Bone Metastasis

The human body skeleton is one of the areas where cancer often spreads. Existing cancer cells (primary tumor) migrate through the circulatory system (blood) or lymph system to other parts of the body. These cancer cells can get stuck in different places and form new tumors called secondary tumors. The term implies the existence of multiple metastatic tumors.

Breast cancer, prostate cancer, lung cancer are types of cancer that commonly cause bone metastasis. Other cancer types like thyroid cancer and kidney cancer can also spread to the bones and metastasize. Metastatic cancer� borrows the name of the location where it first developed before it spread. For example, breast cancer that metastasize in bones, still bears the name of breast cancer. Cancer that is formed in bone cells is considered bone cancer (primary tumor). Metastatic bone cancer is more common than bone cancer itself.

Bone Metastasis

Bone Metastasis Causes

There are many reasons why cancer spreads to the bone tissue. Some cancer cells contain proteins that allow adherence to certain parts of the body, including bones. Another reason is that bones have certain characteristics that stimulate the development of certain cancers. As tumors get larger near lymph nodes, the chances of developing bone metastasis are higher. Bone metastases, most often are found in the spine, skull, ribs, upper limbs, femur bone, pelvic bones, and hip bone.

Bone Metastasis Symptoms

Cancer cells make bones more fragile and weakens them, in advanced forms of cancer, bones will start dissolving. There are several symptoms that can annouce bone metastasis but most often, patients do not experience any symptoms and bone metastasis are diagnosed after a routine x-ray.

• Pain � the most common symptom of bone metastases is intermittent pain, during slight movement. As metastases increase in size the pain is constant and gets worse when a person carries out certain activities;
• Fractures– cancer can cause bone fractures and this can happen even during the normal course of daily tasks, not only as a result of an accident. Bone metastasis is often first discovered when a cancer patient sufferes a fracture and is subject to medical investigation
• Numbness � tumors located in certain areas of the spine can cause compresion of nervous structures. The first sign of this phenomenon could be back pain, state of numbness and general weakness
• Difficulty urinating � among the symptoms of spinal metastases difficulties urinating or fecal incontinence can be present. These bone metastasis symptoms, present in a person with cancer are considered medical emergencies
• Paralysis � pressure on the spine can also cause paralysis. Different body parts can be affected, depending on the spinal area affected by tumor compression. Usually paralysis affects the legs.
• Hypercalcemia – bone metastasis can determine the transfer of calcium into the bloodstream. The high level of calcium in the bloodstream is called hypercalcemia, which can cause a variety of problems including constipation and dehydration. Weakness, decreased energy and confusion can be symptoms of these conditions. In severe cases, hypercalcemia can lead to coma even death.

Bone Metastasis Diagnosis

In most cases, bone metastasis is discovered before or at the same time as the primary cancer. When bone metastases are found before any other type of cancer, your doctor will try to determine the primary tumor, considering the type of cancer cells that lead to metastasis. Depending on the suspected cause of bone metastases, the specialist will require further investigations.

• X-ray radiography, CT scans and other imaging techniques provide detailed images inside the body and can confirm the presence of bone cancer. They will also reveal the severity of metastasis. These investigations can prevent any fractures that may occur due to bone metastasis.
• Blood and urine tests � Blood and urine tests can detect some specific evidence of bone metastases, such as high blood calcium level. Certain specific bone metastasis proteins can be dosed.
• Biopsy. The process involves taking a sample of tissue with a long needle and analyzing it under a microscope. In some cases surgery to perform the biopsy may be needed.

Bone Metastasis Treatment And Side Effects

Researchers constantly present new ways to treat bone metastases. These range from early detection techniques that could detect bone metastases before they cause severe damage to various ways to fight cancer, slowing its development or even preventing it. Current methods for treating bone metastases and its symptoms include:

• Chemotherapy � a common treatment used for advanced metastatic cancer. Drugs used in chemotherapy are usually injected or given orally and act throughout the entire body. The drawback is that chemotherapy affected healthy cells along with cancerous ones and there are a number of unpleasant side effects such as hair loss, nausea and vomiting. Chemotherapy can affect the bone marrow leading to clotting disorders, bleeding, increased risk of infection and fatigue
• Hormone therapy � hormones such as estrogen, and androgen hormones can encourage the growth of cancer cell types. To limit the effects of hormones on cancer cells, doctors can remove ovaries or testes (organs that produce these hormones). Administration of drugs that stop the production of hormones or are designed to block their effect on cancer cells are also useful. Hormone therapy has side effects similar to those seen during menopause and other hormonal fluctuations: hot flashes, anemia.
• Radiation therapy � bone metastases can be treated�using radiation therapy . This treatment can use high or low doses of radiation depending on tumor size. Treatment is not painful, but can not be established if the bones are already severely damaged and weakened.

Diabetes Insipidus

Diabetes insipidus is a condition that manifests itself by increasing sensation of urination, fluid consumption and extreme�thirst.�Because urine does not have time to accumulate, to�concetrate�and get yellow, urine color is pale in�diabetes insipidus, colorless and with a low concentration. The disease may occur acutely, eg, after head trauma or surgical procedures near the pituitary region, or may be chronic and insidious in onset. It is due to insufficiency of the posterior pituitary or impaired function of the supraoptic�pathways that regulate water metabolism. Partial forms of the disease exist. More rarely, it is due to unresponsiveness of the kidney to vasopressin (nephrogenic diabetes insipidus).

Diabetes Insipidus Causes

Central Diabetes Insipidus (due to deficiency of vasopressin)

• Primary diabetes insipidus, due to a defect inherent in the gland itself (no organic lesion), may be familial, occurring as a dominant trait; or, more commonly, sporadic or idiopathic.
• Secondary diabetes insipidus is due to destruction of the functional unit by trauma, infection (eg, encephalitis, tuberculosis, syphilis), breast cancer�or lung cancer�(common), vascular accidents (rare), and xanthomatosis�(eosinophilic�granuloma�or Hand-Schuller-Christian disease)

Nephrogenic Diabetes Insipidus

This disorder is due to a defect in the kidney tubules that interferes with water reabsorption and occurs as an X-linked recessive trait. Patients with this type of the disease are the so-called water babies. In adults it may be associated with hyperuricemia. At times this type is acquired, eg, after pyelonephritis, potassium depletion, or amyloidosis. Certain drugs (eg, demeclocycline, lithium) may induce nephrogenic diabetes insipidus. The disease is unresponsive to vasopressin.

Diabetes Insipidus Symptoms

The outstanding signs and symptoms of the disease are intense thirst, especially with a craving for ice water, and polyuria (large�volumes of urine), the volume of ingested fluid varying from 4 to 20 L daily, with correspondingly large urine volumes. Restriction of fluids causes marked weight loss, dehydration, headache, irritability, fatigue, muscular pains, hypothermia, tachycardia, and shock.

Diabetes Insipidus Diagnosis

Polyuria of over 6 L daily with a specific gravity below 1.006 is highly suggestive of diabetes insipidus. Simple water deprivation with measurement of urine osmolality�may be diagnostic. Special tests have been devised to distinguish true diabetes insipidus from psychogenic polydipsia. The latter will often respond (with reduction in urine flow and increase in urinary specific gravity) to administration of hypertonic (3%) saline solution; true diabetes insipidus does not. Hypertonic saline infusion may be dangerous to patients with abnormal cardiovascular status. Although a positive response tends to rule out true diabetes insipidus, a negative must be followed by careful prolonged dehydration�and measurement of both urine and plasma�osmolarity�and body weight under hospital conditions, plasma osmolality�is normally maintained in the range of 285-�290 mosm/kg.

Impaired ability to either synthesize or release ADH�results in diminished ability of the kidney to conserve water. Patients with severe diabetes insipidus minimally concentrate urine following dehydration. After administration of 5 units of vasopressin, urine�osmolarity�promptly rises.�The high levels of plasma vasopressin in nephrogenic diabetes insipidus are diagnostic.

Diabetes Insipidus�Differential Diagnosis

The most important differentiation is from the psychogenic� water-drinking habit. This may be difficult, since patients with long-standing polydipsia develop a true defect in renal concentrating ability. The baseline serum osmolality�is helpful, since subjects with psychogenic polydipsia have low values, whereas the serum�osmolarity�is normal or high in patients with diabetes insipidus. Polydipsia and polyuria may also be seen in diabetes mellitus, chronic nephritis, hypokalemia�(eg, in primary hyperaldoste-tonism), and in hypercalcemic�states such as hyperparathyroidism. The low fixed specific gravity of the urine in chronic nephritis does not rise after administration of vasopressin. On the other hand, in spite of the inability of patients with diabetes insipidus to concentrate urine, other tests of renal function yield essentially normal results.

Diabetes Insipidus�Complications

If water is not readily available, the excessive output of urine will lead to severe dehydration, which rarely proceeds to a state of shock. Insomnia and dysphagia may occur. All the complications of the primary disease may eventually become evident.

Diabetes Insipidus Treatment

Diabetes insipidus�treatment depends on the�type and severity of patient illness. The treatment�options for the main forms of diabetes insipidus are listed below

Central origin diabetes insipidus. Because this form of diabetes�is caused by�lack of antidiuretic hormone, treatment usually consists of a synthetic hormone called desmopressin�administration. It can be administered as a nasal spray, oral tablets or by injection. Synthetic hormones will balance the amount of urine. For most patients with diabetes insipidus of central causes, desmopressin�is a safe and effective treatment. If the�diabetes�insipidus�is caused by a disorder of the pituitary gland or hypothalamus (such as a tumor), the anomaly must be treated first. In central type diabetes insipidus, replacing lost fluids is essential. During�desmopressin�administration the patient should�drink water or other liquids only when thirsty because the drug prevents excess water excretion, kidneys excreting�less urine and are less responsive to changes in the amount of body fluids. In mild cases of diabetes insipidus of central causes, increased water intake may be the only remedy required.�A certain amount of water intake�– usually less than 2.5 liters per day – to ensure proper hydration.

Nephrogenic diabetes insipidus. This is the result of kidney disease�and does not respond adequately to ADH, so desmopressin�is not a treatment option. Instead a�diet low in salt to help reduce the amount of urine�the kidney produce is recommended. Also�the patient must drink enough water to avoid dehydration. The drug hydrochlorothiazide, used alone or in drug combinations, can relieve symptoms. Although hydrochlorothiazide�is a diuretic (usually used to increase the amount of urine excreted), in some cases it can reduce excretion in patients with nephrogenic�diabetes insipidus. If symptoms of nephrogenic�diabetes insipidus are causd by�certain drug, it is recommended that administration to be stopped.

Diabetes Insipidus Prognosis

Diabetes insipidus may be latent, especially if there is associated lack of anterior pituitary function; and may be transient, eg, following head trauma. The ultimate prognosis is essentially that of the underlying disorder. Since many cases are associated with organic brain disease, the prognosis is often poor. Surgical correction of the primary brain lesion rarely alters the diabetes insipidus.

Surgery

Surgery is a great stress for one’s organism, especially if we talk about children. However, in most cases it is the only way out. So the task of every parent is to make the procedure as easy and stress- free for a child, as it is possible.

Why a Child May Need Surgery?

There are various reasons why doctors insist on surgery even for babies. Three groups of diseases and disorders, sorted by the time and necessity of surgery, can be singled out.

1. Emergency surgery. To this group belong such cases as strangulated hernia, penetrating wound, congenital esophageal obstruction, other congenital diseases etc.

2. Elective surgery. Here we talk about diseases that are treated only surgically, but the surgery is not urgent. Most common cases are hydrocephaly, hemangioma, polydactyly, not strangulated hernia, and so on.

3. Delayed surgery. To this third group belong diseases that have to be operated in a certain stage or certain age. Such kind of surgery is needed when a child has some kind of heart or great vessels disease, maldevelopment of urino-genital organs, cleft palate, and some other.

Preparing Your Child for Surgery

Any kind of operation is a great stress both for organism and for psychical equilibrium. Therefore, you must do everything for the comfort of your child.

First thing you should do is to consult with your child’s doctor and anesthesiologist. Children of different ages have various peculiarities of organism development. For instance, kids under 3 years are more susceptible to atelectasis and pneumonia. In addition to this, small children have slower coagulability and they are more sensitive to loss of blood.

That’s why a doctor may give you some specific recommendations on child’s nutrition and drinking before the surgery. However, your main task is to create a highly comfortable and loving atmosphere for your kid. No stress, no worrying, no uncertainty. Remember, children feel everything!

If your child can understand what will be happening, then try to explain everything to him/her. Unknown things are much more frightening then something you are expecting!

Small children are mostly afraid of new surroundings, parting with parents, strange people. Elder children are usually afraid of operation itself, pain, consequences of surgery, etc. It all means that every child needs serious pre-surgical psychological preperation. And your role as a parent is essential for a child! However, if we talk about emergency case, there is no possibility to provide due psychological preparation. In this case your task will be to talk to your child afterwards and explain everything that was happening.

How to Explain Everything to Your Child

You don’t have to explain the process of operation to your child, it’s pointless. You must describe the situation from the side of your child’s feelings. What is meant by this? Try to be very specific about what your kid will be feeling during the operation and especially after it.

The most strange and therefore frightening thing to your child may be anesthesia. Somebody makes you sleep and when you wake up you don’t remember anything, but you feel strange, uncomfortable, something hurts… Not good condition for a quick recovery, is it? That’s why you have to talk to your child about what is anesthesia and what are the consequences of it.

Child Surgery

A good thing is to introduce an anesthesiologist to your child. Well-experienced professional will tell your kid about kinds of anesthesia, about possible effects of it, about feeling of discomfort and confusion after wakening, etc. In a word, an anesthesiologist will explain to your child that everything he/she will feel is normal, nothing bad is happening.

So if you face the necessity to operate your child, don’t panic! Find reputable and experienced specialists and rely on them. Don’t forget about positive mood. Try to create favorable conditions for your child, and you will see that he or she will become healthy and strong again in no time!

Secondary Amenorrhea Causes And Diagnosis

Temporary cessation of menses is extremely common and usually does not require extensive endocrine investigation. In the childbearing age, pregnancy must be ruled out. In women beyond the childbearing age, menopause should be considered first. States of emotional stress, malnutrition, anemia, and similar disorders may be associated with temporary amenorrhea and correction of the primary disorder will usually also reestablish menstruation. Some women fail to menstruate regularly for prolonged intervals after stopping oral contraceptive pills. Lactation may be associated with amenorrhea, either physiologically or for abnormally prolonged periods after delivery. An increasing number of small pituitary tumors causing secondary amenorrhea and often lactation have been discovered by means of prolactin assays and pituitary tomography.

Secondary Dismenorrhea

By the use of the�dilation and curettage, the administration of progesterone with subsequent withdrawal, these amenorrhea�can be arbitrarily divided into amenorrhea with negative dilation and curettage�and amenorrhea with positive dilation and curettage. The former (with the exception of pregnancy) show an atrophic�or type of endometrium; the latter show an endometrium of the proliferative type but lacking progesterone.

Secondary amenorrhea with negative medical�dilation and curettage�may be due to the following causes: premature ovarian failure, pituitary tumor, pituitary infarction (Sheehan's syndrome). The measurement of serum FSH and LH is extremely helpful in separating ovarian causes (high gonadotropins) from hypothalamic-pituitary�origin (low gonadotropins). Serum prolactin levels must be measured. Less common causes include virilizing�syndromes such as arrhenoblastoma, Cushing's disease, Addison's disease, and miscellaneous causes such as anorexia nervosa, profound myxedema, and irradiation of the uterine lining.

Secondary amenorrhea with positive medical�dilation and curettage�may be due to metropathia�hemorrhagica, Stein-Leventhal syndrome, estrogen medication, estrogenic tumors,�like granulosa cell tumors (rare), hyperthyroidism, and perhaps liver disease. A common cause is psychogenic amenorrhea� related to emotional trauma (divorce, going to college, stressful new job and so on). Menstruation usually returns in a few months without any specific therapy. Tonic elevation of serum LH with normal FSH is helpful in the diagnosis of polycystic�ovary syndrome. Amenorrhea or oligomenorrhea is also often found in athletes (long-distance runners, dedicated ballet dancers, etc). Depletion of body fat due to strenuous exercise may play a role in the pathogenesis of this problem.

Some degree of overlap in these 2 groups is sometimes found.

Secondary Amenorrhea Treatment

The aim of therapy is not only to reestablish menses (although this is valuable for psychologic reasons) but also to attempt to establish the cause (eg. pituitary tumor) of the amenorrhea and to restore productive function.Treatment depends upon the underlying disease. It is not necessary to treat all cases, especially temporary amenorrhea or irregular menses in unmarried girls or women. These cases usually are corrected spontaneously after marriage or the first pregnancy

In patients whose�are response to progesterone is normal, the administration of this hormone�during the las�5-10 days of each month, can correct the amenorrhea. In patients who are unresponsive to progesterone� and whose urinary gonadotropin levels are�low treatment�of�the pituitary lesion may restore�menstruation

A commonly used schedule is the oral administration of 1.2 mg of conjugated estrogens from days 1 to 20 of each month and 10 mg of medroxyprogesterone�daily during days 21 to 25. Corticosteroids may restore menstruation in virilizing disorders that are due to enzymatic abnormalities in cortisol biosynthesis. Wedge resection of the ovaries often restores regular menstruation in the polycystic ovary syndrome) Transsphenoidal�resection of small prolactin-produc-ing�pituitary adenomas likewise has resulted in restoration of fertility.

General measures include dietary management as required to correct overweight or underweight; psychotherapy in cases due to emotional disturbance; and correction of anemia and any other metabolic abnormality that may be present (eg, mild hypothyroidism).

Primary Amenorrhea

Since regular menstruation depends upon normal function of the entire physiologic axis extending from the hypothalamus and pituitary gland�to the ovary and the uterine lining, it is not surprising that menstrual disorders are among the most common presenting complaints of endocrine disease in women. Correct diagnosis depends upon proper evaluation of each component of the axis, and nonendocrine factors must also be considered. If menstruation is defined as shedding of endometrium which has been stimulated by estrogen or�by estrogen and progesterone which are subsequently withdrawn, it is obvious that amenorrhea can occur either when hormones are deficient or lacking (the hypohormonal or ahormonal type) or when these hormones, though present in adequate amounts, are never withdrawn (the continuous hormonal type).

Amenorrhea

Primary amenorrhea implies that mentruation has never been established. This diagnosis is not usually made before the age of about 15-16. Secondary amenorrhea means that�the menstruation�once established has ceased (temporarily or permanently). The most common type of hypohormonal amenorrhea is the menopause, or physiologic failure of ovarian function. The most common example of continuous hormonal amenorrhea is that due to pregnancy, when cyclic withdrawal is prevented by the placental secretions. These 2 conditions should always be considered before extensive diagnostic studies are undertaken.

Primary Amenorrhea Diagnosis

The principal diagnostic aids that are used in the study of amenorrhea are as follows:

1. Vaginal smear for estrogen effect
2. Endometrial biopsy
3. Medical dilation and curretage
4. Basal body temperature determination
5. Urine determinations of 17-keto-steroids, FSH, pregnanediol, and pregnanetriol
6. Culdoscopy and gynecography
7. Chromosomal studies
8. Pelvic exploratory operation or laparoscopy and gonadal biopsy
9. Radioimmunoassays of FSH, LH, and prolactin, available for specific diagnosis of certain types of amenorrhea
10. Plasma testosterone assay
11. X-ray studies of the hypothalamic and pituitary areas
12. In young females, bone age.

Primary Amenorrhea

Because of the frequency with which delayed puberty� is found in otherwise normal females, the diagnosis of primary amenorrhea usually is not made until the patient is clearly beyond the age at which normal menarche occurs. In the USA, the mean age at menarche is 12 and a half�years. If menses have not started by age 16, primary amenorrhea is definitely present, and the cause should be investigated.

Most cases of primary amenorrhea are of the hypohormonal or ahormonal type. Exact diagnosis is essential to rule out an organic lesion along the hypo-thalamic-pituitary-gonadal axis. The chromosomal sex pattern must be determined in many cases. Laparoscopy or pelvic exploration may be required to establish the diagnosis. In large series, the most common cause has always been Turner's syndrome.

Primary Amenorrhea Causes

• Hypothalamic causes: Constitutional delay in onset, debility, serious organic illness, lack of LHRH (GnRH)
• Pituitary causes (with low or absent FSH): Suprasellar cyst, pituitary tumors (eosinophilic adenomas, chromophobe adenomas, basophilic adenomas), isolated lack of pituitary gonadotropins.
• Ovarian causes (with high FSH): Ovarian agenesis (Turner's syndrome), destruction of ovaries (eg, due to infection or, possibly, autoimmunity).
• Uterine causes: Malformations, congenital miillerian dysgenesis, imperforate hymen, hermaphroditism, unresponsive or atrophic endometrium.
• Miscellaneous causes: All forms of male pseudohermaphroditism (enzymatic defects in testosterone synthesis, androgen resistance syndromes), androgen excess syndromes (adrenal or ovarian tumors, polycystic ovaries).

Since primary amenorrhea is only a manifestation of multiple and often complex underlying defects, treatment must be individualized according to the specific cause.

Nausea And Vomiting

Nausea and vomiting , two intensely disagreeable symptoms may occur singly or concurrently and may be due a wide variety of factors. The pathophysology�of vomiting is not completely understood. Vomiting appears to involve 2 functionally distinct medullary centers: the vomiting center, which controls and initiates the act of vomiting and the chemoreceptor trigger zone, which is activated by many drugs and different kinds of toxins. The vomiting center may receive stimuli from the alimentary tract, from the brain, from the vestibular apparatus (see motion sickness), and from the chemoreceptor trigger�zone.

Vomiting

Vomiting Causes

• Alimentary disorders: irritation, inflammation, or mechanical disturbance at any level of the gastrointestinal tract.
• Hepatic, biliary and pancreas�disorders
• Central nervous system disorders: increased intracranial pressure, stroke, migraine, infection, toxins, radiation sickness.
• Motion Sickness
• Endocrine Disorders: diabetic acidosis, adrenocortical crisis, pregnancy, starvation, lactic acidosis
• Genitourinary disorders: uremia, infection, urinary obstruction
• Cardiovascular disorders: acute myocardial infarction, congestive heart failure
• Drugs: morphine, meperidine, anesthetics, chemotherapy, alcohol
• Psychologic disorders: reaction to pain, fear or displeasure chronic anxiety reaction, anorexia nervosa.

Vomiting�Complications

Complications of vomiting include fluid and electrolyte disturbances (dehydration), pulmonary aspiration of vomitus, gastroesophageal mucosal tear, malnutrition, rupture of esophagus.

Vomiting�Treatment

Simple acute vomiting such as occurs following dietary or�excessive alcohol consumption, or during morning sickness of early pregnancy, may require little or no treatment. Avoiding known aggravating factors and taking simple corrective dietary measures usually suffice.

Severe and prolonged nausea and vomiting usually require carefull medical management in the hospital. Attempt to determine and correct the causes of the vomiting as soon as possible. The vomiting patient will be checked if aspiration has occurred. The following general measures may be used as adjuncts to specific or surgical treatment.

Fluids And Nutrition

Mentain�adequate hydration and nutrition, and�any electrolyte disturbance will be corrected as soon as it occurs. Hypokalemia�and metabolic alkalosis are common in patients with severe vomiting. The food will be temporarily�withhold and 5% dextrose in saline with appropriate KCL�supplementation. If vomiting continues, a nasogastric�tube to intermittent suction for gastric decompresion. When oral feeding is resumed, begin with dry foods in small quantities like salted crackers, graham crackers.� With morning sickness these foods may best be taken before arising. Later, frequent small feedings or simple paltable foods. Hot beverages like tea and cold beverages like iced tea are tolerated quite early. Avoid lukewarm beverages, and always consider what kind of food you would like to eat.

Vomiting�Medication

All unnecessary drugs should be withheld from pregnant woman during the early critical early phase of fetal development. Unless nausea and vomiting of pregnancy are severe and progressive, avoid using medication for vomiting. The possible teratogenic�effects of may classes of drugs may harm the pregnancy. Antiemetic�drugs are usually better for preventing vomiting, nut they may be emplyed selectively if the cause of vomiting cannot be treated effectively. The drugs should be used cautiously to avoid masking of a severe illness. The choice of drug treatment depends on the causes of vomiting.

Sedatives, alone or with anticholinergics, may be helpful in patients with psyhogenic�vomoting.

Antihistamines like Dimenhydrinate may be useful for patients with vestibular disorders (motion sickness)

Phenothiazines�like prochlorperazine�is prefered vor vomiting caused by drugs, radiation vomiting, or surgery.

Metoclopramide, is particularly�helpful for diabetic gastroparesis vomiting and preventing nausea and vomiting of cancer chemotherapy.

Vomiting�Medical Measures

1. Sedation with any of the common sedative drugs can be effective.
2. Stimulation of the nasopharynx – a soft catheter is introduces nasally to stimulate the pharynx and is often successful.
3. Local anesthetics
4. Antispasmodics – atropine sulfate
5. Amyl nitrite inhalations may also be effective
6. Antacids

Vomiting�Surgical Measures

Various phrenic nerve operations, including�bilateral phrenicotomy, may be indicated in extreme cases that fail to respond to all other measures and are considered to be a threat to life.

Infertility

Infertility is a problem�that increasingly more couples are facing,�about one in five couples�having difficulty in�conceiving a child. Infertility is�defined as�inability to�conceive�a child�after one year of�unprotected intercourse�and its causes can be related to both men and women�health aspects.�Primary infertility�is defined as no previous pregnancy�in patient history and secondary infertility implies the existence of at least one pregnancy. The term sterility is different from infertility and is used when�an effective therapy that can deal with the cause of�infertility�is not available.

The two partners equally share�the conception failure causes:

• Female factor 30-40%
• Male factor 30-40%
• Combined�factor�15 to 20%
• Idiopathic (no known cause) 2-15%

Approximately 70% of couples treated for infertility will�conceive.

The Most Common Causes Of Infertility

The infertility causes can be very varied, based on independent or associated conditions, belonging to one or both partners.�Some causes of infertility can not be detected or�unknown disorders interact with this aspect of conception.

Causes of infertility

For women:

• Pelvic infections�that interfere with�the sexual organs, the most common�effects being the formation of ductal clamps that�affect the ductal tract�or blockage�of the fallopian tubes (constriction).
• Endometriosis, a condition represented by the presence of uterine tissue�outside the uterus�(eg fallopian tube) – a situation more common in women�aged over�30 who are nulliparous (without any pregnancy in history).
• Ovarian Disease (ovarian cysts, polycystic ovarian syndrome, ovarian dystrophy, ovarian cancer) that lead to impossibility of forming�of a�normal egg, healthy, which can be fertilized.
• Congenital anomalies of the sexual organs (“T” shaped uterus)
• Diseases of the fallopian tubes,�adnexitis (infection that reaches�the ovary), congenital disorders, narrow�fallopian tubes that do not allow the egg to reach the uterus, that�are scared due to an infection with the same consequences on egg migration, which are�unable to absorb the egg, or fallopian tubes which do not ensure the egg viability.
• Diseases of the uterus: congenital, structural disorders,�womb infections, diseases of the cervix��that do not allow penetration or migration�of sperm, uterine fibroids, etc.
• Sexual dysfunction�during intercourse (dyspareunia�– pain during intercourse – or vaginismus), vaginitis, trichomoniasis etc.
• Menstrual cycle disorders: amenorrhea (lack of menstruation) or irregular menstruation
• Organic lesions�of the central nervous system
• Hormonal disorders�such as hyperprolactinemia
• Body weight – obesity seems to interfere with reproductive function
• Some chronic diseases.

For men:

• Some�sexual dysfunctions�(impotence, premature ejaculation or delayed ejaculation)
• Dysfunction in sperm production (quantity, mobility, structure, maturation).
• Varicose veins in the scrotum
• Infections of the reproductive organs
• Hormones dysfunction caused by mumps or drug use
• Certain chronic diseases that can cause reproductive disorders: tuberculosis, diabetes, etc
• Testicular diseases that cause�their inflammation (orchitis), cysts, varicocele;
• Environmental factors: heat (eg. occupational exposure)
• Excessive smoking, more than two packs a day lowers sperm count and motility
• Toxic byproducts: lead, boric acid, ultrasound.

Men and woman�common causes of infertility

• Gonorrhea, chlamydiosis and other sexually transmitted diseases (STDs)
• Drugs: methadone, heroin, etc
• Certain drugs that either interfere with hormone metabolism.

See also: �Couple's Infertility � Management And Treatment

Dyslipidemia

Fats are essential nutrients, and cholesterol and triglycerides are fat fractions coming from animal products. Cholesterol products are�a major constituent of blood cells, cholesterol being the�basic component of the�cell wall.�Cholesterol is involved in�precise body functions, such as formation of bile which helps with the�digestion processes.�Cholesterol is used to synthesize vitamin D in the skin, also essential�for proper�brain functioning, for�hormone synthesis and transport of vitamins.�Cholesterol represents�an excess of energy storage and also provides�mechanical protection of vital organs (the fat that surrounds certain organs). Cholesterol and triglycerides are not in plants, but produced only by the human or animal body.�We�do not need to consume cholesterol, because the body can synthesize�it in sufficient quantities in the liver from �vegetable fat, sugar and alcohol.

There are several�types of cholesterol, a form is “bad” cholesterol that is deposited in artery walls, causing atherosclerosis, it is called�LDL cholesterol. The other form is “good” cholesterol or HDL cholesterol and it is called “good” cholesterol because it�can be�“removed” from the arteries walls�and other tissues�and from the body.

Normal Values

• Total cholesterol below 200 mg/100 ml
• LDL-cholesterol below 130 mg/100 ml
• HDL-cholesterol more�than 35-40 mg/100 ml
• Triglycerides�below 150 mg/100 ml

In normal�a normal person�blood, there is about four times more�LDL cholesterol�than HDL cholesterol. If this ratio increases, atherosclerosis�process begins. Dyslipidemia, hypercholesterolemia (high blood cholesterol) are names for the same disease, the cholesterol found�in�the bloodstream, the excess is deposited in artery walls where�it forms�over time “plates” of fat (atheroma), which leads to narrowing of the arteries, or the plaque can break off and clog arteries suddenly. The next stage of the disease caused by high blood cholesterol is atherosclerosis�that�can lead�to�a myocardial infarction or stroke. Smoking, hypertension and diabetes aggravates and speeds the�atherosclerosis process.

Causes Of High�Cholesterol /�Triglycerides

There are two main causes: an inherited predisposition and an�unhealthy diet. Very often�the two�conditions coexist, inherited predisposition� and�unhealthy diet, which�leads to�particularly serious consequences during the modern era, characterized by inactivity, stress and pollution. Diets low in cholesterol and triglycerides decrease the risk of heart disease, hypertension, diabetes, obesity, certain forms of intestinal cancer, prostate cancer and breast cancer.

Dyslipidemia�Treatment

The objective of treatment�is to maintain cholesterol and triglycerides at the lowest possible level. This objective is achieved by dietary changes, exercise (at least 30 minutes�each day), normalizing or maintaining normal weight, moderate alcohol consumption (a glass of red�wine each day�is considered healthy), stress reduction and smoking cessation . Drug treatment applies when non-pharmacological treatment of dyslipidemia�has bad results�(with correctly kept diet). The ideal�dyslipidemia drug�should decrease both cholesterol and triglycerides, without side effects�and��low cost ( it is used often for life) . Talking with your doctor is very important�in order to�prevent and / or treat dyslipidemia complications .

Dyslipidemia Diet

Cholesterol is found mainly in: animal fat, fatty meats, egg yolks and dairy fats (butter, cream, cheese etc). But not all fats�lead to�high cholesterol and triglycerides levels. Conversely, there are some fats�that tend to�lower cholesterol and triglycerides. Cholesterol-lowering fats: These are unsaturated fats�that are�found primarily in plants, especially walnuts, flax, soy, avocado, olive seed and vegetable oils (olive, sunflower, rapeseed, corn, etc.).

Dyslipidemia

Tips to reduce Dietary cholesterol and triglycerides

1. Avoid frying meat�in oil or fat
2. Avoid pastries, biscuits, cakes, donuts and chocolate.
3. Do not eat more than�one yolk�a week.
4. Do not use butter, margarine, mayonnaise�but occasionally
5. Avoid fat�meats, sausages.
6. Avoid processed foods
7. Drink only�low-fat milk.
8. Eat lean meat, beef, chicken, fish.
9. Replace meat with some vegetables (beans, peas, lentils) a few times a week.
10. Replace fatty products with�green leaves, spices, lemon juice, vegetable, powders to flavor food.
11. Whole wheat, fruits and�vegetables
12. Read�the food labels properly�before you buy pre-packed food�and�look especially�for grams�of total fat, saturated “bad” and unsaturated “good”, cholesterol.
13. Use�spices that can�significantly decrease cholesterol: garlic and thyme. Among fruits, apples are the best choice.
14. Fish�can lower the risk of plaque. Eat fish instead of meat, but not fried fish.

The daily cholesterol�need of�a healthy man, is between 200 and 400mg, depending on the daily physical activity. For those with increased cholesterol levels�50mg/day maximum�is allowed. Cholesterol content of� food is expressed in mg per 100 g or ml:

• Egg albumen�– 1 mg
• Bread�1 mg
• Skim milk� 4 mg
• Whole cow milk 10 mg
• Condensed milk� 35 mg
• Yogurt 10 mg
• Camembert cheese 70 mg
• Cheddar cheese 70 mg
• Cottage cheese 15 mg
• Mayonnaise 8 mg
• Macaroni and cheese 17 mg
• Cooked beef 80 mg
• Cooked chicken 90 mg, 100 mg fried
• Chicken breast (without skin) 73
• Rate 160 mg
• Lamb 110mg
• Pork 110 mg
• Fried turkey 80 mg
• Pork liver 420 mg,
• Organs 300 mg,
• Egg-yolk 500 mg
• Parmesan 90 mg
• Butter = 260 mg (1 teaspoon ~ 31)
• Margarine between 0 and 5 mg
• Crab 65 mg
• Lobster 70 mg
• Canned salmon 90 mg
• Sardines in preserve 80 mg
• Raw�oysters = 40 mg
• Tuna in oil = 90 mg
• Ice cream = 45 mg, (1 cup ~ 29)
• Chocolate milk = 90 mg
• Fried brain�= 1697 mg
• Fried eggs� 2000 mg.

Dyslipidemia

Prohibited�food due to high�cholesterol and / or triglycerides are fatty meat (pork, mutton, meat sauce, chicken fat, liver, brain, stomach, kidney, bone), shellfish ( shrimp, crayfish, crawfish), snails, shellfish, egg yolks, whole milk, concentrated (condensed or powdered), sour cream, cream, milk-based products, cheese, sheep cheese, crackers, pastries , fat soups, french fries, butter, fat dishes (bacon, scrambled eggs, lard), sauces oil, margarine, alcoholic drinks, fruit juices�from commerce, fruit concentrates, sugar, honey, jam, candy, chocolate , syrup, sweets

Recommended foods�allowed in dyslipidemia: �lean meat (beef, veal, chicken breast, rabbit) grilled or cooked without fat, low-fat unsmoked ham, fresh fish or frozen (but not cooked ) grilled or baked, 1 egg / week, skim milk, low-fat yogurt, white cheese (cow), white bread, black, fried (in limited quantity if there is excess weight), weak broths, soups with vegetables, boiled potatoes mashed without butter, vegetable oils (corn, soybean, olive, sunflower), fresh fruit, mineral water, tea, weak coffee, vegetable juices, fibers (flakes / grains) of any kind in moderation (especially oats).

How To Prevent Infections During Pregnancy

The following tips�can help prevent infections that can harm your baby during pregnancy. Sometimes infection symptoms are not present but if you feel that�something is wrong,�a visit to�your doctor will elucidate the cause.

1. Wash your hands often with soap and water, especially when you use the�toilet, touch raw meat, eggs, raw or unwashed vegetables, prepare or eat, you worked in the garden or touched the ground, you play with animals, you have been around sick people, you played with children, changed diapers. If you do not have access to soap and water, you can use an alcohol based hand gel.

2. Try not to borrow cutlery, cups or food from children and wash your hands more often when you are around them. Saliva can contain viruses that are harmless to them, but can be very dangerous for you and your baby.

3. Do not eat hot dogs or other meat-based�foods that�were not cooked properly. Insufficiently cooked meat may contain harmful bacteria(Listeria).

4. Avoid unpasteurized milk or foods that can contain unpasteurized milk. Do not eat feta cheese or other cheese if�you notice no�proper labels that specify�how�the cheese was�prepared.

5. Do not come into contact with cat feces, but if you have to, wear gloves and wash your hands after. Cat feces may contain an extremely dangerous parasite (Toxoplasma gondii)

6. Stay away from rodents and their droppings. If you�have hamsters or guinea pigs, let someone else take care of them until you give birth.

7. Test yourself for STDs, like HIV, hepatitis B, hepatitis�C�and�seek information to protect yourself from them. Infected people, in most cases do not experience any�symptoms. If you are infected, consult your doctor, and ask him�how�you�can reduce the risk of transmission to your baby.

8. Talk to your doctor about vaccinations need during pregnancy. Some of them are�recommended before you become pregnant, during pregnancy and others after giving�birth. Vaccination during pregnancy is recommended when the benefits outweigh the potential risks, ie the probability of exposure to�the disease is higher, the infection may create risks for mother and fetus, and vaccination does not affect fetal development. If you are planning a pregnancy or you are�already pregnant, your needed�vaccinations are determined by factors such as age, lifestyle, risk conditions, previous vaccinations.

9. Ask your doctor about group B streptococcus. One�in�four women carriers the bacteria.

Recommended Vaccines Before Pregnancy

Before getting pregnant, you should be up to date with vaccinations�from your�national immunization schedule. Generally, live attenuated vaccines or supraatenuate antigens (BCG, oral polio, measles, mumps, rubella, varicella, cytomegalovirus, rotavirus, Japanese encephalitis, hepatitis A, typhoid fever, cholera, dysentery), should not be administered before conception. Instead inactivated-killed antigen vaccines (injectable polio, pertussis, herpes, hepatitis A, dysentery, tularemia, anti-Hemophilus�influenza�type B, cytomegalovirus, meningococcal) can be�administered anytime before or during pregnancy, if needed.

If you are rubella vaccinated�you�should avoid pregnancy for at least 4 weeks after vaccination.

Recommended�Vaccines During Pregnancy

• Influenza vaccine�(especially if you have medical conditions that increase the risk of complications) significantly reduce the risks of infection.
• Hepatitis B vaccination if you have an�increased risk�for�hepatitis B infection�during pregnancy (especially in Q3) has great�results in�preventing infection of the child, who would have increased chances of developing subsequent porting of HBV.

Recommended Vaccines After Pregnancy

If you have not been�vaccinated against diphtheria, tetanus and pertussis (DTP), you should vaccinate immediately after birth. Also�if you have not experienced�childhood diseases such as measles, chickenpox, mumps or rubella, you should be vaccinated before leaving the�hospital.

Breastfeeding is not affected by any vaccine.

Group B strep is a type of bacteria found in the vagina and rectum of�many healthy women. If you are the bearer of such bacteria it�does not mean that you have an infection. Group B strep can be passed from mother to child during birth.�Group B strep�is the causes�of certain newborns�infections, such as pneumonia, septicemia, meningitis. Unfortunately, many infants can die from these causes or may experience long-term complications.

Before going into labor, it is recommended to ask your doctor about group B strep test�during week 35-37�and inform your doctor about possible allergies to penicillin or other antibiotics.

Life Insurance

Although many of us are tempted to believe that our health is invulnerable, unfortunately often the reality is different. How would your family cope if all outstanding loans and all debts would fall on their shoulders, if something unexpected happens? When your loved ones�depend directly�on you, concern for their safety and comfort can block some of your�initiatives.

Here are some reasons why you should�benefit from a�life insurance:

• You can cover the financial needs caused by the inability to work and income loss�due to�hospitalization, surgery, critical illness and death.
• Life insurance�represents financial security –�it can represent the�only source in unexpected moments, mentioned above, which generate costs difficult to sustain�by the family.
• Are essential for people who want to financially protect their health, family and people in care.
• Benefits from life insurance are non-taxable.

Life Insurance

Considering the above aspects and the existence of the�unstable economic situation in Europe, the conclusion of insurance covering the risk of death is a problem that any person should consider,�avoiding therefore�creating an imbalance in the offsprings financially dependent situation. If�case�of�the insured person’s death, life insurance provides money to a designated beneficiary.

Life insurance is a contract signed between the insurer and the insured in favor of a beneficiary or multiple beneficiaries. The purpose of this contract is the sum insured, which�is established�by both parties or at the request of the insured. Depending on the sum insured and other factors the size of insurance premium that the insured will�have to pay over the duration of the contract at predetermined time intervals will be established.

The contract involves three people:

Insurer – The insurance company in return for insurance premiums�that will cover�the risks that threaten the insured and undertakes to pay compensation, the amount insured in case of undesired events.
Insured – the person or entity seeking the contract�that�will pay premiums for the determined�duration of the contract.
Beneficiary – the person designated by the insured, who will receive the sum insured if�case of the�insured’s death. The beneficiary can be changed at the request of the insured during the contract.