Avascular necrosis

Avascular necrosis

Definition:

Avascular necrosis is the death of bone tissue due to a lack of blood supply. Also called osteonecrosis, avascular necrosis can lead to tiny breaks in the bone and the bone's eventual collapse.

The blood flow to a section of bone can be interrupted if the bone is fractured or the joint becomes dislocated. Avascular necrosis of bone is also associated with long-term use of high-dose steroid medications and excessive alcohol intake.

The hip is the joint most commonly affected by avascular necrosis. While avascular necrosis of bone can happen to anyone, it usually occurs in men between the ages of 30 and 60.


Symptoms:

Many people have no symptoms in the early stages of avascular necrosis of bone. As the disease worsens, your affected joint may hurt only when you put weight on it. Eventually, the joint may hurt even when you're lying down.

Pain can be mild or severe and usually develops gradually. Joints most likely to be affected are the hip, shoulder, knee, hand and foot. Pain associated with avascular necrosis of the hip may be focused in the groin, thigh or buttock. Some people experience avascular necrosis bilaterally — for example, in both hips or in both knees.

When to see a doctor
See your doctor if you experience persistent pain in any joint. Seek immediate medical attention if you believe you have a broken bone or a dislocated joint.


Causes:

Avascular necrosis occurs when blood flow to a bone is interrupted or reduced, which may be caused by:

• Joint or bone injury. A traumatic injury, such as a dislocated joint, may reduce the blood supply to a section of bone, leading to bone death. Cancer treatments involving radiation also can weaken bone and harm blood vessels.
  
• Pressure inside the bone. Some medical conditions, such as sickle cell anemia or Gaucher's disease, can increase the pressure inside the bone — making it more difficult for fresh blood to enter.

Complications:

 Avascular necrosis that goes untreated will worsen with time. Eventually the bone may become weakened enough that it collapses. When the bone loses its smooth shape, severe arthritis can result.


Treatments and drugs:
The treatment goal for avascular necrosis is to prevent further bone loss. What treatment you receive depends on the amount of bone damage you already have.

Medications
In some people, avascular necrosis symptoms may be reduced with medications such as:

• Nonsteroidal anti-inflammatory drugs (NSAIDs). Medications such as ibuprofen (Advil, Motrin, others) or naproxen (Aleve) may help relieve the pain and inflammation associated with avascular necrosis.
  
• Osteoporosis drugs. Some studies indicate that osteoporosis medications, such as alendronate (Fosamax, Binosto), may slow the progression of avascular necrosis.
  
• Cholesterol drugs. Reducing the amount of fat (lipids) in your blood may help prevent the vessel blockages that often cause avascular necrosis.
  
• Blood thinners. If you have a clotting disorder, blood thinners such as warfarin (Coumadin, Jantoven) may be prescribed to prevent clots in the vessels feeding your bones.

Therapy
In the early stages of avascular necrosis, your doctor might suggest:

• Rest. Reducing the amount of weight and stress on your affected bone may slow the damage of avascular necrosis. You may need to restrict the amount of physical activity you engage in. In the case of hip or knee avascular necrosis, you may need to use crutches to keep weight off your joint for several months.
  
• Exercises. Certain exercises may help you maintain or improve the range of motion in your joint. A physical therapist can choose exercises specifically for your condition and teach you how to do them.
  
• Electrical stimulation. Electrical currents may encourage your body to grow new bone to replace the area damaged by avascular necrosis. Electrical stimulation can be used during surgery and applied directly to the damaged area. Or it can be administered through electrodes attached to your skin.

Surgical and other procedures
Because most people don't start having symptoms until the disease is fairly advanced, you may need to consider surgeries such as:

• Core decompression. In this operation, your surgeon removes part of the inner layer of your bone. In addition to reducing your pain, the extra space within your bone stimulates the production of healthy bone tissue and new blood vessels.
  
• Bone transplant (graft). This procedure can help strengthen the area of bone affected by avascular necrosis The graft is a section of healthy bone taken from another part of your body.
  
• Bone reshaping (osteotomy). This procedure removes a wedge of bone above or below a weight-bearing joint to help shift your weight off the damaged bone. Bone reshaping may allow you to postpone joint replacement.
  
• Joint replacement. If your diseased bone has already collapsed or other treatment options aren't helping, you may need surgery to replace the damaged parts of your joint with plastic or metal parts.

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Autonomic neuropathy

Autonomic neuropathy

Definition:

Autonomic neuropathy is a nerve disorder that affects involuntary body functions, including heart rate, blood pressure, perspiration and digestion.

It isn't a specific disease. Autonomic neuropathy refers to damage to the autonomic nerves. This damage disrupts signals between the brain and portions of the autonomic nervous system, such as the heart, blood vessels and sweat glands. This can cause decreased or abnormal performance of one or more involuntary body functions.

Autonomic neuropathy can be a complication of a number of diseases and conditions. And some medications can cause autonomic neuropathy as a side effect. Signs, symptoms and treatment of autonomic neuropathy vary depending on the cause, and on which nerves are affected.

Symptoms:

Signs and symptoms of autonomic neuropathy vary, depending on which parts of your autonomic nervous system are affected. They may include:

• Dizziness and fainting upon standing caused by a drop in blood pressure.
• Urinary problems, including difficulty starting urination, urinary incontinence and an inability to completely empty your bladder, which can lead to urinary tract infections.
• Sexual difficulties, including problems achieving or maintaining an erection (erectile dysfunction) or ejaculation problems in men, and vaginal dryness and difficulties with arousal and orgasm in women.
• Difficulty digesting food, due to abnormal digestive function and slow emptying of the stomach (gastroparesis). This can cause a feeling of fullness after eating little, loss of appetite, diarrhea, constipation, abdominal bloating, nausea, vomiting, difficulty swallowing and heartburn.
• Sweating abnormalities, such as excessive or decreased sweating, which affects the ability to regulate body temperature.
• Sluggish pupil reaction, making it difficult to adjust from light to dark and causing problems with driving at night.
• Exercise intolerance, which may occur if your heart rate remains unchanged instead of appropriately increasing and decreasing in response to your activity level.

When to see a doctor
Seek medical care promptly if you begin experiencing any of the signs and symptoms of autonomic neuropathy. If you have diabetes, a compromised immune system or another chronic medical condition, see your doctor regularly to be checked for nerve damage.
The American Diabetes Association (ADA) recommends that people with type 2 diabetes be screened every year for autonomic neuropathy starting as soon as they receive their diabetes diagnosis. For people with type 1 diabetes, the ADA advises annual screening beginning five years after being diagnosed with diabetes.


Causes:

Autonomic neuropathy can be caused by a large number of diseases and conditions or can be a side effect of treatment for diseases unrelated to the nervous system. Some common causes of autonomic neuropathy include:

• Abnormal protein buildup in organs (amyloidosis), which affects the organs and the nervous system.
• Autoimmune diseases, in which your immune system attacks and damages parts of your body, including your nerves. Examples include Sjogren's syndrome and systemic lupus erythematosus. Autonomic neuropathy may also be caused by an abnormal attack by the immune system that occurs as a result of some cancers (paraneoplastic syndrome).
• Diabetes, which is the most common cause of autonomic neuropathy, can gradually cause nerve damage throughout the body.
• Injury to nerves caused by surgery or radiation to the neck.
• Treatment with certain medications, including some drugs used in cancer chemotherapy, some antidepressants and some heart medications.
• Other chronic illnesses, such as Parkinson's disease.
• Certain infectious diseases. Some viruses and bacteria, such as botulism, leprosy and diphtheria, can cause autonomic neuropathy.
• Inherited disorders. Certain hereditary disorders can cause autonomic neuropathy. 

Treatments and drugs:

Treatment of autonomic neuropathy includes:

• Treating the underlying disease. The first goal of treating autonomic neuropathy is to manage the disease or condition damaging your nerves. For example, if the underlying cause is diabetes, you'll need to control your blood sugar to keep it as close to normal as possible. Treating the underlying disease can help stop autonomic neuropathy from progressing.
  
• Managing specific symptoms. Some treatments can relieve the symptoms of autonomic neuropathy. Treatment is based on what part of your body is most affected by nerve damage.

Digestive (gastrointestinal) symptoms
Your doctor may recommend:

• Modifying your diet. This could include increasing the amount of fiber you eat and fluids you drink. Supplements containing fiber, such as Metamucil or Citrucel, also may help. Be sure to increase the fiber in your diet slowly to avoid gas and bloating.
  
• Medication to help your stomach empty. A prescription drug called metoclopramide (Reglan) helps your stomach empty faster by increasing the contractions of the digestive tract. This medication may cause drowsiness, and its effectiveness wears off over time.
  
• Medications to ease constipation. Over-the-counter laxatives may help ease constipation. Ask your doctor how often you should use these medications. In addition, increasing the amount of fiber in your diet may help relieve constipation.
  
• Antidepressants. Tricyclic antidepressants, such as imipramine (Tofranil) or nortriptyline (Pamelor), can help treat diarrhea and abdominal pain. Dry mouth and urine retention are possible side effects of these medications.

Urinary symptoms
Your doctor may suggest:

• Retraining your bladder. Following a schedule of when to drink fluids and when to urinate can help increase your bladder's capacity and retrain your bladder to empty completely at the appropriate times.
  
• Medication to help empty the bladder. Bethanechol is a medication that helps ensure complete emptying of the bladder. Possible side effects include headache, abdominal cramping, bloating, nausea and flushing.
  
• Urinary assistance (catheterization). During this procedure, a tube is threaded through your urethra to empty your bladder.
  
• Medications that decrease overactive bladder. These include tolterodine (Detrol) or oxybutynin (Ditropan XL). Possible side effects include dry mouth, headache, fatigue, constipation and abdominal pain.

Sexual dysfunction
For men with erectile dysfunction, your doctor may recommend:

• Medications that enable erections. Drugs such as sildenafil (Viagra), vardenafil (Levitra) or tadalafil (Cialis) can help you achieve and maintain an erection. Possible side effects include mild headache, flushing, upset stomach and altered color vision. Men with a history of heart disease, stroke or high blood pressure need to use these medications with caution and medical supervision. Seek immediate medical assistance if you have an erection that lasts longer than four hours.
  
• An external vacuum pump. This device helps pull blood into the penis using a hand pump. A tension ring helps keep the blood in place, maintaining the erection for up to 30 minutes.

For women with sexual symptoms, your doctor may recommend:

• Vaginal lubricants. If vaginal dryness is a problem, vaginal lubricants may make sexual intercourse more comfortable and enjoyable.

Heart rhythm and blood pressure symptoms
Autonomic neuropathy can cause a number of heart rate and blood pressure problems. Your doctor may prescribe:

• Medications that help raise your blood pressure. If you get dizzy or feel faint when you stand up, your doctor may suggest a drug called fludrocortisone acetate. This medication helps your body retain salt, which helps regulate your blood pressure. Other drugs that can help raise your blood pressure include midodrine (ProAmatine) and pyridostigmine (Mestinon). High blood pressure when lying down is a possible side effect of midodrine.
  
• Medication that helps regulate your heart rate. A class of medications called beta blockers helps to regulate your heart rate if your heart rate doesn't respond normally to changes in activity level.
  
• A high-salt, high-fluid diet. If your blood pressure drops when you stand up, a high-salt, high fluid diet may help maintain your blood pressure.

Sweating
If you experience excessive sweating, your doctor may prescribe:

• A medication that decreases perspiration. The drug glycopyrrolate (Robinul, Robinul Forte) can decrease sweating. Side effects may include dry mouth, urinary retention, blurred vision, changes in heart rate, loss of taste and drowsiness.

There is no medication to increase sweating if you have lost the ability to sweat.

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Autoimmune hepatitis

Autoimmune hepatitis

Definition:

Autoimmune hepatitis is inflammation in your liver that occurs when your body's immune system attacks your liver. Although the cause of autoimmune hepatitis isn't entirely clear, some diseases, toxins and drugs may trigger autoimmune hepatitis in susceptible people, especially women.

Untreated autoimmune hepatitis can lead to scarring of the liver (cirrhosis) and eventually to liver failure. When diagnosed and treated early, however, autoimmune hepatitis often can be controlled with drugs that suppress the immune system.

A liver transplant may be an option when autoimmune hepatitis doesn't respond to drug treatments or when liver disease is advanced.


Symptoms:

Signs and symptoms of autoimmune hepatitis can range from minor to severe and may come on suddenly or develop over time. Some people have few, if any, recognized problems in the early stages of the disease, whereas others experience signs and symptoms that may include:

• Fatigue
• Abdominal discomfort
• Joint pain
• Itching (pruritus)
• Yellowing of the skin and whites of the eyes (jaundice)
• An enlarged liver
• Abnormal blood vessels on the skin (spider angiomas)
• Nausea and vomiting
• Loss of appetite
• Skin rashes
• Dark-colored urine
• In women, loss of menstruation

When to see a doctor
Make an appointment with your doctor if you have any signs or symptoms that worry you.


Causes:

Autoimmune hepatitis occurs when the body's immune system, which ordinarily attacks viruses, bacteria and other pathogens, instead targets the liver. This attack on your liver can lead to chronic inflammation and serious damage to liver cells. Just why the body turns against itself is unclear, but researchers think autoimmune hepatitis could be caused by an interaction between several risk factors, such as infections, medications and a genetic predisposition.

Types of autoimmune hepatitis
Doctors have identified two main forms of autoimmune hepatitis:

• Type 1 (classic) autoimmune hepatitis. This is the most common type of the disease. It can occur at any age. About half the people with type 1 autoimmune hepatitis have other autoimmune disorders, such as thyroiditis, rheumatoid arthritis or ulcerative colitis.
  
• Type 2 autoimmune hepatitis. Although adults can develop type 2 autoimmune hepatitis, it's most common in young girls and often occurs with other autoimmune problems.

Complications:

Autoimmune hepatitis may be associated with a variety of other autoimmune diseases, including:

• Pernicious anemia. Associated with a number of autoimmune disorders, pernicious anemia occurs when a lack of vitamin B-12 interferes with your body's ability to form red blood cells.
  
• Hemolytic anemia. In this type of anemia, your immune system attacks and breaks down red blood cells faster than your bone marrow can replace them.
  
• Ulcerative colitis. This inflammatory bowel disease can cause severe bouts of watery or bloody diarrhea and abdominal pain.
  
• Autoimmune thyroiditis (Hashimoto's thyroiditis). In this condition, the immune system attacks the thyroid gland.
  
• Rheumatoid arthritis. Rheumatoid arthritis occurs when the immune system attacks the lining of your joints, leading to stiffness, pain, swelling, and sometimes deformity and disability.
  
• Celiac disease. This disease causes an abnormal reaction to gluten, a protein found in many grains. Eating gluten sets off an immune response that damages the small intestine.

Complications of liver damage
Autoimmune hepatitis that goes untreated can cause permanent scarring of the liver tissue (cirrhosis). Complications of cirrhosis include:

• Increased blood pressure in the portal vein. Blood from your intestine, spleen and pancreas enters your liver through a large blood vessel called the portal vein. If scar tissue blocks normal circulation through your liver, this blood backs up, leading to increased pressure within the portal vein (portal hypertension).
  
• Enlarged veins in your esophagus (esophageal varices). When circulation through the portal vein is blocked, blood may back up into other blood vessels — mainly those in your stomach and esophagus. The blood vessels are thin walled, and because they're filled with more blood than they're meant to carry, they're likely to bleed. Massive bleeding in the esophagus from these blood vessels is a life-threatening emergency that requires immediate medical care.
  
• Fluid in your abdomen (ascites). Liver disease can cause large amounts of fluid to accumulate in your abdomen. Ascites can be uncomfortable and may interfere with breathing and is usually a sign of advanced cirrhosis.
  
• Liver failure. This occurs when extensive damage to liver cells makes it impossible for your liver to function adequately. At this point, a liver transplant is the only option.
  
• Liver cancer. People with cirrhosis have an increased risk of liver cancer.

Treatments and drugs:

Whatever type of autoimmune hepatitis you have, the goal of treatment is to slow or stop your body's immune system from attacking your liver. This may help slow the progression of the disease.

Medications to control your immune system (immunosuppressants)
Medications used to treat autoimmune hepatitis include:

• Prednisone. Doctors usually recommend an initial high dose of the corticosteroid drug prednisone for people with autoimmune hepatitis. The medication is reduced to the lowest possible dose that controls the disease over a few weeks. Most people need to continue taking the prednisone for at least 18 to 24 months, and some people remain on it for life. Although you may experience remission a few years after starting treatment, the disease often returns if the drug is discontinued.
  
  Prednisone, especially when taken long term, can cause a wide range of serious side effects, including diabetes, thinning bones (osteoporosis), broken bones (osteonecrosis), high blood pressure, cataracts, glaucoma and weight gain.
  
  
• Azathioprine (Azasan, Imuran). Azathioprine, another immunosuppressant medication, is sometimes used along with prednisone. Using both medications may allow you to take a smaller dose of prednisone, reducing its side effects. Side effects of azathioprine may include difficulty fighting infections and nausea. Rare side effects include liver damage, pancreas inflammation (pancreatitis) and cancer.
  
• Other immunosuppressants. If you don't respond to prednisone or azathioprine, your doctor may prescribe stronger immunosuppressants, such as mycophenolate (CellCept), cyclosporine (Neoral, Sandimmune, others) or tacrolimus (Prograf).

Liver transplant
When medications don't halt the progress of the disease, or you develop irreversible scarring (cirrhosis) or liver failure, the remaining option is a liver transplant.
During a liver transplant, your diseased liver is removed and replaced by a healthy liver from a donor. Liver transplants most often use livers from deceased organ donors. In some cases, a living-donor liver transplant can be used. During a living-donor liver transplant, you receive only a portion of a healthy liver from a living donor. Both livers begin regenerating new cells almost immediately.

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Autism

Autism

Definition:

Autism is one of a group of serious developmental problems called autism spectrum disorders that appear in early childhood — usually before age 3. Though symptoms and severity vary, all autism spectrum disorders affect a child's ability to communicate and interact with others.

The number of children diagnosed with autism appears to be rising. It's not clear whether this is due to better detection and reporting of autism or a real increase in the number of cases or both.
While there is no cure for autism, intensive, early treatment can make a big difference in the lives of many children with the disorder.

Symptoms:

Children with autism generally have problems in three crucial areas of development — social interaction, language and behavior. But because autism symptoms and severity vary greatly, two children with the same diagnosis may act quite differently and have strikingly different skills. In most cases, though, children with severe autism have marked impairments or a complete inability to communicate or interact with other people.

Some children show signs of autism in early infancy. Other children may develop normally for the first few months or years of life, but then suddenly become withdrawn or aggressive or lose language skills they've already acquired.

Though each child with autism is likely to have a unique pattern of behavior, these are some common autism symptoms:

Social skills

• Fails to respond to his or her name
• Has poor eye contact
• Appears not to hear you at times
• Resists cuddling and holding
• Appears unaware of others' feelings
• Seems to prefer playing alone — retreats into his or her own world
• Doesn't ask for help or request things

Language

• Doesn't speak or has delayed speech
• Loses previously acquired ability to say words or sentences
• Doesn't make eye contact when making requests
• Speaks with an abnormal tone or rhythm — may use a singsong voice or robot-like speech
• Can't start a conversation or keep one going
• May repeat words or phrases verbatim, but doesn't understand how to use them
• Doesn't appear to understand simple questions or directions

Behavior

• Performs repetitive movements, such as rocking, spinning or hand-flapping
• Develops specific routines or rituals and becomes disturbed at the slightest change
• Moves constantly
• May be fascinated by details of an object, such as the spinning wheels of a toy car, but doesn't understand the "big picture" of the subject
• May be unusually sensitive to light, sound and touch, and yet oblivious to pain
• Does not engage in imitative or make-believe play
• May have odd food preferences, such as eating only a few foods, or craving items that are not food, such as chalk or dirt
• May perform activities that could cause self-harm, such as headbanging

Young children with autism also have a hard time sharing experiences with others. When read to, for example, they're unlikely to point at pictures in the book. This early-developing social skill is crucial to later language and social development.

As they mature, some children with autism become more engaged with others and show fewer disturbances in behavior. Some, usually those with the least severe problems, eventually may lead normal or near-normal lives. Others, however, continue to have difficulty with language or social skills, and the teen years can bring worse behavioral problems.

Most children with autism are slow to gain new knowledge or skills, and some have signs of lower than normal intelligence. Other children with autism have normal to high intelligence. These children learn quickly, yet have trouble communicating, applying what they know in everyday life and adjusting in social situations. A small number of children with autism are savants — they have exceptional skills in a specific area, such as art, math or music.

When to see a doctor
Babies develop at their own pace, and many don't follow exact timelines found in some parenting books. But children with autism usually show some signs of delayed development within the first year. If you suspect that your child may have autism, discuss your concerns with your doctor. The symptoms associated with autism can also be associated with other developmental disorders.The earlier that treatment begins, the more effective it will be.

Your doctor may recommend more developmental tests if your child:

• Doesn't respond with a smile or happy expression by 6 months
• Doesn't mimic sounds or facial expressions by 9 months
• Doesn't babble or coo by 12 months
• Doesn't gesture — such as point or wave — by 12 months
• Doesn't say single words by 16 months
• Doesn't say two-word phrases by 24 months
• Loses previously acquired language or social skills at any age

Causes:

Autism has no single, known cause. Given the complexity of the disease, and the fact that symptoms and severity vary, there are probably many causes. Both genetics and environment may play a role.

• Genetic problems. Several genes appear to be involved in autism. Some may make a child more susceptible to the disorder. Others affect brain development or the way that brain cells communicate. Still others may determine the severity of symptoms. Each problem in genes may account for a small number of cases, but taken together, the influence of genes is likely substantial. Some genetic problems seem to be inherited, while others happen spontaneously.
  
• Environmental factors. Researchers are currently exploring whether such factors as viral infections, complications during pregnancy and air pollutants play a role in triggering autism.

No link between vaccines and autism
One of the greatest controversies in autism is centered on whether a link exists between autism and certain childhood vaccines, particularly the measles-mumps-rubella (MMR) vaccine. Despite extensive research, no reliable study has shown a link between autism and the MMR vaccine.
Avoiding childhood vaccinations can place your child in danger of catching and spreading serious diseases, including whooping cough (pertussis), measles or mumps.


Treatments and drugs:


No cure exists for autism, and there is no one-size-fits-all treatment. The range of home-based and school-based treatments and interventions for autism can be overwhelming.
The goal of treatment is to maximize your child's ability to function by reducing autism symptoms and supporting development and learning. Your doctor can help identify resources in your area. Treatment options may include:

• Behavior and communication therapies. Many programs address the range of social, language and behavioral difficulties associated with autism. Some programs focus on reducing problem behaviors and teaching new skills. Others focus on teaching children how to act in social situations or how to communicate better with other people. Though children don't always outgrow autism, they may learn to function well.
  
• Educational therapies. Children with autism often respond well to highly structured education programs. Successful programs often include a team of specialists and a variety of activities to improve social skills, communication and behavior. Preschool children who receive intensive, individualized behavioral interventions often show good progress.
  
• Family therapies. Parents and family members can learn how to play and interact with their children in ways that promote social interaction skills, manage problem behaviors, and teach daily living skills and communication.
  
• Medications. No medication can improve the core signs of autism, but certain medications can help control symptoms. For example, antidepressants may be prescribed for anxiety, and antipsychotic drugs are sometimes used to treat severe behavioral problems. Other medications may be prescribed if your child is hyperactive.

Managing other medical conditions
Children with autism may also have other medical conditions, such as epilepsy, sleep disorders, limited food preferences or stomach problems. Ask your child's doctor how to best manage these conditions together. Keep all of your child's health care providers updated on any medications and supplements your child is taking. Some medications and supplements can interact, causing dangerous side effects.
Teens and young adults with autism may have issues with body changes, increased social awareness and transitions. Your health care provider and community advocacy and service organizations can offer help.

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Atypical hyperplasia of the breast

Atypical hyperplasia of the breast

Definition:

Atypical hyperplasia is a precancerous condition that affects cells in the breast. Atypical hyperplasia describes an accumulation of abnormal cells in a breast duct (atypical ductal hyperplasia) or lobule (atypical lobular hyperplasia).

Atypical hyperplasia isn't cancer, but it can be a forerunner to the development of breast cancer. Over the course of your lifetime, if the atypical hyperplasia cells keep dividing and become more abnormal, your condition may be reclassified as noninvasive breast cancer (carcinoma in situ) or breast cancer.

If you've been diagnosed with atypical hyperplasia, you have an increased risk of developing breast cancer in the future. For this reason, doctors sometimes recommend more frequent breast cancer screening and careful consideration of medications and other strategies to reduce breast cancer risk.

Symptoms:

Atypical hyperplasia doesn't cause any specific signs or symptoms.

When to see a doctor
Make an appointment with your doctor if you have any signs or symptoms that worry you.
Atypical hyperplasia doesn't cause signs and symptoms, but it's usually discovered during a breast biopsy to investigate breast signs and symptoms caused by another condition or an abnormality found on a mammogram.


Causes:
It's not clear what causes atypical hyperplasia. Atypical hyperplasia forms when breast cells become abnormal in number, size, shape, growth pattern and appearance. Location of the abnormal cells within the breast tissue — the lobules or the milk ducts — determines whether the cells are atypical lobular hyperplasia or atypical ductal hyperplasia.

Atypical hyperplasia is thought to be part of the complex, multistep process by which breast cancer develops. The process begins when normal cell development and growth become disrupted, causing an overproduction of normal-looking cells (hyperplasia). Atypical hyperplasia occurs when the excess cells stack upon one another and begin to take on an abnormal appearance.

The abnormal cells can continue to change in appearance and multiply, evolving into noninvasive (in situ) cancer, in which cancer cells remain confined to the area where they start growing. Left untreated, the cancer cells may eventually become invasive cancer, invading surrounding tissue, blood vessels or lymph channels.

Complications:

Increased risk of breast cancer
If you've been diagnosed with atypical hyperplasia, you have an increased risk of breast cancer in the future. Women with atypical hyperplasia have a risk of breast cancer that is about four times higher than that of women who don't have atypical hyperplasia.

Being diagnosed with atypical hyperplasia at a younger age may increase the risk of breast cancer even more. Women diagnosed with atypical hyperplasia before age 45 have a greater risk of developing invasive breast cancer during their lifetimes, compared with older women, especially those older than 55.

Treatments and drugs:

Atypical hyperplasia is generally treated with surgery to remove the abnormal cells and to make sure no in situ or invasive cancer also is present in the area. Doctors often recommend more frequent screening for breast cancer and strategies to reduce your breast cancer risk.

Follow-up tests to monitor for breast cancer
Your doctor may recommend you undergo follow-up tests to screen for breast cancer. This may increase the chance that breast cancer is detected early, when a cure is more likely. Talk about your breast cancer screening options with your doctor. Your options may include:

• Self-exams of your breasts to develop breast familiarity and to detect any unusual breast changes
• Clinical breast exams by your health care provider once or twice a year
• Screening mammograms every year
• Screening breast magnetic resonance imaging (MRI), depending on other risk factors, such as a strong family history or a genetic predisposition to breast cancer

Ways to reduce your risk of breast cancer
To reduce your risk of developing breast cancer, your doctor may recommend that you:

• Take preventive medications. Treatment with a selective estrogen receptor modulator (SERM), such as tamoxifen or raloxifene (Evista), for five years may reduce the risk of breast cancer. These drugs work by blocking estrogen from binding to estrogen receptors in breast tissue. Estrogen is thought to fuel the growth of some breast cancers. Another option for certain women may be exemestane (Aromasin), which decreases production of estrogen in the body.
  
• Avoid menopausal hormone therapy. Researchers have concluded that combination hormone therapy to treat symptoms of menopause — estrogen plus progestin — increases breast cancer risk in postmenopausal women. Many breast cancers depend on hormones for growth.
  
• Participate in a clinical trial. Clinical trials test new treatments not yet available to the public at large that may prove helpful in reducing breast cancer risk associated with atypical hyperplasia. Ask your doctor if you're a candidate for any clinical trials.
  
• Consider risk-reducing (prophylactic) mastectomy. For women at very high risk of breast cancer, risk-reducing mastectomy — surgery to remove one or both breasts — reduces the risk of developing breast cancer in the future. You might be considered at very high risk of breast cancer if you have a genetic mutation in one of the breast cancer genes or you have a very strong family history of breast cancer that suggests a likelihood of having such a genetic mutation.

But this surgery isn't right for everyone. Discuss with your doctor the risks, benefits and limitations of this risk-reducing surgery in light of your personal circumstances. If you have a strong family history of breast cancer, you might benefit from also meeting with a genetic counselor to evaluate your risk of carrying a genetic mutation and the role of genetic testing in your situation.

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Atypical depression

Atypical depression

Definition  :

Any type of depression can make you feel sad and keep you from enjoying life. However, if you have atypical depression, certain key signs and symptoms tend to occur. These include increased hunger, weight gain, sleeping a lot, feeling that your arms and legs are heavy, and difficulty maintaining relationships.

Atypical depression often starts in the teenage years and is more common in women than in men. Despite the name, atypical depression isn't uncommon or unusual. Similar to other forms of depression, treatment for atypical depression includes medications, psychological counseling (psychotherapy) and lifestyle changes.


Symptoms:

Depression of any kind can cause feelings of sadness and a decreased ability to enjoy life. But atypical depression includes these main signs and symptoms:

• Depression that temporarily lifts when you're cheered up by good news or positive events but returns later
• Increased appetite with unintentional weight gain
• Increased desire to sleep, usually more than 10 hours a day
• Heavy, leaden feeling in your arms and legs that lasts an hour or more in a day
• Trouble maintaining long-lasting relationships because of sensitivity to rejection or criticism, which affects your relationships, social life or job

When to see a doctor
If you feel depressed, make an appointment to see your doctor as soon as you can. Depression may get worse if it isn't treated. Untreated depression can lead to other mental and physical health problems or problems in other areas of your life. Feelings of depression can also lead to suicide.
If you're reluctant to seek treatment, talk to a friend or loved one, a health care professional, a faith leader, or someone else you trust.

If you have suicidal thoughts
If you or someone you know is having suicidal thoughts, get help right away. Here are some steps you can take:

• Reach out to a close friend or loved one.
• Contact a minister, a spiritual leader or someone in your faith community.
• Call a suicide hotline number — in the United States, call the National Suicide Prevention Lifeline at 800-273-TALK (800-273-8255) to reach a trained counselor. Use that same number and press 1 to reach the Veterans Crisis Line.
• Make an appointment with your doctor, mental health provider or other health care provider.

When to get emergency help
If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately.
If you have a loved one who is in danger of committing suicide or has made a suicide attempt, make sure someone stays with that person. Call 911 or your local emergency number immediately. Or, if you think you can do so safely, take the person to the nearest hospital emergency room.

Causes:

It's not known exactly what causes atypical depression. As with other types of depression, a combination of factors may be involved. These include:

• Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. When these chemicals are out of balance, it may lead to depression symptoms.
  
• Inherited traits. Depression is more common in people whose biological (blood) relatives also have the condition.
  
• Life events. Events such as the death or loss of a loved one, financial problems, and high stress can trigger depression in some people.
  
• Early childhood trauma. Traumatic events during childhood, such as abuse or loss of a parent, may cause changes in the brain that make you more susceptible to depression.

Complications:

Like other types of depression, atypical depression is a serious illness that can cause major problems. Atypical depression can result in emotional, behavioral and health problems that affect every area of your life. Complications associated with atypical depression may include:

• Excess weight or obesity, which can lead to heart disease and diabetes
• Alcohol or drug abuse
• Anxiety and panic disorder or social phobia
• Family conflicts, relationship difficulties, and work or school problems
• Social isolation
• Suicidal feelings or suicide

Treatments and drugs:

Treatment for atypical depression is generally the same as for other types of depression. In some cases, a primary care doctor can prescribe medications to relieve symptoms. However, many people with atypical depression need to see a psychiatrist. Most people also benefit from seeing a psychologist or other mental health counselor. Usually the most effective treatment is a combination of medication and psychotherapy.

Atypical depression most often occurs as part of mild, long-lasting depression. However, it can cause more severe symptoms in some people, such as feeling suicidal or not being able to do basic day-to-day activities.
Here's a closer look at your treatment options.

Medications
Many types of medications are available to treat depression. They include:

• Selective serotonin reuptake inhibitors (SSRIs). Doctors often start treatment by prescribing an SSRI. These medications are safer and generally cause fewer side effects than do other types of antidepressants. SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro). The most common side effects include decreased sexual desire and delayed orgasm. Other side effects may go away as your body adjusts to the medication. They can include digestive problems, jitteriness, restlessness, headache and insomnia.
  
• Serotonin and norepinephrine reuptake inhibitors (SNRIs). These medications include duloxetine (Cymbalta), venlafaxine (Effexor XR) and desvenlafaxine (Pristiq). Side effects are similar to those caused by SSRIs. These medications can cause increased sweating, dry mouth, fast heart rate and constipation.
  
• Norepinephrine and dopamine reuptake inhibitors (NDRIs). Bupropion (Wellbutrin) falls into this category. It's one of the few antidepressants that doesn't cause sexual side effects, and it usually doesn't cause weight gain. At high doses, bupropion may increase your risk of having seizures.
  
• Atypical antidepressants. These medications don't fit neatly into another antidepressant category. They include trazodone and mirtazapine (Remeron). Both are sedating and usually taken in the evening. A newer medication called vilazodone (Viibryd) has a low risk of sexual side effects. The most common side effects of vilazodone are diarrhea, nausea, vomiting and insomnia.
  
• Tricyclic antidepressants. Tricyclic antidepressants — such as imipramine (Tofranil) and nortriptyline (Pamelor) — tend to cause more severe side effects than newer antidepressants. So tricyclics generally aren't prescribed unless you've tried an SSRI first without improvement. Side effects may include low blood pressure, dry mouth, blurred vision, constipation, urinary retention, fast heartbeat, confusion or weight gain, among others.
  
• Monoamine oxidase inhibitors (MAOIs). MAOIs — such as tranylcypromine (Parnate) and phenelzine (Nardil) — may be prescribed as a last resort, when other medications haven't worked, because they can have serious side effects. Use of MAOIs requires a strict diet because of dangerous (or even deadly) interactions with foods — such as certain cheeses, pickles and wines — and some medications including birth control pills, decongestants and certain herbal supplements. Selegiline (Emsam), a newer MAOI that you stick on your skin as a patch, may cause fewer side effects than other MAOIs. These medications can't be combined with SSRIs.
  
• Other medications. Other medications may be added to an antidepressant to enhance antidepressant effects. Your doctor may recommend combining two antidepressants or medications, such as mood stabilizers or antipsychotics. Anti-anxiety and stimulant medications might also be added for short-term use. In addition, the FDA approved a medical food — a prescription that provides dietary management for a disease or condition — called Deplin, which contains L-methylfolate, a form of the vitamin folate. Studies have shown that adding Deplin to an antidepressant can be helpful, especially in women and those who can't process (metabolize) folate — a condition identified through a genetic test.

Finding the right medication
If a family member has responded well to an antidepressant, it may be one that could help you. You may need to try several medications before you find one that works. This requires patience, as some medications need eight weeks or longer to take full effect and for side effects to ease as your body adjusts.

If you're bothered by side effects, don't stop taking an antidepressant without talking to your doctor first. Some antidepressants can cause withdrawal symptoms unless you slowly taper off, and quitting abruptly may cause a sudden worsening of depression. Don't give up until you find a medication that's suitable for you.

If antidepressant treatment doesn't seem to be working, your doctor may recommend a blood test called the cytochrome P450 (CYP450) to check for specific genes that affect how your body processes antidepressants. This may help identify which antidepressant might be a good choice for you, although these genetic tests may not be widely available and they have limitations.

Antidepressants and pregnancy
If you're pregnant or breast-feeding, some antidepressants may pose an increased health risk to your unborn child or nursing child. Talk to your doctor if you become pregnant or are planning to become pregnant.

Antidepressants and increased suicide risk
Most antidepressants are generally safe, but the Food and Drug Administration (FDA) requires that all antidepressants carry "black box" warnings, the strictest warnings for prescriptions. In some cases, children, teenagers and young adults under 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. So these age groups need close monitoring by loved ones, caregivers and health care providers. If you — or someone you know — have suicidal thoughts when taking an antidepressant, immediately contact your doctor or get emergency help.

Psychotherapy
Psychotherapy is a general term for treating depression by talking about your condition and related issues with a mental health provider. Psychotherapy is also known as talk therapy, counseling or psychosocial therapy.

Through these talk sessions, you can learn how to identify and make changes in unhealthy behavior or thoughts, explore relationships and experiences, find better ways to cope and solve problems, and set realistic goals for your life. Psychotherapy can help you regain a sense of satisfaction and control in your life and help ease depression symptoms such as hopelessness and anger.

Hospitalization and residential treatment programs
In some people, depression is so severe that a hospital stay is needed. Inpatient hospitalization may be necessary if you can't care for yourself properly or when you're in immediate danger of harming yourself or someone else. Psychiatric treatment at a hospital can help keep you calm and safe until your mood improves. Partial hospitalization or day treatment programs also are helpful for some people. These programs provide the support and counseling you need while you get symptoms under control.

Other treatments
Other options include:

• Electroconvulsive therapy (ECT). In ECT, electrical currents are passed through the brain. This procedure is thought to affect levels of neurotransmitters in your brain and typically offers immediate relief of even severe depression when other treatments don't work. The most common side effect is confusion, which can last from a few minutes to several hours. Some people also have memory loss, which is usually temporary. ECT is usually used for people who don't get better with medications, can't take antidepressants for health reasons or are at high risk of suicide.
  
• Transcranial magnetic stimulation (TMS). TMS may be an option for those who haven't responded to antidepressants. During TMS, you sit in a reclining chair with a treatment coil placed against your scalp. The coil sends brief magnetic pulses to stimulate nerve cells in your brain that are involved in mood regulation and depression. Typically, you'll have five treatments each week for up to six weeks.
  
• Vagus nerve stimulation. This treatment uses electrical impulses with a surgically implanted pulse generator to affect mood centers of the brain. This may be an option if you have long-term, treatment-resistant depression.

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Atrioventricular canal defect

Atrioventricular canal defect

Definition  :

Atrioventricular canal defect is a combination of several abnormalities in the heart present at birth (congenital abnormalities). This defect, which is sometimes called endocardial cushion defect or atrioventricular septal defect, occurs when there's a hole between the chambers of the heart and problems with the valves that regulate blood flow in the heart.

Atrioventricular canal defect allows extra blood to circulate to the lungs. Ensuing problems overwork the heart and cause it to enlarge.

Atrioventricular canal defect is often associated with Down syndrome. If left untreated, atrioventricular canal defect may cause heart failure and high blood pressure in the lungs. To fix this defect, doctors often recommend surgery during the first year of life to close the hole and reconstruct the valves.

Symptoms:
There are two common types of atrioventricular canal defect — partial and complete. The partial form involves only the two upper chambers of the heart. The complete form allows blood to travel freely among all four chambers of the heart. In either type, extra blood circulates in the lungs.

Complete atrioventricular canal defect
Signs and symptoms of complete atrioventricular canal defect usually develop in the first several weeks of life. They include:

• Difficulty breathing (dyspnea)
• Lack of appetite
• Poor weight gain
• Bluish discoloration of the lips and skin (cyanosis)

If your baby has complete atrioventricular canal defect, he or she may also develop signs and symptoms of heart failure, including:

• Fatigue
• Wheezing
• Swelling (edema) in the legs, ankles and feet
• Sudden weight gain from fluid retention
• Excessive sweating
• Decreased alertness
• Irregular or rapid heartbeat

Partial atrioventricular canal defect
Signs and symptoms of a partial atrioventricular canal defect may not appear until early adulthood. When they do become noticeable, signs and symptoms may be related to complications that develop as a result of the defect, and may include:

• Abnormal heartbeat (arrhythmia)
• Heart valve problems
• Heart failure
• High blood pressure in the lungs (pulmonary hypertension)

When to see a doctor
Contact your doctor if you or your child develops any of the following signs or symptoms. These could be indications of heart failure or another complication of atrioventricular canal defect:

• Poor appetite
• Failure to gain weight, in infants and children
• Shortness of breath
• Easily tiring
• Swelling of the legs, ankles or feet
• Bluish discoloration of the skin

Some babies with the partial form of atrioventricular canal defect may not have any signs or symptoms for weeks, months or even years, depending on the severity of the defect. But, anytime the signs or symptoms above start to appear, seek medical care.


Causes:


Atrioventricular canal defect occurs during fetal growth when your baby's heart is developing. While some factors, such as Down syndrome, may increase the risk of atrioventricular canal defect, in most cases the cause is unknown.

The normal-functioning heart
Your heart is divided into four chambers, two on the right and two on the left. In performing its basic job — pumping blood throughout your body — your heart uses its left and right sides for different tasks. The right side moves blood into vessels that lead to your lungs. In your lungs, oxygen enriches your blood, which circulates to your heart's left side. The left side of your heart pumps blood into a large vessel called the aorta, which circulates blood to the rest of your body. Valves control the flow of blood into and out of the chambers of your heart. These valves open to allow blood to move to the next chamber or to one of the arteries, and they close to keep blood from flowing backward.

What happens in atrioventricular canal defect
In partial atrioventricular canal defect, a hole exists in the wall (septum) that separates the upper chambers (atria) of the heart. Also, the mitral valve between the upper and lower left chambers often has a defect called a cleft that causes it to leak (mitral valve regurgitation).

In complete atrioventricular canal defect, there's a large hole in the center of the heart where the walls between the upper chambers (atria) and lower chambers (ventricles) meet. Instead of two separate valves — one on the right (tricuspid) and one on the left (mitral) — one large common valve exists between the upper and lower chambers. And, this valve may not close tightly.

Oxygen-rich and oxygen-poor blood mix through the hole in the septum, and the abnormal valves leak blood into the heart's lower chambers (ventricles). These problems make the heart work harder, causing it to enlarge.

Complications:

Treating an atrioventricular canal defect helps your child avoid potential complications, such as:

• Enlargement of the heart. Increased blood flow through the heart forces it to work harder than normal, causing it to enlarge.
  
• Heart failure. Untreated, atrioventricular canal defect will usually result in heart failure — a condition in which the heart is unable to pump enough blood to meet the body's needs.
  
• High blood pressure in the lungs (pulmonary hypertension). When the heart's left ventricle weakens and can't pump out enough blood, the increase in pressure backs up through the pulmonary veins to the arteries in the lungs, causing high blood pressure in the lungs.
  
• Pneumonia. If your baby has an untreated atrioventricular canal defect, he or she may have recurrent bouts of pneumonia — a serious lung infection.

Complications later in life
Although treatment greatly improves the outlook for children with atrioventricular canal defect, some who have corrective surgery may still be at risk of the following associated conditions later in life:

• Leaky heart valves (regurgitation)
• Narrowing of the heart valves (stenosis)
• Heart rhythm abnormalities (arrhythmias)
• Breathing difficulties associated with damage to the lungs (pulmonary vascular disease)

Common signs and symptoms of these complications include shortness of breath, fatigue and a rapid, fluttering heartbeat, among others. In some cases, such as a leaky heart valve, a second surgery may be needed.


Treatments and drugs:


Surgery is necessary to fix both complete and partial atrioventricular canal defects. During the procedure, the hole in the septum is closed using one or two patches. The patches remain in the heart permanently, becoming part of the septum as the heart's lining grows over it. The surgeon also
separates the one large heart valve between the upper and lower chambers into two separate valves.

For a partial atrioventricular canal defect, the surgery also involves repair of the mitral valve so it will close tightly. If repair isn't possible, the valve may need to be replaced instead.

If your baby has complete atrioventricular canal defect, the surgery also includes separation of the single valve into two valves, one on the left side and one on the right side of the repaired septum. If reconstruction of the single valve into two valves isn't possible, heart valve replacement may be necessary.

After surgery
If the atrioventricular canal defect has been successfully repaired with surgery, your child will likely lead a normal life, often with no activity restrictions.

However, your child will need lifelong follow-up care with a heart doctor (cardiologist) who specializes in congenital heart disease. The recommendation for follow-up is usually once a year, unless you have lingering problems, such as a leaky heart valve. In that case, follow-up will be more frequent.

Your child may also need to take preventive antibiotics before certain dental procedures and other surgical procedures if he or she is at risk of severe complications of endocarditis, a bacterial infection of the lining of the heart. Typically, this is when your child has some remaining defects after surgery, has received an artificial valve or has had repair with artificial (prosthetic) material.

Many people who have corrective surgery for atrioventricular canal defect don't need additional surgery. However, some complications, such as heart valve leaks, may require treatment.

Pregnancy
When an atrioventricular canal defect has been surgically corrected before any permanent lung damage has occurred, women can generally expect to have normal pregnancies. Pregnancy is not recommended, however, if serious heart or lung damage occurred before surgery. An evaluation by a cardiologist is advised before women with repaired or unrepaired atrioventricular canal defect attempt pregnancy.

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Atrial septal defect (ASD)

Atrial septal defect (ASD)

Definition  :

An atrial septal defect (ASD) is a hole in the wall between the two upper chambers of your heart. The condition is present from birth (congenital). Smaller atrial septal defects may close on their own during infancy or early childhood.

Large and long-standing atrial septal defects can damage your heart and lungs. An adult who has had an undetected atrial septal defect for decades may have a shortened life span from heart failure or high blood pressure in the lungs. Surgery is often necessary to repair atrial septal defects to prevent complications.

Symptoms:

Many babies born with atrial septal defects don't have associated signs or symptoms. In adults, signs or symptoms usually begin by age 30, but in some cases signs and symptoms may not occur until decades later.

Atrial septal defect symptoms may include:

• Heart murmur, a whooshing sound that can be heard through a stethoscope
• Shortness of breath, especially when exercising
• Fatigue
• Swelling of legs, feet or abdomen
• Heart palpitations or skipped beats
• Frequent lung infections
• Stroke
• Bluish skin color

When to see a doctor
Contact your doctor if you or your child has any of these signs or symptoms:

• Bluish discoloration of the skin
• Shortness of breath
• Tires easily, especially after activity
• Swelling of legs, feet or abdomen
• Heart palpitations or skipped beats

These could be symptoms of heart failure or another complication of congenital heart disease.

Causes:

Doctors know that heart defects present at birth (congenital) arise from errors early in the heart's development, but there's often no clear cause. Genetics and environmental factors may play a role.
An atrial septal defect allows freshly oxygenated blood to flow from the left upper chamber of the heart (left atrium) into the right upper chamber of the heart (right atrium).

There, it mixes with deoxygenated blood and is pumped to the lungs, even though it's already refreshed with oxygen. If the atrial septal defect is large, this extra blood volume can overfill the lungs and overwork the heart. If not treated, the right side of the heart eventually enlarges and weakens. In some cases, the blood pressure in your lungs increases as well, leading to pulmonary hypertension.

Complications:

A small atrial septal defect may never cause any problems. Small atrial septal defects often close during infancy.

Larger defects can cause mild to life-threatening problems, including:

• Right-sided heart failure
• Heart rhythm abnormalities
• Shortened life expectancy
• Increased risk of a stroke

Less common serious complications may include:

• Pulmonary hypertension. If a large atrial septal defect goes untreated, increased blood flow to your lungs increases the blood pressure in the lung arteries (pulmonary hypertension).
  
• Eisenmenger syndrome. In rare cases, pulmonary hypertension can cause permanent lung damage, and it becomes irreversible. This complication, called Eisenmenger syndrome, usually develops over many years and occurs only in a small percentage of people with large atrial septal defects.

Treatment can prevent or help manage many of these complications.

Atrial septal defect and pregnancy
Most women with an atrial septal defect can tolerate pregnancy without any problems. However, having a larger defect or having complications such as heart failure, arrhythmias or pulmonary hypertension can increase your risk of complications during pregnancy. Doctors strongly advise women with Eisenmenger syndrome not to become pregnant because it can endanger the woman's life.

The risk of congenital heart disease is higher for children of parents with congenital heart disease, whether in the father or the mother. Anyone with a congenital heart defect, repaired or not, who is considering starting a family should carefully discuss it beforehand with a doctor. Some medications may need to be stopped or adjusted before you become pregnant because they can cause serious problems for a developing fetus.


Treatments and drugs:


If your child has an atrial septal defect, your doctor may recommend monitoring it for a period of time to see if it closes on its own, while treating any symptoms with medications. Many atrial septal defects close on their own during childhood. For those that don't close, some small atrial septal defects don't cause any problems and may not require any treatment. But many persistent atrial septal defects eventually require surgery to be corrected.

If your child needs treatment, the timing of it depends on your child's condition and whether your child has any other congenital heart defects.

Medications
Medications won't repair the hole, but they may be used to reduce some of the signs and symptoms that can accompany an atrial septal defect. Drugs may also be used to reduce the risk of complications after surgery. Medications may include those to:

• Keep the heartbeat regular. Examples include beta blockers (Lopressor, Inderal) and digoxin (Lanoxin).
  
• Reduce the risk of blood clots. Anticoagulants, often called blood thinners, can help reduce the chances of developing a blood clot and having a stroke. Anticoagulants include warfarin (Coumadin) and anti-platelet agents, such as aspirin.

Surgery
Many doctors recommend repairing an atrial septal defect diagnosed during childhood to prevent complications as an adult. For adults and children, surgery involves plugging or patching the abnormal opening between the atria. Doctors can do this through two methods:

• Cardiac catheterization. A thin tube (catheter) is inserted into a blood vessel in the groin and guided to the heart. Through the catheter, a mesh patch or plug is put into place to close the hole. The heart tissue grows around the mesh, permanently sealing the hole.
  
• Open-heart surgery. This type of surgery is done under general anesthesia and requires the use of a heart-lung machine. Through an incision in the chest, surgeons use patches or stitches to close the hole.

Medical monitoring
Follow-up care depends on the type of defect and whether other defects are present. For simple atrial septal defects closed during childhood, only occasional follow-up care is needed. For adults, follow-up care may depend on any resulting complications.

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Atrial fibrillation

Atrial fibrillation

Definition  :

Atrial fibrillation is an irregular and often rapid heart rate that commonly causes poor blood flow to the body. During atrial fibrillation, the heart's two upper chambers (the atria) beat chaotically and irregularly — out of coordination with the two lower chambers (the ventricles) of the heart. Atrial fibrillation symptoms include heart palpitations, shortness of breath and weakness.

Episodes of atrial fibrillation can come and go, or you may have chronic atrial fibrillation. Although atrial fibrillation itself usually isn't life-threatening, it is a serious medical condition that sometimes requires emergency treatment. It can lead to complications. Treatments for atrial fibrillation may include medications and other interventions to try to alter the heart's electrical system.

Symptoms:

A heart in atrial fibrillation doesn't beat efficiently. It may not be able to pump enough blood out to your body with each heartbeat.
Some people with atrial fibrillation have no symptoms and are unaware of their condition until it's discovered during a physical examination. Those who do have atrial fibrillation symptoms may experience:

• Palpitations, which are sensations of a racing, uncomfortable, irregular heartbeat or a flopping in your chest
• Decreased blood pressure
• Weakness
• Lightheadedness
• Confusion
• Shortness of breath
• Chest pain

• Occasional. In this case it's called paroxysmal (par-ok-SIZ-mul) atrial fibrillation. You may have symptoms that come and go, lasting for a few minutes to hours and then stopping on their own.
• Chronic. With chronic atrial fibrillation, your heart rhythm is always abnormal.

When to see a doctor
If you have any symptoms of atrial fibrillation, make an appointment with your doctor. Your doctor should be able to tell you if your symptoms are caused by atrial fibrillation or another heart arrhythmia.
If you have chest pain, seek emergency medical assistance immediately. Chest pain could signal that you're having a heart attack.

Causes:

Your heart consists of four chambers — two upper chambers (atria) and two lower chambers (ventricles). Within the upper right chamber of your heart (right atrium) is a group of cells called the sinus node. This is your heart's natural pacemaker. The sinus node produces the impulse that starts each heartbeat.

Normally, the impulse travels first through the atria and then through a connecting pathway between the upper and lower chambers of your heart called the atrioventricular (AV) node. As the signal passes through the atria, they contract, pumping blood from your atria into the ventricles below. As the signal passes through the AV node to the ventricles, the ventricles contract, pumping blood out to your body.
In atrial fibrillation, the upper chambers of your heart (atria) experience chaotic electrical signals. As a result, they quiver.

The AV node — the electrical connection between the atria and the ventricles — is overloaded with impulses trying to get through to the ventricles. The ventricles also beat rapidly, but not as rapidly as the atria. The reason is that the AV node is like a highway on-ramp — only so many cars can get on at one time.

The result is a fast and irregular heart rhythm. The heart rate in atrial fibrillation may range from 100 to 175 beats a minute. The normal range for a heart rate is 60 to 100 beats a minute.

Possible causes of atrial fibrillation
Abnormalities or damage to the heart's structure are the most common cause of atrial fibrillation. Possible causes of atrial fibrillation include:

• High blood pressure
• Heart attacks
• Abnormal heart valves
• Heart defects you're born with (congenital)
• An overactive thyroid gland or other metabolic imbalance
• Exposure to stimulants such as medications, caffeine or tobacco, or to alcohol
• Sick sinus syndrome — improper functioning of the heart's natural pacemaker
• Emphysema or other lung diseases
• Previous heart surgery
• Viral infections
• Stress due to pneumonia, surgery or other illnesses
• Sleep apnea

However, some people who have atrial fibrillation don't have any heart defects or damage, a condition called lone atrial fibrillation. In lone atrial fibrillation, the cause is often unclear, and serious complications are rare.

Atrial flutter
Atrial flutter is similar to atrial fibrillation, but the rhythm in your atria is more organized and less chaotic than the abnormal patterns common with atrial fibrillation. Sometimes you may have atrial flutter that develops into atrial fibrillation and vice versa. The symptoms, causes and risk factors of atrial flutter are similar to those of atrial fibrillation. For example, strokes are a concern in someone with atrial flutter. As with atrial fibrillation, atrial flutter is usually not life-threatening when it's properly treated.

Complications:

Sometimes atrial fibrillation can lead to the following complications:

• Stroke. In atrial fibrillation, the chaotic rhythm may cause blood to pool in your heart's upper chambers (atria) and form clots. If a blood clot forms, it could dislodge from your heart and travel to your brain. There it might block blood flow, causing a stroke.
  
  The risk of stroke in atrial fibrillation depends on your age (you have a higher risk as you age) and on whether you have high blood pressure, diabetes, or a history of heart failure or previous stroke, and other factors. Medications such as blood thinners can greatly lower your risk of stroke or damage to other organs caused by blood clots.
  
  
• Heart failure. Atrial fibrillation, especially if not controlled, may weaken the heart, leading to heart failure — a condition in which your heart can't circulate enough blood to meet your body's needs.

Treatments and drugs:

In some people, a specific event or an underlying condition, such as a thyroid disorder, may trigger atrial fibrillation. If the condition that triggered your atrial fibrillation can be treated, you might not have any more heart rhythm problems — or at least not for quite some time. If your symptoms are bothersome or if this is your first episode of atrial fibrillation, your doctor may attempt to reset the rhythm.

The treatment option best for you will depend on how long you've had atrial fibrillation, how bothersome your symptoms are and the underlying cause of your atrial fibrillation. Generally, the goals of treating atrial fibrillation are to:

• Reset the rhythm or control the rate
• Prevent blood clots

The strategy you and your doctor choose depends on many factors, including whether you have other problems with your heart and if you're able to take medications that can control your heart rhythm. In some cases, you may need a more invasive treatment, such as surgery or medical procedures using catheters.

Resetting your heart's rhythm
Ideally, to treat atrial fibrillation, the heart rate and rhythm are reset to normal. To correct your condition, doctors may be able to reset your heart to its regular rhythm (sinus rhythm) using a procedure called cardioversion, depending on the underlying cause of atrial fibrillation and how long you've had it. Cardioversion can be done in two ways:

• Cardioversion with drugs. This form of cardioversion uses medications called anti-arrhythmics to help restore normal sinus rhythm. Depending on your heart condition, your doctor may recommend trying intravenous or oral medications to return your heart to normal rhythm. This is often done in the hospital with continuous monitoring of your heart rate. If your heart rhythm returns to normal, your doctor often will prescribe the same anti-arrhythmic or a similar one to try to prevent more spells of atrial fibrillation.
  
• Electrical cardioversion. In this brief procedure, an electrical shock is delivered to your heart through paddles or patches placed on your chest. The shock stops your heart's electrical activity momentarily. When your heart begins again, the hope is that it resumes its normal rhythm. The procedure is performed with sedation, so you shouldn't feel the electric shock.

Before cardioversion, you may be given a blood-thinning medication, such as warfarin (Coumadin), for several weeks to reduce the risk of blood clots and stroke. Unless the episode of atrial fibrillation lasted less than 24 hours, you'll need to take warfarin for at least four to six weeks after cardioversion to prevent a blood clot from forming even after your heart is back in normal rhythm. Warfarin is a powerful medication that can have dangerous side effects if not taken exactly as directed by your doctor. If you have any concerns about taking warfarin, talk to your doctor.

Or, instead of taking warfarin, you may have a test called transesophageal echocardiography — which can tell your doctor if you have any heart blood clots — just before cardioversion. In transesophageal echocardiography, a tube is passed down your esophagus and detailed ultrasound images are made of your heart. You'll be sedated during the test.

Maintaining a normal heart rhythm
After electrical cardioversion, anti-arrhythmic medications often are prescribed to help prevent future episodes of atrial fibrillation. Commonly used medications include:

• Amiodarone (Cordarone, Pacerone)
• Dronedarone (Maltaq)
• Propafenone (Rythmol)
• Sotalol (Betapace)
• Dofetilide (Tikosyn)
• Flecainide (Tambocor)

Although these drugs can help maintain a normal heart rhythm in many people, they can cause side effects, including:

• Nausea
• Dizziness
• Fatigue

Rarely, they may cause ventricular arrhythmias — life-threatening rhythm disturbances originating in the heart's lower chambers. These medications may be needed indefinitely. Even with medications, the chance of another episode of atrial fibrillation is high.

Heart rate control
Sometimes atrial fibrillation can't be converted to a normal heart rhythm. Then the goal is to slow the heart rate to between 60 and 100 beats a minute (rate control). Heart rate control can be achieved two ways:

• Medications. Doctors have prescribed the medication digoxin (Lanoxin). It can control heart rate at rest, but not as well during activity. Most people require additional or alternative medications, such as calcium channel blockers or beta blockers. Other blood pressure lowering medications, such as angiotensin-converting enzyme (ACE) inhibitors, also are sometimes used to lower blood pressure and reduce the risk of atrial fibrillation complications.
  
• Atrioventricular (AV) node ablation. If medications don't work, or you have side effects, AV node ablation may be another option. The procedure involves applying radiofrequency energy to the pathway connecting the upper and lower chambers of your heart (AV node) through a long, thin tube (catheter) to destroy this small area of tissue.
  
  The procedure prevents the atria from sending electrical impulses to the ventricles. The atria continue to fibrillate, though, and anticoagulant medication is still required. A pacemaker is then implanted to establish a normal rhythm. After AV node ablation, you'll need to continue to take blood-thinning medications to reduce the risk of stroke, because your heart rhythm is still atrial fibrillation.
  

Other surgical and catheter procedures
Sometimes medications or cardioversion to control atrial fibrillation doesn't work. In those cases, your doctor may recommend a procedure to destroy the area of heart tissue that's causing the erratic electrical signals and restore your heart to a normal rhythm. These options can include:

• Radiofrequency catheter ablation. In many people who have atrial fibrillation and an otherwise normal heart, atrial fibrillation is caused by rapidly discharging triggers, or "hot spots." These hot spots are like abnormal pacemaker cells that fire so rapidly that the upper chambers of your heart quiver instead of beating efficiently.
  
  Radiofrequency energy is directed to these hot spots through a catheter inserted in an artery near your groin and threaded up to your heart. This catheter is used to destroy these hot spots, scarring the tissue so the erratic electrical signals are normalized. This corrects the arrhythmia without the need for medications or implantable devices. In some cases, other types of catheters that can freeze the heart tissue (cryotherapy) are used.
  
  
• Surgical maze procedure. The maze procedure is done during an open-heart surgery. Using a scalpel, doctors create several precise incisions in the upper chambers of your heart to create a pattern of scar tissue. Because scar tissue doesn't carry electricity, it interferes with stray electrical impulses that cause atrial fibrillation. Radiofrequency or cryotherapy also can be used to create the scars, and there are several variations of the surgical maze technique.
  
  The procedure has a high success rate, but because it usually requires open-heart surgery, it's generally reserved for people who don't respond to other treatments or when it can be done during other necessary heart surgery, such as coronary artery bypass surgery or heart valve repair. Some people need a pacemaker implanted after the procedure.

Preventing blood clots
Most people who have atrial fibrillation or who are undergoing certain treatments for atrial fibrillation are at especially high risk of blood clots that can lead to stroke. The risk is even higher if other heart disease is present along with atrial fibrillation. Your doctor may prescribe blood-thinning medications (anticoagulants) such as:

• Warfarin (Coumadin). If you're prescribed warfarin, carefully follow your doctor's instructions on taking it. Warfarin is a powerful medication that can have dangerous side effects. You'll need to have regular blood tests to monitor warfarin's effects.
  
• Dabigatran (Pradaxa). Another option for preventing blood clots is dabigatran. Dabigatran is as effective as warfarin at preventing blood clots that can lead to strokes, and doesn't require blood tests to make sure you're getting the proper dose. Talk to your doctor about taking dabigatran as an alternative to warfarin if you're concerned about your risk of stroke.
  
• Rivaroxaban (Xarelto). Rivaroxaban is another anticoagulant medication that's as effective as warfarin for preventing strokes. Rivaroxaban is a once-daily medication. Like any other anticoagulant, follow your doctor's dosing instructions carefully and don't stop taking rivaroxaban without talking to your doctor first.

You may need to take medications to prevent blood clots in addition to medications designed to treat your irregular heartbeat. Many people have spells of atrial fibrillation and don't even know it — so you may need lifelong anticoagulants even after your rhythm has been restored to normal.

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Atopic dermatitis (eczema)

Atopic dermatitis (eczema)

Definition  :

Atopic dermatitis (eczema) is an itchy inflammation of your skin. It's a long-lasting (chronic) condition that may be accompanied by asthma or hay fever.

Eczema may affect any area of your skin, but it typically appears on your arms and behind your knees. It tends to flare periodically and then subside. The cause of atopic dermatitis is unknown, but it may result from a combination of inherited tendencies for sensitive skin and malfunction in the body's immune system.

Self-care measures, such as avoiding soaps or other irritants and applying creams or ointments, can help relieve itching. See your doctor if your symptoms distract you from your daily routines or prevent you from sleeping.

Symptoms:


Signs and symptoms of atopic dermatitis (eczema) include:

• Red to brownish-gray colored patches
• Itching, which may be severe, especially at night
• Small, raised bumps, which may leak fluid and crust over when scratched
• Thickened, cracked or scaly skin
• Raw, sensitive skin from scratching

Though the patches can occur anywhere, they most often appear on the hands and feet, in the front of the bend of the elbow, behind the knees, and on the ankles, wrists, face, neck and upper chest. Atopic dermatitis can also affect the skin around the eyes, including your eyelids. Scratching can cause redness and swelling around the eyes.

Atopic dermatitis most often begins in childhood before age 5 and may persist into adulthood. For some, it flares periodically and then subsides for a time, even up to several years. Itching may be severe, and scratching the rash can make it even itchier and cause more inflammation. Once the skin barrier is broken, the skin can become infected by bacteria, especially Staphylococcus aureus, which commonly live on the skin. Breaking this itch-scratch cycle can be challenging.

Factors that worsen atopic dermatitis
Most people with atopic dermatitis also have Staphylococcus aureus bacteria on their skin. The staph bacteria multiply rapidly when the skin barrier is broken and fluid is present on the skin, which in turn may worsen symptoms, particularly in young children.
Other factors that can worsen signs and symptoms of atopic dermatitis include:

• Dry skin
• Long, hot baths or showers
• Stress
• Sweating
• Rapid changes in temperature
• Low humidity
• Solvents, cleaners, soaps or detergents
• Wool or man-made fabrics or clothing
• Dust or sand
• Cigarette smoke
• Living in cities where pollution is high
• Certain foods, such as eggs, milk, fish, soy or wheat

Infantile eczema
When atopic dermatitis occurs in infants, it's called infantile eczema. This condition may continue into childhood and adolescence.
Infantile eczema often involves an oozing, crusting rash, mainly on the skin of the face and scalp, but it can occur anywhere. After infancy, the rash becomes dryer and tends to be red to brown-gray in color. In adolescence, the skin may be scaly or thickened and easily irritated. The intense itching may continue.

When to see a doctor
See your doctor if:

• You're so uncomfortable that you're losing sleep or are distracted from your daily routines
• Your skin is painful
• You suspect your skin is infected
• You've tried self-care steps without success

If you suspect your child has atopic dermatitis or you notice the above signs and symptoms, see your child's doctor.
Early, effective treatment helps keep atopic dermatitis from worsening. The more severe it becomes, the more difficult it is to control.

Causes:

The exact cause of atopic dermatitis (eczema) is unknown, but it's likely due to a combination of dry, irritable skin with a malfunction in the body's immune system. Stress and other emotional disorders can worsen atopic dermatitis, but they don't cause it.

Most experts believe atopic dermatitis has a genetic basis. It has been thought to be connected to asthma and hay fever, but that theory is being questioned. Not all people with atopic dermatitis have asthma or hay fever, and not all people with asthma or hay fever develop atopic dermatitis, but these diseases do seem to be present together in families of those affected.


Complications:

Complications of atopic dermatitis (eczema) include:

• Neurodermatitis. Prolonged itching and scratching may increase the intensity of the itch, possibly leading to neurodermatitis (lichen simplex chronicus). Neurodermatitis is a condition in which an area of skin that's frequently scratched becomes thick and leathery. The patches can be raw, red or darker than the rest of your skin. Persistent scratching can also lead to permanent scars or changes in skin color.
  
• Skin infections. Sometimes, scratching can break the skin and cause open sores and fissures that can become infected, a process called impetiginization. A milder form of infection is impetigo, usually due to staphylococcal infection. Having atopic dermatitis predisposes you to this infection.
  
• Eye complications. Severe atopic dermatitis can also cause eye complications, which may lead to permanent eye damage. When these complications occur, itching in and around the eyelids becomes severe. Signs and symptoms of eye complications also include eye watering and inflammation of the eyelid (blepharitis) and the lining of the eyelid (conjunctivitis). If you suspect complications with your eyes, see your doctor promptly.

Treatments and drugs:
Treatments for atopic dermatitis (eczema) aim to reduce inflammation, relieve itching and prevent future flare-ups. Over-the-counter (nonprescription) anti-itch creams and other self-care measures may help control mild atopic dermatitis.

Although atopic dermatitis is related to allergies, eliminating allergens is rarely helpful in clearing the condition. Occasionally, items that trap dust — such as feather pillows, down comforters, mattresses, carpeting and drapes — can worsen the condition. Allergy shots usually aren't successful in treating atopic dermatitis.

Medications

• Corticosteroid creams or ointments. Your doctor may recommend prescription corticosteroid creams or ointments to ease scaling and relieve itching. Some low-potency corticosteroid creams are available without a prescription, but you should always talk to your doctor before using any topical corticosteroid. Side effects of long-term or repeated use can include skin irritation or discoloration, thinning of the skin, infections, and stretch marks on the skin.
  
• Antibiotics. You may need antibiotics if you have a bacterial skin infection or an open sore or fissure caused by scratching. Your doctor may recommend taking antibiotics for a short time to treat an infection or for longer periods of time to reduce bacteria on your skin and to prevent recurrent infections.
  
• Oral antihistamines. If itching is severe, oral antihistamines may help. Diphenhydramine (Benadryl, others) can make you sleepy and may be helpful at bedtime. If your skin cracks open, your doctor may prescribe mildly astringent wet dressings to prevent infection.
  
• Oral or injected corticosteroids. For more severe cases, your doctor may prescribe oral corticosteroids, such as prednisone, or an intramuscular injection of corticosteroids to reduce inflammation and to control symptoms. These medications are effective, but can't be used long term because of potential serious side effects, which include cataracts, loss of bone mineral (osteoporosis), muscle weakness, decreased resistance to infection, high blood pressure and thinning of the skin.
  
• Immunomodulators. A class of medications called immunomodulators, such as tacrolimus (Protopic) and pimecrolimus (Elidel), affect the immune system and may help maintain normal skin texture and reduce flares of atopic dermatitis. This prescription-only medication is approved for children older than 2 and for adults. Due to possible concerns about the effect of these medications on the immune system when used for prolonged periods, the Food and Drug Administration recommends that Elidel and Protopic be used only when other treatments have failed or if someone can't tolerate other treatments.

Light therapy (phototherapy)
As the name suggests, this treatment uses natural or artificial light. The simplest and easiest form of phototherapy involves exposing your skin to controlled amounts of natural sunlight. Other forms of light therapy include the use of artificial ultraviolet A (UVA) or ultraviolet B (UVB) light including the more recently available narrow band ultraviolet B (NBUVB) either alone or with medications.

Though effective, long-term light therapy has many harmful effects, including premature skin aging and an increased risk of skin cancer. For these reasons, it's important to consult your doctor before using light exposure as treatment for atopic dermatitis. Your doctor can advise you of possible advantages and disadvantages of light exposure in your specific situation.

Infantile eczema
Treatment for infantile eczema includes identifying and avoiding skin irritations, avoiding extreme temperatures, and lubricating your baby’s skin with bath oils, lotions, creams or ointments.
See your baby's doctor if these measures don't improve the rash or if the rash looks infected. Your baby may need a prescription medication to control his or her symptoms or to treat the infection. Your doctor may recommend an oral antihistamine to help lessen the itch and to cause drowsiness, which may be helpful for nighttime itching and discomfort.

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