, and the redness may last several months. While psoriasis will improve, it may not completely go away. Sometimes, certain scaly spots will get better at the same time that other spots get
worse. After you've been using a certain type of medicine for awhile, your psoriasis may "get used to" the treatment. If this happens, your medicine may not be as effective as it once was. Your doctor may change your medicine. Sometimes you may need a stronger dose of medicine. Talk to your doctor if your psoriasis doesn't seem to be getting better with treatment.
(AAFP)

Are Doctors Just Playing Hunches?

Nobody pretends medicine is easy, but if there's one thing we ought to be able to rely on, it's that the doctors looking out for us are doing more than playing hunches. We take certain medicines because they work, right? We go into the operating room for certain procedures because they'll make us well, don't we?
Well, maybe. More and more, however, doctors are making the unnerving case that no matter how reliable a drug or other treatment appears to be, too often there's simply little hard evidence that it would make a long-term difference in a person's quality of life or prolonged survival. Obviously, drugs are tested rigorously to show that they are safe and effective before
they are approved by the U.S. and other developed countries. But a clinical study is not the real world, and just because a drug leads to a statistically significant improvement in, say, cholesterol levels doesn't guarantee that the desired effect--a healthier heart and a longer life--will follow. Often your doctor is left to make prescription decisions based at least in part on faith, bias or even an educated guess. That ought to be enough to spook even the least jumpy patient, but the fact is, recognizing just what a roll of the dice medicine can be may be a good thing. Increasingly, doctors seeking to provide their patients with the best possible care are exploring what is known as evidence-based medicine--a hard, cold, empirical look at what works, what doesn't and how to distinguish between the two. It's not enough to prove that a particular blood test or CT scan really spots cancer, for example. You also need to know whether early detection of that cancer would make a difference in your ability to respond to treatment or it merely means that you would die at the same point but learn about your illness earlier than you would have without the test.
Evidence-based medicine, which uses volumes of studies and show-me skepticism to answer such questions, is now being taught--with varying degrees of success--at every medical school in North America. It has been extraordinarily successful in shooting down some of the most cherished beliefs in health care, like the idea that long-term hormone-replacement therapy would help prevent heart disease in women. And it has clearly saved lives. Many doctors used to give anti-arrhythmia drugs to everyone who experienced irregular heartbeats after a heart attack because severely irregular beats could rapidly prove fatal. But then came the results of a
randomized trial showing that patients with only mildly irregular heartbeats were more likely to die if given the anti-arrhythmia medication than their untreated counterparts were. Doctors now prescribe more judiciously, though treatment still saves lives in the case of severe arrhythmias. Advocates believe that evidence-based medicine can go much further, reducing
the reliance on expert opinion and overturning the flawed assumptions and even financial incentives that underlie many decisions. "This is a whole way of looking at the world," says Dr. Gordon Guyatt of McMaster University in Hamilton, Ont., who coined the term and is a pioneer of the evidence-based movement.
But is such certainty possible--or even desirable? Medicine, after all, is a personalized service, one built around the uniqueness of each patient and the skilled physician's ability to design care accordingly. "I'm worried about training a generation of physicians who don't have the other skills they need for the optimal practice of medicine," says Dr. Mark Tonelli, a pulmonary-care specialist at the University of Washington in Seattle. "They can read the scientific literature, understand the statistics, but they don't understand how that should influence their treatment of the individual in front of them." What's more, some insurance companies have been very aggressive in using evidence-based arguments to deny payment for untested treatments-- a circular problem, because how do you create the evidence the insurers demand unless you test the untested?
Whatever the merits of evidence-based medicine, it got off to a rocky start. When Guyatt began championing it back in the 1990s, he called it "scientific medicine," but he learned quickly that if you want to start a revolution, it helps to pick the right slogan. Many of his colleagues were outraged by the implied insult to their expertise. So he quickly went with "evidence-based, "
and tempers cooled.
Guyatt's ideas complemented the work of the Cochrane Collaboration, an international network of researchers, physicians and others that was founded in 1993 to systematically gather and evaluate the knowledge found in medical research. The organization aggregates all published scientific studies on a particular treatment question to get a sense of the field. Then reviewers
carefully consider the design of the research to determine just how strong the evidence is. One of their most famous reports was a 2005 finding based on 139 studies showing that there was "no credible evidence" that the vaccine against measles, mumps and rubella was involved in the development of either autism or Crohn's disease.
Guyatt and another doctor, David Sackett, wanted to go a step further by making sure doctors used the evidence that was collected and ranked. Many physicians began doing just that, but there have been a few nasty surprises.
Consider the case of Dr. Daniel Merenstein, a family-medicine physician trained in evidence-based practice. In 1999 Merenstein examined a healthy 53-year-old man who showed no signs of prostate cancer. As he had been taught, Merenstein explained to his patient that there are advantages and disadvantages to having a blood test for prostate-specific antigen (PSA).
The test can lead to early detection of prostate cancer but also to unnecessary biopsies and even treatment--with all its attendant risks of impotence and incontinence- -for a cancer that might have grown so slowly that it didn't need immediate attention. And for aggressive prostate
cancers, there is little evidence that early detection makes a difference in whether treatment could save your life. As a result, the patient did not get a PSA test.
Unfortunately, several years later, the patient was found to have a very aggressive and incurable prostate cancer. He sued Merenstein for not ordering a PSA test, and a jury agreed--despite the lack of evidence that it would have made a difference. Most doctors in the plaintiff's state, the lawyers showed, would have ignored the debate and simply ordered the test.
Although Merenstein was found not liable, the residency program that trained him in evidence-based practice was--to the tune of $1 million. Even champions of evidence-based practice acknowledge that the approach has limits. "Some things can't be tested in randomized trials, and some things are so obvious, they don't need it," says Dr. Paul Glasziou, director of the
Center for Evidence-Based Medicine in Oxford, England. There have never been randomized trials to show that giving electrical shocks to a heart that has stopped beating saves more lives than doing nothing, for example. Similarly, giving antibiotics to treat pneumonia has never been rigorously tested from a scientific point of view. It's clear to everyone, however, that if you
want to survive a bout of bacterial pneumonia, antibiotics are your best bet, and nobody would want to go into cardiac arrest without a crash cart handy. "Where randomized trials are most important is where you're trying to affect a long-term condition, like stroke or cancer," Glasziou says.
Finally, the very definition of evidence-based medicine is something of a moving target. Physicians who encouraged their female patients to take hormone-replacement therapy to prevent heart problems later on were practicing a kind of evidence-based medicine, since the best available evidence at the time--observational studies and the like--suggested a benefit. Of course, when a randomized controlled trial showed otherwise, the advice changed. Even at that, the case is not entirely closed. Some researchers now believe there may be a window of opportunity right around the years of menopause during which hormone-replacement therapy could help the heart. Proving that would, naturally, require another study.
All the same, few people deny that the trend in medicine is increasingly to be guided, if not governed, by the data--an idea that is spreading to other fields as well. Evidence-based practice is now being taught in nursing, general education and even philanthropy, thanks to the influence of the Bill and Melinda Gates Foundation, a results-based group if ever there was one. You could see even the political fights over global warming as the birth pangs of the new practice of evidence-based policy. But it is in medicine that the practice will have the most emotional impact.
All patients would probably benefit if their doctors were abreast of the latest data, but none would benefit from being reduced to one of those statistical points. "You have to be able to take a good history and do a physical examination, " Guyatt says. "And you have to have an understanding of patients' values and preferences. " As much as some physicians might wish it otherwise, there is still as much art to medicine as there is science.
(Time)

Tattoos

Michele Van Vranken, MD

It seems like everyone has a tattoo these days. What used to be the property of sailors, outlaws, and biker gangs is now a popular body decoration for many people. And it's not just anchors, skulls, and battleships anymore - from school emblems to Celtic designs to personalized symbols, people have found many ways to express themselves with their tattoos. Maybe you've
thought about getting one. But before you head down to the nearest tattoo shop and roll up your sleeve, there are a few things you need to know.

So What Exactly Is a Tattoo?
A tattoo is a puncture wound, made deep in your skin, that's filled with ink. It's made by penetrating your skin with a needle and injecting ink into the area, usually creating some sort of design. What makes tattoos so long-lasting is they're so deep - the ink isn't injected into the epidermis (the top layer of skin that you continue to produce and shed throughout your
lifetime). Instead, the ink is injected into the dermis, which is the second, deeper layer of skin. Dermis cells are very stable, so the tattoo is practically permanent.
Tattoos used to be done manually - that is, the tattoo artist would puncture the skin with a needle and inject the ink by hand. Though this process is still used in some parts of the world, most tattoo shops use a tattoo machine these days. A tattoo machine is a handheld electric instrument that uses a tube and needle system. On one end is a sterilized needle, which is
attached to tubes that contain ink. A foot switch is used to turn on the machine, which moves the needle in and out while driving the ink about 1/8 inch (about 3 millimeters) into your skin.
Most tattoo artists know how deep to drive the needle into your skin, but not going deep enough will produce a ragged tattoo, and going too deep can cause bleeding and intense pain. Getting a tattoo can take several hours, depending on the size and design chosen.

Does It Hurt to Get a Tattoo?
Getting a tattoo can hurt, but the level of pain can vary. Because getting a tattoo involves being stuck multiple times with a needle, it can feel like getting a bunch of shots or being stung by a hornet multiple times. Some people describe the tattoo sensation as "tingling." It all depends on your pain threshold, how good the person wielding the tattoo machine is, and where exactly on your body you're getting the tattoo. Also, keep in mind that you'll probably bleed a little.

If You're Thinking About It
If you're thinking about getting a tattoo, there is one very important thing you have to keep in mind - getting it done safely. Although it might look a whole lot cooler than a big scab, a new tattoo is also a wound. Like any other slice, scrape, puncture, cut, or penetration to your skin, a tattoo is at risk for infections and disease.
First, make sure you're up to date with your immunizations (especially hepatitis and tetanus shots) and plan where you'll get medical care if your tattoo becomes infected (signs of infection include excessive redness or tenderness around the tattoo, prolonged bleeding, pus, or changes in your skin color around the tattoo).
If you have a medical problem such as heart disease, allergies, diabetes, skin disorders, a condition that affects your immune system, or infections - or if you are pregnant - ask your doctor if there are any special concerns you should have or precautions you should take beforehand. Also, if you're prone to getting keloids (an overgrowth of scar tissue in the area of the wound), it's probably best to avoid getting a tattoo altogether.
It's very important to make sure the tattoo studio is clean and safe, and that all equipment used is disposable (in the case of needles, gloves, masks, etc.) and sterilized (everything else). Some states, cities, and communities set up standards for tattoo studios, but others don't. You can
call your state, county, or local health department to find out about the laws in your community, ask for recommendations on licensed tattoo shops, or check for any complaints about a particular studio. Professional studios usually take pride in their cleanliness. Here are some
things to check for:

• Make sure the tattoo studio has an autoclave (a device that uses steam, pressure, and heat for sterilization) . You should be allowed to watch as equipment is sterilized in the autoclave.
• Check that the tattoo artist is a licensed practitioner. If so, the tattoo artist should be able to provide you with references.
• Be sure that the tattoo studio follows the Occupational Safety and Health Administration' s Universal Precautions. These are regulations that outline procedures to be followed when dealing with bodily fluids (in this case, blood). If the studio looks unclean, if anything looks out of the ordinary, or if you feel in any way uncomfortable, find a better place to get your tattoo.
  

What's the Procedure Like?
Here's what you can expect from a normal tattooing procedure:

• The tattoo artist will first wash his or her hands with a germicidal soap.
• The to-be-tattooed area on your body will be cleaned and disinfected.
• The tattoo artist will put on clean, fresh gloves (and possibly a surgical mask).
• The tattoo artist will explain the sterilization procedure to you and open up the single-use, sterilized equipment (such as needles, etc.).
• Using the tattoo machine (with a sterile, single-use needle attached), the tattoo artist will begin drawing an outline of the tattoo under your skin.
• The outline will be cleaned with antiseptic soap and water.
• Sterile, thicker needles will be installed on the tattoo machine, and the tattoo artist will start shading the design. After cleaning the area again, color will be injected.
• Any blood will be removed by a sterile, disposable cloth or towel.
• When finished, the area, now sporting a finished tattoo, will be cleaned once again and a bandage will be applied.
  

Taking Care of a Tattoo
The last step in getting a tattoo is very important - taking care of the tattoo until it fully heals. Follow all of the instructions the studio gives you for caring for your tattoo to make sure it heals properly. Also, keep in mind that it's very important to call your doctor right away if you see or
feel any signs of infection such as pain, spreading redness, swelling, or drainage of pus. To make sure your tattoo heals properly:

• Keep a bandage on the area for up to 24 hours.
• Avoid touching the tattooed area and don't pick at any scabs that may form.
• Wash the tattoo with an antibacterial soap (don't use alcohol or peroxide - they'll dry out the tattoo). Use a soft towel to dry the tattoo - just pat it dry and be sure not to rub it.
• Rub antibiotic ointment into the tattoo. Don't use petroleum jelly!
• Put an ice pack on the tattooed area if you see any redness or swelling.
• Try not to get the tattoo wet until it fully heals. Stay away from pools, hot tubs, or long, hot baths.
• Keep your tattoo away from the sun until it's fully healed.
  

Even after it's fully healed, a tattoo is more susceptible to the sun's rays, so it's a good idea to always keep it protected from direct sunlight. If you're outside often or hang out at the beach, it's recommended that you always wear a sunscreen with a minimum sun protection factor (SPF) of 30 on the tattoo. This not only protects your skin, but keeps the tattoo from
fading.

What Are the Risks?
If you decide to get a tattoo, chances are everything will go as planned. But if disinfection and sterilization steps aren't followed, there are some things you need to be aware of that can go wrong. If you don't go to a tattoo studio or the tattoo studio doesn't follow precautions like using
sterilized equipment or if it shares ink between customers, you're putting yourself at risk for getting viral infections such as hepatitis, bacterial skin infections, or dermatitis (severe skin irritation).
Also, some people have allergic reactions to the tattoo ink. And if you already have a skin condition such as eczema, you may have flare-ups as a result of the tattoo. Serious complications can result if you attempt to do a tattoo yourself, have a friend do it for you, or have it done in any unclean environment. Because tattooing involves injections under the skin, viruses such as HIV and hepatitis B and C can be transferred into your body if proper precautions aren't followed. For this reason, the American Red Cross and some other blood banks require people to wait 12 months after getting a tattoo before they can donate blood.

Tattoo Removal
A lot of people love their tattoos and keep them forever. But others decide a couple of years down the road that they really don't like that rose on their ankle or snake on their bicep anymore. Or maybe you broke up with your boyfriend or girlfriend and no longer want his or her initials on yourstomach.

What then?
In the past, tattoo removal required surgery, but now it can be done through a medical procedure that uses a laser. Some tattoo shops also offer tattoo removal, but it's a better idea to make sure the person doing the removal is a medical doctor. Before you go just anywhere to get your tattoo removed, check with your doctor or contact the American Dermatological Association to find a reputable laser removal specialist in your area.
Although it's called tattoo removal, completely removing a tattoo can be difficult depending on factors like how old the tattoo is, how big the tattoo is, and the types and colors of inks that were used. Removal of the entire tattoo is not always guaranteed. It's best to consult with a dermatologist who specializes in tattoo removal to get your questions answered - such as whether anesthesia is used. The dermatologist can also give you a good idea of how much (if not all) of the tattoo can be removed. Laser tattoo removal usually requires a number of visits, with each procedure lasting only a few minutes. Anesthesia may or may not be used. What happens is the laser sends short zaps of light through the top layers of your skin, with the laser's energy aimed at specific pigments in the tattoo. Those zapped pigments are then removed by your body's immune system.
Removing a tattoo by laser can be uncomfortable and can feel a lot like getting a tattoo. The entire process can take several weeks. Just like when you get a tattoo, you must look after the wound area after a tattoo is removed. The area should be kept clean, but it shouldn't be scrubbed. Also, it might turn red for a few days and a scab might form. Don't rub or scrub the area or pick at the scab. Let it heal on its own. Laser tattoo removal is usually effective for the most part, but there can be some side effects. The area can become infected or scarred, and it can also be susceptible to hyperpigmentation, which causes the area where your tattoo used to be to become darker than your normal skin, or hypopigmentation, which causes the area where your tattoo used to be to become lighter than your normal skin color. Now for the big part - tattoo removal can be pretty expensive. Depending on factors like the size and design of the tattoo, removal can cost significantly more than the actual tattoo.

So Is It Worth It?
Is getting a tattoo worth the money and hassle? It's up to you. Some people really enjoy their tattoos and keep them for life, whereas others might regret that they acted on impulse and didn't think enough about it before they got one. Getting a tattoo is a big deal, especially because they're designed to be permanent. If you've thought about it and decided you want a tattoo, make sure you do a little detective work and find a clean, safe, and professional tattoo shop.
Also, remember that getting and maintaining a tattoo involves some responsibility - after you leave the tattoo shop, it's up to you to protect and treat it to prevent infections or other complications.
(AAFP)

Ectopic Pregnancy

S.H. Ural, MD

Ectopic means "out of place." In an ectopic pregnancy, a fertilized egg has implanted outside the uterus. The egg settles in the fallopian tubes more than 95% of the time. This is why ectopic pregnancies are commonly called "tubal pregnancies. " The egg can also implant in the ovary, abdomen, or the cervix, so you may see these referred to as cervical or abdominal pregnancies.
None of these areas has as much space or nurturing tissue as a uterus for a pregnancy to develop. As the fetus grows, it will eventually burst the organ that contains it. This can cause severe bleeding and endanger the mother's life. A classical ectopic pregnancy never develops into a live birth.

What Are the Signs and Symptoms?
Ectopic pregnancy can be difficult to diagnose because symptoms often mirror those of a normal early pregnancy. These can include missed periods, breast tenderness, nausea, vomiting, or frequent urination.
Pain is usually the first red flag. You might feel pain in your pelvis, abdomen, or, in extreme cases, even your shoulder or neck (if blood from a ruptured ectopic pregnancy builds up and irritates certain nerves). Most women describe the pain as sharp and stabbing. It may concentrate on one side of the pelvis, and it may come and go or vary in intensity. Any of the following additional symptoms can suggest an ectopic pregnancy:

• vaginal spotting or bleeding
• dizziness or fainting (caused by blood loss)
• low blood pressure (also caused by blood loss)
• lower back pain
  

What Causes an Ectopic Pregnancy?
An ectopic pregnancy results from a fertilized egg's inability to work its way quickly enough down the fallopian tube into the uterus. An infection or inflammation of the tube may have partially or entirely blocked it. Pelvic inflammatory disease (PID) is the most common of these infections. Endometriosis (when cells from the lining of the uterus detach and grow elsewhere in the body) or scar tissue from previous abdominal or fallopian surgeries can also cause blockages. More rarely, birth defects or abnormal growths can alter the shape of the tube and disrupt the egg's progress.

How Is It Diagnosed?
If you arrive in the emergency department complaining of abdominal pain, you'll likely be given a urine pregnancy test. Although these tests aren't sophisticated, they are fast - and speed can be crucial in treating ectopic pregnancy.
If you already know you're pregnant, or if the urine test comes back positive, you'll probably be given a quantitative hCG test. This blood test measures levels of the hormone human chorionic gonadotropin (hCG), which is produced by the placenta. The hormone hCG appears in the blood and urine as early as 10 days after conception, and its levels double every 2 days for the first 10 weeks of pregnancy. If hCG levels are lower than expected for your stage of pregnancy, doctors are one step closer to diagnosing ectopic pregnancy.
The doctor will also give you a pelvic exam to locate the areas causing pain, to check for an enlarged, pregnant uterus, or to find any masses in your abdomen. You'll probably also get an ultrasound examination, which shows whether the uterus contains a developing fetus or if masses are present elsewhere in the abdominal area. But the ultrasound may not be able to detect every ectopic pregnancy.
A less commonly performed test, a culdocentesis, may be used to look for internal bleeding. In this test, a needle is inserted into the space at the very top of the vagina, behind the uterus and in front of the rectum. Any blood or fluid found there likely comes from a ruptured ectopic pregnancy.
Even with the best equipment, it's hard to see a pregnancy that's less than 6 weeks along. If your doctor can't diagnose ectopic pregnancy but can't rule it out, he or she may ask you to return every 2 days to measure your hCG levels. If these levels don't rise as quickly as they should, the doctor will continue to monitor you carefully until 6 weeks, when an ultrasound can
be used.

What Are the Options for Treatment?
Treatment of an ectopic pregnancy varies, depending on its size and location and whether you want the ability to conceive again. An early ectopic pregnancy can sometimes be treated with an injection of methotrexate, which dissolves the fertilized egg and allows your body to reabsorb it. This nonsurgical approach minimizes scarring of your pelvic organs.
If the pregnancy is further along, you'll likely need surgery to remove the abnormal pregnancy. In the past, this was a major operation, requiring general anesthesia and a large incision across the pelvic area. This may still be necessary in cases of emergency or extensive internal injury.
However, the pregnancy may sometimes be removed using laparoscopy, a less invasive surgical procedure. The surgeon makes a small incision in the lower abdomen and then inserts a laparoscope. This long, hollow tube with a lighted end allows the doctor to view internal organs and insert other instruments as needed. Sometimes, a second small abdominal incision is made
for the instruments. The ectopic pregnancy is then surgically removed and any damaged organs are repaired or removed. General or regional anesthesia may be used.
Whatever your treatment, the doctor will want to see you regularly afterward to make sure your hCG levels return to zero. This may take up to 12 weeks. An elevated hCG could mean that some ectopic tissue was missed. This tissue may have to be removed using methotrexate or additional surgery.

What About Future Pregnancies?
Approximately 30% of women who have had ectopic pregnancies will have difficulty becoming pregnant again. Your prognosis depends mainly on the extent of the damage and the surgery that was done. If the fallopian tube has been spared, the chances of a future successful pregnancy are 60%. Even if one fallopian tube has been removed, the chances of having a successful pregnancy with the other tube can be greater than 40%.
The likelihood of a repeat ectopic pregnancy increases with each subsequent ectopic pregnancy. Once you have had one ectopic pregnancy, you face an approximate 15% chance of having another.

Who's at Risk for an Ectopic Pregnancy?
The risk of ectopic pregnancy is highest for women who are between 35 and 44 years old and have had:

• PID
• a previous ectopic pregnancy
• surgery on a fallopian tube
• infertility problems or medication to stimulate ovulation
  

Some birth control methods can also increase your risk of ectopic pregnancy. If you get pregnant while using progesterone- only oral contraceptives, progesterone intrauterine devices (IUDs), or the morning-after pill, you're more likely to have an ectopic pregnancy.

When Should You Call Your Doctor?
If you believe you're at risk for an ectopic pregnancy, meet with your doctor to discuss your options before you become pregnant. There's nothing anyone can do to prevent ectopic pregnancy, but you can make sure it's detected early. You and your doctor may want to plan on checking your hormone levels starting at 10 days or scheduling an ultrasound at 6 weeks to ensure that your pregnancy is developing normally.
Call your doctor immediately if you're pregnant and experiencing any of the signs or symptoms of ectopic pregnancy. When it comes to detecting an ectopic pregnancy, "better safe than sorry" is more than just a cliche.

Malaria

What is malaria?
Malaria is an infection that causes high fevers and chills. It's spread by a type of mosquito that feeds at night. The mosquito carries a parasite that causes malaria. If this mosquito bites you, the parasite can get into your blood. The parasite lays eggs, which develop into more parasites, and they feed on your blood cells until you get very sick. Some people die from malaria.

Where is malaria most common?
Malaria is a health problem in many tropical countries. It's also a problem for people visiting these countries. Your chance of getting malaria is highest when you travel in New Guinea, the Solomon Islands, African countries south of the Sahara Desert and some remote places in southeast Asia. Your chance of getting malaria is a little lower in the Caribbean, in the areas around the Amazon River in South America, in India and in some rural areas of Central America. In many countries in Asia and South America, malaria is only in the countryside. If you travel to these countries, you may not need to take malaria medicine if you stay in the malaria-free big cities or take only day trips outside the cities.

How can I protect myself from getting malaria?
You should do whatever you can to keep from getting mosquito bites. If you can, sleep in a room with screens on the windows and doors. Use a mosquito net over your bed. If possible, spray the net with permethrin (Permethrin is a spray that repels mosquitos.) During the evening, wear light-colored clothes with long sleeves. It's important to protect yourself with a bug repellant spray that contains no more than 35% of a chemical called "deet."
Try not to go outside after the sun sets.

What medicines can I take to prevent malaria?
If you plan to travel to a country where malaria is common, you'll probably take a medicine that may keep you from getting malaria. This is called "prophylactic" malaria medicine. Remember, however, no medicine can protect you 100%.
Prophylactic malaria medicines require you to start taking the medicine a few days or a week before you leave on your trip. You keep taking the medicine during your trip and after your trip for about 1 to 4 weeks, depending on which medicine you are taking. It's important to keep taking the medicine after your trip because the malaria parasites could still be in your blood. Stopping the medicine too soon could give the parasites an opportunity to grow and make you sick. These medicines have some side effects, and not everyone can take them. Your doctor can tell you which medicine is right for you.
Mefloquine and atovaquone/proguani l are two medicines you can take. If you can't take one of these, your doctor might recommend you take doxycycline. Doxycycline makes you sunburn easily, so you must wear a hat, long sleeves and sunscreen whenever you're outside during the day. Some people can't take this medicine.
If you're traveling to parts of Central America, Haiti or the Middle East, you may be able to take chloroquine. Again, your doctor can tell you which medicine is right for you.
(AAFP)

Failure to Thrive

Barbara P. Homeier, MD

The first few years of life are a time when most children gain weight and grow much more rapidly than they will later on. Sometimes, however, babies and children don't meet expected standards of growth. Although most of these children follow growth patterns that are variations of normal, others are considered to have "failure to thrive."
This is a general diagnosis, with many possible causes. Common to all cases, though, is the failure to gain weight as expected, which is often accompanied by poor height growth. Diagnosing and treating a child who fails to thrive focuses on identifying any underlying problem. From there, doctors and the family work together to get the child back into a healthy growth pattern.

What Is Failure to Thrive?
Although it's been recognized for more than a century, failure to thrive lacks a precise definition, in part because it describes a condition rather than a specific disease. Children who fail to thrive don't receive or are unable to take in, retain, or utilize the calories needed to gain weight and
grow as expected.
Most diagnoses of failure to thrive are made in infants and toddlers - in the first few years of life - a crucial period of physical and mental development. After birth, a child's brain grows as much in the first year as it will grow during the rest of the child's life. Poor nutrition during this period can have permanent negative effects on a child's mental development.
Whereas the average term baby doubles his or her birth weight by 4 months and triples it at 1 year, children with failure to thrive often don't meet those milestones. Sometimes, a child who starts out "plump" and who shows signs of growing well can begin to fall off in weight gain. After a while, linear (height) growth may slow as well.
If the condition progresses, the undernourished child may:

• become disinterested in his or her surroundings
• avoid eye contact
• become irritable
• not reach developmental milestones like sitting up, walking, and talking at the usual age
  

What Causes It?
Failure to thrive can result from a wide variety of underlying causes. Some children fail to thrive because of:

• social factors. In some cases, doctors may not identify a medical problem,but may find that the parents are actually causing the failure to thrive.For example, some parents inappropriately restrict the amount of caloriesthey give their infants. They may fear their child will get fat or put himor her on a limited diet similar to one they follow. Or, they may simply not feed the child enough either because of a lack of interest or because there are too many distractions in the household, which contributes to the neglect of the child. Living in poverty can also lead to an inability to provide a child with the necessary nutritional requirements.
• conditions involving the gastrointestinal system like gastroesophageal reflux, chronic diarrhea, cystic fibrosis, chronic liver disease, and celiac disease. With reflux, the esophagus may become so irritated that the child refuses to eat because it hurts. Persistent diarrhea can interfere with the body's ability to hold on to the nutrients and calories from food that's eaten.
• Cystic fibrosis, chronic liver disease, and celiac disease are conditions that limit the body's ability to absorb nutrients. These are known as malabsorptive disorders - the infant may eat a lot, but his or her body doesn't absorb and retain enough of that food. Celiac disease results from a sensitivity to a dietary protein found in wheat and certain other grains. The immune system's abnormal response to this protein causes damage to the lining of the intestine, interfering with its ability to absorb nutrients.
• a chronic illness or medical disorder. If a child has trouble eating - because of prematurity or a cleft lip or palate, for example - he or she may not take in enough calories to support normal growth. Other conditions that can lead to failure to thrive would include cardiac, endocrinologic, and respiratory disorders. These disorders can increase the child's caloric needs so that it becomes difficult to keep up with them.
• an intolerance of milk protein. This condition can initially lead to difficulty with absorbing nutrients until it's recognized. It can also put an entire class of food out of reach, restricting the child's diet and occasionally leading to failure to thrive.
• infections (parasites, urinary tract infections, tuberculosis, etc.), which place great energy demands on the body and force it to use nutrients rapidly (and the appetite may be impaired as well), sometimes bringing about short- or long-term failure to thrive.
• metabolic disorders, which can also limit a child's capacity to make the most of calories consumed. Metabolic disorders might make it difficult for the body to break down, process, or derive energy from food, or they can cause a buildup of toxins during the breakdown process, which can make the child feed poorly or vomit.
  

In some cases, doctors are unable to pinpoint a specific cause. Although doctors in the past tended to categorize cases of failure to thrive as either organic (caused by an underlying medical disorder) or inorganic (caused by caregivers' or parents' actions), they're less likely to make such sharp distinctions today. That's because medical and behavioral causes often appear together.
For instance, if a baby has severe reflux and is reluctant to eat, feeding times can be stressful for a caregiver. He or she may become tense and frustrated, and this may make it difficult for the caregiver to sustain attempts to feed the child adequate amounts of food.

How Is It Diagnosed?
Many normal babies go through brief periods when their weight gain plateaus or they even lose a little weight. However, if a baby doesn't gain weight for 3 consecutive months during the first year of life, doctors usually become concerned.
Doctors diagnose failure to thrive by using standard growth charts to plot the child's weight, length, and head circumference, which are measured at each well-baby exam. Children who fall below a certain weight range for their age or who are failing to gain weight at the expected rate will likely be evaluated further to determine if there's a problem.
Along with obtaining a thorough medical and feeding history and performing a detailed physical examination, the doctor may order a complete blood count, urinalysis, and various blood chemical and electrolyte tests that can be helpful in the search for underlying medical problems. If the doctor suspects a particular disease or disorder as a possible cause, he or she may
perform additional specific tests to identify that condition.
To determine whether the child is receiving enough food, the child's doctor (sometimes with the help of a dietitian) will do a calorie count after asking the parents what the child eats every day. And talking to the parents can help a doctor identify any problems at home, such as neglect, poverty, household stress, or feeding difficulties.

How Is It Treated?
Children with failure to thrive need the help of their parents and a doctor. Sometimes, an entire medical team will work on the child's case. In addition to the child's primary doctor, the team might include a nutritionist to evaluate the child's dietary needs and an occupational or speech therapist to help the caregiver and child develop successful feeding behaviors and address any sucking or swallowing problems the child might have. Occupational and speech therapists are often helpful because of their expertise in the muscular control that's involved in eating.
Because treatment of failure to thrive involves treating any disease or disorder causing the problem, specialists such as a cardiologist, neurologist, or gastroenterologist may also be part of the care team. Particularly in cases of failure to thrive that are thought to be caused by caregivers' or parents' actions, a social worker and a psychologist or other mental health professional may help address problems in the child's home environment and provide any needed support. Often, in cases of poor nutrition, the treatment can be carried out at home,
with frequent follow-up visits to the doctor's office or clinic. The doctor will recommend high-calorie foods and place an infant on a high-calorie formula.
More severe cases may call for tube feedings in which a tube is put in that runs from the nose into the stomach. Liquid nutrition is provided at a steady rate through the tube. Once the tube is put in place, the child is usually fed at night, so as not to interfere with his or her activities or
limit the child's desire to eat during the day. (About half of a child's caloric needs can be delivered at night through a continuous drip.) Once the child is more adequately nourished, he or she will feel better and will probably start to eat more on his or her own. At that point, the tube can be removed.
A child with extreme failure to thrive may need to be hospitalized so that he or she can be fed and monitored continuously. During this time, any possible underlying causes of the condition can be evaluated and treated appropriately. This also gives the treatment team the opportunity to observe firsthand the caregiver's feeding technique and the interaction between caregiver and child during feedings and at other times.
How long treatment lasts varies significantly from case to case. Weight gain takes time, so several months may pass before a child is back in the normal range for his or her age. Children who require hospitalization may stay for 10 to 14 days or more to establish satisfactory weight gain, but it can be many months until the symptoms of severe malnutrition are no longer present. Failure to thrive caused by a chronic illness or disorder may have to be monitored periodically and treated for even longer, perhaps for a lifetime.

Does My Child Have Failure to Thrive?
If you're worried that your child is failing to thrive, remember that there are many reasons why he or she might be slower to gain weight other than failure to thrive. For instance, breastfed babies and bottle-fed babies often gain weight at different rates in the early newborn period.
Genetics also play a big role in weight gain, so if you and your spouse are slim, your baby may not put on pounds quickly. However, infants should still gain weight steadily and it can be difficult to monitor this from home. So, it's important to see your child's doctor on a regular basis.
As a guideline, babies usually eat eight to 12 times in a 24-hour period (a couple 60 milliliters every few hours) in the first weeks after birth. By the time they're 2 to 3 months old, the number of feedings has dropped to six to eight, but the amount they eat each time has increased. At 4 months, about 890 milliliters a day provides sufficient nutrition for most
bottle-fed infants. Your child's doctor will have plenty of opportunities to identify a problem
at regular well-baby checkups. You can also periodically check your baby's weight at home, if you feel you need the reassurance.

When Should I Call Doctor?
If you notice a drop in weight gain or your baby doesn't seem to have a normal appetite, get in touch with your child's doctor. Any major change in eating pattern also warrants a call to the doctor. Toddlers and other kids may have days and sometimes weeks when they show little interest in eating, but that shouldn't happen in infants.
If you have trouble feeding your baby, your child's doctor can offer some advice. For any reason, when a child doesn't readily eat, parents tend to become frustrated and feel they aren't taking care of their child well. That can magnify the problem and increase the stress for both you and your baby. Instead, get help for both of you by consulting your doctor.
(AAFP)

Weight-loss Medicines

Do weight-loss medicines really work?
When combined with a reduced-calorie diet and regular physical activity, weight-loss medicines can help obese people lose weight. People who use these drugs may not feel as hungry, or they may feel full after eating only a small amount of food.
Weight-loss medicines include diethylpropion, phentermine, sibutramine and orlistat. Unlike other weight-loss medicines, orlistat works by keeping your body from digesting some of the fat that you eat.
Although some weight-loss supplements containing ephedra, ephedrine or caffeine are available without a prescription, it is not known whether these drugs are safe. Such supplements have been linked to reports of heart attack, seizure, stroke and death. It is important to talk to your doctor if you are considering taking a weight-loss supplement or if you are already taking one.

Are weight-loss medicines used for people who are just a little overweight?
No. Weight-loss medicines are only for people who are very obese. Most weight-loss medicines are designed for people who weigh 20% or more above what is ideal for their height and body type or who have a high body mass index (BMI). The BMI is a measure of your weight and height. Your doctor can tell you if weight-loss medicines might be helpful for you.

Are there any side effects from using weight-loss medicines?
Yes. Common side effects of weight-loss medicines may include the following:

• Nervousness
• Irritability
• Headaches
• Dry mouth
• Nausea
• Constipation
• Abdominal pain
• Diarrhea
• Sleep problems (including very intense dreams)
  

Orlistat may cause gas, frequent or uncontrollable bowel movements, diarrhea and oily stools.
Sometimes weight-loss medicines can have very serious side effects. Your family doctor can tell you more about these side effects.

How can I avoid gaining weight back when I stop using the medicine?
There is no magic cure for being overweight. Weight-loss medicines can help you get off to a good start. But once you stop taking them, the weight you lost may come back. To keep the weight off, you must eat a healthy low-calorie diet and be physically active on a regular basis. You must continue these healthy habits even after you stop taking the medicine.
Remember that losing weight and keeping it off is a lifelong effort.

Do I have to use weight-loss medicines to lose weight?
No. If you decide weight-loss medicines aren't right for you, you can still meet your weight-loss goals. It's important to develop healthy eating habits, but don't expect to change everything overnight. Start by training yourself to eat without doing anything else at the same time. For example, don't eat while you watch TV. Focus on what you're eating. Try to eat slowly.
Next, change what and how much you eat. Your doctor can help you create a low-calorie diet plan that will help you lose weight. It is also important to be physically active. A good goal for many people is to work up to exercising for at least 30 minutes, 4 to 6 times a week.
Regular exercise helps you burn calories faster, even when you are sitting still. Exercise also helps you burn fat and build muscle. Aerobic exercise raises your heart rate and helps you burn calories. Aerobic exercises include swimming, brisk walking, jogging and bicycling. Anaerobic exercise, such as weight training, is also good because it adds muscle mass to your body. Muscles burn calories faster than fat. Be sure to check with your family doctor before you begin an exercise program. He or she can help you create an exercise plan that will help you meet your goals.
(AAFP)

Tuberculosis: Treatment of Tuberculosis Infection

What is tuberculosis?
Tuberculosis (say: too-burr-cue- low-sis), also called TB, is an infection caused by a bacteria (a germ). Tuberculosis usually affects the lungs, but it can spread to the kidneys, bones, spine, brain and other parts of the body.

How does my doctor check for tuberculosis?
The most commonly used method to check for tuberculosis is the PPD skin test. If you have a positive PPD, it means you have been exposed to a person who has tuberculosis and you are now infected with the bacteria that causes the disease.
After you have a positive PPD skin test, you must have a chest x-ray and a physical exam to find it whether have active disease or are contagious (able to spread the disease). It usually takes only a few days to tell whether you're contagious. Most people with a positive skin test aren't contagious.

If I have a positive PPD test, do I have tuberculosis?
Not necessarily. A person can be infected with the bacteria that causes tuberculosis but not actually have tuberculosis disease. Many people are infected with the bacteria that causes tuberculosis, but only a few of these people (about 10%) go on to develop the disease. People who do have the disease are said to have "active" tuberculosis.
Healthy people who get infected with the tuberculosis bacteria are able to fight off the infection and do not get tuberculosis disease. The bacteria is dormant (inactive) in their lungs. If the body is not able to fight off the infection and the bacteria continues to grow, active tuberculosis develops.

How will my doctor treat the tuberculosis infection?
To be sure that you remain healthy, your doctor may recommend that you take medicine for 6 months to kill the tuberculosis infection. If you don't take the medicine, the bacteria will remain in your lungs, and you will always be in danger of getting active tuberculosis. The medicine used to treat tuberculosis infection is isoniazid (say: eye-so-nye-ah- zid), which is also called INH. You need to take 1 pill every day for 6 months. It is very important that you take the medicine every day. Keep the medicine in a place where you will always see it. Take it at the same time every day. Ask your doctor what to do if you forget to take a pill.
People who take INH may have side effects, but not very often. Side effects include a skin rash, an upset stomach or liver disease. Ask your doctor about other side effects that might happen. Don't drink alcohol or take paracetamol/ acetaminophen when you're taking INH. Always check with your doctor before you take any other medicine because some drugs interact with INH and cause side effects.
Every month you will need to visit your doctor to get another prescription of the medicine you are taking and to be sure you don't have any side effects or problems from the medicine. If you are feeling well, your doctor will give you a prescription for the next month.

Could I still get active tuberculosis after I take the medicine for 6 months?
Even after you take the medicine every day for 6 months there is a small chance that you could develop active tuberculosis disease, because some bacteria are resistant to the medicine. Staying healthy depends on having sensible living habits. You need enough sleep and exercise and a healthy diet to keep up your health and resistance to the tuberculosis bacteria.

Would I know if I developed active tuberculosis?
You might not know that you have active tuberculosis. Tuberculosis bacteria can grow in your body without making you feel sick. However, most people with active tuberculosis don't feel well. People with tuberculosis often feel tired and have a cough that won't go away. They may also lose weight, have a fever or break out in a sweat during the night (called "night sweats"). They may have trouble breathing.
If you have active tuberculosis, you will have to get regular checkups and chest x-rays for the rest of your life to make sure you stay free of disease, even after you have taken tuberculosis medicine.

What is the treatment for active tuberculosis?
If you have active TB, your doctor may recommend that you take 4 medicines:

• Isoniazid
• Rifampin
• Ethambutol
• Pyrazinamide
  

It's very important that you take all the medicine given to you. For the medicines to work at curing your tuberculosis, you must not skip a single dose.
Avoid drinking alcohol or taking paracetamol/ acetaminophen while you're taking the tuberculosis medicine. Tell your doctor about any other medicines you may be taking.
Your doctor may also order several sputum and blood tests to be done while you are being treated for tuberculosis. (Sputum is phlegm coughed up from deep inside the lungs.) These tests can be done by the nurse or at a clinic.
Call your doctor immediately if you have any of the symptoms listed here:

• Abdominal pain
• Blurred vision
• Continued loss of appetite
• Dark (coffee-colored) urine
• Fever
• Nausea
• Rash or itching
• Tingling or burning feeling in your hands or feet
• Tiredness without reason
• Vomiting
• Yellow color of eyes or skin
  

(AAFP)

All About Menstruation

Elana Pearl Ben-Joseph, MD & Neil Izenberg, MD

Menstruation (a period) represents a major stage of puberty in girls; it's one of the many physical signs that a girl is turning into a woman. And like a lot of the other changes associated with puberty, menstruation can be confusing for women. Some women can't wait to start their periods, whereas others may feel afraid or anxious. Many women don't have a complete
understanding of a woman's reproductive system or what actually happens during the menstrual cycle, making the process seem even more mysterious.

Puberty and Periods
When girls begin to go through puberty (usually starting between the ages of 8 and 13), their bodies and minds change in many ways. The hormones in their bodies stimulate new physical development, such as growth and breast development. About 2 to 2 1/2 years after a girl's breasts begin to develop, she usually gets her first menstrual period.
About 6 months or so before getting her first period, a girl might notice an increased amount of clear vaginal discharge. This discharge is common. There's no need for a girl to worry about discharge unless it has a strong odor or causes itchiness.
The start of periods is known as menarche (pronounced: meh-nar-kee) . Menarche doesn't happen until all the parts of a girl's reproductive system have matured and are working together. Baby girls are born with ovaries, fallopian tubes, and a uterus. The two ovaries are oval-shaped and sit on either side of the uterus (womb) in the lowest part of the abdomen called the pelvis. They contain thousands of eggs, or ova. The two fallopian tubes are long and thin - like hollow strands of spaghetti (only a little bit thicker). Each fallopian tube stretches from an ovary to the uterus, a pear-shaped organ that sits in the middle of the pelvis. The muscles in a female's uterus are powerful and are able to expand to allow the uterus to accommodate a growing fetus and then help push the baby out during labor.
As a girl matures and enters puberty, the pituitary gland releases hormones that stimulate the ovaries to produce other hormones called estrogen and progesterone. These hormones have many effects on a girl's body, including physical maturation, growth, and emotions.
About once a month, a tiny egg leaves one of the ovaries - a process called ovulation - and travels down one of the fallopian tubes toward the uterus. In the days before ovulation, the hormone estrogen stimulates the uterus to build up its lining with extra blood and tissue, making the walls of the uterus thick and cushioned. This happens to prepare the uterus for
pregnancy: If the egg reaches the uterus and is fertilized by a sperm cell, it attaches to the cushiony wall of the uterus, where it slowly develops into a baby.
If the egg isn't fertilized, though - which is the case during most of a girl's monthly cycles - it doesn't attach to the wall of the uterus. When this happens, the uterus sheds the extra tissue lining. The blood, tissue, and unfertilized egg leave the uterus, going through the vagina on the way out of the body. This is a menstrual period. This cycle happens almost every month for several more decades (except, of course, when a female is pregnant) until a woman reaches menopause and no longer releases eggs from her ovaries. A menstrual cycle is counted from the first day of bleeding in one month to the first day of bleeding in the next month.

How Often Does a Woman Get Her Period?
Just as some girls begin puberty earlier or later than others, the same applies to periods. Some girls may start menstruating as early as age 9 or 10, but others may not get their first period until later in their teens. The amount of time between a woman's periods is called her menstrual cycle (the cycle is counted from the start of one period to the start of the next). Some women will find that their menstrual cycle lasts 28 days, whereas others might have a 24-day cycle, a 30-day cycle, or even a 35-day cycle.
Irregular periods are common in girls who are just beginning to menstruate. It may take the body a while to sort out all the changes going on, so a girl may have a 28-day cycle for 2 months, then miss a month or have two periods with hardly any time in between them, for example. Usually, after a number of months, the menstrual cycle will become more regular. Many women continue to have irregular periods into adulthood, though. As a girl gets older and her periods settle down - or she gets more used to her own unique cycle - she will probably find that she can predict when her period will come.

How Long and How Much?
The amount of time that a woman has her period also can vary. Some women have periods that last just 2 or 3 days; other women may have periods that last 7 days or longer. The menstrual flow - meaning how much blood comes out of the vagina - can vary widely from person to person, too. Some women have such light blood flow that they wonder if they even have their period at all.
Other women may be concerned that they're losing too much blood. It can be a shock to see all that blood, but it's highly unlikely that a woman will lose too much: For most women an entire period consists of anywhere from a few spoonfuls to less than 1/2 cup (118 milliliters) of blood - it just looks like a lot! It is possible for a woman to lose an excessive amount of blood during her period, but it's not at all common. (In some cases, a woman can bleed too much because she has a medical condition - such as von Willebrand disease.) The amount of blood a woman loses and how long her period lasts can differ from month to month.
If you're worried about your blood flow or whether your period is normal in other ways, talk to a doctor or nurse. Some changes in menstrual periods can be normal - but only a doctor can help determine the cause of irregular, heavy, painful periods, or no periods at all.

Cramps, PMS, and Pimples
Some women may notice physical or emotional changes around the time of their periods. Menstrual cramps are pretty common - in fact, more than half of all women who menstruate say they have cramps during the first few days of their periods. Doctors think that cramps are caused by prostaglandin, a chemical that causes the muscles of the uterus to contract.
Depending on the woman, menstrual cramps can be dull and achy or sharp and intense, and they can sometimes be felt in the back or the thighs as well as the abdomen. These cramps often become less uncomfortable and sometimes even disappear completely as a girl gets older. In the meantime, many girls and women find that over-the-counter pain medications (like acetaminophen or ibuprofen) can relieve cramps, as can taking a warm bath or applying a warm
heating pad to the lower abdomen. Exercising regularly throughout the monthly cycle may help lessen cramps, too. If these things don't help, ask your doctor for advice.
Some girls and women find that they feel depressed or easily irritated during the few days or week before their periods. Others may get angry more quickly than normal or cry more than usual. Some women crave certain foods.
These types of emotional changes may be the result of premenstrual syndrome (PMS). PMS is related to changes in the body's hormones. As hormone levels rise and fall during a woman's menstrual cycle, they can affect the way she feels, both emotionally and physically. Some women, in addition to feeling more intense emotions than they usually do, notice physical changes along with their periods - some feel bloated or puffy because of water retention, others notice swollen and sore breasts, and some get headaches. PMS usually goes away soon after a period begins, but it can come back month after month. Doctors recommend that women with PMS try to exercise to help feel better. And some women notice that restricting caffeine intake may help relieve PMS.
It's not uncommon for women to have an acne flare-up during certain times of their cycle; again, this is due to hormones. Fortunately, the pimples associated with periods tend to become less of a problem as girls get older.
Periods shouldn't get in the way of exercising, having fun, and enjoying life. If you have questions about pads, or coping with periods, ask your family physician. You also can search online for health-related websites with answers to some of your most personal questions. (AAFP)
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Detecting and Dating a Pregnancy

If a menstrual period is a week or more late in a woman who usually has regular menstrual periods, she may be pregnant. Sometimes a woman may guess she is pregnant because she has typical symptoms. They include enlarged and tender breasts, nausea with occasional vomiting, a need to urinate frequently, unusual fatigue, and changes in appetite.
When a menstrual period is late, a woman may wish to use a home pregnancy test to determine whether she is pregnant. Home pregnancy tests detect human chorionic gonadotropin (HCG) in the urine. Human chorionic gonadotropin is a hormone produced by the placenta. Results of home pregnancy tests are accurate about 97% of the time. If results are negative but the woman still suspects she is pregnant, she should repeat the home pregnancy test a few
days later. The first test may have been performed too early (before the next menstrual period is expected to start). If results are positive, the woman should contact her doctor, who may perform another pregnancy test to confirm the results.
Doctors test a sample of blood or urine from the woman to determine whether she is pregnant. These tests are very accurate. One of these tests, called an enzyme-linked immunosorbent assay (ELISA), can quickly and easily detect a low level of human chorionic gonadotropin in the urine. Some tests can detect the very low level that is present about 1� weeks after fertilization
(before a menstrual period is missed). Results may be available in about half an hour. During the first 60 days of a normal pregnancy with one fetus, the level of human chorionic gonadotropin in the blood approximately doubles about every 2 days. Measurement of these levels during the pregnancy can be used to determine whether the pregnancy is progressing normally. After pregnancy is confirmed, the doctor asks the woman when her last menstrual period was. Pregnancies are conventionally dated in weeks, starting from the first day of the last menstrual period. The doctor calculates the approximate date of delivery by counting back 3 calendar months from the first day of the last menstrual period and adding 1 year and 7 days. Only 10% or fewer of pregnant women give birth on the calculated date, but 50% give birth within 1 week and almost 90% give birth within 2 weeks (before or after the date). Delivery between 3 weeks before and 2 weeks after the calculated date is considered normal.
Ovulation usually occurs about 2 weeks after a woman's menstrual period starts, and fertilization usually occurs shortly after ovulation. Consequently, the embryo is about 2 weeks younger than the number of weeks traditionally assigned to the pregnancy. In other words, a woman who is 4 weeks pregnant is carrying a 2-week-old embryo. If a woman's periods are
irregular, the actual difference may be more or less than 2 weeks. Pregnancy lasts an average of 266 days (38 weeks) from the date of fertilization (conception) or 280 days (40 weeks) from the first day of the last menstrual period if the woman has regular 28-day periods. Pregnancy is divided into three 3-month periods, based on the date of the last menstrual period. They are called the 1st trimester (0 to 12 weeks of pregnancy), 2nd trimester (13 to 24 weeks), and 3rd trimester (25 weeks to delivery).
If a woman and her doctor cannot confidently calculate when she became pregnant based on her menstrual period, ultrasonography may be performed to measure the fetus and thus establish the date. For the most accurate measurements, ultrasonography is performed during the first 12 weeks of a pregnancy. An accurate date helps doctors determine whether the pregnancy is progressing normally.
(AAFP)

Measles / Campak

Kate Cronan, MD

Measles, also called rubeola, is a highly contagious respiratory infection that's caused by a virus. It causes a total-body skin rash and flu-like symptoms, including a fever, cough, and runny nose.
Since measles is caused by a virus, symptoms typically go away on their own without medical treatment once the virus has run its course. But while your child is sick, it's important to make sure that he or she has plenty of fluids and rest, and to keep your child from spreading the infection to others. If you have any concerns about your child's condition, talk to your
child's doctor.

Signs and Symptoms
While measles is probably best known for the full-body rash that it causes, the first symptoms of the infection are usually a hacking cough, runny nose, high fever, and watery red eyes. Another marker of measles are Koplik's spots, small red spots with blue-white centers that appear inside the mouth. The measles rash typically has a red or reddish brown blotchy appearance, and first usually shows up on the forehead, then spreads downward over the face, neck, and body, then down to the feet. Measles is highly contagious. When someone with measles sneezes or coughs, he or she can spread virus droplets through the air and infect others. Due to widespread immunizations, the number of measles cases has steadily declined. Most of the time, the cases occur in settings where there are lots of kids, some of whom haven't gotten vaccinated or whose immunity has diminished since they got the vaccine.
The most important thing you can do to protect your child from measles is to have him or her vaccinated according to the schedule prescribed by your child's doctor.

Prevention
Infants are generally protected from measles for 6 to 8 months after birth due to immunity passed on from their mothers. Older kids are usually immunized against measles according to state and school health regulations.
For most kids, the measles vaccine is part of the measles-mumps- rubella immunizations (MMR) given at 12 to 15 months of age and again at 4 to 6 years of age. Measles vaccine is not usually given to infants younger than 12 months old. But if there's a measles outbreak, the vaccine may be given when a child is 9 months old, followed by the usual MMR immunization at
12-15 months.
As is the case with all immunization schedules, there are important exceptions and special circumstances. Your child's doctor should have the most current information regarding recommendations about the measles immunization. Measles vaccine should not be given to pregnant women, or to kids with active tuberculosis, leukemia, lymphoma, or people whose immune systems are suppressed for some reason.
Also, the vaccine shouldn't be given to kids who have a history of severe allergic reaction to gelatin or to the antibiotic neomycin, as they are at risk for serious reactions to the vaccine. These kids can be protected from measles infection with an injection of antibodies called gamma globulin if it's given within 6 days of exposure - these antibodies can either prevent measles or make the symptoms less severe.
Measles vaccine occasionally causes side effects in kids who don't have any underlying health problems. In about 10% of cases the measles vaccine causes a fever between 5 and 12 days after vaccination, and in about 5% of cases the vaccine causes a rash, which isn't contagious and usually fades on its own.

Treatment
The symptoms of measles usually lasts for about 2 weeks. It is highly contagious, and 90% of people who haven't been vaccinated for measles will get it if they live in the same household as an infected person.
If your child has been diagnosed with measles, it's important to closely monitor him or her for fever and other symptoms to spot any complications. In some cases, measles can lead to other health problems, such as croup, and infections like bronchitis, bronchiolitis, pneumonia, conjunctivitis (pinkeye), myocarditis, and encephalitis. Measles also can make the body more susceptible to ear infections or other health problems caused by bacteria.
If fever is making your child more uncomfortable, you may want to give a non-aspirin fever medication such as paracetamol/ acetaminophen. Remember, you should never give aspirin to a child who has a viral illness since the use of aspirin in such cases has been associated with the development of Reye syndrome.
As with any viral infection, encourage your child to drink clear fluids: water, fruit juice, tea, and lemonade. These will help replace bodily fluids your child loses in the heat and sweating of fever episodes.
Use a cool-mist vaporizer to relieve cough and to soothe breathing passages. Clean the vaporizer each day to prevent mold from growing. Avoid hot-water or steam vaporizers that can cause accidental burns and scalds in children.
Children with measles should get extra rest to help them recover. It's usually safe for your child to return to school 7 to 10 days after the fever and rash go away. But to be sure, check with your child's doctor.

When to Call Your Child's Doctor
Call your child's doctor immediately if you suspect that your child has measles. Also, it's important to get medical care if your child:

• is an infant and has been exposed to measles
• is taking medicines that depress the immune system
• has tuberculosis, cancer, or a disease that affects the immune system
  

Keep track of your child's temperature. Let the doctor know if your child has an earache, since this may be a sign of an infection.
Remember that if your child is properly vaccinated it's extremely unlikely that he or she will contract the disease.

How to Stay Healthy

Will the habits I have now really make a difference when I'm older?
Yes, 65% of all deaths in adults are caused by heart disease, cancer and stroke. In many cases, these diseases were preventable. Many of the behaviors that cause these diseases begin at a young age. For example, if you use tobacco, you're more likely to get heart disease, cancer or stroke when you're older.

What can I do now to keep myself healthy?

• Avoid using any type of tobacco product. Try not to breathe second hand cigarette smoke.
• Get regular exercise.
• Eat a healthy diet.
• Always use your seat belt.
• Don't drink and drive. Don't get into a car with a driver who has been drinking alcohol or using drugs.
• Wear protective headgear, such as motorcycle or bike helmets, when participating in sports.
• Never swim alone.
• Talk to your parents or your doctor if you're feeling really sad or if you're thinking about harming yourself.
• Avoid situations where violence or fighting may cause you to be physically injured.
• If you have sex, use condoms to avoid pregnancy and sexually transmitted diseases. (Remember, however, the "safest" sex is no sex.)
• See your doctor regularly.
  

What might my doctor do?
The doctor might do any of the following to help you stay healthy:

• Determine your risk for certain health problems.
• Measure your height, weight, cholesterol levels and blood pressure.
• Order tests to check your general health or to find certain diseases.
• Provide immunizations ("shots" or "vaccines") to reduce your risk of getting diseases such as mumps, tetanus and hepatitis.
  

At my age, what should I especially be concerned about?
Car accidents, unintentional physical injury, homicide and suicide are the top killers of young adults. Cancer and heart disease can also affect you at this age. Unplanned pregnancy and sexually transmitted diseases (including HIV and AIDS) can cause you social and personal problems, in addition to harming your health.

Do young men have different health risks than young women?
Yes. Young men don't wear seat belts as often as young women do. They're also more likely to carry weapons, to get into physical fights, to use smokeless tobacco or marijuana, to drink alcohol heavily, and to have more sexual partners. On the other hand, young women have some special risks. They try to commit suicide more often and they try to lose weight in harmful ways more often than young men.

Should I talk to my doctor if I'm worried about my health or my body?
Yes. It's important to talk to your doctor if you have any concerns about your health or your body. Your doctor is there to help you.
(AAFP)

The Four Day Diet Craze

I like to think that I have a truly fascinating job; I monitor the aggregate online behavior of over 10 million Internet users everyday. I can see collectively what web sites people visit and what search terms they use; through Google, Yahoo! Search and other search engines, I have a view into our collective thoughts. You won't be shocked to hear that, come January, we're thinking thin.
Over the past four years I've graphed searches for "diets," and, not surprisingly, the yearly pinnacle occurs during the first week of January. What is surprising is just how fleeting an interest Internet users have in losing weight. By the second week of the year, diet searches begin a precipitous fall, dropping 32% within the first few days of the New Year, only to briefly recover in the summer months for swimwear season. The collapse then resumes until diet interest reaches an all time low on Thanksgiving Day. Diet searches remain in the trough in the weeks between Thanksgiving and Christmas, until the last few days of the year, when they
surge again and the yearly cycle repeats.
Even more revealing than when we search for diets are the kinds of diet solutions we search for. During the first weeks of the year, diet searches outnumber their closest self-improvement counterpart, "exercise," by 250%. And the list of most popular dieting queries are riddled with quick fixes such as "diet pills" and "the sacred heart diet," an urban-legend diet promising a 10-pound weight loss in seven days. This year even saw the shortest diet query in search engine history, the "three-hour diet." A look at the top ten searches containing the term "diet" for the first week of 2007 proves long-term solutions aren't a major pre-occupation:

• South Beach Diet: 3.68%
• Atkins Diet: 1.51%
• Diet Pills: 1.29%
• Diet: 1.23%
• Diet Plans: 0.98%
• Cabbage Soup Diet: 0.81%
• Free Diet Plans: 0.79%
• You on a Diet: 0.77%
• Special K Diet: 0.70%
• Lemonade Diet: 0.67%
  

Of course, even someone with the purest of dieting intentions might have problems on the Internet, where temptation is never more than a click away. In the Food & Beverage category, six of the top 10 food related URLs in January were pizza delivery sites.
(Time)

Cuts, Scrapes and Stitches: Caring for Wounds

How should I clean a wound?
The best way to clean a cut, scrape or puncture wound (such as from a nail) is with cool water. You can hold the wound under running water or fill a tub with cool water and pour it from a cup over the wound. Use soap and a soft washcloth to clean the skin around the wound. Try to keep soap out of the wound itself because soap can cause irritation. Use tweezers that have been cleaned in isopropyl alcohol to remove any dirt that remains in the wound after washing.
Even though it may seem that you should use a stronger cleansing solution (such as hydrogen peroxide or an antiseptic), these things may irritate wounds. Ask your family doctor if you feel you must use something other than water.

What about bleeding?
Bleeding helps clean out wounds. Most small cuts or scrapes will stop bleeding in a short time. Wounds on the face, head or mouth will sometimes bleed a lot because these areas are rich in blood vessels. To stop the bleeding, apply firm but gentle pressure on the cut with a clean cloth, tissue or piece of gauze. If the blood soaks through the gauze or cloth you're holding over the cut, don't take it off. Just put more gauze or another cloth on top of what you already have in place and apply more pressure. If your wound is on an arm or leg, raising it above your heart will also help slow the bleeding.

Should I use a bandage?
Leaving a wound uncovered helps it stay dry and helps it heal. If the wound isn't in an area that will get dirty or be rubbed by clothing, you don't have to cover it. If it's in an area that will get dirty (such as your hand) or be irritated by clothing (such as your knee), cover it with an adhesive strip or with sterile gauze and adhesive tape. Change the bandage each day to keep the
wound clean and dry.
Certain wounds, such as scrapes that cover a large area of the body, should be kept moist and clean to help reduce scarring and speed healing. Bandages used for this purpose are called occlusive or semiocclusive bandages. You can buy them in drug stores without a prescription. Your family doctor will tell you if he or she thinks this type of bandage is best for you.

Should I use an antibiotic ointment?
Antibiotic ointments help healing by keeping out infection and by keeping the wound clean and moist. A bandage does pretty much the same thing. If you have stitches, your doctor will tell you whether he or she wants you to use an antibiotic ointment. Most minor cuts and scrapes will heal just fine without antibiotic ointment, but it can speed healing and help reduce scarring.

What should I do about scabs?
Nothing. Scabs are the body's way of bandaging itself. They form to protect wounds from dirt. It's best to leave them alone and not pick at them. They will fall off by themselves when the time is right.

When should I call my doctor?
Call your doctor if your wound is deep, if you can't get the edges to stay together or if the edges are jagged. Your doctor may want to close your wound with stitches or skin adhesive. These things can help reduce the amount of scarring. You can close small cuts yourself with special tape, called butterfly tape, or special adhesive strips, such as Steri-Strips.

Taping a wound
Call your family doctor if any of the following things occur

• The wound is jagged.
• The wound is on your face.
• The edges of the cut gape open.
• The cut has dirt in it that won't come out.
• The cut becomes tender or inflamed.
• The cut drains a thick, creamy, grayish fluid.
• You start to run a temperature over 38�C.
• The area around the wound feels numb.
• You can't move comfortably.
• Red streaks form near the wound.
• It's a puncture wound or a deep cut and you haven't had a tetanus shot inthe past 5 years.
• The cut bleeds in spurts, blood soaks through the bandage or the bleedingdoesn't stop after 10 minutes of firm, direct pressure.
  

How do I take care of stitches?
You can usually wash an area that has been stitched in one to three days. Washing off dirt and the crust that may form around the stitches helps reduce scarring. If the wound drains clear yellow fluid, you may need to cover it.
Your doctor may suggest that you rinse the wound with water and rebandage it in 24 hours. Be sure to dry it well after washing. You may want to keep the wound elevated above your heart for the first day or two to help lessen swelling, reduce pain and speed healing.
Your doctor may also suggest using a small amount of antibiotic ointment to prevent infection. The ointment also keeps a heavy scab from forming and may reduce the size of a scar.
Stitches are usually removed in 3 to 14 days, depending on where the cut is located. Areas that move, such as over or around the joints, require more time to heal.

What is skin adhesive?
Skin adhesive is a new way to close small wounds. Your doctor will apply a liquid film to your wound and let it dry. The film holds the edges of your wound together. You can leave the film on your skin until it falls off (usually in 5 to 10 days).
It's important not to scratch or pick at the adhesive on your wound. If your doctor puts a bandage over the adhesive, you should be careful to keep the bandage dry. Your doctor will probably ask you to change the bandage every day.
Don't put any ointment, including antibiotic ointment, on your wound when the skin adhesive is in place. This could cause the adhesive to loosen and fall off too soon. You should also keep your wound out of direct light (such as sunlight or tanning booth lamps).
Keep an eye on your wound. If the skin around your wound becomes very red and warm to touch, or if the wound reopens, call your doctor.

Do I need a tetanus shot?
Tetanus is a serious infection you can get after a wound. The infection is also called "lockjaw," because stiffness of the jaw is the most frequent symptom.
To prevent tetanus infection when the wound is clean and minor, you'll need a tetanus shot if you haven't had at least three doses before or haven't had a dose in the last 10 years. When the wound is more serious, you'll need a tetanus shot if you haven't had at least 3 doses before or if you haven't had a shot in the last 5 years. The best way to avoid tetanus infection is to talk to your family doctor to make sure your shots are up to date.
(AAFP)

The Common Cold: What You Should Know

What is a cold?
A cold is a common illness that can be caused by many viruses. It can be passed easily from one person to another. If you have a cold, your throat may be sore or scratchy. After a couple of days, you may have a runny or stuffy nose and a cough that lasts about a week. The mucus from your runny nose might be yellow or green for a few days. Some people have a fever and muscle aches in the first few days.
Sometimes, you can have more serious symptoms like an ear infection, sinus infection, or pneumonia. Colds do not cause serious health problems for most people. But they can cause problems for people who smoke, people whose bodies can't fight infection, and people who have lung problems.

What should I do if I have a cold?
Usually, you don't have to do anything. Most colds don't cause serious problems. There is no medicine to cure a cold, but over-the-counter medicine might help you feel better. These medicines may not be good for young children and older adults. Some may have bad side effects. Ask your doctor what medicine is best for you or your child.

How do I know if I have a cold and not something worse?
If your symptoms are normal for a cold and you've been around people with colds, you probably have a cold and not something more serious. See your family doctor if you have:

• symptoms that are worse than those of a normal cold or that haven't gottenbetter in 10 days
• a high fever
• an earache that gets worse
• a headache or pain in your face or eyes
• a stiff neck
• shortness of breath
• sleepiness or confusion
• a health problem that makes it more likely that you will have problemswith a cold (for example: asthma and other lung diseases or a disease thataffects how your body fights infection)

(AAFP)

Migraine Headaches: Ways to Deal With the Pain

What causes migraine headaches?
Migraine headaches seem to be caused in part by changes in the level of a body chemical called serotonin. Serotonin plays many roles in the body, and it can have an effect on the blood vessels. When serotonin levels are high, blood vessels constrict (shrink). When serotonin levels fall, the blood vessels dilate (swell). This swelling can cause pain or other problems.
Many things can affect the level of serotonin in your body, including your level of blood sugar, certain foods and changes in your estrogen level if you're a woman.

What does a migraine feel like?
The pain of a migraine headache can be intense. It can get in the way of your daily activities. Migraines aren't the same in all people. Possible symptoms of migraines are listed in the box below. You may also have a "premonition" several hours to a day before your headache starts. Premonitions are feelings you get that can signal a migraine is coming. These feelings can include intense energy, fatigue, food cravings and mood changes.

Possible symptoms of migraines

• Intense throbbing or dull aching pain on one side of your head or bothsides.
• Nausea or vomiting
• Changes in how you see, including blurred vision or blind spots
• Being bothered by light, noise or odors
• Feeling tired and/or confused
• Stopped-up nose
• Feeling cold or sweaty
• Stiff or tender neck
• Light-headedness
• Tender scalp
  

Are there different kinds of migraine headaches?
Yes. The most common are classic migraine and common migraine. Classic migraines start with a warning sign, called an aura. The aura often involves changes in the way you see. You may see flashing lights and colors.
You may temporarily lose some of your vision, such as your side vision. You may also feel a strange prickly or burning sensation, or have muscle weakness on one side of your body. You may have trouble communicating. You may also feel depressed, irritable and restless.
Auras last about 15 to 30 minutes. Auras may occur before or after your head pain, and sometimes the pain and aura overlap, or the pain never occurs. The head pain of classic migraines may occur on one side of your head or on both sides.
Common migraines don't start with an aura. Common migraines may start more slowly than classic migraines, last longer and interfere more with daily activities. The pain of common migraines may be on only one side of your head.

How long do migraines usually last?
Migraines may last from 4 to 72 hours. They may happen only once or twice a year, or as often as daily. Women are more likely to have migraines than men.

What things may set off a migraine?
Certain things that can set off migraines in some people include the following:

• Strong or unusual odors, bright lights or loud noises
• Changes in weather or altitude
• Being tired, stressed or depressed or the let-down after a stressful event
• Changes in sleeping patterns or sleeping time
• Certain foods (see the list below), especially those that contain tyramine, sodium nitrate or phenylalanine
• Missing meals or fasting
• Menstrual periods, birth control pills or hormones
• Intense physical activity, including sexual activity
  

Foods that may trigger migraines

• Aged, canned, cured or processed meat, including bologna, game, ham,herring, hot dogs, pepperoni and sausage
• Aged cheese
• Alcoholic beverages, especially red wine
• Aspartame
• Avocados
• Beans, including pole, broad, lima, Italian, navy, pinto and garbanzo
• Brewer's yeast, including fresh yeast coffee cake, donuts and sourdough bread
• Caffeine (in excess)
• Canned soup or bouillon cubes
• Chocolate, cocoa and carob
• Cultured dairy products, such as buttermilk and sour cream
• Figs
• Lentils
• Meat tenderizer
• Monosodium glutamate (MSG)
• Nuts and peanut butter
• Onions, except small amounts for flavoring
• Papaya
• Passion fruit
• Pea pods
• Pickled, preserved or marinated foods, such as olives and pickles, and some snack foods
• Raisins
• Red plums
• Sauerkraut
• Seasoned salt
• Snow peas
• Soy sauce
  

How are migraines treated?
There are 2 types of migraine treatments. Some treatments are used to relieve the headache pain. Most of these treatments should be started as soon as you think you're getting a migraine. The other type includes treatments that are used to prevent headaches before they occur.

Can nonprescription medicines help relieve the pain?
Yes. Nonprescription medicines can help migraine pain. They include aspirin, paracetamol/acetaminophen, an acetaminophen, aspirin and caffeine combination, ibuprofen, naproxen, and ketoprofen.

What about prescription medicines?
People with more severe pain may need prescription medicine. A medicine called ergotamine can be effective alone or combined with other medicines. Dihydroergotamine is related to ergotamine and can be helpful. Other prescription medicines for migraines include sumatriptan,
zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan, and frovatriptan.
If the pain won't go away, stronger medicine may be needed, such as a narcotic or medicines that contain a barbiturate. These medicines can be habit-forming and should be used cautiously.

Can medicine help prevent migraines?
Yes. Medicine to prevent migraines may be helpful if your headaches happen more than twice a month or if your headaches make it hard for you to work and function. Examples of medicines used to prevent migraines include propranolol, timolol, divalproex and some antidepressants.

What else can I do to prevent migraines?
Try to avoid foods or other things that seem to cause migraines for you. Get plenty of sleep. Try to relax and reduce the stress in your life.

Tips on reducing the pain

• Lie down in a dark, quiet room.
• Put a cold compress or rag over your forehead.
• Massage your scalp using a lot of pressure.
• Put pressure on your temples.
  

(AAFP)