Health Issues
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Health Issues Volume 1 Abortion – Hypertensi...
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Health Issues
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MAGILL’S C H O I C E
Health Issues Volume 1 Abortion – Hypertension
edited by The Editors of Salem Press project editor Tracy Irons-Georges
SALEM PRESS, INC. Pasadena, California Hackensack, New Jersey
Copyright © 2001, by Salem Press, Inc. All rights in this book are reserved. No part of this work may be used or reproduced in any manner whatsoever or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission from the copyright owner except in the case of brief quotations embodied in critical articles and reviews. For information address the publisher, Salem Press, Inc., P.O. Box 50062, Pasadena, California 91115. The essays in Magill’s Choice: Health Issues were adapted from Women’s Issues (1997), Encyclopedia of Family Life (1998), Children’s Health (1999), Encyclopedia of Environmental Issues (1999), Aging (2000), Magill’s Choice: Psychology and Mental Health (2000), and Magill’s Medical Guide, Second Revised Edition (2002). All bibliographies have been updated, and formats have been changed. ∞ The paper used in these volumes conforms to the American National Standard for Permanence of Paper for Printed Library Materials, Z39.48-1992 (R1997). Library of Congress Cataloging-in-Publication Data Health issues / edited by the editors of Salem Press ; project editor, Tracy Irons-Georges p. cm. — (Magill’s choice) Includes bibliographical references and index. ISBN 0-89356-042-1 (set). — ISBN 0-89356-048-0 (v. 1). — ISBN 0-89356-049-9 (v. 2) 1. Public health. 2. Social medicine. I. Irons-Georges, Tracy. II. Salem Press. III. Series RA425.H39 2001 362.1—dc21 200102087 First Printing
printed in the united states of america
Table of Contents Publisher’s Note . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Contributor List . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Abortion . . . . . . . . . . . . . Abortion among teenagers . . . Acupuncture . . . . . . . . . . . Addiction . . . . . . . . . . . . . Aging . . . . . . . . . . . . . . . AIDS . . . . . . . . . . . . . . . AIDS and children . . . . . . . . AIDS and women . . . . . . . . . Alcoholism . . . . . . . . . . . . Alcoholism among teenagers . . Alcoholism among the elderly . Allergies . . . . . . . . . . . . . . Alternative medicine . . . . . . . Alzheimer’s disease . . . . . . . Amniocentesis . . . . . . . . . . Anorexia nervosa . . . . . . . . . Antibiotic resistance . . . . . . . Arteriosclerosis . . . . . . . . . . Arthritis . . . . . . . . . . . . . . Asbestos . . . . . . . . . . . . . . Asthma . . . . . . . . . . . . . . Attention-deficit disorder (ADD) Autism . . . . . . . . . . . . . .
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Biofeedback . . . . . . . . . . . . Birth control and family planning Birth defects . . . . . . . . . . . . Breast cancer . . . . . . . . . . . . Breast-feeding . . . . . . . . . . . Breast surgery . . . . . . . . . . . Broken bones in the elderly . . . . Burns and scalds . . . . . . . . . .
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117 121 126 133 137 143 147 149
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Cancer . . . . . . . . . . . . . . . . . . Canes and walkers . . . . . . . . . . . Cardiac rehabilitation . . . . . . . . . Carpal tunnel syndrome . . . . . . . . Cervical, ovarian, and uterine cancers . Chemotherapy . . . . . . . . . . . . . Child abuse . . . . . . . . . . . . . . . Childbirth complications . . . . . . . . Childhood infectious diseases . . . . . Children’s health issues . . . . . . . . Chlorination . . . . . . . . . . . . . . . Choking . . . . . . . . . . . . . . . . . Cholesterol . . . . . . . . . . . . . . . Chronic fatigue syndrome . . . . . . . Circumcision of boys . . . . . . . . . . Circumcision of girls . . . . . . . . . . Cleft lip and palate . . . . . . . . . . . Colic . . . . . . . . . . . . . . . . . . . Colon cancer . . . . . . . . . . . . . . Condoms . . . . . . . . . . . . . . . . Cosmetic surgery and aging . . . . . . Cosmetic surgery and women . . . . .
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152 157 160 165 167 172 176 184 187 191 197 198 200 202 208 213 216 222 224 227 229 231
Death and dying . . . . . . . Dementia . . . . . . . . . . . Dental problems in children . Dental problems in the elderly Depression . . . . . . . . . . . Depression in children . . . . Depression in the elderly . . . Diabetes mellitus . . . . . . . Disabilities . . . . . . . . . . . Domestic violence . . . . . . . Down syndrome . . . . . . . . Drowning . . . . . . . . . . . Drug abuse by teenagers . . . Dyslexia . . . . . . . . . . . .
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234 239 244 252 256 262 265 268 274 279 287 293 295 300
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Eating disorders . . . . . . . . . . . . . . . . . . . . . . . . . . 305 Elder abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311 Electrical shock . . . . . . . . . . . . . . . . . . . . . . . . . . 316 vi
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Emphysema . . . . . . . Endometriosis . . . . . Environmental diseases Epidemics . . . . . . . . Ethics . . . . . . . . . . Euthanasia . . . . . . . Exercise . . . . . . . . . Exercise and children . Exercise and the elderly
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318 323 325 331 336 341 346 351 356
Factitious disorders . . . . . . . Failure to thrive . . . . . . . . . Falls among children . . . . . . . Falls among the elderly . . . . . Fetal alcohol syndrome . . . . . Fetal tissue transplantation . . . First aid . . . . . . . . . . . . . . Fluoridation of water sources . . Fluoride treatments in dentistry Food irradiation . . . . . . . . . Food poisoning . . . . . . . . . . Foot disorders . . . . . . . . . . Frostbite . . . . . . . . . . . . .
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364 367 368 370 372 373 376 378 381 382 385 390 395
Gene therapy . . . . . . . . . Genetic counseling . . . . . . Genetic diseases . . . . . . . Genetic engineering . . . . . Genetically engineered foods
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Hair loss and baldness . . . . . . Hazardous waste . . . . . . . . . Headaches . . . . . . . . . . . . Health insurance . . . . . . . . . Hearing aids . . . . . . . . . . . Hearing loss . . . . . . . . . . . Heart attacks . . . . . . . . . . . Heart disease . . . . . . . . . . . Heart disease and women . . . . Heat exhaustion and heat stroke Herpes . . . . . . . . . . . . . .
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414 418 421 426 432 435 439 442 447 450 452
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Hippocratic oath . . . . . . . . HMOs . . . . . . . . . . . . . . Holistic medicine . . . . . . . . Homeopathy . . . . . . . . . . Hormone replacement therapy Hospice . . . . . . . . . . . . . Hospitalization of the elderly . Hydrocephalus . . . . . . . . . Hypertension . . . . . . . . . .
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458 461 465 467 471 473 476 481 483
Publisher’s Note The maintenance of health has always been a crucial concern both for individuals and for societies. Health Issues focuses on important topics in public health such as epidemic, occupational, and environmental diseases, as well as on such social issues as ethical debates and the financial and sociological impact of particular diseases. This set offers 251 articles adapted from other Salem Press products: Women’s Issues (1997), the Encyclopedia of Family Life (1998), Children’s Health (1999), the Encyclopedia of Environmental Issues (1999), Aging (2000), Magill’s Choice: Psychology and Mental Health (2000), and Magill’s Medical Guide, Second Revised Edition (2002). All essays have been updated with the latest information and bibliographical sources. Examined here are preventive measures such as exercise, vitamin supplements, and prenatal care. The myriad ramifications of diseases such as AIDS, Alzheimer’s disease, and cancer are discussed, as well as traditional and alternative treatments, including gene therapy, biofeedback, and acupuncture. Emerging, or reemerging, public health threats receiving coverage include sick building syndrome, tuberculosis, and Lyme disease. Social trends that put health at risk are addressed, such as eating disorders, steroid abuse, smoking, and domestic violence. Some medical or industry practices that have aroused controversy are considered, such as circumcision, hysterectomy, cosmetic surgery, pesticide use, and the genetic engineering of foods. Issues pertaining to vulnerable groups—children, teenagers, and the elderly—are highlighted. Each article begins with information about type of health issue and a brief definition of the topic. The text of the essay follows, divided into helpful subheadings that guide the reader through the discussion. An author byline, a bibliography, and cross-references to other entries in the encyclopedia conclude every entry. At the back of volume 2 can be found a full Alphabetical List of Entries and a Category List by type of issue: children’s health, economic issues, elder health, environmental health, epidemics, ethics, industrial ix
Health Issues
practices, medical procedures, men’s health, mental health, occupational health, prevention, public health, social trends, treatment, and women’s health. Volume 2 also features a Glossary of relevant medical terms and a comprehensive subject Index. Health Issues is made possible by the work of many physicians, academicians, and other scholars. We would like to extend our gratitude to them. A list of their names and affiliations appears in the front of volume 1.
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Contributor List Richard Adler University of Michigan, Dearborn
Mitzie L. Bryant St. Louis Board of Education
E. Victor Adlin, M.D. Temple University School of Medicine
Edmund C. Burke, M.D. University of California Medical Center, San Francisco
Patricia A. Ainsa, M.P.H. University of Texas at El Paso Bruce Ambuel Medical College of Wisconsin
Louis A. Cancellaro, M.D. Veterans Affairs Medical Center, Mountain Home, Tennessee
P. Michele Arduengo Morningside College
Byron D. Cannon University of Utah
Iona C. Baldridge Lubbock Christian University
Jack Carter University of New Orleans
Lawrence W. Bassett, M.D. Iris Cantor Professor of Radiology University of California, Los Angeles, School of Medicine
Sonya H. Cashdan East Tennessee State University
Paul F. Bell The Medical Center, Beaver, Pennsylvania
Paul J. Chara, Jr. Loras College
Alvin K. Benson Brigham Young University
Francis P. Chinard New Jersey Medical School
Cynthia Beres Independent Scholar
Arlene R. Courtney Western Oregon State College
Carol D. Berkowitz, M.D. Harbor-UCLA Medical Center
Maureen C. Creegan Dominican College of Blauvelt
Matthew Berria Weber State University
Margaret Cruikshank University of Maine
Robert W. Block, M.D. University of Oklahoma
Roy L. DeHart, M.D., M.P.H. University of Oklahoma
Paul R. Boehlke Dr. Martin Luther College
Patrick J. DeLuca Mt. St. Mary College
Barbara Brennessel Wheaton College
Shawkat Dhanani West Los Angeles VAMC
Peter N. Bretan, M.D. University of California Medical Center, San Francisco
M. Casey Diana University of Illinois
Karen Chapman-Novakofski University of Illinois
xi
Health Issues Kristen L. Easton Valparaiso University
Ronald C. Hamdy, M.D. James H. Quillen College of Medicine
C. Richard Falcon Roberts and Raymond Associates, Philadelphia
Linda Hart Independent Scholar H. Bradford Hawley, M.D. Wright State University
L. Fleming Fallon, Jr., M.D., M.P.H. Jameson Hospital, New Castle, Pennsylvania
Robert M. Hawthorne, Jr. Independent Scholar
Frank Fedel Henry Ford Hospital, Detroit
Celia Ray Hayhoe University of Kentucky
Mary C. Fields Collin County Community College
Diane Andrews Henningfeld Adrian College
K. Thomas Finley State University of New York, Brockport
Martha M. Henze, R.D. Boulder Community Hospital, Colorado
Bonnie Flaig Kalamazoo Valley Community College
Mary Ann Holbein-Jenny Slippery Rock University
Kimberly Y. Z. Forrest Slippery Rock University
David Wason Hollar, Jr. Rockingham Community College
Ronald B. France LDS Hospital, Salt Lake City, Utah
Betsy B. Holli Dominican University
Katherine B. Frederich Eastern Nazarene College
Carol A. Holloway Independent Scholar
C. George Fry Lutheran College of Health Professions
Robert M. Hordon Rutgers University
Keith Garebian Independent Scholar
Howard L. Hosick Washington State University
Soraya Ghayourmanesh City University of New York
Jennifer J. Hostutler University of Akron
Wallace A. Gleason, Jr., M.D. University of Texas, Houston
Katherine H. Houp Midway College
D. R. Gossett Louisiana State University—Shreveport
Shih-Wen Huang, M.D. University of Florida
Karen Gould Independent Scholar
Larry Hudgins, M.D. Veterans Affairs Medical Center, Mountain Home, Tennessee
Daniel G. Graetzer University of Montana
Diane White Husic East Stroundsburg University
Hans G. Graetzer South Dakota State University
Vicki J. Isola Independent Scholar
L. Kevin Hamberger Medical College of Wisconsin
Albert C. Jensen Central Florida Community College
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Contributors Michelle L. Jones Muskingum College
Louise Magoon Independent Scholar
Karen N. Kähler Independent Scholar
Nancy Farm Manniko Michigan Technological University
Karen E. Kalumuck Cañada College
Bonita L. Marks University of North Carolina at Chapel Hill
Armand M. Karow Xytex Corporation
Charles C. Marsh, Pharm.D. University of Arkansas for Medical Sciences
Robert Kastenbaum Arizona State University
Linda Mealey University of Queensland
Laurence M. Katz University of North Carolina at Chapel Hill
Randall L. Milstein Oregon State University
Mara Kelly-Zukowski Felician College
Paul Moglia St. Joseph’s Medical Center, Yonkers, New York
Cassandra Kircher Elon College Hillar Klandorf West Virginia University
John Monopoli Slippery Rock University
Sharon L. Larson University of Nebraska-Lincoln
Sharon Moore, M.D. Veterans Affairs Medical Center, Mountain Home, Tennessee
Shirley A. Leckie University of Central Florida
Rodney C. Mowbray University of Wisconsin, LaCrosse
Gary J. Lindquester Rhodes College
Trina Nahm-Mijo University of Hawaii-Hawaii Community College
Stan Liu, M.D. University of California, Los Angeles, School of Medicine
Donald J. Nash Colorado State University
Joe E. Lunceford Georgetown College
Cherilyn Nelson Eastern Kentucky University
Fai Ma University of California, Berkeley
Anthony J. Nicastro West Chester University
John Arthur McClung, M.D. New York Medical College
Jane Cross Norman Tennessee State University
Maxine M. McCue College of Eastern Utah-San Juan Campus
Kathleen O’Boyle Wayne State University
Nancy E. Macdonald University of South Carolina at Sumter
Janet Rose Osuch, M.D. Michigan State University
Wayne R. McKinny, M.D. University of Hawaii School of Medicine
Oliver Oyama Duke/Fayetteville Area Health Education Center
Scott Magnuson-Martinson South Dakota State University
Maria Pacheco Buffalo State College
xiii
Health Issues Cheryl Pawlowski University of Northern Colorado
Rebecca Lovell Scott College of Health Sciences
Kate L. Peirce Southwestern Texas State University
Rose Secrest Independent Scholar
Joseph G. Pelliccia Bates College
Kevin S. Seybold Grove City College
Leslie Pendleton Independent Scholar
Martha Sherwood-Pike University of Oregon
Thomas W. Pierce Radford University
R. Baird Shuman University of Illinois, Urbana-Champaign
Nancy A. Piotrowski University of California, Berkeley
Bobbie Siler Medical College of Ohio
George R. Plitnik Frostburg State University
Sanford S. Singer University of Dayton
Lillian M. Range University of Southern Mississippi
Virginia Slaughter University of Queensland
Wendy E. S. Repovich Eastern Washington University
Genevieve Slomski Independent Scholar
Kris Riddlesperger Texas Christian University
Roger Smith Linfield College
Connie Rizzo, M.D. Pace University
Lisa Levin Sobczak, R.N.C. Independent Scholar
Larry M. Roberts Independent Scholar
Diane Stanitski-Martin Shippensburg University
Gene D. Robinson James Madison University
Sharon W. Stark Monmouth University
John Alan Ross Eastern Washington University
Irene Struthers Independent Scholar
John G. Ryan, Dr.P.H. University of Texas, Houston
Wendy L. Stuhldreher, R.D. Slippery Rock University
William J. Ryan Slippery Rock University
Billie M. Taylor Independent Scholar
Virginia L. Salmon Northeast State Technical Community College
John M. Theilmann Converse College
Robert Sandlin San Diego State University Steven A. Schonefeld Tri-State University John Richard Schrock Emporia State University
Nicholas C. Thomas Auburn University at Montgomery Roberta Tierney Indiana University and Purdue University Leslie V. Tischauser Prairie State College
xiv
Contributors James T. Trent Middle Tennessee State University
Diane E. Wille Indiana University Southeast
Mary S. Tyler University of Maine
Lee Williams Independent scholar
Maxine Urton Xavier University
Bradley R. A. Wilson University of Cincinnati
Kimberly A. Wallet Lamar University
Virginia M. Witt, M.D. St. Joseph’s Hospital and Medical Center
Annita Marie Ward Salem-Teikyo University
Jay R. Yett Orange Coast College
Marcia Watson-Whitmyre University of Delaware
Kathleen M. Zanolli Kansas University
David J. Wells, Jr. University of South Alabama Medical Center
Chester J. Zelasko Buffalo State College
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Abortion ✧ 1
✧ Abortion Type of issue: Ethics, medical procedures, social trends, women’s health Definition: The induced termination of pregnancy, which is usually legal only before the fetus is viable. Abortion is the deliberate ending of a pregnancy before the fetus is viable, or capable of surviving outside the woman’s body. It has been practiced in every culture since the beginning of civilization. It has also been controversial. Abortion in the United States In the United States, abortion before quickening was legal until the 1840’s. By 1841, ten states declared abortion to be a criminal act, but punishments were weak and the laws frequently ignored. The movement against abortion was led by the American Medical Association (AMA), founded in 1847. Doctors were becoming increasingly aware that the “first sign of life” took place well before the fetus actually moved. By this time, scientists had established that fetal development actually began with the union of sperm and egg. In 1859, the AMA passed a resolution condemning abortion as a criminal act. Within a few years, every state declared abortion a felony. Not until 1950 did the AMA reverse its position, when it began a new campaign to liberalize abortion laws. Many doctors were concerned about the thousands of women suffering from complications and even death from illegal abortions. In 1973, the Supreme Court of the United States ruled in Roe v. Wade that abortions were generally legal. That ruling made abortions in the United States available on the request of pregnant women. In the nineteenth century, it is believed that there was one abortion for every four live births, a rate only a bit lower than that in the latter part of the twentieth century. The number of abortions in any year varied from 500,000 to 1 million, most of them illegal. In 1969, the Centers for Disease Control (CDC), a branch of the U.S. Department of Health and Human Services, began an annual abortion count. Legal abortions in 1970 numbered about 200,000. The number of illegal abortions is unknown. Ten years later, legal abortions reached 1,200,000 and by 1990 had increased to 1,600,000; they have remained at that level fairly consistently since then. The CDC estimated that there were about 325 abortions for every 1,000 live births in the 1980’s, a number consistent with findings for the 1990’s. The number of abortions in any year rarely fluctuated by more or less than 3 percent from these figures. In Roe v. Wade, the Supreme Court ruled that abortions were legal under certain conditions. Those conditions included the welfare of the woman and
2 ✧ Abortion the viability of the fetus. During the first three months of pregnancy, according to the Court, the government had no legitimate interest in regulating abortions. The only exception was that states could require that abortions be performed by a licensed physician in a “medical setting.” Otherwise, the decision to abort was strictly that of the pregnant woman as a constitutional right of privacy. During the second trimester, abortions were more restricted. They would be legal only if the woman’s health needed to be protected and would require the consent of a doctor. The interest of the fetus would be protected during the third trimester, when it became able to survive on its own outside of the woman’s body, with or without artificial life support. States, at this point, could grant abortions only to women for whom, according to medical opinion, the continued pregnancy would be lifethreatening. The determination of viability would be made by doctors, not by legal authorities. This ruling effectively struck down all antiabortion laws across the United States. In the aftermath of Roe v. Wade, abortion became an intensely emotional political issue in the United States. The Hyde Amendment of 1976 eliminated federal funding for abortions, and other legislation blocked foreign aid to programs such as family planning that members of Congress who were opposed to abortion saw as “pro-abortion.” In Webster v. Reproductive Health Services (1989), the Supreme Court upheld its ruling in Roe v. Wade, but it also sustained a rule forbidding the use of public facilities or public employees for carrying out abortions. The Court also supported a requirement that a test for viability be done before any late abortion and said states could ban funding for abortion counseling. The issue continued to divide Americans, with opponents arguing that abortion at any point in the process of birth was murder. Reasons for Seeking an Abortion A 1987 survey done by the Alan Guttmacher Institute of 1,900 women who had abortions revealed the most common reasons for making that decision. Ninety-three percent of the respondents gave more than one reason, but these reasons could usually be reduced to four basic notions. The most common was that having a baby would interfere with work or going to school. Next came not being able to afford a child. Third was a concern about relationship problems with the father. The last was that the potential mother did not want to be a single parent. A study done by the CDC of what types of women wanted to have an abortion revealed that almost 60 percent were experiencing their first pregnancy. Women beneath the poverty level, regardless of race, religion, or ethnic background, were more likely to have an abortion than middle-class women. African American and Hispanic women had higher rates of abortion than did white women. The largest number of abortions were per-
Abortion ✧ 3 formed on white, single women, eighteen to twenty-five years of age. This same group, however, also had the highest number of live births. Religion appeared to make little difference: The percentage of Catholic women having abortions was actually a bit higher than the percentage of Protestant women. The lowest percentage of abortions was found among Evangelical, “born-again” Christians. Teenagers under fifteen and women over forty had the highest rates of abortion of any age groups. The study showed that the reasons for late abortions, defined as those sixteen weeks or later after conception, differed somewhat from those given by women who had their abortions during the first trimester. Two key factors were involved in late abortions. Seventy-one percent of the women interviewed said that they had waited so long because they had not realized they were pregnant or did not know soon enough how long they had been pregnant. Fifty percent said that they had taken so long because they had problems raising enough money to pay for an abortion. Thus, poverty appears to be a leading cause of late abortions. Many in this latter group also reported that they had to leave their home states to obtain legal abortions because there were no facilities in these states. Almost 90 percent of counties in the United States do not have facilities or doctors who will perform abortions. Death rates for women who have abortions after sixteen weeks are thirty times higher than the rate at eight weeks. Abortion Procedures A variety of techniques can be used to perform abortions. They vary according to the length of the pregnancy, which is usually measured by the number of weeks since the last menstrual period (LMP). Instrumental techniques are usually used very early in a pregnancy. They include a procedure called menstrual extraction, in which the entire contents of the uterus are removed. It can be done as early as fourteen days after the expected onset of a period. A major problem with this method is a high risk of error; the human embryo may still be so small at this age that it can be missed. It is also true that a high proportion of women undergoing this procedure turn out not to have been pregnant. Nevertheless, this method is easy to do and very safe. Death rates from this technique average less than 1 out of 100,000. About 96 percent of all abortions in the United States are done by a procedure known as vacuum aspiration, or suction curettage. This technique can be used up to about fourteen weeks after the LMP. It can be performed with local anesthesia and follows these steps. First, the cervix is expanded with metal rods that are inserted into it one at a time, with each rod being slightly larger than the previous one. When the cervix is expanded to the right size, a transparent, hollow tube called the vacuum cannula is placed into the uterine cavity. This instrument is attached to a suction device, which looks something like a drinking straw. An electric or hand-
4 ✧ Abortion operated vacuum pump then empties the uterus of its contents. Finally, a spoon-shaped device called a curette is used to check for any leftover tissue in the uterus. The entire procedure takes less than five minutes. This method, first used in China in 1958, is among the safest procedures in medicine. There are about six times more maternal deaths during regular birth than during vacuum aspiration. An older method, dilation and curettage (D & C), was common up to the 1970’s, but it has largely been replaced by vacuum aspiration. In a D & C, the cervix was expanded or dilated, and a curette was used to scrape out the contents of the uterus. The biggest difference was the use of general anesthesia during the process. Since most abortion-related deaths result from complications from anesthesia, a method that requires only local anesthesia, such as aspiration, greatly reduces the dangers of the procedure. For the period from thirteen to twenty weeks, a method called dilation and evacuation (D & E) is usually preferred. The cervix is expanded with tubes of laminaria (a type of seaweed), and the fetus is removed with the placenta, the part of the uterus by which the fetus is nourished. Forceps, suction, or a sharp curette is sometimes used. The procedure is usually safe, but sometimes a large fetus must be crushed and dismembered in order to remove it through the cervix. This process can be upsetting for the doctor and the patient and is more dangerous than procedures done earlier in the pregnancy. Generally, the later abortions are performed, the more dangerous they are for women. Physicians can also use “medical induction” techniques when required. Amnioinfusion is an old example of this method that was used on fetuses from sixteen to twenty weeks old. This process has largely been replaced by D & E, which has proved far less dangerous. Amnioinfusion usually required hospitalization, local anesthesia, and the insertion of a large needle into the uterus. Between 100 and 200 milliliters of fluid were withdrawn and a similar amount of hypertonic saline solution was infused into the uterine cavity. Within ninety minutes, the fetal heart would stop. The woman would go into labor and deliver a dead fetus within twenty-four to seventy-two hours. These kinds of abortions generally had much higher risks of complications than did D & E. On rare occasions, a fetus was born alive, but the main risks were infection, hemorrhage, and cervical injuries to the woman. The psychological difficulties associated with such long labor are very upsetting, especially the knowledge that the fetus delivered will be dead. Another method used prostaglandins, naturally occurring hormones that cause uterine contractions and expulsion of the fetus, rather than a saline solution. The hormones could be given to the patient in several different ways: intravenously, intramuscularly, through vaginal suppositories, or directly into the amniotic sac. Prostaglandins are used for inducing second trimester abortions and are as safe as saline solutions. Their major advantage is to reduce the time for the abortion, but they also have severe side effects.
Abortion ✧ 5 They cause intense stomach cramps and other gastrointestinal discomfort, and about 7 percent of the fetuses expelled show some sign of life. Surgical techniques for abortion are very rare, although sometimes they prove necessary in special cases. Hysterotomy resembles a Cesarean section. An incision is made in the abdomen, and the fetus is removed. Hysterotomy is usually used in the second trimester, but only in cases where other methods have failed. The risk of death is much higher in this procedure than in most others. Even more rare is a hysterectomy, the removal of the uterus. This is done only in cases in which a malignant tumor threatens the life of the pregnant woman. In the late 1980’s, the French “abortion pill,” RU-486, was approved for use in many parts of Europe. By the mid-1990’s, it had been used in more than fifty thousand abortions. Progesterone is a hormone that tells the uterus to develop a lining that can be used to house a fertilized egg. If the egg is not fertilized, the production of progesterone stops, and the uterine lining is discarded during menstruation. RU-486 contains an antiprogesterone, which means that it prevents the production of progesterone. The pill has proved to be effective about 90 percent of the time if used in early pregnancy. A few serious side effects sometimes occur with RU-486, the major one being sustained bleeding. About one out of a thousand users bleeds so much that a transfusion is required. Cramps and nausea are also reported in a number of cases. There is apparently no effect on subsequent pregnancies. The drug must be taken under medical supervision and requires, under French law, at least three visits to a doctor’s office. The first visit is for testing and counseling. On the second visit, the patient is given the drug. On the third, she receives an injection of prostaglandin. In late 2000, RU-486 was approved for use in the United States. Relative Risks of Legal vs. Illegal Abortions Abortion is the most frequently performed surgical procedure in the United States. As long as women have unwanted pregnancies, that will continue to be true. Abortion is a very safe procedure, although there can be some complications. Generally, however, the earlier the procedure is performed, the less the risk. The lowest chance of medical complications occurs during the first eight weeks of pregnancy. After eight weeks, the risk of complications increases by 30 percent for each week of delay. Nevertheless, the death rate per case is very low, about half that for tonsillectomy. These statistics apply only to those areas of the world where abortion is legal, since women in those places tend to have earlier abortions. In the United States, deaths declined when abortions became legal in 1973. Before the Roe v. Wade decision, it was estimated that anywhere from a few hundred to several thousand American women died every year from the
6 ✧ Abortion procedure. The best estimate was that in the 1960’s, about 290 women died every year as a result of complications from abortions. In the 1980’s, the average was twelve per year, mostly from anesthesia complications. More than 90 percent of abortions in the United States take place during the first twelve weeks of pregnancy. —Leslie V. Tischauser See also Abortion among teenagers; Birth control and family planning; Birth defects; Condoms; Ethics; Fetal tissue transplantation; Genetic counseling; Hippocratic oath; Law and medicine; Miscarriage; Morning-after pill; Pregnancy among teenagers; Sterilization; Women’s health issues. For Further Information: Githens, Marianne, and Dorothy McBride Stetson, eds. Abortion Politics: Public Policy in Cross-Cultural Perspective. New York: Routledge, 1996. The essays in this collection provide some insight on the contentious nature of this issue. Includes bibliographical references and an index. Paul, Maureen, et al., eds. A Clinician’s Guide to Medical and Surgical Abortion. New York: Churchill Livingstone, 1999. Includes a historical review and an analysis of the epidemiological and public health aspects of abortion. Discusses preprocedure assessment and management, abortion techniques and procedures, postabortion management, and abortion service delivery. Sciarra, John J., et al. Gynecology and Obstetrics. Rev. ed. Vol. 6. Philadelphia: Harper & Row, 1996. A textbook that discusses methods, demographics, health concerns, and the psychological and medical consequences of abortions. Sloan, Irving J. The Law Governing Abortion, Contraception, and Sterilization. Legal Almanac Series. London: Oceana, 1996. Covers historical and modern legislation relating to abortions, contraception, and the rights of minors to these services. Appendixes include selected state and federal laws. Solinger, Rickie, ed. Abortion Wars: A Half Century of Struggle, 1950-2000. Berkeley: University of California Press, 1998. Solinger is a noted historian of reproductive behavior and its social and cultural meanings. Here she brings together activists, providers, attorneys, and academics for this collection of essays, which takes a strong pro-rights stance and examines abortion as it figures in the United States and countries around the world.
Abortion among teenagers ✧ 7
✧ Abortion among teenagers Type of issue: Children’s health, ethics, medical procedures, social trends, women’s health Definition: The medical termination of a pregnancy by a teenage girl. Each year, according to the Alan Guttmacher Institute, a leading provider of information on abortion, more than one million teenagers in the United States become pregnant. Almost nine out of ten of these pregnancies are unintended. As a consequence, about one-third (35 percent) of teenage girls who become pregnant decide to have an abortion. This means that there are more than 350,000 teenage abortions every year in the United States. The Societal Contexts of Teenage Pregnancy The United States has far more abortions than any other wealthy, developed country. For example, in the Netherlands where teenage sexual activity occurs at about the same rate as it does in the United States, only about one out of ten teenage girls becomes pregnant. Experts believe that this difference is accounted for by the easier availability of contraception and family planning services in the Netherlands and by the fact that Dutch teenagers receive much more sex education than do Americans. American teenagers, both male and female, have limited knowledge about ways of preventing pregnancy, even though four out of five report having had intercourse by the time they reach eighteen years of age. This sexual activity is not always voluntary, especially for very young women. Of those girls under fifteen who reported having sexual relations, more than 60 percent said that the sex was forced upon them by older males. Teenagers with unplanned pregnancies generally face difficult, lonely choices, especially if they are poor or if they are living in broken families. Teenage girls who give birth and keep their babies are likely to drop out of school, go on public assistance, develop health problems (both mother and child), and live in single-parent households. Teenage marriages are much more likely to end in divorce than are later marriages. The younger the mother, the more likely the child will suffer from medical, psychological, economic, and educational disadvantages. By 1998, twenty-eight of the fifty U.S. states had enacted laws restricting access to abortion for girls under eighteen by requiring involvement of one or both parents in the abortion decision. These laws required medical personnel to notify a girl’s parents if she requests an abortion. Only two states—Connecticut and Maine—and the District of Columbia allowed teenage girls the right to obtain abortions on their own.
8 ✧ Abortion among teenagers The U.S. Supreme Court ruled that a state cannot give parents the absolute right to deny abortion to their daughter. In some states, girls who do not want their parents notified can seek a judicial bypass, which requires authorization from a judge before an abortion can be performed. The judge is required to give the authorization unless he or she decides that the girl is too immature to make the decision by herself. If any woman, regardless of age, is going to have an abortion, it is best to have the procedure done as early as possible in the pregnancy. Thus, laws that make teenagers wait before an abortion is performed also increase the risk of complications. According to the best evidence, about 1 in every 100,000 legal abortions results in the death of the pregnant woman. If an abortion takes place before the eighth week of pregnancy, then the death rate is only about 2 out of 1 million. The rate increases after the twelfth week of pregnancy, however, to about 12.7 deaths per 100,000 abortions. The death rate for illegal abortions in all age groups is about four times higher. Early abortion lessens the risk to the health of the teenager, and abortions are among the safest of any type of medical procedure. The Abortion Debate The major debate over abortion is one of ethics: Is it right to end a pregnancy deliberately before the fetus is capable of living outside the uterus? The Supreme Court’s decision in Roe v. Wade (1973) made the right to an abortion, at least during the first twelve weeks of pregnancy, legal in the United States. The question concerning teenage pregnancy is whether girls under the age of eighteen are ready to make the decision to abort an unwanted pregnancy on their own or whether they should be required to notify their parents or guardians first. U.S. states justify parental involvement laws by arguing that the decision to end a pregnancy is not simply a medical choice but one that can have a significant long-term impact on a teenager’s psychological and emotional health and that teenagers are not ready to make such difficult decisions by themselves. Critics of parental consent point out, however, that several states allow teenagers to marry without parental consent, while others even allow teenagers to drop out of school without parental involvement. Even more striking is the fact that, in 1998, forty-five states allowed a teenage mother to place her baby for adoption without consulting an adult. It can be argued that difficult decisions such as these are just as important in a young person’s life as is the choice to have an abortion. If teenagers can make these choices on their own, should they also have the right to end a pregnancy? The debate over abortion is based on ethics. New abortion techniques have largely eliminated any major medical complications for the teenager or adult woman undergoing this procedure. Factors involved in the choice of whether to have an abortion vary from individual to individual. Restrictive
Acupuncture ✧ 9 laws create problems of their own. If a parent or judge makes the decision and a young woman is forced to have a baby against her will, the consequences can be devastating. She may decide to run away from home and have an illegal abortion, which is dangerous and unsafe. Restrictions can rob a young woman of the power to take control of her own life and may force her to raise her baby in poverty and isolation. —Leslie V. Tischauser See also Abortion; Birth control and family planning; Condoms; Ethics; Pregnancy among teenagers; Women’s health issues. For Further Information: Baird, Robert M., and Stuart E. Rosenbaum, eds. The Ethics of Abortion: Pro-Life vs. Pro-Choice. Rev. ed. Buffalo, N.Y.: Prometheus Books, 1993. Covers a wide range of opinions. Feinberg, Joel, and Susan Dwyer, eds. The Problem of Abortion. 3d ed. Belmont, Calif.: Wadsworth, 1997. An excellent selection of articles. Gordon, Mary. Good Boys and Dead Girls and Other Essays. New York: Viking Press, 1991. Has several interesting essays on abortion as well as the accounts of several women recalling abortions from their teenage years. Solinger, Rickie, ed. Abortion Wars: A Half Century of Struggle, 1950-2000. Berkeley: University of California Press, 1998. Solinger is a noted historian of reproductive behavior and its social and cultural meanings. Here she brings together activists, providers, attorneys, and academics for this collection of essays, which takes a strong pro-rights stance and examines abortion as it figures in the United States and countries around the world.
✧ Acupuncture Type of issue: Medical procedures, treatment Definition: An ancient therapy developed in China in which designated points on the skin are stimulated by the insertion of needles, the application of heat, massage, or a combination of these techniques in order to treat impaired body functions or induce anesthesia. The theory and practice of acupuncture is rooted in the Chinese concept of life—the Ch’i (pronounced “chee”)—which, according to ancient writings, is the beginning and the end, life and death. The belief, which has been handed down for thousands of years, is that all things animate and inanimate have an internal source of energy. This energy stabilizes the chemical composition of matter, and when this matter is broken down, energy is released. The Chinese view differs from the Western view of life in its
10 ✧ Acupuncture adherence to the belief that human beings are all one with the cosmos, obeying the rhythms of the natural order. This oneness with the entire universe is represented by two forces: Yin and Yang. Yang, the positive force in human beings and nature, is exemplified by powerful elements such as heat, energy, vitality, the lush growing period of summer, and the sun. Yin, on the other hand, is the passive, almost negative force that is most obvious during winter, when plant growth almost comes to a standstill and certain animals hibernate. The Yin force is believed to be at work nightly in humans when they sleep. People who suffer from rheumatic pains frequently claim that they can forecast a change in the weather by noting the onset of those pains, and many people respond emotionally to the flow of energy in their bodies. They can feel either full of life or deeply depressed for no apparent reason. The Flow of Ch’i According to the ancient Chinese system of medicine, there are two categories of organs associated with the Ch’i: the Tsang and the Fou. The Fou is the group of organs that absorb food, digest it, and expel waste products. They are all hollow organs such as the stomach, the large and small intestines, the bladder, and the gallbladder, and all are Yang by nature. Tsang organs are all associated with the blood—the heart, which circulates the blood around the body; the lungs, which oxygenate the blood; the spleen, which controls the red corpuscles; and the liver and the kidneys. These organs are Yin by nature. For the flow of energy to remain steady, it must pass unimpeded from one organ to another. If the organ is weak, the resultant energy that is passed on to the next organ is weakened. Acupuncture stimulates specifically designated points on the body (called “meridians”) and corrects the problem. According to the Chinese, the human “circuit” of energy is made up of twelve meridians, which stretch along the limbs from the toes and the fingers to the face and chest. There are six meridians in the upper limbs and six in the lower. Ten meridians are connected to a main organ by branches from the sympathetic nervous system, and each of these meridians contains the Ch’i, which varies in strength and is governed by the nerve impulses arising from the organs. The meridians and their attendant vessels contain the flow of energy that enables the body to function efficiently. The meridian points that proved to be effective for certain ailments were organized, and specific names were given to each. Later, the meridian line concept was hypothesized in order to explain the effectiveness of the points. These meridian points were selected by observing the effects of stimulation on particular signs and symptoms. According to modern medical concepts, some of these points are thought to be relating points at which the autonomic nervous system is stimulated by
Acupuncture ✧ 11 a specific visceral disorder. Anatomically, some of the meridian points appear to correspond to areas where a nerve appears to surface from a muscle or areas where vessels and nerves are relatively superficially located, such as areas between a muscle and a bone or between a bone and a joint. These areas are generally composed of connective tissue. Tapping the Flow The meridians are stimulated by the insertion of needles. The needles that are commonly used range in size from the diameter of a hair to that of a sewing needle. In China, round and cutting needles are commonly used. The lengths of the needles range from approximately 0.14 millimeter to approximately 0.34 millimeter. In Europe, the needles are slightly shorter and slightly wider in diameter. The needles are made of gold, silver, iron, platinum, or stainless steel. Stainless steel needles are most commonly used. Infection caused by needle puncture is said to be extremely rare. This may be the case because the minor injury created by the needle is controlled by biological reaction. It is routine to wipe the skin with alcohol before inserting the sterilized needle. The needle itself may be wiped with alcohol sponges before each insertion on the same patient. Needles are discarded after being used in patients with a history of jaundice or hepatitis. Insertion of a needle requires great skill and much practice. There are three different angles of penetration into the skin: perpendicular, oblique, and horizontal. These angles correspond to 90 degrees, 45 degrees, and a minimum angle, respectively. The angles may be chosen on the basis of the thickness of the skin and the proximity to muscle or bone at the desired puncture point. The depth of penetration will vary, with an average of 10, 30, and 40 millimeters in the head, shoulder, and back regions, respectively. Tapping (the tube method) is one method of insertion: When the diameter of the needle is small, this method is extremely effective. The needle is placed into the tube from either direction, and the tube is shorter than the needle by 5 millimeters or more. Gentle tapping of the needle handle with the right index finger introduces the needle easily. The tapping finger must be removed from the needle head immediately; otherwise, it causes pain. The tube is removed gently with the right index finger and thumb. In the twirling method (the freehand method), the left thumb and index finger make contact at the acupuncture point. The left hand is called the pushing hand. Next, the skin is cut with the needle tip, after which the needle is inserted by pushing and twirling it with the right hand.
12 ✧ Acupuncture Needle Manipulation The objective of the advancement of the needle and the needle motion is to create a needle feeling in the patient. This is a dull, aching, paralyzing, or compressing feeling or a combination of these sensations that radiates to a distal or proximal portion of the body. When the patient notices the needle feeling, the operator increases the feeling by using various needle motions. Numerous motions are available, such as the single-stick, twirling, vibration, intermittent, and retention motions. The amount of stimulation equals the strength of stimulation multiplied by the number of treatments; this is dependent on the sensitivity of the patient. Gradual increases of stimulation are essential. In general, for acute disease, treatment is usually given once a day for ten days and then terminated for three to seven days. For chronic ailments, treatment is administered once every two to three days for ten treatments and then terminated for seven days. The patient is placed in a supine, sitting, prone, or side position—the position that is most convenient for the patient and physician. A special position, however, may be needed in order to relax the painful area. Western Uses for Acupuncture The basic approach of modern medicine involves removing the causal factor of disease. In this approach, the pain associated with disease or with a surgical procedure may not be eradicated instantaneously, however, and the management of pain becomes an issue until the disease is cured or until the surgery and recuperation are complete. Controlling chemical receptors and reducing the sensitivity of those receptors is one way of treating pain. Intensive studies of the stimulation that causes pain have indicated that intrinsic chemical substances (polypeptides) such as histamine and serotonin, which stimulate the receptors, are essential for pain. Therefore, an antagonistic drug for these chemicals is often effective in controlling pain. Although acupuncture is used to treat conditions as diverse as allergies, circulatory disorders, dermatologic disorders, gastrointestinal disorders, genital disorders, musculoskeletal disorders, neurologic disorders, and psychiatric and emotional disorders, the use of acupuncture for pain control (analgesia) can be described as the most basic level of treatment. The popularity of acupuncture, like that of most techniques and discoveries, has waxed and waned throughout the years; for the most part, however, the Chinese have remained faithful to the five-thousand-year-old practice. The laws and method of acupuncture have endured, although these methods have been increasingly combined with Western medical techniques. —Genevieve Slomski
Addiction ✧ 13 See also Addiction; Alternative medicine; Biofeedback; Holistic medicine; Homeopathy; Pain management; Stress; Yoga. For Further Information: Ernst, Edzard, and Adrian White, eds. Acupuncture: A Scientific Appraisal. London: Butterworth Heinemann Medical Publishers, 1999. Examines acupuncture’s possible mechanisms of action. Contains chapters on both Eastern and Western approaches. Reviews the evidence for the effectiveness of acupuncture and provides in-depth coverage of safety aspects. Manaka, Yoshio, Kazuko Itaya, and Stephen Birch. Chasing the Dragon’s Tail: The Theory and Practice of Acupuncture in the Work of Yoshio Manaka. Brookline, Mass.: Paradigm, 1997. The definitive text by Manaka, one of the most famous acupuncturists of the twentieth century. Explains his treatment approach and his research in and understanding of acupuncture. Mann, Felix. Acupuncture: Cure of Many Diseases. 2d ed. London: Butterworth Heinemann Medical Publishers, 1992. Written by a practicing acupuncture therapist. A beginning book on the theory and practice of acupuncture. Stux, Gabriel, and Bruce Pomeranz. Basics of Acupuncture. 4th ed. New York: Springer-Verlag, 1998. An updated reference on acupuncture that provides details about the procedure. Also examines the history of acupuncture treatment. Tan, Leong T., et al. Acupuncture Therapy. 2d rev. ed. Philadelphia: Temple University Press, 1976. A useful introduction to the theory and practice of acupuncture. The authors state that acupuncture, as a simple, efficient, and effective means of medical therapy, has successfully withstood the tests of time and scrutiny, earning acceptance in the United States. Numerous charts and illustrations. Bibliography.
✧ Addiction Type of issue: Mental health, social trends Definition: A psychological and sometimes physiological process whereby an organism comes to depend on a substance; defined by a persistent need to use the substance and to increase the dosage used as a result of tolerance, as well as the experience of withdrawal symptoms when the substance is withheld or use is reduced. Addiction is a disorder that can affect any animal and may result from the use of a variety of psychoactive substances. Typically, it involves both psychological and physiological dependence. Psychological dependence is marked by compulsions to use a substance of abuse because of its reinforcing
14 ✧ Addiction qualities. Physiological dependence results when the body responds to the presence of the addictive substance. Tolerance, withdrawal, and significant decreases in psychological, social, and occupational dysfunction characterize physiological dependence. The Development of Tolerance Tolerance involves pharmacokinetics, pharmacodynamics, and environmental or behavioral conditioning. Pharmacokinetics refers to the way in which a biological system, such as a human body, processes a drug. Substances are subject to absorption into the bloodstream, distribution to different organs (such as the brain and liver), metabolization by these organs, and then elimination. Over time, the processes of distribution and metabolism may change, such that the body eliminates the substance more efficiently. Thus, the substance has less opportunity to affect the system than it did initially, reducing any desired effects. As a result, dose increases are needed to achieve the initial or desired effect. Pharmacodynamics refers to changes in the body as a result of a pharmacologic agent being present. Tissue within the body responds differently to the substance at the primary sites of action. For example, changes in sensitivity may occur at specific sites within the brain, directly or indirectly impacting the primary action site. Direct changes at the primary sites of action denote tissue sensitivity. An example might be an increase in the number of receptors in the brain for that particular substance. Indirect changes in tissue remote from the primary action sites denote tissue tolerance, or functional tolerance. In functional tolerance, physiologic systems that oppose the action of the drug compensate by increasing their effect. Once either type of tolerance develops, the only way for the desired effect to be achieved is for the dose of the substance to be increased. Finally, environmental or behavioral conditioning is involved in the development of tolerance. Organisms associate the reinforcing properties of substances with the contexts in which the drugs are experienced. Such contexts may be physical environments, such as places, or emotional contexts, such as when the individual is depressed or anxious. Over the course of repeated administrations in the same context, the tolerance that develops is associated with that specific context. Thus, an organism may experience tolerance to a drug in one situation, but not another. Greater doses of the reinforcing substance would be needed to achieve the same effect in the former situation, but not in the latter. Variations in Tolerance Development Tolerance develops differently depending on the type of substance taken, the dose ingested, and the routes of administration used. Larger doses may
Addiction ✧ 15 contribute to quicker development of tolerance. Similarly, routes of administration that produce more rapid and efficient absorption of a substance into the bloodstream tend to increase the likelihood of an escalating pattern of substance abuse leading to dependence. For many drugs, injection and inhalation are two of the fastest routes of administration, while oral ingestion is one of the slowest. Other routes include intranasal, transdermal, rectal, sublingual, and intraocular administration. For some substances, the development of tolerance also depends on the pattern of substance use. For example, even though two individuals might use the same amount of alcohol, it is possible for tolerance to develop more quickly in one person than in the other. Two individuals might each drink fourteen drinks per week, but they would develop tolerance at different rates if one consumes two drinks each of seven nights and the other consumes seven drinks each of two nights in a week. Because of their patterns of use, the first drinker would develop tolerance much more slowly than the second, all other things being equal. Withdrawal Withdrawal occurs when use of the substance significantly decreases. Withdrawal varies by the substance of abuse and ranges from being minor or nonexistent with some drugs (such as hallucinogens) to quite pronounced with other drugs (such as alcohol). Mild symptoms include anxiety, tension, restlessness, insomnia, impaired attention, and irritability. Severe symptoms include convulsions, perceptual distortions, irregular tremors, high blood pressure, and rapid heartbeat. Typically, withdrawal symptoms can be alleviated or extinguished by readministration of the substance of abuse. Thus, a compounding problem is that the addicted individual often learns to resume drug use in order to avoid the withdrawal symptoms. Addiction occurs with both legal and illegal drugs. Alcohol and nicotine are two of the most widely abused legal addictive drugs. Over-the-counter drugs, such as sleeping aids, and prescription drugs, such as tranquilizers (for example, sedative-hypnotics) and antianxiety agents, also have addiction potential. Common illegal addictive drugs include cocaine, marijuana, hallucinogens, heroin, and methamphetamine. Not everyone who uses these substances will automatically become addicted. In the United States, for example, surveys have shown that approximately 65 percent of adults drink alcohol each year. In contrast, less than 13 percent of the population goes on to develop alcohol problems serious enough to warrant a medical diagnosis of alcohol abuse or dependence. Similarly, despite the fact that large numbers of individuals are prescribed opiates or sedative-hypnotics for pain while hospitalized, roughly 0.7 percent of the adult population is addicted to opiates and 1.1 percent is addicted to sedative-hypnotics or antianxiety drugs. Thus, the development
16 ✧ Addiction of addiction often requires repeated substance administration, as well as other biological and environmental factors. Consequences of Addiction When addiction is present, the consequences are multiple and complex. While substance abuse involves deteriorated functioning in psychological, social, occupational, or physical functioning, substance dependence usually involves more severe problems in each of these areas for significantly longer amounts of time. Psychologically, problems with depression, anxiety, the ability to think clearly or remember information, motivation, judgment, and one’s sense of self may result. Socially, one can become isolated from friends and family, or even unable to deal with the stresses and demands of normal, everyday relationships. Finally, occupational disruptions can result from the inability to plan, to manage one’s feelings and thoughts, and to deal with social interactions. In terms of health, there are many acute and chronic effects of addiction. With cocaine, for example, acute cardiac functioning may be affected, such that the risk of heart attacks is increased. Similarly, individuals addicted to opiates, alcohol, and sedative-hypnotics must contend with such risks as falling into a coma or experiencing depressed respiratory functioning. Finally, the acute effects of any of these drugs can impair judgment and contribute to careless behavior. As a result, accidents, severe trauma, and habitually dangerous behavior, such as risky sexual behavior, may be associated with addiction. Chronic health consequences are common. Smoking is associated with cancers of the mouth, throat, and lungs, as well as premature deterioration of the skin. Alcohol is associated with cancers of the mouth, throat, and stomach, as well as ulcers and liver problems. General malnutrition is a risk for heroin and alcohol users, since they often fail to eat properly. Injected drugs such as heroin and cocaine are associated with problems such as hepatitis and acquired immunodeficiency syndrome (AIDS), since shared needles may transmit blood-borne diseases. Finally, addiction contributes to health problems in the unborn children of addicted individuals. Problems such as low birth weight in the children of smokers, fetal alcohol syndrome in the children of female drinkers, and withdrawal difficulties in the children born to other types of addicts are well documented. Psychological Treatment Because of the combination of psychological and physiological dependence, addiction is a disorder that often demands both psychological and pharmacological treatments. Typically, interventions focus on decreasing or stopping the substance use and reestablishing normal psychological, social,
Addiction ✧ 17 occupational, and physical functioning in the addicted individual. Though the length and type of treatments may vary with the particular addictive drug and the duration of the addiction problem, similar principles are involved in the treatment of all addictions. Psychological treatments focus primarily on extinguishing psychological dependence, as well as on facilitating more effective functioning by the addicted individual in other areas of life. Attempts to change the behavior and thinking of the addicted individual usually involve some combination of individual, group, and family therapy. Adjunctive training in new occupational skills and healthier lifestyle habits are also common. In general, treatment focuses on understanding how the addictive behavior developed, how it was maintained, and how it can be removed from the person’s daily life. Assessments of the situations in which the drug was used, the needs for which the drug was used, and alternative means of addressing those needs are primary to this understanding. Once these issues are identified, a therapist then works with the client to break habitual behavior patterns that were contributing to the addiction (for example, driving through neighborhoods where drugs might be sold, going to business meetings at restaurants that serve alcohol, or maintaining relationships with drug-using friends). Concurrently, the therapist helps the client design new behavior patterns that will decrease the odds of continued problems with addiction. Problems related to the drug use would then be addressed in some combination of individual, family, or group therapy. The therapy or therapies selected depend on the problems related to drug use. For example, family therapy might be more appropriate in cases in which family conflicts are related to drug use. In contrast, individual therapy might be more appropriate for someone whose drug use is linked to thinking distortions or mood problems. Similarly, group therapy might be most appropriate for individuals lacking social support to deal with stress, or whose social interactions are contributing to their drug use. Regardless of the type of therapy, however, the basic goal remains: facilitating the client’s solving of his or her specific problems. Additionally, the development of new ways of coping with intractable problems, rather than relying on drug use as a means of coping, would be critical. Cognitive and behavioral therapies have been quite useful for breaking the conditioned effects of addiction. Some psychological dependence, for example, is based on placebo effects. A placebo effect occurs as a result of what people believe a drug is doing for them, rather than from anything that the drug actually has the power to accomplish. In addition, the practice of using addictive drugs within certain contexts is associated with drug tolerance, such that certain situations trigger compulsions leading to drug use. In this way, cognitive therapy can be used to challenge any faulty thinking associations that individuals have made about what the drugs do for them in different situations. This may involve increasing patients’ awareness of the
18 ✧ Addiction negative consequences of their drug use and challenging what they perceive to be its positive consequences. As a complement, such therapies correct distorted thinking that is related to coping with stressful situations or situations in which drug use might be especially tempting. In such situations, individuals might actually have the skill to handle the stress or temptation without using drugs. Without the confidence that they can successfully manage these situations, however, they may not even try, instead reverting to drug use. As such, therapy facilitating realistic thinking about stress and coping abilities can be quite beneficial. Similarly, behavioral therapies are used to break down conditioned associations between situations and drug use. For example, smokers are sometimes made to smoke not in accordance with their desire to smoke, but according to a schedule over which they have no control. As a result, they are made to smoke at times or in situations where it is inconvenient, leading to an association between unpleasant feelings and smoking. While such assigned drug use would not be used with illegal drugs, the basic principles of increasing negative or unpleasant feelings with drug use in specific situations can be used. Rewarding abstinence has also been a successful approach to treatment. In this way, positive reinforcement is associated with abstinence and may contribute to behaviors related to abstinence being more common than behaviors related to drug use. Pharmacological Treatment Pharmacological treatments concentrate on decreasing physical dependence on the substance of abuse. They rely on behavioral principles and on five primary strategies. The first strategy, based on positive reinforcement, is pharmacological replacement. Prescribed drugs with effects at the sites of action similar to those of the addictive drug are used. These prescribed drugs, however, usually fail to have reinforcing properties as powerful as the addictive drug and focus mainly on preventing the occurrence of withdrawal symptoms. Nicotine patches for smokers and methadone for heroin users are examples of replacement therapies. A second strategy involves the use of both reinforcement and extinction, the behavioral process of decreasing and eventually extinguishing the drugtaking behavior. Partially reinforcing and partially antagonistic drugs are prescribed. The net effect is that the prescribed drug staves off withdrawal symptoms, but yields less reinforcement than drug replacement therapy, serving to facilitate the process of extinction for the drug taking. Antagonists, or drugs that completely block the receptors responsible for the reinforcing effects of the drug action, are prescribed alone as a third strategy. With this strategy, extinction is the primary behavioral principle in effect. The prescribed drug blocks the primary receptor sites and does not yield positively reinforcing drug effects. Even if the addictive drug is taken
Addiction ✧ 19 in addition to the antagonist, no positively reinforcing effects are experienced. Thus, without reinforcement, drug-taking behavior should eventually cease. Naltrexone, typically used for opiate addiction, is a good example of this strategy. Punishment is another behavioral principle used in pharmacological therapy. Metabolic inhibitors, or drugs that make the effects of the addictive substance more toxic, are often used to discourage drug use. Antabuse, a drug often given for problems with alcohol, is such a substance. When metabolic inhibitors are prescribed, individuals using these drugs in combination with their substance of abuse experience toxic and unpleasant effects. Thus, they begin to associate use of the addictive substance with very noxious results and are discouraged from continuing their drug use. Symptomatic treatment of withdrawal effects is used as a fifth strategy. Based on reinforcement, this strategy simply encourages the use of drugs likely to reduce withdrawal effects. Unfortunately, these drugs may also have abuse potential. For example, when benzodiazepines are given to individuals with alcohol or opiate dependence, one dependency may be traded for another. As such, symptomatic treatment is helpful but is not a treatment of choice by itself. In fact, none of these pharmacological treatments is recommended for use in isolation; they are recommended for use with complementary psychological treatments. Societal Attitudes Toward Substance Use and Abuse The use of substances to alter the mind or bodily experiences is a practice that has been a part of human cultures for centuries. Time and again, even through legislated acts such as Prohibition, drug and alcohol use have persisted. The continued use of drugs for recreational and medicinal practices seems virtually inevitable, and it is unlikely that substance abuse and dependence will disappear from the world’s societies. Consequently, an understanding of substance use, how it leads to addiction, ways to minimize the development of addiction problems, and strategies for improving addiction treatments will be critical. At different times in history, addiction has been viewed as strictly a moral, medical, spiritual, or behavioral problem. As the science of understanding and treating addiction has progressed, the variety of ways in which these aspects of addiction combine has been noted. Modern treatments and theories no longer view addiction from one strict point of view, but instead recognize the heterogeneity of paths leading to addiction. Such an approach has been helpful not only in treating addiction but also in preventing it. Efforts to curb the biological, social, and environmental forces contributing to addiction have become increasingly important. Addiction remains a disorder with no completely effective treatment. Of individuals seeking treatment across all addictive disorders, fewer than
20 ✧ Addiction 20 percent succeed the first time that they attempt to achieve long-term abstinence. As a result, individuals suffering from addiction often undergo multiple treatments over several occasions, with some individuals experiencing significant problems throughout their lives. Even though treatments for physiological and psychological dependence offer some improvement, much work remains to be done. In this context, the challenge ahead is not to prevent all substance use, but rather to decrease the odds that a person will become addicted. Improving the pharmacological and psychological treatments currently available will be important. Discoveries of new ways of tailoring treatment for addiction to the needs and backgrounds of the different individuals affected will be one critical task for health professionals. Continued exploration of new pharmacological treatments to combat withdrawal and facilitate abstinence is necessary. —Nancy A. Piotrowski See also Alcoholism; Alcoholism among teenagers; Alcoholism among the elderly; Drug abuse by teenagers; Eating disorders; Recovery programs; Smoking; Steroid abuse; Stress; Tobacco use by teenagers. For Further Information: Dupont, Robert L. The Selfish Brain: Learning from Addiction. Washington, D.C.: American Psychiatric Association, 1997. Discusses the commonalities across different types of addiction in an easy-to-understand manner. Julien, Robert M. A Primer of Drug Action. 9th ed. New York: W. H. Freeman, 2000. A nontechnical guide to drugs written by a medical professional. Describes the different classes of drugs, their actions in the body, their uses, and their side effects. Basic pharmacologic principles, classifications, and terms are defined and discussed. Miller, William R., and Nick Heather, eds. Treating Addictive Behaviors: Processes of Change. 2d ed. New York: Plenum Press, 1998. This book, written by medical and psychological scientists, is an overview of treatment strategies for problems ranging from nicotine to opiate addiction. Psychological, behavioral, interpersonal, familial, and medical approaches are outlined and discussed. Schlaadt, Richard G., and Peter T. Shannon. Drugs: Use, Misuse, and Abuse. 4th ed. Englewood Cliffs, N.J.: Prentice Hall, 1994. A good introduction to the complex issues surrounding addiction and drug use. Describes different drugs of abuse, individual differences in drug use, legal and social issues, and continuing controversies. Also included is an overview of the differences between illegal and legal drugs, as well as drug myths and facts. Weil, Andrew, and Winifred Rosen. From Chocolate to Morphine: Everything You Need to Know About Mind-Altering Drugs. Rev. ed. Boston: Houghton Mifflin, 1998. This book on psychoactive substances provides basic informa-
Aging ✧ 21 tion to the general reader. Psychoactive substances are identified and defined. Also outlines the relationships between different types of drugs, the motivations to use drugs, and associated problems. As the title suggests, the discussion ranges from legal, caffeinated substances to illegal and prescription drugs.
✧ Aging Type of issue: Elder health, mental health, social trends Definition: The manifestation of biological, psychological, and sociocultural events occurring in a human being over the passage of time. Gerontologists, those people who study aging, make two important distinctions regarding the aging process. First, chronological aging, which occurs with the passage of time from birth or conception, is distinguished from functional aging, measured by how well people function over that passage of time. Second, longevity, the average number of years people can expect to live, is distinguished from life span, the theoretical upper limit on how long a person can live. These distinctions provide a necessary context for understanding the course of the biological, psychological, and sociocultural facets of aging. The Expanding Human Life Span Advances in medicine and health care, especially in the eradication of many childhood diseases, greatly increased the longevity of humans in the twentieth century. To illustrate, only 4 percent of Americans were age sixty-five and older at the beginning of the twentieth century. By the close of that century, that percentage had more than tripled to approximately 13 percent, with life expectancy reaching the high seventies. This optimistic picture, however, needs to be qualified in two regards. First, longevity varies greatly across culture and era. For example, Moses, living in the thirteenth century b.c.e., wrote in the Ninetieth Psalm of the Bible that the life expectancy of his contemporaries was between seventy and eighty years. Furthermore, extrapolations from Leonard Hayflick’s work on cell division begun in the 1950’s strongly suggest that there is an upper limit to how long a person can live: approximately 120 years, the same number that is told to Noah in Genesis 6:3. Great variation is also found between the genders within most species of animals. The general rule is that females experience greater longevity than males. Among humans, female life expectancy is approximately seven years longer.
22 ✧ Aging Programmed Events and Random Occurrences Why are there consistent differences in the course of aging among the sexes and species? An obvious inference is that all animals are biologically determined to live a particular number of years and then die. Three main theories interpret aging as the consequence of purposeful, predetermined events. The cellular clock theory is based on Hayflick’s work with cell cultures derived from embryonic tissue. A 1990 study by Hayflick demonstrated that human cells placed in a dish and fed nutrients grow, divide, and multiply rapidly at first. The rate of division then slows down, and the cells die somewhere between forty and sixty divisions, with male cells ceasing their doubling before female cells. Hayflick’s explanation is that an intracellular clock determines an end to each cell’s life. The genetic design theory, proposed by Charles Minot in 1908, contends that the deoxyribonucleic acid (DNA) of every cell determines the course of aging in that cell. In other words, aging is designed into the “blueprint” of each organism at the time of conception. Consistency of aging in a species is therefore seen to be the consequence of similar DNA. Extracellular mechanisms are the focus of the neuroendocrine theory. Many declines in vitality are induced by drops of particular hormones. For example, dehydroepiandrosterone (DHEA) diminishes with age, and some research indicates that supplements of DHEA in older adults restore many youthful characteristics. According to this theory, aging is predetermined by changes in endocrine gland functioning that reduce levels of various hormones. Theories of aging based on random events can be roughly categorized into three types. The wear-and-tear approach to aging assumes that people and all other biological organisms simply wear out like machines. Aging is seen to be an erosion process, and the greater the stress on the body, the greater the acceleration of aging. For example, the more skin is exposed to the sun, the more rapidly it ages. Error theories of aging focus on something going wrong with physiological functioning. Many sorts of errors are implicated in aging. Some of these errors may be intracellular, such as flaws in the transcription process involving ribonucleic acid (RNA) that lead to the loss of DNA or flaws in enzymes that impair the production of proteins. Other errors may be extracellular, such as the immune system attacking and weakening the host body or failures to maintain proper homeostatic balances such as temperature or blood sugar level. A third random event approach to aging emphasizes the accumulation of harmful substances which then interfere with the smooth functioning of the body. Some of the accumulated substances are produced within the body, such as waste products, genetic mutations, cross linkages (interconnections that reduce pliability in bodily tissues), and caramelization (coating of proteins by excess sugars). Some harmful substances come from outside the
Aging ✧ 23 body. Free radicals—molecules with one or more unpaired electrons—are highly reactive and can initiate chemical changes in the wrong place and at the wrong time. Oxygen is a major source of free radicals, and breathing ensures a constant influx of these damaging substances. While free radicals are also produced in the body and play roles in digestion and immunological responses, their accumulation, if not checked by antioxidants and free radical scavengers such as melatonin, inevitably leads to physiological damage. Various pollutants and drugs can also add and subtract from the vigors of youth. For example, smokers show excessive and accelerated wrinkling of the skin as compared to nonsmokers. No one theory of aging, whether based on random or programmed events, offers a complete explanation of the aging process. That is why many gerontologists adopt an eclectic perspective that views aging as a consequence of numerous events, designed and undesigned. External Aging Normal aging involves bone loss that is more severe in women (30 percent) than in men (17 percent). Two main consequences follow when the bones lose calcium. First, osteoporosis, in which bone loss leads to a stooping posture and a high risk of fractures, increases in incidence. Second, height decreases with aging. Lifetime average losses in height are greater for women (2.0 inches) than for men (1.25 inches), with the rate of loss increasing with age. Tooth loss is primarily a result of periodontal disease, the swelling and shrinking of infected gums, not calcium loss. While height declines with age, the pattern is different for weight. Most studies show increases of weight until the mid-sixties and then declining weight through late adulthood. Because excess weight is a risk factor for premature death, late adulthood averages are lower, in part, because of the smaller representation of heavier individuals. Other dimensions of human stature also change with aging. The nose and ears elongate. The chest and head increase in circumference. The trunk becomes thicker, and the legs and arms become thinner, although arm span shows only a slight decrease through the years. Muscle mass, particularly the percentage of lean muscle tissue, decreases with age and further alters physical appearance. The aging of the skin is a consequence of both preventable and unpreventable factors. What is unpreventable is the inevitable loss of elastin and collagen proteins that help the skin retain its suppleness. What is preventable are two lifestyle choices that dramatically impact the rate and severity of wrinkling. Smoking, which accelerates the loss of collagen, leads to excessive wrinkling. In the case of heavy smokers, the wrinkling is several times more severe than in nonsmokers. Time spent in the sun also greatly influences wrinkling: The greater the exposure to the sun, the earlier and more excessive the wrinkling and the greater the risk of skin cancer.
24 ✧ Aging A slowing in the growth rate of hair and fingernails (but not toenails) is observed with aging. The slowing of the growth rate in hair is more rapid in men than in women and can lead to baldness. High levels of certain androgen hormones, which men have more of, appear to play the key role in this process. Graying is caused by decreases of melanin, a pigment that gives hair its color. Body hairs also become less numerous during the aging process; an exception is that hair on the upper lip of women, particularly after the menopause, often increases. Physical strength and capacity for exercise begin to show declines in the thirties and are related primarily to decreases in muscle tissue. In general, people who maintain good and consistent exercise patterns throughout their lives exhibit considerably smaller declines than those whose lifestyles are sedentary. The Senses Several changes occur with aging that impair the ability of the eyes to convey the physical world. Changes in the lens of the eye that affect vision are usually first noticed by people in their forties. The lens becomes thicker and harder through the years, which begins to interfere with the ability to see things close to the eyes. The result is presbyopia, or farsightedness, which is why middle-aged adults usually need reading glasses. The lens also begins to cloud with aging, a condition called cataracts, further obscuring vision in most elderly people. The opening permitting light to reach the lens is called the pupil, and its ability to dilate decreases with age. This results in less light being allowed to enter the eye and can cause night blindness. Directly in front of the pupil is a chamber containing a fluid called aqueous humor. A decrease in the amount of aqueous humor leaving this chamber can result in a buildup of pressure called glaucoma that, if unchecked, can lead to blindness. Two other notable changes in vision are linked with aging. First, peripheral vision usually begins to decrease in the late fifties to sixties. Second, there is often a decrease in the ability to perceive blues and greens. Hearing losses with age occur in ability to detect both pitches and loudness. By the mid-thirties, people begin a progressive loss of the ability to hear higher-pitched sounds, a condition called presbycusis. Furthermore, because the pitch range of male hearing is lower than female hearing, hearing loss enters the range of normal human conversation sooner in men than in women. There is also a diminishment in loudness perception, which is measured in decibels. Both long exposures to dangerous decibel levels (over 90 decibels) and shorter exposures to extremely high decibel levels will damage hearing cells and increase hearing deficits. Age-related deficits in taste are the result of degenerative changes in the taste buds that reduce the perception of bitterness and saltiness more than
Aging ✧ 25 sourness or sweetness. Thirst tends to slacken with age, increasing the risk of dehydration, especially in the elderly. Several studies have also recorded drops in the sense of smell. This drop in the ability to detect odors includes a diminished ability to detect faint odors and a lesser ability to judge the magnitude of strong odors. The decline is steeper and more rapid for men than women. The sense of touch is actually at least three senses, each mediated by different sense organs: skin contact and movement, temperature, and pain. Research indicates some decline in all three tactile abilities. The vestibular sense, or sense of balance, begins to decline in the fifties. Impairment of this sense combined with bone loss greatly increases the risk of broken bones as people grow older. Internal Systems Changes in both the quality and quantity of sleep occur with age. Rapid eye movement (REM) sleep, which facilitates learning and is characterized by a high prevalence of dreaming, gradually declines from birth to death. The amount of sleep also declines from birth to late adulthood: from about sixteen hours to a little under seven hours. As people move into middle age, they typically wake up more frequently from their sleeping (maintenance insomnia) and end their sleeping periods sooner (termination insomnia). Diseases of the cardiovascular system became the leading causes of death in most industrialized countries during the course of the twentieth century. Great variability in the rates of heart attacks, atherosclerosis (thickening and hardening of the arteries), and other cardiovascular problems among different nations demonstrates the importance of environmental factors, particularly diet, in addition to normal aging. What is normal is that both the heart and the blood vessels become less flexible. A combination of these changes and lifestyle dynamics makes several diseases more prevalent with aging. Systolic blood pressure increases and can result in hypertension (high blood pressure); diastolic blood pressure does not increase with aging. Decreased oxygen to the heart can lead to chest pains called angina or, in the case of a complete blockage, a stroke. Decreased heart output and increased blood pressure lead to increased fluid around the heart, a condition called congestive heart failure, a leading reason for hospitalization in the elderly. Declines in the functioning of the organs of the digestive system associated with aging are generally not severe enough to cause major health problems. There are decreases in several digestive enzymes, particularly the protein enzyme hydrochloric acid, secreted by the stomach. On the other hand, bile, which is stored in the gallbladder and helps to break down fats, can increase in concentration and lead to gallstones. The liver, which produces bile and plays the major role in regulating blood contents, shows
26 ✧ Aging
Periodic monitoring of blood pressure is recommended to detect hypertension in older adults. (Digital Stock)
some shrinkage with age. Hardening of the liver, termed cirrhosis, is more attributable to alcohol consumption than to normal aging. The general rule regarding the aging of the endocrine system, the cells and tissues that produce hormones, is that lesser amounts of various hormones are produced and cells become less responsive to the hormones. Drops in melatonin lead to sleep problems; in thyroxin, to decreases in metabolism; in insulin and glucagon, to greater difficulty regulating the blood sugar level; and in androgens and estrogens, to declining reproductive ability and deficits in muscles and bones. Systemic Slowdown Healing capacity is reduced in two ways as people age. Wound repair is slower in older people, and the strength of the repairs is diminished. Once the healing process is completed, however, the repairs are basically as good in older people as in younger individuals. Inflammatory response to irritants is reduced with increasing age, as is immune system responsiveness. Skin with greater exposure to the sun heals slower than skin that is infrequently exposed to the sun. The body’s main defense against attacking microorganisms and foreign
Aging ✧ 27 materials is the immune system. To function effectively, the immune system must maintain a balance between the extremes of too much activity, in which immune cells attack other cells of the body as foreign, and too little activity, in which foreign invaders to the body are not repulsed. As people grow older, there is an increased tendency for the immune system to lose that necessary balance. Thus, cancers become more likely as a result of immunological underreactiveness and, conversely, overreactiveness leads to autoimmune disorders such as certain kinds of arthritis. The most significant observable change in the immune system occurs in the thymus gland, which shrinks after puberty and loses over 90 percent of its original size by the age of fifty. The effectiveness of white blood cells, such as the lymphocytes and neutrophils, also decreases with the increase in years. One of the reasons that people typically put on excess weight during middle age is a decrease in the basal metabolic rate (BMR). Declines in the BMR mean that less food is “burned” as fuel and more food is turned into fat stores. The good news about a lowered BMR is that it is linked with greater longevity: Mammals with lower BMRs generally outlive mammals with higher BMRs, which is also one reason that females (with lower BMRs) outlive males. Age-related changes in the nervous system have a significant impact on the physiological, psychological, and social aspects of aging. As people age, there are two primary changes observed in their nervous systems. First, the speed of messages to and from nerve cells (neurons) slows down about 10 percent. This slowing is partly responsible for increases in reaction time and a general decrease in the speed at which older people do activities. The second major change in the nervous system is a shrinkage in size. For example, measures of the size of the human brain reveal average decreases of approximately 10 percent from young adulthood to late adulthood. This decrease is partly attributable to losses of neurons and partly the consequence of shrinkage of the neurons themselves. There are significant age-related differences in declining reproductive ability (called the climacteric) between females and males. By around the age of fifty, a decline in the number of a woman’s eggs and an associated decline in estrogen levels result in irregular menstrual periods and eventually the cessation of the menstrual cycle (the menopause), ending her ability to reproduce naturally. Furthermore, by middle age a woman’s remaining eggs begin to deteriorate in quality, diminishing her likelihood of becoming pregnant. Shrinkage in the size of the uterus, vagina, and breasts is also typical in postmenopausal women. There is no naturally induced end to a male’s reproductive capability. Declining hormone levels do, however, lead to a decline in the number of sperm produced as a man ages. The most problematic change associated with this gradual climacteric is the enlargement of the prostate gland and an increased risk of prostate cancer in elderly men. As men age, obtaining
28 ✧ Aging an erection becomes more difficult but maintaining it becomes easier. The most significant change in the respiratory system is a drop of over 50 percent in vital capacity (the amount of air volume that can be inspired) from young to late adulthood. Calcification of air passages, increased rigidity of the rib cage, reductions of elastin and collagen in the lungs (reducing their flexibility), and decreases in muscle strength all play a role in this decline. The ability to control body temperature is reduced as people grow older due to a reduction in sweat glands, subcutical skin (which controls the loss of body heat), and the density of the circulatory system of the skin. These changes put the elderly at greater risk in extremes of both cold and hot temperatures. Problems with the urinary tract can be a major source of embarrassment for the elderly. Approximately half of all people over the age of sixty-five have some problems with bladder control. The functioning of the kidneys also declines about 50 percent from young to late adulthood. Slowing Aging Three primary factors will help a person to live long and well: good genes, a good environment, and a good lifestyle. Because the first two factors are largely the result of other people’s decisions, gerontologists have usually emphasized lifestyle choices for people who want to do something about how they age. Lifestyle decisions have the greatest impact on functional aging. Consistent and moderate exercise, a diet high in fruits and vegetables, lower exposure to harsh environments, maintenance of proper weight, and intellectual stimulation have all been demonstrated to improve the quality of life in the later years. Of particular interest in this regard has been work with a group of nuns in Mankato, Minnesota, who are being studied because of their mental sharpness in their elderly years and their great longevity. The nuns lead very stimulating intellectual lives, and autopsies of their brains have revealed fewer signs of aging than in comparable groups. The implication from this research is that intellectual activity slows the ravages of aging. The search for the proverbial fountain of youth and immortality has been the preoccupation of scholar and nonscholar alike throughout the centuries. Many of the supposed “wonder cures” for aging have had consequences worse than the natural progression of aging itself. Research, however, has provided some hope of increasing the life span. Studies with a variety of mammalian species have found that significant drops in caloric intake translate into significant increases in both functional and chronological aging. Nevertheless, limits remain to the beneficial effects of caloric restriction. —Paul J. Chara, Jr.
Aging ✧ 29 See also Alcoholism among the elderly; Alzheimer’s disease; Arthritis; Breast cancer; Broken bones in the elderly; Cancer; Canes and walkers; Cardiac rehabilitation; Colon cancer; Cosmetic surgery and aging; Death and dying; Dementia; Dental problems in the elderly; Depression in the elderly; Diabetes mellitus; Elder abuse; Emphysema; Euthanasia; Exercise and the elderly; Falls among the elderly; Foot disorders; Hair loss and baldness; Health insurance; Hearing aids; Hearing loss; Heart attacks; Heart disease; Heart disease and women; Hormone replacement therapy; Hospitalization of the elderly; Illnesses among the elderly; Immunizations for the elderly; Incontinence; Infertility in men; Infertility in women; Influenza; Injuries among the elderly; Living wills; Lung cancer; Macular degeneration; Malnutrition among the elderly; Mammograms; Mastectomy; Medications and the elderly; Memory loss; Menopause; Mobility problems in the elderly; Muscle loss with aging; Nursing and convalescent homes; Nutrition and aging; Obesity and aging; Osteoporosis; Overmedication; Pain management; Parkinson’s disease; Preventive medicine; Prostate cancer; Prostate enlargement; Reaction time and aging; Safety issues for the elderly; Screening; Sexual dysfunction; Skin disorders with aging; Sleep changes with aging; Strokes; Suicide among the elderly; Temperature regulation and aging; Terminal illnesses; Vision problems with aging; Weight changes with aging; Wheelchair use among the elderly. For Further Information: Erikson, Erik H., and Joan M. Erikson. The Life Cycle Completed. Extended version. New York: W. W. Norton, 1997. This final work of a noted developmental psychologist, with additional material by his wife, presents an eloquent affirmation of what elderly people can become. Evans, William, J., Jacqueline Thompson, and Irwin H. Rosenberg. Biomarkers: The Ten Keys to Prolonging Vitality. New York: Simon & Schuster, 1992. Guidelines for how diet and exercise can improve the aging process are described. Hayflick, Leonard. How and Why We Age. New York: Ballantine Books, 1994. A preeminent scientist offers a comprehensive examination of the aging process. Levinson, Daniel J., et al. The Seasons of a Man’s Life. New York: Ballantine Books, 1978. Examines the issues with which individuals grapple as they age in the book that popularized the concept of midlife crisis. Weiss, Rick, and Karen Kasmauski. “Aging: New Answers to Old Questions.” National Geographic 192, no. 5 (November, 1997). Presents an excellent overview on aging and the techniques used to slow it down.
30 ✧ AIDS
✧ AIDS Type of issue: Epidemics Definition: A disorder that develops when the human immunodeficiency virus (HIV) attacks the body’s T cells, eventually destroying them in sufficient numbers to render victims of the disease unable to fight opportunistic infections that, in cases of full-blown AIDS, lead to their deaths. No one really knows how long ago AIDS first afflicted human populations, but it received its first official recognition in the United States in 1981. The disease probably took lives for at least a decade prior to its being recognized and diagnosed. AIDS was characterized by a wasting away of those who fell ill with it. Symptoms and Systemic Effects A first symptom was often the appearance of black, purple, or pink spots on the extremities that were diagnosed as a rather rare condition called Kaposi’s sarcoma. This was once thought to be a form of cancer of the walls of blood and lymphatic vessels, although it is no longer classified as cancer in the conventional sense. Other frequent precursors of AIDS are persistent flu-like symptoms, a general loss of weight, diarrhea, continued nausea, and, in some patients, dementia. These symptoms may be accompanied or followed by Pneumocystis carinii pneumonia (PCP), which is the most common cause of death in AIDS patients, who are also particularly vulnerable to tuberculosis. Both PCP and tuberculosis attack the lungs, causing severe respiratory problems in those afflicted with these diseases. It is perhaps imprecise to say that people die of AIDS. It is more accurate to say that people suffering from AIDS are left with an immune system so weakened that it cannot serve its normal purpose, that of warding off infection. The cells that attack disease in the body, having been consumed by the HIV, are rendered useless. As T cell counts drop, usually to below five hundred, patients lack defenses against the opportunistic diseases that they contract and that generally kill them. The immune system functions in such a way that cells attacked by viruses typically respond by releasing chemicals that summon white blood cells, the body’s chief defense against disease. Some of these white cells, called macrophages, consume offending germs before they are able to cause an infection. Other such cells, called lymphocytes, produce antibodies in the form of proteins that attach themselves to parts of virus proteins, preventing them from attacking the cells they seek to destroy or weakening them, thus clearing the path for macrophages to destroy them.
AIDS ✧ 31 The lymphocytes called killer T cells destroy infected cells and cancer cells. Another type of T cell, called a helper T cell, causes lymphocytes designated B cells, to propagate and produce antibodies bent on attacking cells infected by viruses. In AIDS victims, the T cells are so diminished that the body’s natural defenses virtually disappear. Slow Recognition of the AIDS Epidemic In its earliest manifestations, AIDS baffled medical researchers. The virus that causes it, while so fragile that it dies almost immediately on exposure to air, is capable of endlessly changing its shape and characteristics so that those devising ways to fight it have to find ways to fight a multiplicity of related viruses. HIV is particularly insidious because it can lurk undetected for long periods—some AIDS researchers say for more than ten years—in the bloodstreams, lymph nodes, and livers of those who have been infected. The infected person may display no symptoms of the disease. The presence of HIV can be detected through a relatively simple blood test, but those who are asymptomatic often see no reason to be tested. False negatives can be recorded if one is tested shortly after exposure. Tests given three or more months after exposure produce the most reliable results. AIDS was first thought to be a disease that mostly afflicted homosexual males who contracted it through the exchange of body fluids during sex, particularly anal sex, in which the passive partner (bottom) was more susceptible to contracting the disease than the active partner (top). Because of the stigma attached to the gay lifestyle, government agencies and the medical profession responded to the growing AIDS epidemic more slowly than they characteristically respond to health emergencies and potential epidemics. Although the Centers for Disease Control (CDC) issued warnings about the disease as early as 1981, President Ronald Reagan never publicly acknowledged its existence until 1987, a lapse for which he made a public apology in 1990. United States Surgeon General C. Everett Koop recognized the threat and urged the establishment of national sex education programs, but with a public either apathetic about the disease or openly hostile toward those who had it, the lag time between its discovery and concerted efforts to control it was shockingly long. Ultimately, it was the AIDS deaths of such prominent people as actor Rock Hudson, tennis star Arthur Ashe, and child activist Ryan White that heightened public awareness of the AIDS dilemma. It soon became apparent that AIDS was not wholly a gay disease but one that could afflict other groups of people, including children born to parents who carried the virus and heterosexual men and women who engaged in unprotected sex. Prostitutes, both male and female, were particularly vulnerable.
32 ✧ AIDS People at Risk for Contracting HIV People who received blood transfusions in the early days of the epidemic, as was the case with Ryan White, a hemophiliac who required regular transfusions, had little protection against receiving tainted blood. This problem has diminished in recent years. Another high-risk group was intravenous drug users who often injected themselves with needles that had been used previously by other addicts whose blood, clinging to the shared needle, carried the virus. Medical personnel began to exercise extreme caution to avoid sticking themselves with needles they had used for injecting patients. New protocols were developed for the disposal of such needles and of other materials used with HIV-positive patients. As people became more cognizant of the causes of AIDS, physicians, nurses, dentists, and oral hygienists began routinely to wear latex gloves and masks in all their contacts with patients. When the disease was first brought to public attention, the public was extremely fearful that it might be spread through touching, sharing food, and kissing. Although such fears were groundless, some medical personnel, including physicians and dentists, refused to treat those suffering from AIDS. Parents rebelled against school districts that integrated HIV-positive children into the general school population. Some such prejudices continue to exist, although the more enlightened members of society realize that the possibility of infection exists only where bodily fluids have been exchanged intravenously or through sexual contact. The best defenses against AIDS are sexual abstinence and the use of measures to prevent infection. Sexual encounters should involve the use of condoms unless one is absolutely certain that his or her partner is not infected. Complete honesty about sexual matters is essential for married people or for those in committed relationships. Members of such relationships who have unprotected sex with one other person are at risk not only from the person with whom they have an encounter but from every person with whom that person has had previous unprotected encounters. It is essential in any casual sexual encounter that body fluids not be exchanged. Treatment Options Although AIDS has been an acknowledged health problem since 1981, no cure for the disease has emerged nor have vaccines been developed to prevent infection. The CDC and other government agencies have engaged in considerable research to find both a cure and a preventive vaccine, but progress has been slow, often hampered by lack of funding and by the stigma that still makes AIDS a politically uncomfortable topic for public discussion. Scientists have found HIV particularly challenging to combat because it is such a complex virus and because it has the ability to change itself, virtually to reinvent itself, almost at will. Vaccines that have controlled or eliminated
AIDS ✧ 33 such diseases as polio, smallpox, and measles are effective because they are aimed at viruses that, although complex, remain relatively stable. HIV is part of a different category of viruses altogether. Despite the challenges that HIV offers, considerable headway has been achieved in making the presence of this virus in HIV-positive people manageable for considerable periods of time. There was a 19 percent decrease in AIDS-related deaths from the first nine months of 1995 to the first nine months of the following year, with 37,900 such deaths recorded in the United States in 1995 and 30,700 recorded in 1996. When AIDS was first recognized in 1981, a diagnosis was equivalent to a death sentence. It was not until 1986 that the CDC revealed that a new drug, azidothymidine, commonly called AZT, first developed in 1964 as a cancer drug and sold under the brand name Retrovir, was proving effective in combating retroviruses, of which HIV was one. CDC’s tests showed that those on a course of AZT showed a weight gain within four weeks, whereas those on the placebo lost weight. After six months, just 1 of the AIDS patients on AZT had died, whereas 19 of the 137 patients in the group receiving the placebo had succumbed. So dramatic were the initial results that the United States Food and Drug Administration approved of the CDC’s halting the study and granted approval to distribute AZT in 1987. The drug worked by blocking the ability of an enzyme necessary for the early stage of HIV reproduction to function. Not only were the lives of AIDS sufferers being extended, but they were also less subject to the opportunistic infections that had plagued them in the past. The drug also appeared to inhibit the growth of the virus in the brain, thereby reducing substantially the dementia that earlier AIDS victims had often endured. AZT treatment of HIV-positive pregnant women reduced by two-thirds the risk that the disease would be transmitted from mother to baby. Even though AZT quickly became the major drug for treating AIDS, it was not without its hazards. A very toxic drug, AZT was first given in large doses at frequent intervals. It took the medical profession some time to realize that smaller doses taken less frequently were beneficial. The drug, even when the dosage was reduced, caused such substantial side effects in many patients that an estimated 40 to 80 percent had to discontinue treatment because of acute anemia, diarrhea, nausea, and damage to the liver, bone marrow, and nerves. Even those with minimal side effects often were taken off the drug because they developed a resistance to it. Physicians soon learned that it was more effective to treat HIV-positive and AIDS patients with several drugs rather than merely with AZT. When a single drug is used, any particles of the virus not killed by the drug may mutate, creating a new strain of HIV that becomes resistant to the drug. When three drugs are used simultaneously, the virus has to go through three mutations, which is much more difficult for it to do.
34 ✧ AIDS These drug cocktails, while effective in reducing substantially the amounts of virus present in the blood—sometimes to virtually undetectable levels— involve taking between fourteen and twenty pills and capsules a day and having one’s life revolve around medicating at precise times twenty-four hours a day. To violate the strict routine imposed by such a course of medication is to invite failure, yet many people on this routine are destined to stay on it throughout their lives. The most promising treatment for HIV was developed after researchers discovered the HIV protease in 1986. Protease is needed if HIV is to reproduce in the later stages of its life cycle. Protease inhibitors prevent such reproduction, but the early ones were so toxic in tests on humans and animals that they could not be used. Finally, however, less toxic versions of the protease inhibitors were developed and by 1994, they went beyond slowing viral reproduction as AZT had, seemingly eliminating it altogether. It has been determined that in the first few weeks after infection, HIV occurs in the lymph nodes where standard blood tests do not detect it. Tests have shown that during this period, HIV makes billions of copies of itself every day. By the time HIV is detected in the bloodstream, the lymph nodes have probably been destroyed and the immune system is collapsing. Therefore, it is now thought that protease inhibitors should be used as soon after exposure as possible. Cost has been an inhibiting factor in the treatment of HIV-positive and AIDS patients. Therapy with three protease inhibitors costs between twelve and sixteen thousand dollars a year. Many insurance companies balk at covering such expenses, and a number of states limit state-funded treatment to one protease inhibitor, whereas seventeen states provide none. In Third World countries, where AIDS is wiping out huge numbers of people, treatment is virtually unobtainable. Those who are HIV-positive simply wait for their devastated immune systems to collapse and give way to full-blown AIDS, which will quickly be followed by death from one or more opportunistic diseases. The Scope of the Problem In order to gain a perspective on the HIV/AIDS dilemma, it is necessary to realize the extent of it. No continent is exempt from AIDS, and the United States is less affected than some other parts of the world where the problem is intensified by both poverty and political infighting that make the care of AIDS victims severely substandard, indeed, virtually nonexistent except for what families can to do provide for stricken relatives. The highest incident of AIDS is in sub-Saharan Africa, where well over 20 million people are afflicted. Nearly 6 million cases are reported in south and southeast Asia, a million and a half in Latin America. This compares with about 860,000 cases in North America. Statistics show that worldwide, just
AIDS ✧ 35 under 6 million people were newly infected in 1997 alone. Of these, just over 2 million were women and about 590,000 were children. The number of children orphaned by AIDS through the deaths of both parents is estimated at over 8 million, most of them in Third World countries. In 1997, over 30 million people worldwide suffered from HIV/AIDS. In that year, some 2.3 million died of AIDS-related diseases, although in the same year there was a percentage decrease in AIDS deaths in the United States, partly because many people were avoiding risky sexual and drug encounters, but mostly because of the availability of protease inhibitors and other drugs that reduce AIDS from an unquestionably fatal disease to a manageable one that is often compared to diabetes, which is manageable through medications. Half of all HIV-positive people develop AIDS within nine years of the onset of the infection, and 40 percent die within ten years. The only reasonable way to conquer this disease is through the development of one or more vaccines that will make people immune from it. If an HIV/AIDS vaccine is developed, the next major tasks facing agencies like the World Health Organization will be to find money to produce it for the whole world and to devise a means of inoculating entire populations in the Third World—Africa, Latin America, and Asia. But developing a vaccine for HIV/ AIDS is much more complicated than developing one for many of the other diseases that have been brought under control. To begin with, there are at least twelve identifiable strains of HIV, each unique, each diabolically tricky in reinventing itself. A vaccine that offers immunity to one strain of the virus may well leave one defenseless against other strains. A further complication is that most effective vaccines have been produced by using weakened or inactivated forms of the virus that the vaccine is being created to attack. HIV, however, changes form with such lightning speed that the danger of transmitting the virus to those being inoculated is quite real. Viruses against which successful vaccines have been devised, unlike HIV, do not attack and destroy the immune system. They trigger antibodies that combat the offending cells that cause the disease. With HIV, there is the danger that the virus will change form quickly enough that any antibodies produced will not recognize the characteristics of the viruses they are supposed to attack. This could result in the collapse of the immune system in a person who, before the immunization, was healthy. Because of the risks involved, testing of HIV/AIDS vaccines in the United States has been carried out mostly on monkeys and chimpanzees, whose immune systems are much like those of humans. One genetically engineered vaccine was given to chimpanzees who were injected one year later with enough of the AIDS virus to infect about 250 animals. Subsequent tests revealed that these animals were completely free of the virus, although there is always the danger that some remnant of it might still lurk somewhere in the systems of the inoculated animals. This test has been sufficiently prom-
36 ✧ AIDS and children ising, however, that limited testing is being done on human subjects who are HIV-negative. —R. Baird Shuman See also AIDS and children; AIDS and women; Epidemics; Sexually transmitted diseases (STDs); Terminal illnesses. For Further Information: Bellenir, Karen, ed. AIDS Sourcebook. 2d ed. Detroit: Omnigraphics, 1999. This book provides the most comprehensive coverage currently available on matters relating to AIDS. It is rich with statistical information. Its sections on the management of the disease and prevention are particularly notable. Bartlett, John G., and Ann K. Finkbeiner. The Guide to Living with HIV Infection. 4th ed. Baltimore: The Johns Hopkins University Press, 1998. Developed at the AIDS clinic of the Johns Hopkins University Hospital; offers practical advice for dealing with HIV and AIDS on a day-to-day basis. Goes into such matters as making legal and financial decisions and preparing to die. Check, William A. AIDS. Philadelphia: Chelsea House, 1999. This volume, part of The Encyclopedia of Health, is directed toward the adolescent audience. The presentation is crisp and direct; C. Everett Koop’s introduction well organized and effective. Houts, Peter S., ed. Home Care Guide for HIV and AIDS: For Family and Friends Giving Care at Home. Philadelphia: American College of Physicians, 1998. Well organized, as comprehensive as any book available on the practical aspects of managing HIV/AIDS treatment at home. Deals not only with the problems of the afflicted but also with the problems of those who care for them. Shein, Lori. AIDS. San Diego: Lucent Books, 1998. Aimed at general and adolescent audiences. Strong chapter on prevention. Offers a list of AIDS organizations.
✧ AIDS and children Type of issue: Children’s health, epidemics Definition: The effects of human immunodeficiency virus (HIV) on the children, who often acquired it from their mothers during childbirth. As a segment of the growing AIDS epidemic, pediatric cases offer a unique set of issues pertaining to the transmission, physical health, and psychological care of children and their families.
AIDS and children ✧ 37 Reported AIDS Cases Among Children and Teenagers in the United States 800 750 700
Und
er 5
600
year
s ol d
673
610 561
585
556
500
CASES
485
13-19 years old
400 399
386
381
300
5-12 year 200
173
s old
220
198
193
148 139
175 139
100
0 1990
1992
1994
1993
1995
1996
YEAR
Source: Statistical Abstract of the United States 1997. Washington, D.C.: GPO, 1997.
Awareness and detection of the disease known as acquired immunodeficiency syndrome, or AIDS, began in the 1980’s, and the first cases of children with AIDS appeared in 1982. AIDS was diagnosed only after the struggle to determine the reason behind immunodeficiency and opportunistic infections that began to occur in children under the age of two. Such baffling cases had appeared in the late 1970’s but were not yet linked with the AIDS disorder. Incidence and Spread The number of pediatric cases of AIDS reached 189 by the end of 1981. The number of cases increased during that decade, and by the middle of 1992 more than 4,000 cases of pediatric AIDS in the United States had been reported to the Centers for Disease Control (CDC). In comparison to the
38 ✧ AIDS and children number of AIDS cases reported for individuals age thirteen and older, pediatric cases represented only 2 percent of all diagnoses. At the same time, however, AIDS continued to climb as one of the leading causes of death among children. Cases of pediatric AIDS are distributed throughout the United States. The metropolitan areas and larger cities, such as New York, Miami, and Washington, D.C., have a greater proportion of pediatric AIDS cases. In addition, a greater number of pediatric AIDS cases are found among African American children. There are slightly more cases of AIDS among male children than among female children, a difference attributed to transfusions of tainted blood to male hemophilia patients. Transmission of the Virus Most children acquire AIDS through the transmission of human immunodeficiency virus (HIV) by their mothers. Known as “vertical transmission,” this can occur during pregnancy through the placental tissue or amniotic fluid, during labor and delivery via blood or vaginal secretions, or postnatally through mothers’ breast milk. Nevertheless, not all infants born to HIVpositive women acquire HIV. About half of all infected infants test positive for HIV soon after birth, indicating that the virus was transmitted during pregnancy. Some cases of HIV in fetuses have been detected as early as the first and second trimesters by testing fetal tissue. Evidence of infection, however, may not appear until a few days, months, or even years following birth. HIV-infected children are thus often the result of HIV-infected mothers. Many such mothers are intravenous drug users. Most other women infected with HIV are believed to have acquired the virus by heterosexual contact with male intravenous drug users. Some of these women may also have exchanged sex for drugs, engaged in unprotected sex, or had sex with multiple partners. Cases of pediatric AIDS can also be transmitted through the receipt of blood and blood products. The number of cases of HIV transmission linked to blood transfusions has drastically decreased since 1985 because of more stringent procedures for screening blood by medical personnel. While not generally acknowledged, it is also possible for children to acquire HIV through sexual abuse, child prostitution, or children’s use of intravenous drugs. Physical Health Experiences HIV affects the immune system, thus rendering infected children vulnerable to common infections and opportunistic infections. Children are more susceptible to infections than adults, because, unlike adults, they have not
AIDS and children ✧ 39 had time to develop a healthy immune system prior to becoming infected. Symptoms of the disease vary in number, duration, and severity from child to child. Children infected with HIV alternate between ill and healthy periods and are often asymptomatic in their early lives. The earlier children show symptoms of HIV, the more rapid the advancement of the disease and the progression toward death. In 1987 the CDC designed a classification system specifically for children. This classification system lists many diagnoses as AIDS indicators and is arranged in such a way so that practitioners can track the progress of the disease. Although this system is very similar to that used for adults, two conditions are listed for children only: a chronic lung condition called lymphoid interstitial pneumonitis and recurrent serious bacterial infections. Some of the more common symptoms in HIV-infected children include recurrent diarrhea, thrush, fever, malnutrition, and failure to thrive. Failure to thrive can include a lack of height and weight gain and a lack of growth of head circumference. HIV-infected children may also experience bacterial infections, such as sinusitis, meningitis, pneumonia, urinary tract infection, and anemia—an extremely common symptom. The opportunistic infection Pneumocystis carinii pneumonia (PCP), considered to be the most common opportunistic infection for infants and children, affects about half of all children with AIDS. The signs of PCP include shortness of breath, fever, cough, and rapid breathing. Often the disease indicating the presence of HIV, it is most often diagnosed in the early months of life and is associated with a high rate of mortality. Neurologic disease, another potential diagnosis, can cause developmental delay, loss of previously achieved milestones, and attention deficits. Children with neurologic disease may experience seizures, weakness, or even blindness. In the advanced stages of HIV infection, the virus can cause damage to the central nervous system, the heart, lungs, and kidneys. Effects on Families Children and other family members can be affected by pediatric AIDS in numerous ways. If children require hospitalization, they may be separated from their families for extended periods, thus necessitating their segregation from the family environment. In other circumstances, infants may be abandoned or relocated to other family members’ homes, because caregivers are unable to care for their children’s needs, as in the case of drug-addicted mothers. In addition, caregivers may also be infected with HIV, thus intensifying the impact of all aspects of the disease. Families with HIV-infected children may also suffer financially. Physical care, equipment, visits by doctors and specialists, and the costs of hospitalization and medication are just some of the expenses that families with seriously ill members face. If families’ resources are limited, provisions for
40 ✧ AIDS and children basic needs may be inadequate. Proper nutrition, vital to attempting to maintain children’s health, may have to be sacrificed in order to pay health costs. Caregivers’ health may also be at risk, as they ignore their own needs while trying to meet those of their sick children. Family members may find that they must take on new roles, as they become nurses or income providers. Siblings may report feeling neglected or may feel burdened by the added responsibilities placed on them. Grandparents or other extended family members may assume greater primary caregiving responsibilities. Married couples may experience stress because their time and energy often become focused on their ailing children. Such experiences can emotionally drain family members, especially those who do not have adequate coping skills. Taking time for other family members and expressing appreciation for their contributions can help to reduce the intensity of these difficulties. Anticipatory grief, guilt, anxiety, and depression are some of the commonly faced emotional problems. These emotions can be triggered or heightened by social stigmatization, lack of social support, a reduction in the amount of time for socializing or being alone, and a sense of being overwhelmed by the physical and emotional burden of caring for terminally ill loved ones. Other children may be discouraged from spending time with children who have pediatric AIDS because of the fear of transmission. However, this fear is often based on a lack of knowledge about the disease. On the other hand, in order to ease some of the burden on families with ill children, the community may provide them with support, such as child care while parents run errands or take required time for themselves. The medical community can potentially offer support and understanding, providing parents with referrals to community programs and personnel that may be of assistance. The reaction and assistance of family members and the community are key to the impact upon the family system. —Kimberly A. Wallet See also AIDS; AIDS and women; Children’s health issues; Depression in children; Epidemics; Sexually transmitted diseases (STDs); Terminal illnesses. For Further Information: Cohen, Felissa L., and Jerry D. Durham, eds. Women, Children, and HIV/AIDS. New York: Springer, 1993. Kelly, Patricia, Susan Holman, Rosalie Rothenberg, and Stephen Paul Holzemer, eds. Primary Care of Women and Children with HIV Infection: A Multidisciplinary Approach. Boston: Jones and Bartlett, 1995. Pizzo, Philip A., and Catherine M. Wilfert, eds. Pediatric AIDS: The Challenge of HIV Infection in Infants, Children, and Adolescents. 3d ed. Baltimore: Lippincott Williams & Wilkins, 1999.
AIDS and women ✧ 41 Sherr, Lorraine, ed. AIDS and Adolescents. Amsterdam: Harwood Academic, 1997. Zeichner, Steven L., and Jennifer S. Read, eds. Handbook of Pediatric HIV Care. Baltimore: Lippincott Williams & Wilkins, 1999.
✧ AIDS and women Type of issue: Epidemics, women’s health Definition: The effects of human immunodeficiency virus (HIV) on the female body. Acquired immunodeficiency syndrome (AIDS), which is caused by HIV, presents a real and significant threat to women’s health. By the early 1990’s, HIV was spreading four times faster among women than among men, and it was the fifth leading cause of death of women aged fifteen to forty-four in the United States. Additionally, a disproportionate number of minority women had contracted HIV. While African American and Hispanic women constituted 21 percent of the general population, they made up 74 percent of all women with HIV. This trend seemed not to stem from racial issues but rather was representative of the socioeconomic statistics of the epidemic. Prior to 1992, the majority of cases of HIV in women were caused by intravenous drug use. Since 1992, the majority of reported new transmissions have been from sexual activities. It is considerably more likely for a man to transmit the virus to a woman through intercourse than it is for a woman to transmit the virus to a man. There are two primary reasons for this finding: because semen is introduced into the vagina during ejaculation and because microscopic tears may occur in the vaginal tissue during intercourse, breaking the skin barrier and allowing the virus easy access to open tissue. Consequently, the use of a condom is considered helpful in reducing the risk of transmission, although it does not provide complete protection. Only by abstinence from intercourse can one be sure to avoid contracting HIV through sexual contact. The Effects of the Virus At one time it was believed that women had a significantly reduced survival time compared to men after becoming infected with HIV, but this trend is more accurately a reflection of the socioeconomic status of women with the virus. In women, the virus was first seen in those with a history of blood transfusion (a few cases) and in those who used drugs intravenously, women who traditionally represented a poor economic picture. In men, the virus made its first significant statement among white gay men, who as a group
42 ✧ AIDS and women were more educated, had greater access to the health care system, and were in potentially better health in general than members of poorer populations. It is also true that until the 1990’s, all major HIV studies of drugs, treatments, and diseases associated with AIDS were conducted on male subjects; there were no reliable data to determine the action of the virus in women. More recent research, however, indicates that women often have different health problems after contracting HIV but that their life span is equal to that of men if all other factors are equal. The Needs of Women with HIV Areas of special consideration for women with HIV include physical, psychological, and social needs. Physically, women with HIV have a greater incidence of sexually transmitted diseases, including human papillomavirus (genital warts), chlamydia, candidiasis (yeast infections), and herpes than do women who are not HIV-positive. They also have a greatly increased incidence of uterine, ovarian, cervical, and breast cancers. Once any infection or cancer occurs in a woman with HIV, it may be very difficult to cure or slow the process of that disease because of the compromised condition of the patient’s immune system. Along with such gender-specific diseases and sexually transmitted diseases, a woman with HIV also must cope with all the other diseases that affect a failing immune system, such as pneumonia and various cancers. Another physical consideration for women is the possibility of conceiving or continuing a pregnancy once they have tested positive for HIV. If the drug zidovudine (formerly azidothymidine, or AZT) is used from the earliest point possible in pregnancy, the infant’s chances of contracting HIV may be reduced to as low as 5 percent. Questions arise, however, regarding the advisability of maintaining a pregnancy if AZT was not started early. Such a dilemma might arise, for example, if the diagnosis of AIDS had not yet been made, if the mother is quite ill with HIV and the pregnancy may hasten the mother’s death regardless of medication, or if the mother has no way to ensure support of a child after her own death. To resolve these issues, the woman may seek a therapeutic abortion, which may be available depending on the laws in her state. In addition to the need to deal with the diagnosis of HIV, there are special psychological considerations depending on what stage of life the woman has recently entered. A woman with HIV may be facing adolescence, early adulthood, middle age, or elder years. It is important for an individual who is HIV-positive to accomplish the tasks of each stage of life, just as it is for uninfected women. In the 1990’s, there was a new category of women entering adolescence, those who were born HIV-infected and had lived all their lives in that state. The social needs of the HIV-positive woman are numerous and should be broadly defined because, as with psychological needs, each case differs.
Alcoholism ✧ 43 Financial security is necessary through the progress of the virus, to cover not only health care and the payment of medical bills but also food, clothing, shelter, possibly the provision of the same for dependents, and transportation. The woman with HIV also needs support for her life and lifestyle, and privacy and security considerations accompany the seeking of such help. A woman who has kept her HIV status secret risks letting her family and friends know of the illness, and if there are children involved, she runs the risk of having her children removed from her care. If she is an intravenous drug user, she may be at legal risk if she seeks help. Social support also may be required in the notification of any past sexual partners who may have been exposed to the virus; such contact may be difficult, but it is necessary. By the beginning of the twenty-first century, twenty years into the AIDS epidemic, women had not had a primary voice in research, treatment trials, or the allocation of funds. As the spread of HIV has led to a primarily heterosexual transmission of the virus, the special needs of women with the disease have begun to emerge. There is a distinct need for further study on the impact of HIV and AIDS on the female body. —Kris Riddlesperger See also Abortion; AIDS; AIDS and children; Alcoholism; Condoms; Epidemics; Hospice; Sexually transmitted diseases (STDs); Terminal illnesses; Women’s health issues. For Further Information: Cotton, Deborah J., and D. Heather Watts, eds. The Medical Management of AIDS in Women. New York: Wiley-Liss, 1997. Fan, Hung, Ross F. Conner, and Luis P. Villarreal. The Biology of AIDS. 4th ed. Boston: Jones and Bartlett, 2000. Stine, Gerald J. Acquired Immune Deficiency Syndrome: Biological, Medical, Social, and Legal Issues. 3d ed. Englewood Cliffs, N.J.: Prentice Hall, 1997. _______. AIDS Update 2001. Upper Saddle River, N.J.: Prentice Hall, 2000. White, Edith. Breastfeeding and HIV/AIDS: The Research, the Politics, the Women’s Responses. Jefferson, N.C.: McFarland, 1999.
✧ Alcoholism Type of issue: Mental health, social trends Definition: The compulsive drinking of and dependency on alcoholic beverages; viewed as psychological in origin, it can be arrested but not cured. In 1992, it was estimated that nearly 70 percent of Americans used alcoholic beverages, that more than ten million such people were involved in the
44 ✧ Alcoholism severe substance abuse of alcohol, and that about 250,000 alcohol-related deaths occur each year. The Physiology and Psychology of Alcoholism Some deaths attributable to alcohol occur as a result of alcohol poisoning, from excessive consumption in a short time period. The drug primarily depresses the action of the central nervous system, creating the desired euphoric effects of alcohol consumption. Given a drink or two, a drinker may become relaxed and uninhibited. A few more drinks, however, may increase blood alcohol levels above .10 and further depress the central nervous system, causing lack of coordination, slurred speech, and stuporous sleep. If just a little more alcohol is imbibed before stupor occurs and blood alcohol levels rise much above .25, further depression of the central nervous system stops breathing and kills. People engaged in substance abuse of alcohol, alcoholics, carry out repeated, compulsive abuse that may make them unable to retain their jobs, to obtain an education, or to engage in responsible societal roles. Eventually, alcoholics damage their brains and other body tissues irreversibly. Often, they die of these afflictions or by suicide triggered by depression or terrifying hallucinations. They also engage in behavior that is dangerous to themselves and others, such as driving under the influence or violence. Chronic alcoholism damages many body organs. Best known is liver disease, or cirrhosis of the liver. Another common affliction is organic brain damage. Mental disorders caused by injury to the cerebral hemispheres may include delirium tremens and Korsakoff’s psychosis. Both delirium tremens, characterized by hallucination and other psychotic symptoms, and Korsakoff’s psychosis, which is characterized by short-term memory loss and confabulation, or stories to cover this loss, may be accompanied by severe physical debility requiring hospitalization. In addition, alcoholism damages the kidneys, the heart, and the pancreas. In fact, a large number of instances of diseases of other organs are thought to arise from alcohol abuse. Also, much evidence suggests that alcoholism greatly enhances the incidence of mouth and throat cancer resulting from smoking tobacco. Severe effects in the liver occur because most ingested alcohol is metabolized there. In the presence of alcohol, most other substances normally metabolized by the liver—the factory bloc of the body—are not changed into useful and essential forms. One example has to do with fat, a major dietary source of energy. Decreased fat metabolism in the livers of alcoholics results in the fat accumulation—a fatty liver—that precedes cirrhosis of the liver. Cirrhosis results in the replacement of liver cells with nonfunctional fibrous tissue. Another problem that results from excessive alcohol metabolism is that
Alcoholism ✧ 45 the liver no longer destroys the many other toxic chemicals that are eaten. This defect adds to problems seen in cirrhosis and leads to dissemination of such chemicals through the body, where they can damage other body parts. In addition, resistance to the flow of blood through the alcoholic liver develops, which can burst blood vessels and cause dangerous internal bleeding. As a consequence of these problems, alcoholic liver disease, or cirrhosis, has become a major, worldwide cause of death from disease. Possible Causes for Alcoholism There is no one clear physical explanation for the development of alcoholism. Most often, it is viewed as the result of a biological predisposition to addiction and/or social problems and psychological stresses, especially in those socioeconomic groups in which consumption of alcoholic beverages is equated with manliness or sophistication. Other proposed causes of behaviors that lead to alcoholism include habitual drinking, other mental health problems, domineering parents, adolescent peer pressure, personal feelings of inadequacy, loneliness, job pressures, and marital discord. The fact that 20 percent of children of alcoholics tend to develop the disease, compared to 4 percent of the children of nonalcoholics, has led to investigations of the genetic proclivity for alcoholism. The fact that 80 percent of the progeny of alcoholic parents escape alcoholism, however, diminishes support for such theories. On the other hand, there are clearer indications that genetic factors are important to distaste for alcohol, precluding the development of alcoholism in some ethnic and national groups. Another disease attributable to alcoholism is fetal alcohol syndrome, which occurs in many children of mothers who drank heavily during pregnancy. Such children may be hyperactive, mentally retarded, and facially disfigured, and they may exhibit marked growth retardation. Fetal alcohol syndrome is becoming more frequent as alcohol consumption increases worldwide. Commonly observed symptoms of alcoholism are physical dependence on alcohol consumption shown by tremors, shakes, other physical discomfort, and excitability reversed only by alcohol intake; blackout and accompanying memory loss; diminished cognitive ability, exhibited as an inability to understand verbal instructions or to memorize simple series of numbers; and relaxed social inhibitions. These symptoms are attributable to the destruction of tissues of the central nervous system. Diminished sexual activity and sexual desire may also result from excessive alcohol consumption. A high level of alcohol appears to cause diminished libido and impotence. In addition, alcohol may even increase the rate of destruction of existing testosterone in the body.
46 ✧ Alcoholism Treating Alcoholism While no immediate cure for alcoholism is known, treatments for alcohol problems with demonstrated effectiveness do exist. Treatments involving a combined biological, psychological, and social approach, complete with follow-up, often appear most helpful. For most individuals, however, an important phase—or possibly even a permanent feature—of treatment involves total abstinence from alcoholic beverages, all medications that contain alcohol, and any other potential sources of alcohol in the diet. Two well-known medical treatments for enforcing sobriety are the drugs disulfiram (Antabuse) and citrated calcium carbonate (Abstem). These drugs are given to alcoholics who wish to avoid all use of alcoholic beverages and who require a deterrent to drinking to achieve this goal. Neither drug should ever be given secretly by well-meaning family or friends because of the serious dangers that Antabuse and Abstem pose if an alcoholic backslides and drinks alcohol. These dangers are the result of the biochemistry of alcohol utilization via the two enzymes (biological protein catalysts) alcohol dehydrogenase and aldehyde dehydrogenase. Normally, alcohol dehydrogenase converts alcohol to the toxic chemical acetaldehyde, and aldehyde dehydrogenase quickly converts the acetaldehyde to acetic acid, the main biological fuel on which the body runs. Either Abstem or Antabuse will turn off aldehyde dehydrogenase and cause acetaldehyde levels to build up in the body when alcohol is consumed. The presence of acetaldehyde in the body then quickly leads to violent headache, great dizziness, heart palpitation, nausea, and vertigo. When the amount of alcohol found in a drink or two (or even the amount taken in cough medicine) is consumed in the presence of either drug, these symptoms can escalate to the extent that they become fatal. As a result of the symptoms of alcohol withdrawal common during detoxification and the presence of other mental health disorders in nearly half of all individuals diagnosed with alcohol dependence, other therapeutic drugs are often used in treatment. Examples include lithium, tranquilizers, and sedative hypnotics. The function of these psychoactive drugs is to diminish the discomfort of alcohol withdrawal. Lithium treatment, which must be done with great care because it can become very toxic, appears to be effective only in the alcoholics who drink because of depression or bipolar disorder. The use of tranquilizers and the related sedative hypnotics must also be done with great care, under close supervision of a physician. Many such drugs are addictive. In addition, some of these drugs have strong synergistic (additive) effects when mixed with alcohol, and such synergism can be fatal. Alcoholics Anonymous and Other Group Therapies It is believed that the advent of Alcoholics Anonymous in the 1930’s has been crucial to the perception of alcoholism as a disease to be treated, rather
Alcoholism ✧ 47 than as immoral behavior to be condemned. This organization operates on the premise that abstinence is the best course of treatment for alcoholism—an incurable disease that can, however, be arrested by the cessation of all alcohol intake. The methodology of the organization is psychosocial. First, alcoholics are brought to the realization that they can never use alcoholic beverages without succumbing to alcoholism. Then, the need for help from a “higher power” is identified as crucial to abstinence. In addition, the organization develops a support group of people in the same situation. Estimates of the membership of Alcoholics Anonymous in 1992 ranged between 1.5 and 4 million, meaning up to one-third of American alcoholics were affected by its tenets. These people, ranging widely in age, achieve results varying from periods of sobriety (lasting longer and longer as membership in the organization continues) to lifelong sobriety. A deficit of the sole utilization of Alcoholics Anonymous for alcoholism treatment—in the opinion of some experts—is lack of medical, psychiatric, and trained sociological counseling. The results of the operation, however, are viewed by most as beneficial to all parties who seek help from the organization. Alcohol rehabilitation centers apply varied combinations of drug therapy, psychiatric counseling, and social counseling, depending on the treatment approach for the individual center. Group therapy, however, is the dominant mode of treatment in the United States. Counseling can identify the factors leading to alcohol abuse, explore and help to rectify the associated problems, provide emotional support, and refer patients to Alcoholics Anonymous and other long-term support efforts. The psychotherapist also has experience with managing clients who use or have used psychoactive drugs, understands behavioral modification techniques, and can determine whether an individual requires institutionalization. Behavior modification is a cornerstone of alcoholism psychotherapy, and many choices are available to all alcoholics desiring psychosocial help. An interesting point is that autopsy and a variety of sophisticated medical techniques such as CT (computed tomography) and PET (positron emission tomography) scans identify the atrophy of the cerebral cortex of the brain in many alcoholics. This damage is viewed as participating in the inability of alcoholics to stop drinking, their loss of both cognitive and motor skills, and the eventual development of serious conditions such as Korsakoff’s psychosis and delirium tremens. —Sanford S. Singer; updated by Nancy A. Piotrowski See also Addiction; Alcoholism among teenagers; Alcoholism among the elderly; Dementia; Fetal alcohol syndrome; Recovery programs. For Further Information: Berkow, Robert, and Andrew J. Fletcher, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Rahway, N.J.: Merck Sharp & Dohme Research Labs,
48 ✧ Alcoholism among teenagers 1999. This book contains a compendium of data on the etiology, diagnosis, and treatment of alcoholism. Contains good cross-references to the psychopathology related to the disease, drug rehabilitation, and Alcoholics Anonymous. Designed for physicians, it is also valuable to the layman. Collins, R. Lorraine, Kenneth E. Leonard, and John R. Searles, eds. Alcohol and the Family. New York: Guilford Press, 1990. This book is divided into segments on genetics, family processes, and family-oriented treatment. Genetic testing and markers are well covered, and adolescent drinking, children of alcoholics, and alcoholism’s effect on a marriage are also discussed. Evaluates the ability of the family to cope with stresses of alcoholism and its treatment. Cox, W. Miles, ed. The Treatment and Prevention of Alcohol Problems: A Resource Manual. Orlando, Fla.: Academic Press, 1987. This work contains much information on the psychiatric and behavioral aspects of alcoholism. It is also widely useful in many other related issues, including Alcoholics Anonymous, marital and family therapy, and alcoholism prevention. Eskelson, Cleamond D. “Hereditary Predisposition for Alcoholism.” In Diagnosis of Alcohol Abuse, edited by Ronald R. Watson. Boca Raton, Fla.: CRC Press, 1989. This article provides useful data on the genetic aspects of alcoholism, concentrating on metabolism, animal and human studies, teetotalism, familial alcoholism, and genetic markers. Sixty-five references are included. Torr, James D. Alcoholism. San Diego, Calif.: Greenhaven Press, 2000. This well-balanced selection of primary source materials is designed for children in grades six through twelve. A lengthy bibliography and a list of organizations to contact are appended.
✧ Alcoholism among teenagers Type of issue: Children’s health, mental health, social trends Definition: The consumption of alcoholic beverages (such as beer, wine, or liquors) despite the occurrence of repeated social, interpersonal, or legal problems occurring as a result of that use over the course of a year. Alcohol abuse is a specific diagnosis given for alcohol problems, as described in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., 1994, DSM-IV) by the American Psychiatric Association. It is characterized by repeated psychological, legal, and social problems occurring as a result of alcohol use over the course of a year. Alcohol abuse is distinct from alcohol dependence, which refers to physical and psychological reliance on alcohol despite the presence of problems associated with its use. Both conditions can be diagnosed in children, teenagers, and adults.
Alcoholism among teenagers ✧ 49 Symptoms of alcohol abuse might include repeated legal problems (such as public drunkenness, driving while under the influence, truancy, violence, and crimes related to drinking or other criminal offenses occurring when under the influence). They might also include arguments and violent or aggressive behavior in which drinking results in social problems with friends or family members. Other types of problems that might signal a diagnosis of alcohol abuse would be an adult or child repeatedly not fulfilling what is expected of him or her in daily life, such as not going to work, being late to work, or missing or skipping school because of drinking. The abuse of alcohol as a public health problem has also been linked to binge drinking. Young drinkers are especially prone to binge drinking because alcohol is not as available to them as it is to older drinkers. It is illegal for minors to purchase alcohol in the United States, so having alcohol available to consume can affect how individuals drink. What often happens with teenagers is that they will drink as much as they can when alcohol is available to them, on weekends or at parties, and then abstain when not at such events. Unfortunately, this pattern is conducive to the development of some tolerance to alcohol. Additionally, it is often linked to poor judgment, which may lead to risky sexual behavior (such as unprotected sex), the operation of an automobile while under the influence, or the taking of other drugs. There is also the risk that young or inexperienced drinkers who binge—by thinking that they can drink as much as they want without suffering anything worsse than a hangover—inadvertently put themselves at risk for alcohol poisoning. Teens, Families, and Alcohol By the age of eighteen years, nearly 80 percent of children and teenagers in the United States will experiment with alcohol. Not all will go on to abuse alcohol or to develop more severe problems. Differences in genetics, the influence of family and friends, community norms and expectations, self-esteem, and career and academic interests make some children and teenagers more likely to develop problems than others. Young people who are more likely to develop problems such as alcohol abuse tend to be impulsive, to be less interested in school work, to have lower levels of achievement in school, to be more uninhibited, to experience less positive feelings, to be more tolerant of deviant behavior in others, and to have a greater sensitivity to the positive physical and emotional effects of alcohol. Additionally, children who perceive their friends and family to be accepting of alcohol use are more likely to use alcohol. Those who come from families in which there are alcohol problems are generally at greater risk for problems than those who do not. This is particularly true for teenage boys of fathers with alcohol problems. Teenagers are also more likely to have problems with alcohol if they have problems with self-regulation, have poor self-esteem, or are more suscepti-
50 ✧ Alcoholism among teenagers ble to peer pressure. Parents may recognize budding alcohol problems in children who drink heavily or talk about drinking heavily as acceptable behavior, have friends who drink heavily or talk about drinking heavily as acceptable behavior, glamorize alcohol use or collect promotional materials on drinking products, or begin to have significant negative changes in their relationship with their parents, school performance, moodiness, sleeping habits, choice of friends, or interests in the future. In general, the earlier alcohol use starts in childhood, the more likely it is that this use will lead to heavier drinking in the teenage years. Alcohol problems in the teenage years do not necessarily mean that a person will go on to develop alcohol problems as an adult, but the possibility remains. Because young adults and teenagers are exposed to risks as a result of drinking, understanding their alcohol problems, exclusive of problems experienced by adults, is important. Accidents, loss of life, damaged academic performance, social relationship problems, exposure to sexually transmitted diseases, and other risky situations can result from alcohol misuse and abuse by teenagers and younger children. Attempts by parents and other adults to delay when a child’s experimentation with alcohol starts can be valuable. Some indication exists that children of parents who do not drink at all or who drink very little begin experimentation at later ages. Additionally, having parents who are effective at providing support, setting standards for behavior, and giving guidance lessens the risk for alcohol abuse in teenagers and children. Children of parents who act proactively (who try to prevent problems before they happen) also tend to begin experimentation at later ages. Finally, teenagers who are more involved in school and who are more aware of the potential harmful effects of alcohol delay their drinking experimentation. Alcohol abuse can also show up in the lives of children as a result of drinking done by their parents. Fetal alcohol syndrome is one example. In this case, it is not the children who abuse alcohol but rather their mothers, who drink while pregnant. Fetal alcohol syndrome is a medical condition resulting directly from the effects on the fetus of the mother’s drinking. In the worst cases, it can result in fetal death. In less severe cases, a child of a parent who drank during pregnancy can experience mild to severe facial and dental abnormalities, mental impairments, or problems related to the skeleton and the cardiovascular system. Problems with vision, hearing, and attention span are also common. These problems are thought to result from the alcohol interfering with embryonic development. Children of alcoholic fathers also can have difficulties in learning, language, and temperament. The causes of such problems are multiple and need to be determined. They include the contribution of genetics and the effects of growing up in a home that may be less stable as a result of alcohol-related social, occupational, or psychological problems in the father.
Alcoholism among teenagers ✧ 51 Alcohol Abuse Education and Treatment Treatment for alcohol abuse can take several different forms: primary, secondary, and tertiary prevention. In primary prevention, treatment is applied to the population as a whole. An example might be a campaign against driving while drunk that is advertized on television, such as those promoted by many major beverage companies and groups like Mothers Against Drunk Driving (MADD). Similarly, educational programs focused on educating women about the dangers of drinking while pregnant can be seen as primary prevention approaches. Another example might be educating store clerks and store owners about the laws and fines that may be applied to individuals who sell alcohol to minors. In each case, the effects of the treatment are on the community as a whole, and the attempt is made to avoid a problem before it happens. In secondary prevention, treatment is applied to individuals who are at a higher-than-average risk. Examples of such groups would be children of parents with alcohol problems and children who might be anxious, prone to panic, or depressed and may drink to calm their feelings. Treatment might include giving these children health education information about why people use alcohol (such as social pressure, uncomfortable feelings, boredom) and then teaching them other ways to handle those kinds of problems. Having such children talk to psychological counselors or medical doctors to treat depression or anxiety might also be appropriate. They might also be taught the skills necessary to refuse alcohol in situations where it is tempting to use it. Similarly, since some alcohol use is generally considered socially acceptable, secondary intervention might also include teaching a drinker how to drink in a safer manner or in a manner that is not harmful. With teenagers and children, however, it is important to keep in mind that any alcohol use by minors is illegal in the United States and can have legal consequences if it is occurring outside the home or without responsible parental supervision. In tertiary prevention, treatment is applied to individuals who already have developed alcohol dependence, including children, teenagers, and adults. People can try to quit drinking on their own; however, withdrawal from alcohol can be fatal. As such, it is important for individuals thinking about quitting alcohol consumption to talk to a doctor. For schoolchildren, talking to a health teacher, school nurse, or counselor may be the best way to start. Depending on how long the person has been drinking, different types of treatment might be suggested. If dependence is severe, then seeking a doctor may be necessary for detoxification, a process of being taken off of alcohol in a safe manner. If dependence is less severe, then nonmedical treatments may be sufficient. Such treatments might include counseling, group support, or learning new ways to handle problems that the person was trying to handle with alcohol. Learning what caused the drinking, finding other means of meeting personal needs, and behaving in new ways to break old habits can
52 ✧ Alcoholism among teenagers be as important as any medical interventions in learning how to quit. It is important to realize that alcohol abuse in children and teenagers may involve different issues for girls and boys. Some studies have suggested that boys who have more severe problems with alcohol early on in life, particularly those who have fathers or other male relatives with alcohol problems, are more likely to have a biological propensity to alcohol. Similarly, girls who have alcohol problems as children or adolescents are more likely to have problems with mood, such as depression, mood swings, or anxiety, particularly if they have mothers or female relatives with similar problems. Treatment may need to take these issues into account. For some, this may mean that medication is a best first strategy. For others, it may mean that supportive counseling may be critical to the cessation of alcohol abuse. In each case, the gender and other background characteristics of the child or adolescent must be considered for the best match to treatment. Additionally, problems such as emotional, physical, or sexual abuse must be explored and ruled out in children abusing alcohol. Often, alcohol and other drugs may be used by a child as a coping strategy for dealing with difficult family situations. In such cases, addressing the underlying situation is of critical importance for the immediate and long-term well-being of the child or adolescent. Alcohol Use Versus Abuse Alcohol use has been a common social practice for thousands of years. Done with care and under safe conditions, it may add to the enjoyment that most people experience in social situations. In excess, however, alcohol can contribute to social and health problems in children, teenagers, adults, and families as a whole. Understanding the difference between acceptable levels of alcohol use, as compared to alcohol abuse and alcohol dependence, is important. In the United States, while the number of individuals who drink alcohol has remained fairly constant, average alcohol consumption, heavy drinking, and alcohol-related problems are increasing. Additionally, adolescents are currently drinking, drinking heavily, and experiencing alcohol-related problems at younger ages than they have in the past. Prevention and treatment efforts need to be targeted toward delaying alcohol use in early adolescence and using educational and community resources to promote safe drinking practices. This has been recognized by the alcoholic beverage industry, which is now promoting safer drinking campaigns, and will continue to be important in the future for the betterment of public health. —Nancy A. Piotrowski See also Addiction; Birth defects; Child abuse; Children’s health issues; Depression in children; Drug abuse by teenagers; Fetal alcohol syndrome; Recovery programs; Smoking; Tobacco use by teenagers.
Alcoholism among the elderly ✧ 53 For Further Information: Collins, R. Lorraine, Kenneth E. Leonard, and John R. Searles, eds. Alcohol and the Family. New York: Guilford Press, 1990. This book is divided into segments on genetics, family processes, and family-oriented treatment. Genetic testing and markers are well covered, and adolescent drinking, children of alcoholics, and alcoholism’s effect on a marriage are also discussed. Evaluates the ability of the family to cope with stresses of alcoholism and its treatment. Forrest, Gary G. How to Cope with a Teenage Drinker: Changing Adolescent Alcohol Abuse. Northvale, N.J.: Jason Aronson, 1997. This book is written for parents or friends who know a teenager who may have an alcohol problem. Guidelines for helping teenagers recognize such problems are given. Julien, Robert M. A Primer of Drug Action. 8th ed. New York: W. H. Freeman, 1998. This is a nontechnical guide to mind-altering drugs: their effects, practical uses, and how they work. Torr, James D. Alcoholism. San Diego, Calif.: Greenhaven Press, 2000. This well-balanced selection of primary source materials is designed for children in grades six through twelve. A lengthy bibliography and a list of organizations to contact are appended. Weil, Andrew, and Winifred Rosen. From Chocolate to Morphine: Everything You Need to Know About Mind-Altering Drugs. Rev. ed. Boston: Houghton Mifflin, 1998. This book describes a variety of mind-altering substances. The history, methods, and pros and cons of the use of these substances are described.
✧ Alcoholism among the elderly Type of issue: Elder health, mental health, social trends Definition: A general set of problems associated with alcohol abuse (psychological, social, and legal problems related to alcohol use) and alcohol dependence (a physical and psychological reliance on alcohol despite repeated significant problems associated with its use). “Alcoholism” is a vague clinical term that is sometimes used to describe the condition in which an individual is afflicted with severe physical, social, and psychological problems related to alcohol use. It is not a medical diagnostic term. Rather, it is a colloquial term used to describe the state of an individual experiencing a general set of problems associated with the more formal diagnostic conditions known as alcohol abuse and alcohol dependence. Alcohol abuse is a specific diagnosis given for alcohol problems in which physical dependence on alcohol is not indicated. In cases of alcohol abuse, repeated and significant psychological, legal, and social problems tend to
54 ✧ Alcoholism among the elderly occur over the course of a year. The diagnosis of alcohol abuse is distinct from that of alcohol dependence and is described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (1994, DSM-IV) by the American Psychiatric Association. Alcohol dependence refers to both physical and psychological reliance on alcohol, despite the presence of repeated significant problems associated with its use for a period of a year or more. Prevalence and Special Problems Alcohol problems can be diagnosed in individuals of any age; alcoholism among the elderly is thus to be expected at about the same rate as it would be in other adult age groups. In the elderly, however, alcoholism can be related to more significant problems because of the physical, mental, psychological, social, and financial vulnerabilities that can accompany later life. Changes in resilience accompanying later life can magnify the impact of problems related to alcohol by making recovery from such problems more difficult. This is especially true for elderly women, as physiological differences between men and women appear to cause alcohol problems to escalate in severity more quickly in older adult women than in older adult men. Problematic alcohol use in elders is especially complicated by the greater physiological effects of alcohol that result from changes in how alcohol is processed by the body. As the body ages, the liver and other organs are less able to process alcohol out of the body, thereby altering tolerance to alcohol. As a result, alcohol stays in the body longer and has a more pronounced effect. This slowing of the body’s ability to process substances also affects the processing of other drugs, which may also stay in the body longer. This can create drug interaction problems in the elderly, as they are especially likely to take prescription and nonprescription drugs on a regular basis. Alcohol can intensify the effects of certain drugs, and vice versa; such interactions are particularly hazardous in the elderly. Combined with sedatives, alcohol can cause severe respiratory problems and also worsen problems related to balance. For elders already having respiratory or balance problems, such intensified effects can be very dangerous, leading to increased risk for falls, other accidents, or even death. Similarly, alcohol taken in combination with diuretics can be particularly dangerous, as the combination may encourage dehydration and can affect kidney functioning and blood pressure in a dangerous manner. Treatment and Intervention Alcohol problems in the elderly can come in two important types. For some, problems with alcohol may merely represent a continuation of lifelong habits. In these cases, the problems are chronic and will most likely require intensive intervention and management. Chronic problems of this type may
Alcoholism among the elderly ✧ 55 lead to premature aging, serious cardiovascular health problems, cancers, and death, as well as severe difficulties with memory and other mental problems such as organic brain syndromes, aphasias, and dementias. For other elderly people, though, problems related to alcohol may be a new development. In some cases, such problems may be situational, resulting from a recent stressor such as a death or loss of a loved one. Alcohol may be being used as a means of managing grief or depression. In these cases, interventions from someone such as a psychologist or geriatric psychiatrist may be warranted. Such assistance can help to address the root problem and also decrease the chance that a secondary problem with alcohol might develop as a result of repeated use. Similarly, short-term alcohol problems may result from a lack of knowledge about drug interactions with alcohol. In these cases, the dissemination of information from a pharmacist about the dangers of mixing drugs and alcohol can prevent the elder from using alcohol in dangerous ways. Similarly, education from a family physician about how alcohol interacts with certain health conditions, such as heart problems, blood pressure problems, diabetes, depression, anxiety, insomnia, and stomach problems can also be useful in decreasing misuse of alcohol. Alcohol problems may be more difficult to diagnose in the elderly than in younger adults. Older adults often do not show obvious signs of intoxication and withdrawal; moreover, when such symptoms appear, they may be attributed to other problems related to aging. Additionally, confusion of alcohol problems with other age-related conditions such as tremors, forgetfulness, and disorientation may obscure an accurate diagnosis. Alcohol problems in the elderly may also be masked by other physical or psychological conditions. Such conditions may bring an elder in for treatment, but the alcohol problem may go undetected. Screening for alcohol problems and questioning by medical professionals about alcohol use are thus important, as missing such problems may predispose an elder to relapse and worsened problems in the future. Signs of problem drinking among the elderly may include any of the following: unusual increases in falls or accidents, slurring of speech, anxiety, insomnia or other sleep disorders, irritability, social withdrawal, efforts to hide or lie about the use of alcohol or other drugs, increased consumption of alcohol following significant losses, drinking alone more often, gulping of drinks or drinking fast, loss of interest in food, or any social, medical, or financial problems that appear to be caused or exacerbated by drinking. Evidence of any of these conditions may suggest a need for further medical evaluation. —Nancy A. Piotrowski See also Addiction; Aging; Alcoholism; Alcoholism among teenagers; Depression in the elderly; Medications and the elderly; Overmedication; Suicide among the elderly.
56 ✧ Allergies For Further Information: American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Rev. 4th ed. Washington, D.C.: Author, 2000. Fanning, Patrick, and John T. O’Neill. The Addiction Workbook: A Step-by-Step Guide to Quitting Alcohol and Drugs. Oakland, Calif.: New Harbinger Press, 1996. Miller, William R., and Ricardo F. Munoz. How to Control Your Drinking: A Practical Guide to Responsible Drinking. Rev. ed. Albuquerque: University of New Mexico Press, 1990. Roukema, Richard W. What Every Patient, Family, Friend, and Caregiver Needs to Know About Psychiatry. Washington, D.C.: American Psychiatric Press, 1998.
✧ Allergies Type of issue: Environmental health, occupational health, public health Definition: Exaggerated immune reactions to materials that are intrinsically harmless; the body’s release of certain chemicals during allergic reactions may result in discomfort, tissue damage, or even death. Allergies represent inappropriate immune responses to intrinsically harmless materials, or antigens. Most allergens are common environmental antigens. Approximately one in every six Americans is allergic to material such as dust, molds, dust mites, animal dander, or pollen. The effects range from a mere nuisance, such as the rhinitis associated with hay fever allergies or the itching of poison ivy, to the life-threatening anaphylactic shock that may follow a bee sting. Allergies are most often found in children, but they may affect any age group. Allergy is one of the hypersensitivity reactions generally classified according to the types of effector molecules that mediate their symptoms and according to the time delay that follows exposure to the allergen. There are four types of hypersensitivities. Three of these, types I through III, follow minutes to hours after the exposure to an allergen. Type IV, or delayed-type hypersensitivity (DTH), may occur anywhere from twenty-four to seventytwo hours after exposure. People are most familiar with two of these forms of allergies: Type I, or immediate hypersensitivity, commonly seen as hay fever or asthma; and Type IV, most often following an encounter with poison ivy or poison oak. Type I Reactions Type I hypersensitivities have much in common with any normal immune response. A foreign material, an allergen, comes in contact with the host’s
Allergies ✧ 57 immune system, and an antibody response is the result. The response differs according to the type of molecule produced. A special class of antibody, IgE, is secreted by the B lymphocytes. IgE, when complexed with the specific allergen, is capable of binding to any of several types of mediator cells, mainly basophils and mast cells. Mast cells are found throughout skin and tissue. The mucous membranes of the respiratory and gastrointestinal tract in particular have high concentrations of these cells, as many as ten thousand cells per cubic millimeter. Basophils, the blood cell equivalents of the mast cells, represent 1 percent or less of the total white cell count. Both basophils and mast cells contain large numbers of granules composed of pharmacologically active chemicals. Both also contain surface receptors for IgE molecules. The binding of IgE/allergen complexes to these cells triggers the release of the granules. Type I allergic reactions begin as soon as the sensitized person is exposed to the allergen. In the case of hay fever, this results when the person inhales the pollen particle. The shell of the particle is enzymatically dissolved, and the specific allergens are released in the vicinity of the mucous membranes in the respiratory system. If the person has had prior sensitization to the materials, IgE molecules secreted by localized lymphocytes bind to the allergens, forming an antibody/antigen complex. Events commonly associated with allergies to pollen—a runny nose and itchy, watery eyes—result from the formation of such complexes. A sequence of events is set in place when the immune complexes bind to the surface of the mast cell or basophil. The reactions begin with a crosslinking of the IgE receptors on the cell. After an influx of calcium into the cell, two events rapidly follow: The cell begins production of prostaglandins and leukotrienes, two mediators that play key roles in allergic reactions, and preexisting granules begin moving toward the cell surface. When they reach the cell surface, the granules fuse with the cell membrane, releasing their contents into the tissue. The contents of the granules mediate the clinical manifestations of allergies. These mediators can be classified as either primary or secondary. Thus, clinical responses are divided into immediate and late-phase reactions. Primary mediators are those found in preexisting granules and that are released initially following the activities at the cell surface. They include substances such as histamine and serotonin, associated with increased vascular permeability and smooth muscle contraction. Histamine itself may constitute 10 percent of the weight of the granules in these cells. The result is the runny nose, irritated eyes, and bronchial congestion with which so many are familiar. Secondary mediators, which are released in the late phase, are synthesized following the binding of the immune complexes to the cell surface. These substances include the leukotrienes and prostaglandins. The effects of these chemicals include vasodilation, increased capillary permeability, contraction of smooth muscles in the bronchioles, and, more
58 ✧ Allergies important, activities that attract white cells in the site to magnify the inflammatory reaction. This is why an allergic reaction is divided into two phases and the late reaction may last for days. Common Allergens A large number of common antigens can be associated with allergies. These include plant pollens (as are found in rye grass or ragweed), foods such as nuts or eggs, bee or wasp venom, mold, or animal dander. A square mile of ragweed may produce as much as 16 tons of pollen in a single season. In fact, almost any food or environmental substance could serve as an allergen. The most important defining factor as to whether an individual is allergic to any particular substance is the extent and type of IgE production against that substance. Most individuals are familiar with immediate hypersensitivities as reactions involving a localized area. The most common form of allergy is rhinitis, known as hay fever, which affects approximately 10 percent of the population. When a person inhales an environmental allergen such as ragweed pollen, the result is a release of pharmacologically active mediators from mast cells located in the upper respiratory tract. If the release occurs in the lower respiratory tract, the condition is known as asthma. In both instances, the eyes and nose are subject to inflammation and the release of secretions. In mild cases, the person suffers from watery discharges, coughing, and sneezing. In more severe asthma attacks, the bronchioles may become constricted and obstruct the air passages. Foods to which one is allergic may trigger similar reactions in the gut. Mast cells in the gastrointestinal tract also contain receptors for IgE, and contact with food allergens results in the release of mediators similar to those in the respiratory passages. The result may be vomiting or diarrhea. The allergen may also pass from the gut into the circulation or other tissues, triggering asthmatic attacks or urticaria (hives). In severe allergic reactions, the response may be swift and deadly. The venom released during a bee sting may trigger a systemic response from circulating basophils or mast cells, resulting in the contraction of pulmonary muscles and rapid suffocation, a condition known as anaphylactic shock. The leukotrienes, platelet-activating factor, and prostaglandins play key roles in these reactions. Delayed-type hypersensitivities, also known as contact dermatitis reactions, most commonly occur following exposure to a topical allergen. These may include the catechol-containing oils of poison oak, the constituents of hair dyes or cosmetics, environmental contaminants such as nickel or turpentine, or any of a wide variety of environmental agents. Rather than being mediated by antibodies, as are the other types of hypersensitivities, contact dermatitis is mediated through a special class of T lymphocytes.
Allergies ✧ 59 Type II and III Reactions The other classes of hypersensitivity reactions, types II and III, are less commonly associated with what most people consider to be allergies. Yet they do have much in common with Type I, immediate hypersensitivity. Type II reactions are mediated by a type of antibody called IgG. Clinical manifestations result from the antibody-mediated destruction of target cells, rather than through the release of mediators. One of the most common forms of reaction is blood transfusion reactions, either against the A or B blood group antigen or as a result of an Rh incompatibility. For example, if a person with type O blood is accidentally transfused with type A, an immune reaction will occur. The eventual result is destruction of the incompatible blood cells. Rh incompatibilities are most commonly associated with a pregnant woman who is lacking the Rh protein in her blood (that is, Rh negative) carrying a child who is Rh positive (a blood type obtained from the father’s genes). The production of IgG directed against the Rh protein in the child’s blood can set in motion events that result in the destruction of the baby’s red blood cells, a condition known as erythroblastosis fetalis. Type III reactions are known as immune complex diseases. In this case, sensitivity to antigens results in formation of IgG/antigen complexes, which can lodge in the kidney or other sites in the body. The complexes activate what is known as the complement system, a series of proteins which include vasoactive chemicals and lipolytic compounds. The result can be a significant inflammation that can lead to kidney damage. Type III reactions can include autoimmune diseases such as arthritis or lupus, or drug reactions such as penicillin allergies. Avoiding Allergens There exist three methods for dealing with allergies: avoidance of the allergen, palliative treatments, and desensitization. Ideally, one can attempt to avoid the allergen. For example, cow’s milk, a common allergen, should not be given to a child at too young an age, and one can stay away from patches of poison ivy or avoid eating strawberries if one is allergic to them. Yet avoidance is not always possible or desirable, as the problem may be the fur from the family cat. In any event, it is sometimes difficult to identify the specific substance causing the symptoms. This is particularly true when dealing with foods. Various procedures exist to identify the irritating substance, skin testing being the most common. In this procedure, the patient’s skin is exposed to small amounts of suspected allergens. A positive test is indicated by formation of hives or reddening within about twenty to thirty minutes. If the person is hypersensitive to a suspected allergen and finds a skin test too risky, then a blood test may be substituted. In addition to running a battery of tests, a patient’s allergy history (including family
60 ✧ Allergies history, since allergies are in part genetic) or environment may give clues as to the identity of the culprit. Treating the Symptoms The most commonly used method of dealing with allergies is a palliative treatment—that is, treatment of the symptoms. Antihistamines act by binding to histamine receptors on target cells, interfering with the binding of histamine. There exist two types of histamine receptors: H-1 and H-2. Histamine binding to H-1 receptors results in contractions of smooth muscles and increased mucous secretion. Binding to H-2 receptors results in increased vasopermeability and swelling. Antihistamines that act at the level of the H-1 receptor include alkylamines and ethanolamines and are effective in treating symptoms of acute allergies such as hay fever. H-2 blockers such as cimetidine are effective in the symptomatic treatment of duodenal ulcers through the control of gastric secretions. Many antihistamines can be obtained without a prescription. If they are not used properly, however, the side effects can be serious. Overuse may result in toxicity, particularly in children; overdoses in children can be fatal. Because antihistamines can depress the central nervous system, side effects include drowsiness, nausea, constipation, and drying of the throat or respiratory passage. This is particularly true of H-1 blockers. A new generation of H-1 antihistamines, however, are long-acting and are free of the sedative effect of other antihistamines. Other symptomatic treatments include the use of cromolyn sodium, which blocks the influx of calcium into the mast cell, and thus is called a mast cell stabilizer. It acts to block steps leading to degranulation and the release of mediators. In more severe cases, the administration of steroids (cortisone) may prove useful in limiting symptoms of allergies. Anaphylaxis is the most severe form of immediate hypersensitivity, and unless treated promptly, it may be fatal. It is often triggered in susceptible persons by common environmental substances: bee or wasp venom, drugs such as penicillin, foods such as peanuts and seafood, or latex protein in rubber. Symptoms include labored breathing, rapid loss of blood pressure, itching, hives, and/or loss of bladder control. The symptoms are triggered by a sudden and massive release of mast cell or basophil mediators such as histamine, leukotrienes, or prostaglandin derivatives. Treatment consists of an immediate injection of epinephrine and the maintenance of an open air passage into the lungs. If cardiac arrest occurs, cardiopulmonary resuscitation (CPR) must be undertaken. Persons in known danger of encountering such a triggering allergen often carry an emergency kit containing epinephrine and antihistamines. Rather than resulting from the presence of IgE antibody, the symptoms of contact dermatitis result from a series of chemicals released by sensitized
Allergies ✧ 61 T lymphocytes in the area of the skin on which the allergen (often poison ivy or poison oak) is found. Treatments generally involve the application of topical corticosteroids and soothing or drying agents. In more severe cases, systemic use of corticosteroids may be necessary. Desensitization In some persons, the relief of allergy symptoms may be achieved through desensitization. This form of immunotherapy involves the repeated subcutaneous injection of increasing doses of the allergen. In a significant number of persons, such therapy leads to an improvement in symptoms. The idea behind such therapy is that repeated injections of the allergen may lead to production of another class of antibody, the more systemic IgG. These molecules can serve as blocking antibodies, competing with IgE in binding to the allergen. Because IgG/allergen complexes can be destroyed by phagocytes and do not bind receptors on mast cells or basophils, they should not trigger the symptoms of allergies. Unfortunately, for reasons that remain unclear, not all persons or all allergies respond to such therapy. The type I immediate hypersensitivity reactions commonly run in families, which is not surprising since the regulation of IgE production is genetically determined. Thus, if both parents have allergies, there is little chance that their offspring will escape the problem. On the other hand, if one or both parents are allergy-free, the odds are at least even that the children will also be free from such reactions. —Richard Adler; updated by Shih-Wen Huang, M.D. See also Asthma; Environmental diseases; Food poisoning; Multiple chemical sensitivity syndrome; Poisoning; Poisonous plants; Secondhand smoke; Sick building syndrome; Smog; Snakebites; Zoonoses. For Further Information: Cutler, Ellen W. Winning the War Against Asthma and Allergies. Albany, N.Y.: Delmar, 1998. This clearly written book provides practical information on all aspects of allergies—what they are, their causes, testing, diagnosis, and treatment, including nontraditional therapies. Preventive measures are covered, as are scenarios for various allergy elimination therapies. Kuby, Janis. Immunology. 3d ed. New York: W. H. Freeman, 1997. The section on hypersensitivity in this immunology textbook is well written and includes a mixture of detail and overview of the subject. Particularly useful are discussions of the various types of hypersensitivity reactions. Some knowledge of biology is useful. Roitt, Ivan. Essential Immunology. 9th ed. Boston: Blackwell Scientific Publications, 1997. Written by a leading author in the field, the text provides a fine description of immunology. The section on hypersensitivity is clearly
62 ✧ Alternative medicine presented and profusely illustrated. Most of the material can be understood by individuals who have taken high school-level biology. The first choice as a reference for the subject. Walsh, William. The Food Allergy Book. New York: John Wiley & Sons, 2000. In this excellent guide to one highly prevalent form of allergy, the author presents useful background information on food allergies and a pragmatic guide to identifying and eliminating food allergens from your diet. Young, Stuart, Bruce Dobozin, and Margaret Miner. Allergies. Rev. ed. New York: Plume, 1999. An excellent review from Consumer Reports. In addition to discussing the diagnosis and treatment of allergies, the authors evaluate the various remedies on the market at the time of publication. Also useful are lists of organizations to contact for further information and various clinics that specialize in allergy treatment.
✧ Alternative medicine Type of issue: Public health, social trends Definition: A wide variety of medical practices and therapies which fall outside traditional, Western medical practice. The approaches emphasize the individual as a biopsychosocial whole, or, in some cases, as a biopsychosocial-spiritual whole. They deemphasize focusing treatment on specific diseases or symptoms. Alternative medicine—known also as holistic medicine, complementary medicine, or natural healing—focuses on the relationship among the mind, body, and spirit. The underlying philosophy is that people can maintain health by preventing disease in the first place by keeping the body in “balance” and by utilizing the body’s “natural” healing processes when people succumb to disease. Alternative medicine approaches contrast with Western medicine’s traditional focus on treating symptoms and curing disease and its underemphasis of preventive medicine. Thought “way-out” at one time, complementary medicines and therapies are gaining wide appeal as their anecdotal efficacy and reputation grow. Alternative medicine practitioners treat everything from diseases such as cancer and AIDS to chronic pain and fatigue, stress, insomnia, depression, high blood pressure, circulatory and digestive disorders, allergies, arthritis, diabetes, and drug and alcohol addictions. The major risks associated with alternative medicine include costly delays in seeking appropriate treatment, misinformation, side effects from selfadministered remedies, and psychological distress if patients believe that they are responsible for their own illness or lack of recovery. In addition, many alternative medicine practitioners have little or no formal health
Alternative medicine ✧ 63 training and may discourage traditional medical treatment or oppose proved health measures such as immunization and pasteurization. Therapies Based on Nonwestern Traditions Acupressure and acupuncture are based on the belief that the body has a vital energy that must be balanced in order to maintain good health. Acupressure uses pressure from the fingertips or knuckles to stimulate specific points on the body, while acupuncture uses needles inserted into the skin to restore the balance of energy. Both acupressure and acupuncture have been shown to stimulate the release of endorphins, the body’s natural painkillers. Acupressure is useful for relieving chronic pain and fatigue and increasing blood circulation. Acupuncture is used successfully for relieving chronic pain and treating drug and alcohol withdrawal symptoms. Although hepatitis, transmission of infectious disease, and internal injuries have been reported in connection with acupuncture, such risks are uncommon. Meditation is used to relax the mind and body, to reduce stress, and to develop a more positive attitude. By focusing on a single thought or repeating a word or phrase, a person can release conscious thoughts and feelings and enter deep relaxation. Meditation can affect the pulse rate and muscle tension and so is effective in treating high blood pressure, migraines, insomnia, and some digestive disorders. Qi gong (pronounced “chee-kung”) translates from the Chinese as “breathing exercise.” The Chinese believe that exercise balances and amplifies the vital energy force—Ch’i or qi—within the body. Qi gong is used to increase circulation; to reduce stress; to promote health, fitness, and longevity; and to cure illness. The most common exercises involve relaxation, strengthening, and inward training. Because the exercise involves movement done with gentle circular and stretching movements, people with decreased flexibility or disabilities can participate. Tai Chi Chuan was originally designed as a form of self-defense, but is now practiced as physical exercises based on rhythmic movement, equilibrium of body weight, and effortless breathing. The exercises involve slow and continuous movement without strain. Tai Chi Chuan is beneficial because it demands no physical strength initially. The exercises increase circulation, stimulate the nervous system and glandular activity, and help joint movement and concentration. The ancient art of yoga seeks to achieve the balance of mind, body, and spirit. Practitioners believe that good health is created through proper breathing, relaxation, meditation, proper diet and nutrition, and exercise. The deep breathing and stretching exercises bring relaxation, release of tension and stress, improved concentration, and oxygenation of the blood. The exercises can also provide muscle toning and aerobics, which is beneficial to the heart.
64 ✧ Alternative medicine Mind/Body Therapies Within the Western Tradition Biofeedback involves learning to control automatic physiological responses such as blood pressure, heart rate, circulation, digestion, and perspiration in order to reduce anxiety, pain, and tension. The patient concentrates on consciously controlling the body’s automatic responses while a machine monitors the results and displays them for the patient. Biofeedback can be useful in treating asthma, chronic pain, epilepsy, drug addiction, circulatory problems, and stress. Chiropractic treatment uses traditional medicine techniques such as X rays, physical examinations, and various tests in order to diagnose a disorder. Muscle spasms or ligament strains are treated by manipulation or adjustment to the spine and joints, thus reducing pressure on the spinal nerves and providing relief from pain. Recent research suggests chiropractic should be considered in treating certain types of lower back pain, as it is often superior to conventional interventions. Practitioners should be state licensed, and caution should be taken with practitioners who often repeat full-spine X rays or who ask patients to sign contracts at any time during treatment. Chiropractic is practiced either “straight,” involving only spinal manipulation, or “mixed,” involving other biomedical technologies such as electrical stimulation. Chiropractic treatment can be harmful if it is practiced in patients with fractures or undetected tumors or if it is practiced incorrectly. The use of water for healing or therapeutic purposes is termed hydrotherapy. It is used to treat chronic pain; to relieve stress; to improve circulation,
Chinese medicine may employ a technique called cupping, the application to the back of cups that create a vacuum, in order to restore proper circulation. (PhotoDisc)
Alternative medicine ✧ 65 mobility, strength, and flexibility; to reduce swelling; and to treat injuries to the skin. Because the buoyancy of water offsets gravity, more intense exercise can be done when standing in water, while a lower heart rate is maintained and pain is decreased. The risks associated with hydrotherapy are minimal (such as overdoing exercise) or rare (such as slipping or drowning). Phototherapy, or light therapy, is used to treat health disorders that are related to problems with the body’s inner clock, or circadian rhythms. These rhythms govern the timing of sleep, hormone production, body temperature, and other biological functions. People need the full wavelength spectrum of light found in sunlight in order to maintain health. If the full wavelength is not received, the body may not be able to absorb some nutrients fully, resulting in fatigue, tooth decay, depression, hostility, hair loss, skin conditions, sleep disorders, or suppressed immune functions. Treatment involves spending more time outdoors, exercising, and using light boxes that mimic natural sunlight. It is commonly used to treat seasonal affective disorder, a recognized subtype of depressive illness. Hyperbaric oxygenation therapy, or oxygen therapy, is used to treat disorders in which the oxygen supply to the body is deficient. This therapy can help with heart disease, circulatory problems, multiple sclerosis, gangrene, and strokes. Oxygen therapy is also used for traumas such as crash injuries, wounds, burns, bedsores, and carbon monoxide poisoning. Treatment consists of exposing the patient to 100 percent pure oxygen under greater-than-normal atmospheric pressure. The body tissues receive more than the usual supply of oxygen and so can compensate for conditions of reduced circulation. The increased oxygen helps keep the tissues alive and promotes healing. Sound therapy involves the use of certain sounds to reduce stress, lower blood pressure, relieve pain, improve movement and balance, promote endurance and strength, and overcome learning disabilities. The body has its own rhythm, and illness can arise when the rhythm is disturbed. Tests have shown that particular sounds can slow breathing and a racing heart, create a feeling of well-being, alter skin temperature, influence brain-wave frequencies, and reduce blood pressure and muscle tension. Used extensively in Europe and Japan, aromatherapy involves the use of the essential oils or essence from the flowers, stems, leaves, or roots of plants or trees. These essences can be absorbed through the skin, eaten, or inhaled in vapor form. There is evidence that inhaling some scents may help prevent secondary respiratory infections and reduce stress. Practitioners believe that aromatherapy can benefit people suffering from muscle aches, arthritis, digestive and circulatory problems, and emotional or stress-related problems. Absorption through the skin and inhalation are considered safe, but eating any essence could result in poisoning.
66 ✧ Alternative medicine Quasi-Medical Therapies Although not approved in the United States, cell therapy is widely used worldwide. It involves the injection of cells from the organs, fetuses, or embryos of animals and humans. These cells are used for revitalization purposes; that is, they promote the body’s own healing process for damaged or weak organs. Cell therapy seems to stimulate the immune system and is used to treat cancer, immunological problems, diseased or underdeveloped organs, arthritis, and circulatory problems. Bioenergetic medicine, or energy medicine, uses an energy field to detect and treat health problems. A screening process to measure electromagnetic frequencies emitted by the body can detect imbalances that may cause illness or warn of possible chemical imbalances. One of several machines is then used to correct energy-level imbalances. Energy medicine claims to relieve conditions such as skin diseases, headaches, migraines, muscle pain, circulation problems, and chronic fatigue. Enzyme therapy uses plant and pancreatic enzymes to improve digestion and the absorption of nutrients. Since enzymes provide the stimuli for all chemical reactions in the body, improper eating habits may cause a lack of certain enzymes, resulting in general health problems. Homeopathy is based on the belief that “like cures like”; homeopathy is thought to provide relief from most illnesses. During therapy, the patient receives small doses of prepared plants and minerals in order to stimulate the body’s own healing processes and defense mechanisms. These substances mimic the symptoms of the illness. While studies on this approach remain inconclusive, homeopathic medicine has wide appeal, possibly because most (but not all) homeopathic practitioners are traditionally trained medical physicians. Kinesiology employs muscle testing and standard diagnosis to evaluate and treat the chemical, structural, and mental aspects of the patient. The principle behind kinesiology is that certain foods can cause biochemical reactions that weaken the muscles. Diet and exercise, as well as muscle and joint manipulation, are part of the treatment. There are risks of injury caused by an unqualified practitioner. Herbal medicine uses plants and flowers to treat most known symptoms of physical and emotional illnesses. Almost 75 percent of the world’s population relies on herbal remedies as their primary source of health care, and much of traditional medicine is derived from plants. Herbal medicine mixtures can be complicated, however, and some, like any medications, are toxic if taken incorrectly. Rebalancing Therapies Colon therapy technique involves the cleaning and detoxification of the colon by flushing with water, using enemas, or ingesting herbs or other
Alternative medicine ✧ 67 substances. A healthy colon will absorb water and nutrients and eliminate wastes and toxins. Most modern diets, however, are low in fiber, a substance which helps clean out the colon. If not completely eliminated, layers of wastes can build up in the colon and toxins can leak into the bloodstream, causing many health problems. Although not a specific cure for any disease, colon therapy removes the source of toxins and allows the body’s natural healing processes to function properly. Practitioners claim that symptoms related to colon dysfunction, such as backaches, headaches, bad breath, gas, indigestion and constipation, sinus or lung congestion, skin problems, and fatigue can be relieved when the toxins are removed from the colon. Detoxification focuses on ridding the body of the chemicals and pollutants present in water, food, air, and soil. The body naturally eliminates or neutralizes toxins through the liver, kidneys, urine, and feces and through the processes of exhalation and perspiration. Detoxification therapy accelerates the body’s own natural cleansing process through diet, fasting, colon therapy, and heat therapy. Symptoms of an overtaxed body system include respiratory problems, headaches, joint pain, allergy symptoms, mood changes, insomnia, arthritis, constipation, psoriasis, acne, and ulcers. Magnetic field therapy, also called biomagnetic therapy, uses specially designed magnets or magnetic fields applied to the body. Electrically charged particles are naturally present in the bloodstream, and when magnets are placed on the body, the charged particles are attracted to the magnets. As a result, currents and patterns are created that dilate the blood vessels, allowing more blood to reach the affected area. Magnetic field therapy is used to speed healing after surgery, to improve circulation, and to strengthen and mend bones. It is also used to improve the quality of healing in sprains, strains, cuts, and burns, as well as to reduce or reverse chronic conditions such as degenerative joint disease, some forms of arthritis, and diabetic ulcers. Neural therapy is used to treat chronic illness or trauma (injury) caused by changes in the natural electrical conductivity of the nerves and cells. Every cell has its own frequency range of electricity, and tissue remains healthy as long as the energy flow through the body is normal. Neural therapy uses anesthetics injected into the body to deliver energy to cells blocked by disease or injury. Conditions that respond to neural therapy are allergies; arthritis; asthma; kidney, liver, and heart disease; depression; head and back pain; and muscle injuries. Increasing Investigation of Alternative Therapies Many alternative or complementary therapies, while new to Western society and medicine, are ancient and derive from nontechnologically based understandings of how the human body and the world work. What specifically works for whom, when, and for what conditions remains a complex prob-
68 ✧ Alternative medicine lem. Anecdote and hearsay, and the limits and failures of Western medicine, guide and motivate interest in these approaches. Renewed interest in alternative therapies occurred in the 1970’s and has grown since. By 1998, an estimated one-third of all Americans had used some form of complementary therapy. In 1992, with Americans spending more than 14 billion dollars annually on alternative medicine, the U.S. government established the Office of Alternative Medicine as a part of the National Institutes of Health (NIH). This office evaluates complementary treatments on a scientific basis and provides public information. Health insurers maintain a key interest in alternative medicine, and an increasing number are paying for it. Many traditionally trained physicians are prescribing or recommending some form of alternative medicine as a complement to their own. —Virginia L. Salmon; updated by Paul Moglia See also Acupuncture; Holistic medicine; Homeopathy; Hypnosis; Light therapy; Meditation; Pain management; Stress; Yoga. For Further Information: The CQ Researcher 2, no. 4 (January 31, 1992). This entire issue discusses the topic of alternative medicine. Offers a balanced viewpoint and contains a valuable bibliography for further reading. Goldberg, Burton, comp. Alternative Medicine: The Definitive Guide. Tiburon, Calif.: Future Medicine Publishing, 1999. A well-written reference work which includes long, illustrated entries on various treatments. Provides sources of further information and recommended readings. Jacobs, Jennifer, ed. The Encyclopedia of Alternative Medicine: A Complete Family Guide to Complementary Therapies. Rev. ed. Boston: Journey Edition, 1997. Discusses current alternative medicine approaches. Kastner, Mark, and Hugh Burroughs. Alternative Healing: The Complete A-Z Guide to over 160 Different Alternative Therapies. New York: Henry Holt, 1996. The encyclopedic, one-page to four-page entries are brief but include sources of additional information. Also offers a useful resource section and bibliography. Mauskop, Alexander, and Brill Marietta Abrams. The Headache Alternative: A Neurologist’s Guide to Drug-Free Relief. New York: Dell Paperbacks, 1997. A practical review of how to apply complementary and alternative approaches to treating migraine, sinus, and tension headaches. Contains excellent resources and a bibliography section.
Alzheimer’s disease ✧ 69
✧ Alzheimer’s disease Type of issue: Elder health, mental health, social trends Definition: A progressive degenerative disorder of the brain characterized by loss of cognitive, visual-spatial, and language skills. Dementia, a disorder that mainly affects people aged sixty-five and older, may be thought of as a gradual decline of mental function. The most common form of dementia is the Alzheimer’s type. Alzheimer’s dementia is more fully characterized as a pathological condition in which there is progressive loss of cognitive, visual-spatial, and language skills. Alzheimer’s disease is an acquired condition, the exact causes of which are unknown. Approximately 6 to 8 percent of all people older than sixty-five have Alzheimer’s dementia; roughly 1.7 percent of people from sixty-five to seventy years of age have Alzheimer’s disease. The prevalence of this disorder doubles every five years after age sixty; thus, about 30 percent of people older than eighty-five have Alzheimer’s disease. While Alzheimer’s dementia typically begins late in life, a small percentage of sufferers experience its onset in their thirties or forties. Although some mild decline in memory, primarily demonstrated as slowness of recall, may be considered a normal part of aging, this must be distinguished from the debilitating condition of Alzheimer’s disease. Because of the progressive decline that it causes in its victims’ ability to function in all aspects of daily life, Alzheimer’s dementia eventually results in the need for care and supervision twenty-four hours a day. It was estimated that four million Americans had Alzheimer’s disease in the late 1990’s. It was predicted that fourteen million Americans would have Alzheimer’s disease by 2050. While the average life expectancy is eight to ten years after diagnosis, some patients may live twenty years or more. In 1999, the average lifetime cost per patient was about $174,000, and this cost was expected to rise. Contrary to public perception, 75 percent of people with Alzheimer’s disease receive care at home, often by family members. Nevertheless, nearly half of all nursing home residents have Alzheimer’s disease. The very elderly (those aged eighty and older), as the most rapidly growing segment of the American population, are changing the way in which society copes with this disease. To adjust to the increasing needs and demands for care, assisted-living centers and nursing homes dedicated to the exclusive care of people with Alzheimer’s disease are on the rise. Since most of this long-term care is not covered by Medicare or private insurance policies, families are expected to cover the expenses. The cost to families can be devastating, both financially and emotionally.
70 ✧ Alzheimer’s disease Signs and Symptoms Since the rate of cognitive decline in Alzheimer’s disease can be slowed with medications, early recognition of the signs and symptoms is imperative. With proper medical guidance and quality care at home or in staffed facilities, one can minimize the dehumanization and suffering that Alzheimer’s disease inflicts upon its victims. Three specific areas of decline found with Alzheimer’s disease are in the learning of new information; in complex task completion, organization, and daily planning; and in communication and interactions. The earliest symptoms of Alzheimer’s dementia are noted with difficulty remembering where common items have been placed or recalling basic details of recent conversations. Common examples are forgetfulness concerning appointments with physicians, family gatherings, or meetings that were previously well known and anticipated. For example, a woman who normally goes weekly for salon appointments on a certain day and at a set time might begin to arrive on the wrong day or not at all. Additional early warnings may include inability to recall important recent family events, such as weddings or the birth of new family members. Unfortunately, it is at this stage that family and friends are prone to dismiss these difficulties as normal aging, part of “getting older.” The reluctance to recognize dementia early may arise, in part, from the tendency to dismiss abnormal behaviors as normal, particularly in loved ones. For example, most people can recall a time when, perhaps during a particularly stressful or sad time, they too had been forgetful. Nevertheless, there is a great difference between the minor and time-limited forgetfulness that nearly all people have experienced and the ever-worsening, irreversible forgetfulness of Alzheimer’s disease. Other areas of daily life become increasingly problematic as the dementia progresses. Tasks that require several steps—such as cooking a meal, doing laundry, or balancing a checkbook—may be poorly performed with erosion of the cognitive skills necessary to organize these tasks mentally and physically. Reasoning may decline so that unsound or ill-advised contracts may be signed, perhaps jeopardizing the victim’s financial security. There is an inability to devise coping strategies or to develop solutions when problems arise. As such, relatively minor problems such as a burned-out light bulb, a leaky faucet, or a flooded basement can be viewed as insurmountable. Moreover, the skills of knowing one’s space and orientation within that space, or visual-spatial awareness, also wane. As a result, navigating through a once-familiar neighborhood or within one’s own home becomes increasingly difficult. Even on simple trips, demented individuals are at great risk of getting lost or endangering themselves and possibly others. While this situation is of concern when these individuals are wandering on foot, it is even more problematic when those with dementia are still driving. Personal grooming and hygiene may also decline with Alzheimer’s dis-
Alzheimer’s disease ✧ 71 ease. This may start with subtle cues, such as fingernails not being polished or trimmed. The individual may forget how to shave or shampoo or be unable to remember the last time that bathing occurred. Articles of clothing may be worn in uncharacteristically bizarre or clashing combinations, such as a winter coat with summer sandals, that heretofore would have never been combined by that person. A decline in personal appearance and habits strongly suggests a problem with cognitive skills. Increasingly, words and sentences become difficult to organize for the person with Alzheimer’s disease. Often, the first sign of language decline is the inability to remember words for simple items, such as the palm of the hand or the band of a wristwatch. This inability to find the word to identify an object is called anomia, literally meaning “without name.” When speaking, the patient may experience a sense of frustration while halting to recall a word or even the topic of conversation. Substituted phrases or stammering until someone rescues the patient by speaking for him or her become awkward but adaptive ways to communicate with others. Associated with declining language skills may be an increasing tendency to withdraw from conversations and be uncommonly passive. Alternatively, previously well-mannered people may become socially inappropriate—for example, speaking only in a loud voice. As the ability to modulate behavior deteriorates, social graces are lost. Some people may develop an irritable demeanor; others may become combative or blatantly aggressive with words and actions. These behaviors almost always lead to medical attention if none was previously sought. Alzheimer’s dementia ultimately robs individuals of their personality. At first, this may appear subtly as a loss of interest in once-pleasurable things. Often, there is progression to a more socially withdrawn state, with less expression of mood and feelings evident. Eventually, people who were once full of life, each with unique facial expressions and senses of humor, somehow end up looking very similar—with expressionless, blank faces and eyes that seem to stare deeply into nothing. This flattening of expression and loss of personality usually occur late in Alzheimer’s disease. Diagnosis Dementia of the Alzheimer’s type currently cannot be diagnosed by laboratory tests or imaging techniques such as computed tomography (CT) or magnetic resonance imaging (MRI). As a medical diagnosis, Alzheimer’s dementia is a diagnosis of exclusion. As such, the possibility must be evaluated that the presenting symptoms of confusion, memory loss, and poor ability to take care of oneself derive from other causes. First, other forms of dementia, some of which may be reversible, are explored. In addition, medical conditions such as delirium or depression are carefully considered, as both are generally reversible and, with medical treatment and manage-
72 ✧ Alzheimer’s disease ment, of limited duration. The physician will need to know what medical problems, if any, the patient may have, as well as what prescription and over-the-counter medications are being taken. If a fall has occurred that may coincide with the onset of symptoms, it will be important to assess and evaluate the patient for possible head trauma or injury, including intracranial bleeding. Any history of excessive alcohol consumption or illicit drug use is important; such information can clarify certain health issues, such as vitamin deficiencies, that may be contributing to the clinical picture. Once such factors are identified and resolved or found to be noncontributory, the physician can explore the possibility of Alzheimer’s disease more completely. This diagnosis is made primarily from the doctor’s suspicion and from clinical findings. Thus, the physician will consider the patient’s symptoms as described by family and friends. The physician will observe, engage, and monitor the patient’s ability to perform simple tasks, such as social greetings and recalling names of people in the family, important dates, or current events. The evaluation may include the Mini-Mental Status Exam, the Blessed Information-Memory-Concentration Test, a clock drawing test, a functional activities questionnaire, or other diagnostic aids. While helpful tools, these diagnostic assessments alone cannot diagnose Alzheimer’s dementia definitively. The physician will also ask questions regarding certain risk factors for Alzheimer’s disease. Known risk factors include a family history of Alzheimer’s dementia, increasing age (especially after age eighty), and head trauma in the past that caused a loss of consciousness. An additional risk factor for Alzheimer’s disease is found in people who have been diagnosed with Down syndrome (trisomy 21), as almost all people with trisomy 21 who survive to age forty-five will develop early onset of Alzheimer’s dementia. Although it remains unclear as to the role of estrogen as it may relate to Alzheimer’s disease, the physician may want to know whether female patients are using or have used estrogen replacement therapy after the menopause. Late in the disease, other signs and symptoms may appear as a consequence of neuron (brain cell) loss and the biochemical dysfunction of surviving neurons. One of these is hallucinations, such as hearing voices or seeing images of people or things that are not present yet believing fully that they are real. This condition is known as psychosis. Another familiar psychotic feature is paranoid delusions. This often presents itself in moderate dementia, typically revolving around unfounded beliefs that family members are stealing items. Sometimes the items “stolen” have no value, such as a hat or glove; more important, such paranoia is a demonstration of the confusion that results from the chaos of not having memory. A careful history of the patient’s decline and the severity of symptoms will help to establish the relative rate of cognitive loss. From these data, a prognosis for the patient in terms of both quality and, to a lesser extent, quantity of life may be made.
Alzheimer’s disease ✧ 73 Treatment and Management There is no known cure for or prevention of Alzheimer’s dementia. As a consequence, treatment focuses on managing symptoms, slowing the rate of cognitive decline, and improving quality of life. The most commonly prescribed medications used to abate the progression of Alzheimer’s dementia come from a category of pharmaceutical agents known as cholinesterase inhibitors, including tacrine and donazepril. Although the exact role of cholinergic neurons within the central nervous system is not well understood, it has been demonstrated that in Alzheimer’s disease, there is both a loss in the number of cholinergic neurons and dysfunction in the cholinergic neurons that remain viable. Thus, Alzheimer’s dementia is characterized by a net deficit of cholinergic neurotransmitters. The enzyme cholinesterase biochemically degrades cholinergic neurotransmitters within the central nervous system. In health, this poses no problem, but in Alzheimer’s disease, this process exaggerates symptoms. Even a little reduction of already depleted amounts of cholinergic neurotransmitters worsens the condition. Therefore, an inhibitor that halts the enzyme activity helps to increase the amount of cholinergic neurotransmitter, which, in turn, improves cognition. The optimal benefit from cholinesterase inhibitors is obtained when the medication is started as early in the dementia process as possible. With medications, some people will have improvement of cognition that is evident in their mood, speech, and selfcare or in their ability to perform daily tasks. Even in moderate to severe forms of Alzheimer’s disease, where cognitive decline is marked, these medications have been helpful in reducing symptoms of agitation, aggression, or restlessness. About 25 to 30 percent of all people diagnosed with Alzheimer’s disease will experience depression. Since loss of brain cells occurs with Alzheimer’s disease, it is no surprise that some cells which produce neurochemicals to regulate mood are also lost. Thus, depression should be looked for in all stages of Alzheimer’s disease, as it can be identified and treated with antidepressant medications. In the past, tricyclic antidepressants were used for this illness in the elderly, but because tricyclics have multiple side effects, other medications are increasingly receiving favor. Side effects and drug interactions can be particularly problematic in the elder patient who is frequently taking several medications for other medical conditions. Additional therapies target particular symptoms. For example, paranoia can be managed and often resolved with antipsychotic medications. With the elderly, special efforts are made by physicians to use the lowest dose possible, as well as to select medications that have minimal side effects. Two other common concerns are lack of impulse control or lability of mood and disruption of sleep patterns. Often, the former can be managed with mood stabilizers, such as valproic acid, as well as environmental controls, so that
74 ✧ Alzheimer’s disease the patient is not overly stimulated by activities or sounds that occur in everyday life. The latter can be managed with “sleep hygiene.” This therapy helps to reset the biological clock by establishing fixed hours to go to and awaken from sleep and not allowing napping. Additional aids may include medications, but caution should be exercised because some commonly used agents, such as benzodiazepines, may have paradoxical effects in the elderly. Another caution is to avoid the use of the anticholinergic medications often used to induce sleep, such as diphenhydramine, as this can worsen dementia symptoms. How Families Cope Although Alzheimer’s disease afflicts individuals, entire families are affected by the cruel and prolonged course of this disease. Enormous emotional costs are paid by family members who care for and attend to a loved one who increasingly grows to depend on others for safekeeping. More often than not, it is adult women, many of whom are working mothers of young children or teenagers, who find themselves in the role of providing care for family members with Alzheimer’s disease. In fact, studies indicate that greater than 90 percent of those providing care for patients with Alzheimer’s disease in their or a family member’s home are women. This role is far more demanding than simply providing meals or getting someone to a doctor’s appointment. For example, traveling or even being alone is no longer a safe option for the person with Alzheimer’s disease; constant supervision to prevent wandering from the home and getting lost is needed. Cooking or ironing is no longer safe for someone with Alzheimer’s disease because of the potential for self-injury or household fires, yet these activities are often attempted when a brief lapse of supervision occurs. Unlike children, who lack good judgment but are small and manageable, adults with Alzheimer’s disease may be physically strong and sizable. This fact makes keeping them in safe spaces a real challenge. Families need to “Alzheimer-proof” the home to reduce the risk of injury or tragedy, such as accidental death, for the patient with Alzheimer’s disease and other family members. It is helpful to contact local police and fire departments and to advise them that someone with Alzheimer’s disease lives at that residence. This allows ease of filing a missing person’s report with police or getting a rapid response to home fires, as neither event is uncommon when someone with Alzheimer’s disease lives in a family home. At variable rates, but in a predictable manner, dependence needs grow to include making phone calls to family or friends, finding belongings, grooming and dressing, or using simple appliances such as electric shavers, lamps, or toasters. As the progressive loss of cognition continues, simple housekeeping tasks such as clearing a table or depositing trash into proper receptacles cannot be performed. Assistance with toileting or changing
Alzheimer’s disease ✧ 75 adult diapers also becomes necessary. In the late stage of Alzheimer’s disease, assistance with eating, sitting upright, and walking is required as the disease leads a fully debilitating course. As may be anticipated, caregivers are at risk for emotional burnout and physical fatigue. To alleviate this problem, many areas offer adult day care programs. In these programs, people with Alzheimer’s disease are assisted by trained staff in physical, social, and creative activities that help to optimize the overall well-being of participants. In better programs, such activities are tailored specifically to meet the unique needs of Alzheimer’s patients. These programs also promote improved mood through socialization and offer a sense of independence from family members. Such programs are beneficial not only to participants but also to their caregivers. Clearly, adult day care offers a reprieve to the caregiver who, for a specified number of hours a day, will be relieved from the burden of having to monitor and care for an ill loved one constantly. Institutional Care Although 75 percent of people with Alzheimer’s disease are cared for by family members, 50 percent or more of all nursing home residents have Alzheimer’s disease. This shift occurs as debility consumes the very life of the Alzheimer’s patient, to the point that safety can no longer be maintained without professional supervision, proper medical care, and careful medication management. When this point is reached, family members become resigned to placing loved ones in facilities where assisted-living and medical services can be provided. With guidance from support groups, doctors, and other professionals, good to excellent facilities can be found that meet the emotional, physical, and medical needs of the family and yet fit within their financial constraints. In 1999, the average monthly cost of caring for a family member with Alzheimer’s disease in either an assisted-living facility or a nursing home was $3,100. When the care was provided in the family home, the average monthly cost was $1,500. These numbers, when multiplied by twelve for the months per year and then by eight for the years of possible life expectancy, give a conservative estimate of $144,000 to $297,000 for lifetime care per person with Alzheimer’s disease. Because most families do not have such resources available, great measures are taken to afford care for loved ones, sometimes at great economic risk to these families. Another consideration is the matter of competency. In Alzheimer’s disease, the ability to make important personal decisions such as writing wills or making financial and health care choices is lost. Therefore, early in the course at the disease, families are encouraged to have court-appointed guardianship or executorship established. This allows the appointed person, usually a spouse or child of the patient, to make financial, health care, and
76 ✧ Alzheimer’s disease medical choices for the demented person. Court actions can assist many families with the economic aspect of Alzheimer’s disease as they can manage the patient’s financial matters. As for the emotional toll, support from others who have endured or are enduring the same problem can be found in many communities at Alzheimer’s Association chapters. Many turn to lifelong friends and their religious beliefs for further support and guidance. The cruel reality of Alzheimer’s disease is that at the end of the twentieth century, it was the fourth-leading cause of death in adult Americans. Therefore, end-of-life choices need to be addressed, including the “do not resuscitate” (DNR) status and the personal choice of life support. Some families are lucky to have had the patient with Alzheimer’s disease designate, while fully competent, his or her wishes through drafting a living will or giving someone trusted durable power of attorney. Such actions give chosen individuals the responsibility for making important decisions for patients in the event that they are unable to do so themselves. DNR status allows a person to die without resuscitation if such measures will simply delay death rather than maintain life in anticipation of recovery. Some members of society consider resuscitation an intrusion of modern medicine into the natural course of dying; others want everything done to sustain life, regardless of the ultimate outcome. Often these emotions are based on deeply held personal beliefs. DNR requests are generally made by the patient (while in good health) or by family members to the patient’s physicians without court involvement. Rather, dialogue about prognosis, the pros and cons of DNR status, and family meetings with doctors and other professionals contribute to the family’s decision. Alzheimer’s dementia is a progressive, abnormal loss of one’s ability to think, learn, communicate, and care for oneself. The illness leads to full debility and a dependence on others in order to sustain life. By the end of the twentieth century, because of the prolonged course of Alzheimer’s disease and the need for medical and high-level nursing care, it was the third most costly medical condition, ranked after heart disease and cancer. As people live longer and the “aging of America” continues, the number of people with Alzheimer’s disease will increase. As a result, more nurses and physicians will be needed in geriatric medicine. —Mary C. Fields See also Aging; Dementia; Depression in the elderly; Living wills; Memory loss. For Further Information: Larkin, Marilynn. When Someone You Love Has Alzheimer’s. New York: Dell, 1995. An excellent resource for caregivers. Offers tips on daily management of people with Alzheimer’s disease, including diet, toileting, exer-
Amniocentesis ✧ 77 cise, and medical care. A comprehensive resource list is provided. Mace, Nancy L., and Peter Rabins. The Thirty-six-Hour Day: A Family Guide to Caring for Persons with Alzheimer’s Disease, Related Dementing Illnesses, and Memory Loss Later in Life. 3d ed. Baltimore: The Johns Hopkins University Press, 1999. An excellent resource for caregivers who find comfort in fighting this disease with knowledge. The book also offers tips on coping with typical problems encountered in caring for someone with Alzheimer’s disease. Markin, R. E. Coping with Alzheimer’s: The Complete Care Manual for Patients and Their Families. Secaucus, N.J.: Carol, 1998. A quick read that is helpful in the organization process for caring for someone with Alzheimer’s disease. Some of the medication information is outdated, but otherwise this is a good, practical guide. Nolan, K. A., and R. C. Mohs. “Screening for Dementia in Family Practice.” In Alzheimer’s Disease: A Guide to Practical Management, Part II, edited by Ralph W. Richter and John P. Blass. St. Louis: Mosby-Year Book, 1994. The source from which the clock drawing test was obtained. Although this book is written for physicians, some of the information can be comprehended easily by laypeople who may have a diagnostic interest in Alzheimer’s disease. Powell, Lenore S., and Katie Courtice. Alzheimer’s Disease: A Guide for Families. Rev. ed. Reading, Mass.: Addison-Wesley, 1993. This excellent book is divided into three sections: “The Burden of Love,” “Understanding and Dealing with the Patient’s Problem,” and “Taking Care of Yourself.” Nontechnical chapters about the nature of this disease are helpful. Examples of a living will and a resident’s bill of rights (for nursing homes or assisted-living facilities) are given.
✧ Amniocentesis Type of issue: Children’s health, medical procedures, prevention, women’s health Definition: The removal of amniotic fluid from a pregnant woman for analysis; this fluid provides biochemical and genetic information about the fetus, enabling physicians to identify hereditary problems in the baby well before it is born. Amniocentesis is used to provide diagnostic information before a fetus is born. It is performed most often on fourteen- to sixteen-week-old fetuses because, at that stage of development, the procedure can be carried out very safely, amniotic fluid samples large enough for detailed genetic and biochemical analysis may be obtained without harming a fetus, and adequate
78 ✧ Amniocentesis time is available both to obtain data and to use them to solve any problems that are encountered. The procedure is usually carried out in six consecutive steps. First, the position of the placenta in the uterus is located using ultrasonography. Then, the physician who will carry out the procedure locates the fetus by gentle, careful palpation of the mother’s abdomen. Next, the mother is usually, but not always, given a dose of a local anesthetic. This is followed by the careful insertion of a long hypodermic needle through the abdominal wall and into the amniotic sac. As soon as amniotic fluid is seen in an attached sterile hypodermic syringe, a twenty-milliliter sample (about four teaspoons) of fluid is carefully drawn up into the syringe. Finally, the needle and syringe are removed from the mother’s abdomen. Amniocentesis is reported to be almost painless: Even when patients are subjected to the procedure without being given an anesthetic, most report only an initial needle prick and a feeling of pressure during the process. Amniocentesis is also deemed to be very safe for both mother and fetus: Even if repeated several times, it has been reported to produce a risk factor of well under 1 percent. Amniotic Fluid as a Diagnostic Tool The amniotic fluid of early pregnancy is very like the blood serum from which it arises. As pregnancy continues, the content in the fluid of substances derived from fetal urine and other fetal secretions increases greatly. Amniotic fluid also contains fetal cells arising from the skin, the stomach and other parts of the gastrointestinal organs, the reproductive organs, and the respiratory organs. Consequently, this fluid is a very valuable diagnostic tool. Immediately after the amniotic fluid is collected, these fetal cells are separated out to be used for genetic analysis. The remaining, cell-free amniotic fluid is examined using a wide variety of biochemical techniques. Important tests of the amniotic fluid and the cells that it contains include the determination of lecithin and sphingomyelin content, sex determination, and the identification of chromosomal diseases. Lecithins and sphingomyelins are two kinds of fatlike molecules known as lipids. Lecithins are the essential components of the pulmonary surfactant that acts, at lung surfaces, to prevent the collapse and dysfunction of tiny lung air sacs (alveoli) when a person exhales. Subnormal production of the pulmonary surfactant in a fetus may indicate the presence of the potentially fatal respiratory distress syndrome or hyaline membrane disease. Thus an important measurement made after amniocentesis is the ratio of lecithin and sphingomyelin content in the amniotic fluid. Lecithin-sphingomyelin ratio values of about 2.0 are deemed to be healthy, and those of 1.5 or less indicate a likelihood of risk to the fetus. Many other biochemical problems can be identified by similar analysis of other components of the amniotic fluid.
Amniocentesis ✧ 79 Both the sex of the fetus and the presence of chromosomal diseases can be diagnosed by examining the hereditary material, the deoxyribonucleic acid (DNA), from fetal cells grown in tissue cultures derived from the cells that were obtained by amniocentesis. Sex is determined, and the presence of some diseases caused by abnormal chromosomes is identified, by examination of the number and shape of the chromosomes in the fetal cells, a process known as karyotyping. Human beings usually possess twenty-three pairs of chromosomes, each of which has a characteristic size, shape, and overall appearance. A number of chromosomal diseases are associated with the presence of too many or too few chromosomes. A classical example is Down syndrome, which is always caused by the presence of an extra copy of chromosome number 21 (that is, there are three such chromosomes instead of the usual pair). Some chromosomal abnormalities are caused by much more subtle DNA changes that do not alter human chromosome numbers. Rather, they are attributable to changed DNA in a chromosome that alters a small part of that chromosome. These diseases are discovered using DNA sequence analysis, which identifies existing abnormalities in the organization of parts of DNA molecules. A gene—a piece of DNA in a chromosome that carries genetic information—can be likened to the bar code used in supermarkets to identify a product at the cash register. Changes in that gene are like the changes in the bar code that indicate another, similar product. The bar code in a gene is a sequence of chemical units, and its alteration may signal the presence of a severe disease. Choosing Who Will Be Tested The use of amniocentesis can replace or minimize the uncertainty of indirect genetic counseling. The decision to choose or to exclude a particular course of action in family planning had been based entirely on a calculation of the mathematical odds of an inheritable disease being passed on to the children of those who were counseled. For example, when a family history indicated that both of the prospective parents carried a harmful gene—that is, when there was a history of the frequent occurrence of a disease in past generations—some risk was identifiable. On the other hand, if one or both of the parents actually suffered from a genetic disease, the odds of its being passed on increased to a point at which it was assumed that a child would develop that disease. The use of amniocentesis is most valuable when, because of parental genetics, such a disease is likely but not assured. Genetic and/or biochemical information obtained by testing can either confirm the existence of the problem and suggest a corrective course of action or put the prospective parents’ minds at rest. In such testing, it is important to identify the appropriate maternal group to test for each of the many diseases that are detect-
80 ✧ Amniocentesis able by amniocentesis. Testing only the appropriate cases will ensure that the accompanying small but existent risks of amniocentesis to mothers and their fetuses are minimized. Amniocentesis is usually indicated when an Rh-negative woman and an Rh-positive man conceive a child because of the chance of hemolytic anemia in Rh-positive offspring. In fact, this use of amniocentesis was the basis of the pioneering effort, by Douglas Bevis in the 1950’s, that first demonstrated the great predictive value of this procedure. Additional group selection of subjects appropriate for amniocentesis is possible in many other cases. For example, the use of the procedure to identify Down syndrome is most important in mothers over the age of thirty-five, for whom the risk to a fetus is much higher than that seen in younger women. Likewise, the exploration of the possibility of respiratory distress syndrome is very valuable when there is a family history of previous premature children because premature infants are always at high risk for developing the disease. A test, via amniocentesis, of the lecithin-sphingomyelin ratio is also quite important in pregnant women who suffer from diabetes mellitus. The babies of such mothers are very likely to have subnormal lecithin levels and thus be at risk for various lung disorders. When amniocentesis identifies an at-risk lecithin-sphingomyelin ratio value, the potentially endangered fetus is injected with hormones that help it to produce mature lungs by raising the lecithin-sphingomyelin ratio value. The success or failure of such efforts is confirmed by the repetition of the amniocentesis. Numerous other biochemical problems that may be present in fetuses can be identified through a similar analysis of other components of the amniotic fluid. Pregnancy in women who are more than thirty-five years old is currently viewed as the best reason for carrying out amniocentesis. The main fear, in this circumstance, is the presence of severe chromosomal diseases, the incidence of which is far greater for older women than for younger women. For example, the severe mental retardation caused by Down syndrome occurs in 3 percent of all live births of children to mothers over forty-five, an incidence about one thousand times greater than that in the offspring of twenty-year-old women. Some other chromosomal diseases that can be identified by amniocentesis and DNA analysis are spina bifida, anencephaly, sickle-cell anemia, cystic fibrosis, muscular dystrophy, Huntington’s chorea, and Klinefelter’s syndrome. A number of these potentially devastating diseases can be corrected while a fetus is in the uterus, if they are diagnosed quickly enough. Where such treatment is not possible, an early diagnosis will usually make it possible either to choose whether to undergo a therapeutic abortion or to have the baby within a time window that ensures the safety of the former option.
Amniocentesis ✧ 81 Acting on the Results Where amniocentesis identifies an exceptionally severe chromosomal disease in a fetus, the parents are informed concerning what to expect. In some cases, the decision to terminate the pregnancy may be made, and in others the pregnancy is continued with knowledge regarding the child’s likely physical and mental status. A second amniocentesis procedure is often carried out to confirm the existence of the problem before any kind of action is taken by the parents. It is important to note that, in many cases, amniocentesis will identify a treatable disease that can be handled while the fetus is still in the uterus. One such example is respiratory distress syndrome. When this disease is diagnosed early in the third trimester of a pregnancy, it can be treated successfully with hormones. In such cases, the amniocentesis procedure is then repeated at appropriate intervals after treatment, to assure both the parents and the physician that the problem has been solved. The Future of Fetal Testing Numerous consequences of improvements in the methodologies associated with amniocentesis have produced still more effective avenues of exploration of the state of the fetus in the uterus. One example is the use of telescope-like fetoscopes to examine fetuses directly. In a procedure similar to that used to enter the uterus for amniocentesis, a fetoscope is utilized to examine the fetus for physical defects. In some cases, these defects are repaired via surgery, hormone administration, or chemotherapy. Such avenues of fetal monitoring and care are components of the medical specialty called fetology. Another technique of obtaining fetal cells is chorionic villus sampling. It arose from the demonstration of the clear value of the information derived from fetal cells obtained from amniotic fluid. This useful procedure was devised to shorten the several-week-long time period, after amniocentesis, that is needed to grow enough fetal cells in tissue culture to provide the amount of tissue required for successful karyotyping or DNA sequencing work. Another advantage of the chorionic villus sampling procedure is that it can be carried out with younger fetuses, as young as twelve weeks old, although the risk to such fetuses is somewhat higher than that which is seen after amniocentesis. When an abortion or another type of corrective action is indicated by the results of chorionic villus sampling, moreover, it is often safer to carry out such actions because the testing procedure was performed much earlier in the pregnancy. In chorionic villus sampling, a catheter is usually inserted into the uterus through the vaginal opening. This catheter is then guided by ultrasonography until its tip reaches the many chorionic villi that edge the placenta at its connection to the uterus. Gentle suction is applied, and a few of the villi are
82 ✧ Amniocentesis sucked out, first into the catheter and then into a sampling device. The cells that are obtained are tested in the same manner as with cells obtained after amniocentesis. —Sanford S. Singer See also Abortion; Birth defects; Disabilities; Down syndrome; Genetic counseling; Genetic diseases; Genetic engineering; Mental retardation; Multiple births; Pregnancy among teenagers; Prenatal care; Preventive medicine; Screening; Spina bifida. For Further Information: Filkins, Karen, and Joseph Russo, eds. Human Prenatal Diagnosis. 2d ed. New York: Marcel Dekker, 1990. This book attempts to “clarify and rationalize aspects of diagnosis, genetic counseling, and intervention.” It is meant as a guide for health professionals and is useful to general readers. The fourteen chapters cover a wide range of useful topics, including DNA analysis. Holtzman, Neil A. Proceed with Caution: Predicting Genetic Risks in the Recombinant DNA Era. Baltimore: The Johns Hopkins University Press, 1989. This quite technical text describes the use of karyotyping and numerous other forms of hereditary material testing for identifying genetic problems. Included among these topics are applications associated with amniocentesis. Rapp, Rayna. Testing Women, Testing the Fetus: The Social Impact of Amniocentesis in America. New York: Routledge, 1999. Rapp, an anthropologist, combines personal experience and professional expertise. She has interviewed women of many different racial, cultural, religious, educational, and financial backgrounds for this study, in which she also explores the role of the genetic counselor. Sherwood, Lauralee. Human Physiology: From Cells to Systems. 4th ed. Pacific Grove, Calif.: Brooks/Cole, 2000. This college textbook contains useful biological information about pregnancy and genetic defects, as well as facts useful to understanding amniocentesis and its advantages and disadvantages. Provides many valuable definitions and diagrams. Clearly written, the book is a mine of information for interested readers. Verp, Marion S., and Albert B. Gerbie. “Amniocentesis for Prenatal Diagnosis.” Clinical Obstetrics and Gynecology 24 (1981): 1007-1021. This concise, technical review of amniocentesis covers much material, including genetic counseling, the composition of amniotic fluid, the risks associated with amniocentesis, and Rh sensitization. Seventy-five references are made available to interested readers.
Anorexia nervosa ✧ 83
✧ Anorexia nervosa Type of issue: Children’s health, mental health, social trends, women’s health Definition: Self-induced malnutrition resulting in a body weight 15 percent or more below normal for age and height, and, in women, characterized by the absence of three or more consecutive menstrual periods. Anorexia nervosa is an obsessive-compulsive disorder characterized by a body weight at or below 85 percent of normal and an intense fear of weight gain. Anorexia nervosa is typically a physical manifestation of underlying emotional conflicts such as guilt, anger, and poor self-image. Eating disorders such as anorexia nervosa are the third most common chronic condition among girls ages fifteen to nineteen. Approximately 95 percent of anorexics are female. Anorexia nervosa often occurs following a successful dieting experience, and frequent dieting may contribute to the development of the disorder. Dieters may experience positive feedback regarding weight loss and feel compelled to continue losing weight. Although the term “anorexia” means “loss of appetite,” most anorexics continue to experience hunger but ignore the body’s normal craving for food. Anorexics frequently identify specific areas of the body that they believe are “fat,” despite their emaciated condition. Secrecy and ritual eating habits may be signs of anorexia nervosa. Sufferers often lie to family and friends to avoid eating meals and may eat only a set diet at a specific time of day. The Psychological Aspects of Anorexia Many anorexics are high achievers, exhibiting perfectionist or “peoplepleasing” personalities. In addition, a strong correlation exists between anorexia nervosa and athletic activities that emphasize the physique, such as track, tennis, gymnastics, cheerleading, and dance. Anorexics may demonstrate additional obsessive-compulsive behaviors such as weighing themselves and/or examining themselves in the mirror several times per day, being overly concerned with calorie or fat content, exercising compulsively, maintaining unusually consistent eating patterns, and kleptomania (compulsive stealing). Anorexia nervosa is frequently a symptom of depression, and the accompanying weight loss can be seen as a cry for help. Eating disorders tend to run in families, particularly those that equate thinness with success and happiness. The condition may also occur as a result of a traumatic situation such as death, divorce, pregnancy, or sexual abuse.
84 ✧ Anorexia nervosa Results of Anorexia Symptoms and resulting physical conditions include amenorrhea, the abnormal interruption or absence of menstrual discharge, which can occur when body fat drops below 23 percent. Anorexia nervosa may also be characterized by a distended abdomen as a result of a buildup of abdominal fluids and the slowing of the digestive system. Resulting malnutrition can impair the immune system and cause anemia or decreased white blood cell counts. Brain and central nervous system functions may also be affected, resulting in forgetfulness, attention deficits, and confusion. Anorexics frequently experience fatigue, apathy, irritability, and extreme emotions. Additional symptoms can include thyroid abnormalities, fainting spells, irregular heartbeat, brittle nails, hair loss, dry skin, cold hands and feet, hypotension (low blood pressure), infertility, broken blood vessels in the face, and the growth of downy body hair called lanugo as the body attempts to insulate itself because of the loss of natural fat. The occurrence of eating disorders in adolescents is especially dangerous because the condition can retard growth and delay or interrupt puberty. Anorexia nervosa can also result in the erosion of heart muscle, which lowers the heart’s capacity and can lead to congestive heart failure. Anorexics may experience musculoskeletal problems such as muscle spasms, atrophy, and osteoporosis as a result of potassium and calcium deficiencies. In extreme cases, patients may also experience kidney failure. Treating the Disease It is frequently necessary first to treat the acute physical symptoms associated with anorexia nervosa. Most patients—especially those with severe cases— benefit from treatment in a controlled environment that allows medically supervised “refeeding” to achieve a target rate of weight gain. Less severe cases may be treated on an outpatient basis. During the initial phase of refeeding, the patient may receive a lowcalorie diet to avoid overwhelming low-functioning organs. Patients who do not comply with the recommended diet may receive caloric supplements and, in serious cases, intravenous feeding. Successful treatment also involves resolution of underlying emotional conflicts through individual and/or family counseling and may also include use of antidepressants such as fluoxetine (Prozac). Anorexia nervosa is extremely difficult to treat, with a fatality rate of 5 percent to 10 percent within ten years. Nearly half of all sufferers never recover fully from the condition.
Anorexia nervosa ✧ 85 The Problem of Body Image Anorexia is both an emotional and a cultural phenomenon. More than three-quarters of adolescent girls in the United States report being unhappy with their bodies and, on average, 25 percent of women are on a diet at any given time. Most eating disorders were not recognized as illnesses until the late nineteenth century. Conditions such as anorexia nervosa gained the attention of medical professionals during the 1960’s and beyond as a result of the media’s obsession with thinness. The media are prime contributors to this trend. Television and magazines send confusing messages to young consumers, such as depicting painfully thin models promoting high-fat snacks. Most models weigh about 23 percent less than the average American woman, and up to 60 percent of models suffer from eating disorders. In addition, the media frequently portray overweight people as having a lower socioeconomic status than people who are thin. Obese people are generally portrayed as comical, while thin people are often depicted as more intelligent, sophisticated, successful, and happier with their lives. It appears likely that the incidence of eating disorders will continue to escalate as the media persist in depicting an idealized female body image significantly below normal body weight. —Cheryl Pawlowski See also Addiction; Children’s health issues; Depression; Depression in children; Eating disorders; Malnutrition among children; Menstruation; Nutrition and women; Obesity; Obesity and children; Stress; Women’s health issues. For Further Information: Broccolo-Philbin, Anne. “An Obsession with Being Painfully Thin.” Current Health 2 22, no. 5 (January, 1996): 23. Costin, Carolyn. The Eating Disorder Sourcebook. Los Angeles: Lowell House, 1996. _______. Your Dieting Daughter: Is She Dying for Attention? New York: Brunner/Mazel, 1997. Goodman, Laura J. Is Your Child Dying to Be Thin? A Workbook for Parents and Family Members on Eating Disorders. Pittsburgh: Dorrance, 1992. Vredevelt, Pam, Deborah Newman, Harry Beverly, and Frank Minirth. Thin Disguise: Overcoming and Understanding Anorexia and Bulimia. Nashville: Thomas Nelson, 1992.
86 ✧ Antibiotic resistance
✧ Antibiotic resistance Type of issue: Epidemics, public health, treatment Definition: The ability of a pathogen, formerly susceptible to a particular medication, to change in such a way that it is no longer affected by it. Drug resistance occurs whenever pathogens—microscopic organisms such as bacteria, viruses, and fungi, or larger organisms such as parasites—that have been successfully eradicated with a certain agent develop the ability to resist that agent. The most common and most important form of drug resistance is the ability of bacteria to develop resistance to antibiotics. An antibiotic attacks a bacterial cell by binding to the cell wall and penetrating it to reach the interior of the cell, where it interferes with a vital biochemical process. Bacteria can develop resistance to an antibiotic in several ways. The bacterial cell may develop the ability to produce a substance that inactivates the antibiotic. The structure of the cell wall may be altered so that the antibiotic can no longer bind to or penetrate it. The cell may increase the activity of the biochemical process being attacked, or it may develop a new process to replace the old one. Resistance to a particular antibiotic arises in a bacterial cell by random genetic mutation. Because this cell survives antibiotic treatment that destroys other bacteria of the same kind, it is able to reproduce, resulting in numerous offspring that are also resistant. The bacteria that were formerly susceptible to the antibiotic are now resistant. Even if an antibiotic is completely successful at eradicating a particular type of bacteria, problems with drug resistance can arise. The human body contains billions of bacteria of many different kinds. When one or more of these kinds of bacteria are eliminated by an antibiotic, those kinds that happen to be resistant will multiply in greater numbers. Even if these resistant bacteria are harmless, they often have the ability to transfer antibiotic resistance to harmful bacteria. Use of multiple antibiotics or antibiotics that attack many kinds of bacteria, known as broad-spectrum antibiotics, can cause other problems. By eliminating a large number of the bacteria normally present, powerful antibiotics encourage the growth of fungi such as Candida albicans. Fungal infections are resistant to antibiotics and require special antifungal drugs. An important factor in the emergence of antibiotic resistance is the misuse of antibiotics. For example, antibiotics have no effect on viruses but are often used on viral illnesses. A study published in 1997 revealed that at least half of all patients in the United States who visited doctors’ offices with colds, upper respiratory tract infections, and bronchitis received antibiotics, even though 90 percent of these illnesses are caused by viruses. The same study showed that almost a third of all antibiotic prescriptions written in
Antibiotic resistance ✧ 87 doctors’ offices were used for these kinds of illnesses. Similar problems are also seen in hospitals. A 1997 study of the misuse of the antibiotic vancomycin in U.S. hospitals revealed that 63 percent of vancomycin orders violated guidelines set up by the Centers for Disease Control. Public Health Concerns Several public health concerns have arisen as a result of drug resistance. One of the earliest serious problems to arise was an outbreak of dysentery caused by bacteria resistant to four antibiotics in Japan in 1955. From the 1950’s to the 1990’s, multiple antibiotic resistance emerged in bacteria that caused pneumonia, gonorrhea, meningitis, and other serious illnesses. A case documented in Nashville, Tennessee, from 1973 to 1974 demonstrates the severity of the problem. A patient with a history of being treated with broad-spectrum antibiotics was exposed to bacteria known as Serratia while in the hospital. The Serratia, normally susceptible to many antibiotics, picked up the genetic information encoding for multiple antibiotic resistance from otherwise harmless bacteria in the patient’s body. The newly resistant Serratia spread to other patients in the hospital and to patients in other nearby hospitals. Meanwhile, the Serratia transferred resistance to bacteria known as Klebsiella. By the end of 1974, more than four hundred patients in four hospitals were infected with multiply resistant Serratia or Klebsiella. Seventeen of these patients died. In the 1980’s, drug-resistant tuberculosis emerged as a public health concern. In New York City in 1991, for example, 33 percent of all tuberculosis infections were resistant to at least one drug, and 19 percent were resistant to both of the two most effective drugs used to treat the disease. Because of resistance, many tuberculosis patients require treatment with four drugs for several months. Because of public health concerns and the difficulty of taking so many drugs properly for such an extended period of time, some patients are required to be directly observed by a health care worker every time that they take a dose of medication. The use of multiple drugs and the need for increased numbers of health care workers greatly increase the cost of treating tuberculosis. A new challenge appeared in 1997, when patients in Japan and the United States developed infections caused by bacteria known as Staphylococcus aureus that were partially resistant to the drug vancomycin. These patients required multiple antibiotics for extended periods of time. Staphylococcus aureus is an organism normally found on human skin that can cause potentially fatal infections when it enters the blood. Many of these bacteria are resistant to multiple antibiotics, leaving vancomycin as the only effective treatment. Medical researchers fear that if Staphylococcus aureus with full resistance to vancomycin appears in the near future, it could cause infections that would be nearly impossible to treat.
88 ✧ Antibiotic resistance Addressing the Problem Several different strategies have been suggested for dealing with the problem of antibiotic resistance. In general, these strategies involve educating the public and health care workers, monitoring antibiotic use, and promoting research into methods to deal with resistant bacteria. The general public should be aware of the proper use of antibiotics. Many patients expect to be given antibiotics for illnesses that do not respond to them, such as viral infections. They may pressure physicians into prescribing antibiotics even when physicians are aware that they are useless. Some patients may use another person’s antibiotics or may use old supplies of antibiotics that they have saved from previous illnesses. Even when antibiotics are properly prescribed, patients who begin to feel better may fail to take the entire amount prescribed, leading to an increased risk of drug resistance without completely eliminating the original infection. Public education is even more critical in those nations where many antibiotics can be purchased without a prescription. All health care workers should be aware of the importance of avoiding the spread of resistant pathogens from one patient to another. In the late 1990’s, about two million Americans per year acquired new infections while in hospitals. These infections, known as nosocomial infections, were responsible for about eighty thousand deaths per year. The most important factor in reducing the rate of nosocomial infections is frequent, thorough handwashing with effective disinfectants. Physicians need to be aware of the proper ways to use antibiotics. Experts have suggested better education in antibiotic use in medical schools, more continuing education in the subject for practicing physicians, and the development of computer programs to aid physicians in selecting antibiotics. Some have suggested that all physicians prescribing antibiotics in hospitals be required to consult with physicians who specialize in infectious diseases. Standardized order forms that include guidelines for proper use of each antibiotic have also been proposed. Pharmacists need to be aware of appropriate antibiotic use. They must be able to tell patients how to use antibiotics properly and to use them only under the direction of a physician. Some hospitals have given pharmacists the authority to make changes in antibiotic therapy when appropriate. Reducing the Use of Antibiotics Experts agree that monitoring antibiotic use is critical to fighting drug resistance. A study published in 1997 demonstrated the effectiveness of education and monitoring in reducing resistance. Physicians in Finland were educated in the proper use of the antibiotic erythromycin, and use of the drug was monitored. In 1992, 16.5 percent of bacteria known as group A streptococci were resistant to erythromycin. In 1996, only 8.6 percent were
Antibiotic resistance ✧ 89 resistant. Some experts have proposed using computers to share information about antibiotic use and resistance among as many health care facilities as possible. Faster development of new antibiotics for use on multiply resistant bacteria has been proposed. Experts stress, however, that these new antibiotics must be used only when necessary in order to avoid promoting resistance to them. Increased use of vaccines and the development of new vaccines would reduce the need for antibiotics by preventing certain types of bacterial infections. The vaccine that provides protection against pneumonia caused by bacteria known as pneumococci, for example, is recommended for use by all elderly persons in the United States. Despite this suggestion, in 1985 less than 15 percent of older Americans had received the vaccine. Research into less familiar ways of fighting infections has also been suggested. These methods include developing drugs that strengthen the human immune system. Drugs may also be developed to attack the bacterial genes that encode for drug resistance or to attack the genes that cause certain bacteria to be pathogens. By the late 1990’s, these methods remained mostly speculative. Other methods have been proposed for minimizing antibiotic resistance. Because patients often expect or demand prescriptions when they visit physicians, some experts have suggested that the physician write a “lifestyle” prescription when drug use is not appropriate. Such a prescription would explain why antibiotics should not be used in a particular situation and would give the patient specific instructions on how to treat the illness without them. —Rose Secrest See also Childhood infectious diseases; Children’s health issues; Epidemics; Hospitalization of the elderly; Iatrogenic disorders; Illnesses among the elderly; Influenza; Medications and the elderly; Meningitis; Necrotizing fasciitis; Overmedication; Tuberculosis. For Further Information: Fisher, Jeffrey A. The Plague Makers: How We Are Creating Catastrophic New Epidemics—and What We Must Do to Avert Them. New York: Simon & Schuster, 1994. A discussion of antibiotic resistance and steps that can be taken to prevent it. Includes controversial chapters on AIDS and on antibiotic use in animals. Lappe, Marc. Germs That Won’t Die: Medical Consequences of the Misuse of Antibiotics. New York: Anchor Press, 1982. A clear and concise description of the mechanisms by which antibiotic resistance arises in bacteria. Levy, Stuart B. The Antibiotic Paradox: How Miracle Drugs Are Destroying the Miracle. New York: Plenum Press, 1992. A wide-ranging, in-depth study of the problem of antibiotic resistance by the founder of the Alliance for
90 ✧ Arteriosclerosis Prudent Use of Antibiotics. Includes clear diagrams explaining the methods by which resistance transfers between bacteria. Murray, Barbara E. “Can Antibiotic Resistance Be Controlled?” New England Journal of Medicine 330, no. 17 (April 28, 1994): 1229-1230. An editorial that outlines the future consequences of increasing drug resistance and offers several suggestions for fighting it. Smaglik, Paul. “Proliferation of Pills.” Science News 151, no. 20 (May 17, 1997): 310-311. An account of the frequent misuse of antibiotics, with opinions from several experts.
✧ Arteriosclerosis Type of issue: Prevention, public health, social trends Definition: A general term for the progressive thickening and hardening of the arterial walls. The most common type of arteriosclerosis is atherosclerosis, which is often the cause of heart attacks and strokes. Collectively, arteriosclerosis and other types of heart disease, such as congestive heart failure, are the leading cause of death in the United States for those over the age of sixty-five as well as for all age groups combined. The Development of Arteriosclerosis The changes that lead to atherosclerosis involve the arterial wall, which is the inside lining of the arteries. There are three parts to the arterial wall: the intima, the media, and the adventitia. The intima is a single layer of endothelial cells that line the artery. It rests on connective tissue of the media, which is the thickest layer of the wall. The intima and media are both involved in atherosclerotic changes. The third and outer segment of the arterial wall is the adventitia. It contains collagen, blood vessels, nerves, and lymphatic tissue. Most scientific evidence supports the concept that injury to the epithelial cells of the intima begins the atherosclerotic process. An important function of the epithelial cells is to provide a barrier to keep blood and its components within the artery. Injury to these cells leads to increased permeability, which can allow components that would normally be kept out to pass through the intima and into the media. One of these components is lowdensity lipoproteins (LDLs). LDLs are composed of protein, triglyceride, and cholesterol. The quantity of LDLs secreted from the liver is determined by several factors, including genetics and dietary fat. Fat is absorbed in the gastrointestinal tract and
Arteriosclerosis ✧ 91 secreted into the blood and lymphatics as chylomicrons. The chylomicrons are partially degraded, leaving a chylomicron remnant. This remnant is taken up by the liver and secreted back into the blood as very low-density lipoproteins (VLDLs). The VLDLs are degraded to LDLs. Therefore, the more chylomicrons that are secreted in response to a high-fat diet, the higher the production of LDL. After the LDLs have been transported into the intima of the arterial wall, they may become oxidized. The consequences of oxidation include recruitment of white blood cells. The white blood cells then initiate synthesis of adhesion molecules on the surface of the endothelial cells. The adhesion molecules attract proteins and fats in the blood to also adhere to the inside of the arterial wall. This produces a narrowing and inflexibility in the artery. The earliest visible lesions in the arterial wall are fatty streaks, which do not protrude or disturb blood flow. Fatty streaks have been found to begin in early adulthood or even childhood. They do not contain the adhesion molecules or white blood cells. Fibrous plaques appear to develop from fatty streaks after the LDLs have permeated the intima. They may protrude into the artery, making the diameter of the vessel narrower. They can also make the arterial wall thicker and less flexible, and thus more easily injured. Plaque may partially or totally block the blood’s flow. Bleeding into the plaques can also occur, or a blood clot can form on the plaque’s surface. In any of these situations, a heart attack or stroke may result. A heart attack occurs when the blood is blocked at the heart, while a stroke occurs when blood is blocked going to the brain. Left undisturbed, fatty streaks develop very slowly, becoming widespread only in old age. However, fatty streaks may be triggered into plaque development during middle age. Risk Factors for Atherosclerosis Several factors have been associated with the progression or development of plaques in the artery and subsequent heart disease. Elevated levels of blood cholesterol or LDLs, high blood pressure, cigarette smoking, diabetes mellitus, obesity, and genetic disposition toward heart disease are all risk factors for the development of atherosclerosis. The Framingham Heart Study, begun in 1948, was the first to identify cardiovascular risk factors. The Framingham reports also include advancing age as a risk factor. The National Institutes of Health (NIH) divides cardiovascular risk factors into those that one can do something about and those factors that cannot be changed. The latter category includes age: being forty-five years old or older for men and fifty-five years old or older for women. (Estrogen plays a protective role for women until they are past the menopause.) Another risk factor that cannot be changed is having a family history of early heart disease: a father or brother who developed heart disease before the age of fifty-five,
92 ✧ Arteriosclerosis or a mother or sister who developed heart disease before the age of sixty-five. Risk factors that can be changed include high blood cholesterol, high LDL levels, low high-density lipoprotein (HDL) levels, high blood pressure (hypertension), diabetes, being physically inactive and overweight, and smoking. All these factors have been shown to be associated statistically with atherosclerosis. However, there is also a physiological basis for their being associated statistically. High blood cholesterol and LDL levels are thought to increase the probability that LDL will adhere to or permeate the epithelial cells of the intima. The HDL transports excess cholesterol in the blood back to the liver. Therefore, a higher level of this lipoprotein is a “risk reducer.” Although people cannot be cured of high blood pressure or diabetes, having their blood pressure or blood sugar under control reduces the risks of high blood pressure or elevated blood sugar. Physical inactivity is believed to decrease the levels of HDL in the blood, to decrease uptake of LDL, and to contribute to obesity. Cigarette smoke is thought to directly injure the epithelial cells of the intima in the arterial wall, thus making them more susceptible to LDL adherence to the intima and invasion of the media of the arterial wall. Because fatty streaks are believed to continue to develop throughout life, health policy has aimed at reducing those behaviors that may contribute to the acceleration of the fatty streaks into dangerous plaque formation. National health campaigns and health policies have suggested the elimination of smoking and the control of high blood pressure as ways to decrease the morbidity and mortality associated with atherosclerosis. Professional organizations have also promoted increasing physical activity, screening and treating those with diabetes, and achieving an optimal weight. The reduction of dietary fat is also a national health guideline. Dietary fat is more of a risk factor in the development of atherosclerosis than is dietary cholesterol. Dietary cholesterol is also transported in the intestinal chylomicrons, but there is much less of it. Usual intakes of cholesterol fall well within the recommended 300 milligrams per day. In contrast, even a low-fat diet of 30 grams of calories from fat will result in an intake of 66,000 milligrams of fat when consuming a 2,000 calorie diet. It is clear that dietary fat has more of an impact than dietary cholesterol. Other foods and nutrients continue to be investigated for their role in the prevention and treatment of atherosclerosis. Omega-3 fatty acids may have a role in the prevention or treatment of atherosclerosis, although their contribution remains to be clarified. In general, guidelines suggest that consuming fish once per week as a source of omega-3 fatty acids may be of benefit. Increasing the fiber in the diet can also help in lowering blood cholesterol and LDLs. Soluble fiber reduces blood cholesterol by decreasing absorption of cholesterol or fatty acids. Soluble fiber can be found in some fruits and grains, most notably oats. A variety of other dietary manipulations continue to be investigated. These include soy protein, garlic, isoflavones, and several vitamins.
Arthritis ✧ 93 Medications can also be used to lower elevated blood cholesterol or LDLs. Generally, dietary modification is recommended before medications are used because diet changes have no appreciable side effects. Medications for treating elevated blood lipids include a classification of drugs known as the statins, which work to decrease liver synthesis of cholesterol. Bile acid sequestrants reduce the reabsorption of bile acids and cholesterol. Nicotinic acid is a vasodilator that has been used to decrease blood lipids. Prevention of atherosclerosis begins during young adulthood and continues into old age. Maintaining the integrity of the arteries is a process that must continue over the life span. When arteries are damaged, treatment and repair is much easier if they have been kept in good shape all along. —Karen Chapman-Novakofski See also Cholesterol; Heart attacks; Heart disease; Heart disease and women; Hypertension; Malnutrition among the elderly; Nutrition and aging; Nutrition and women; Obesity; Obesity and aging; Strokes. For Further Information: American Heart Association. American Heart Association Guide to Heart Attack: Treatment, Recovery, and Prevention. New York: Times Books, 1996. Bennett, J. Claude, ed. Cecil Textbook of Medicine. 21st ed. Philadelphia: W. B. Saunders, 2000. Kris-Etherton, Penny, and Julie Burns, eds. Cardiovascular Nutrition: Strategies and Tools for Disease Management and Prevention. Chicago: American Dietetic Association, 1998. Rutherford, Robert B., ed. Vascular Surgery. 5th ed. Philadelphia: W. B. Saunders, 2000. Tierney, Lawrence M., Jr., et al., eds. Current Medical Diagnosis and Treatment. 39th ed. New York: McGraw-Hill, 2000.
✧ Arthritis Type of issue: Elder health, occupational health Definition: A number of diseases causing joint difficulties ranging from discomfort and limitation of motion to loss of motion and extreme pain. Arthritis (from the Greek arthron, or “joint,” and itis, a suffix referring to inflammation) is not one but a number of diseases with the common factor that they affect joints in some way. The term itself is misleading, because joint inflammation is absent in most forms of arthritis. Swelling around the affected joint is not uncommon, and pain is frequent, particularly with extreme muscular effort or range of motion. These symptoms, however, are
94 ✧ Arthritis characteristic of only certain kinds of arthritis. Other kinds can produce growth of nonjoint-type tissue in joints, causing pain and sometimes immobilization of joints; can produce secondary effects such as fatigue or fever; or can operate through interference with the immune system. Osteoarthritis Osteoarthritis is the most common form of arthritis. In 1999, it affected an estimated sixteen million Americans, about three-quarters of them women. Osteoarthritis usually occurs in older persons (“older” is a flexible term, as osteoarthritis can appear in one’s forties or may appear two decades or more after that) and is often thought of as the result of wear and tear on the material of joints. In most of the joints in the body, the bone ends that come together are padded with cartilage on each side. Cartilage, or gristle, is a protein somewhat similar to that which forms the matrix of bones; this matrix is filled with calcium salts for load-bearing strength. Cartilage has no calcium salts and is porous, spongy, and elastic. With age, joint cartilage can lose its elasticity or develop rough surfaces. This makes for slowed or restricted motion, sometimes with accompanying pain. In addition, the tendons and ligaments that hold the joint together may loosen, allowing slippage in the joint and further wear on the cartilage pads. With the restricted motion of the worn cartilage padding, the surrounding muscles get less exercise, and a slow decay in strength results. This brings on the problems often ascribed merely to age, such as a slowed gait, limited motion in limbs or neck, and loss of hand strength so that opening jars and bottles becomes difficult. Osteoarthritis can occur in any joint in the body— knees, hips, shoulders, fingers, or toes—but usually is confined to a relatively small number: one hip, or a thumb or a few fingers, for example. Debilitation is rarely complete but can be a thoroughgoing nuisance. Rheumatoid Arthritis Rheumatoid arthritis is the second most common type of arthritis. In 1999, there were an estimated two million sufferers in the United States, two-thirds to three-quarters of them women. This is the affliction that many people think of as “arthritis,” typified by swollen joints, crooked fingers, and slow and painful movement. Unlike osteoarthritis, rheumatoid arthritis can affect many (or all) joints at once, usually symmetrically—that is, if the left knee and hip are affected, the right ones are almost certain to be affected also. Rheumatoid arthritis is a disease of the synovial membrane, which is the membrane that surrounds the joint (somewhat in the fashion of the rubber boot that seals the joint of the gear lever in a stick-shift car). The synovial membrane holds in the fluid that lubricates the joint, nourishes the joint cartilage, and keeps the joint flexible. The origin of the disease is
Arthritis ✧ 95
Rheumatoid arthritis begins with the inflammation of the synovial membrance and progresses to pannus formation and erosion of cartilage; eventually, the joint cavity is destroyed and the bones (here, the knee bones) become fused. (Hans & Cassidy, Inc.)
unknown (a virus has been suggested), but the results are clear: the synovial membrane is invaded by inflammatory cells that cause it to thicken and release enzymes that initially irritate the joint cartilage but that can eventually cause it to dissolve. It is often replaced by scar tissue, which can restrict the joint’s normal motion and sometimes freeze it altogether. Pain is chronic to acute. Rheumatoid arthritis usually begins in the patient’s forties; it can be a one-time (though damaging) bout of a few weeks or months, or a series of recurrences, or an ongoing condition. The synovitis can be treated, and even in chronic cases the disease tends to lessen its effects over time—but the initial damage remains regardless. Juvenile Rheumatoid Arthritis and Gout Despite its name, this form of arthritis is not related to the adult form of rheumatoid arthritis. Three kinds are known: a form that affects only one or a few joints and that usually goes away without recurrence; a form that shows itself as very high fever with little joint involvement (though this can occur in later life); and the form known as rheumatic fever, which is not an arthritis but a streptococcal infection that sometimes invades the joints. All these forms do not usually persist into adulthood. Gout is a crystalline form of arthritis, in which crystals of uric acid actually deposit in the joint and cause excruciating pain, though usually for only a few days. Sufferers are mainly male. The joints most often affected are those of the foot, usually the big toe, and sometimes the third (metatarsal) joint of the little toe. It was at one time thought that this was a disease of excess—of rich food, much drink, and little exercise. Current thinking suggests that these excesses may be involved but also implicates genetic factors. As animals at the top of the food chain, most humans ingest too
96 ✧ Arthritis many amino acids, from plant and animal sources, that they cannot use in building proteins. The excess nitrogen from these amino acids must be excreted. This is done by passing water-soluble urea in the urine. Some uric acid passes also, but uric acid is only slightly water-soluble; thus, it persists in relatively high concentration in the blood. Some persons are genetically predisposed to precipitate this uric acid, and for some this occurs in the joints, leading to gout. A pseudogout, in which the precipitated crystals are calcium phosphate, is also known. This usually occurs after age seventy, in both men and women; though it may recur, it tends to disappear spontaneously. Ankylosing Spondylitis Ankylosing spondylitis (AS) is an arthritis mainly of the spine, though it sometimes affects other joints in the central part of the body. The name means an inflammation of the vertebrae (spondylitis) that results in ankylosis (stiffening of a joint, with the bones fusing together in late stages). AS is a genetically connected disease, and the gene site is known and can be detected by standard DNA analysis. AS shows up in early adulthood, predominantly in men. Most cases begin with fusion of the sacroiliac joint, immobilizing the lower back. Many never go beyond this stage, and the majority of persons with AS lead perfectly active lives. A few percent of cases progress to general spinal fusion, but even in these cases, mobility is not seriously impeded. Perhaps one case in a hundred freezes the entire spine, the neck, and even the cartilage of the ribs and breastbone, which restricts breathing but is rarely life-threatening. Most AS victims, in fact, have full lives and die of natural causes, despite the agonizing appearance of spinal rigidity and deformity in extreme cases. It should be noted that kyphosis, the “dowager’s hump” seen in elderly women and in some men, is not a result of this or any other arthritis; rather, it comes from osteoporosis, or loss of bone density, which leads to compression and partial collapse of vertebrae. Systemic Lupus Erythematosus and Other Forms of Arthritis Systemic lupus erythematosus is an autoimmune disease—that is, one in which the system’s tissues are attacked by its own antibodies. Arthritis results when the synovium or the joint cartilage is attacked. The symptoms resemble those of rheumatoid arthritis but are much milder and usually do not result in the bone damage of rheumatoid arthritis. On the other hand, the arthritis and its pain persist for the duration of the disease, which can be five to ten years or longer. The overwhelming majority of lupus victims are women. More than a hundred other kinds of arthritis are known, but they affect
Arthritis ✧ 97 relatively fewer people. They include psoriatic arthritis; Reiter’s syndrome; fibromyalgia; arthritis associated with gonorrhea, tuberculosis, or Lyme disease; and polymyositis. Descriptions, treatment, and prognosis of these and other forms of arthritis can be found in the books cited at the end of this entry. Medical Treatment for Arthritis Until the mid-1990’s, most of the medications used for arthritis were painkillers. The most notable exceptions were the corticosteroids, which gave dramatic results in relieving inflammation and swelling, though not without undesirable side effects. The most common pain relievers are the nonsteroidal anti-inflammatory drugs (NSAIDs). They have have no chemical similarity to one another except that they are not steroids. NSAIDS include some of the oldest and cheapest drugs in the pharmacopeia, as well as some newer and correspondingly more expensive drugs. The oldest NSAID is aspirin (acetylsalicylic acid). Other over-the-counter analgesics include acetaminophen, ibuprofen, and naproxen. Although these drugs are available in such brand-name pain relievers as Tylenol and Advil, most of these NSAIDs are available as generic or in-house drugs. They are generally effective pain relievers, but they can cause side effects; for example, all except acetaminophen can cause ulcers and gastric bleeding, sometimes unexpectedly after many months’ use. Acetaminophen in protracted high dosage has been shown to cause liver and kidney damage. In addition, NSAIDs can further damage joint cartilage, an effect that has also been demonstrated with the prescription NSAID indocin (indomethacin). All the standard NSAIDs are cox (short for “cyclooxygenase”) inhibitors that interfere with the production of prostaglandins, which control cell chemistry. Only recently was it found that what had been thought to be a single cox that controlled both inflammation and pain as well as ulceration of the stomach and duodenum was in fact two separate compounds: Cox-1, which protected the stomach lining from acid degradation, and Cox-2, which produced joint inflammation. Thus, a compound that inhibited only Cox-2 could relieve arthritis symptoms without irritating the stomach. In 1999, two Cox-2 inhibitors were submitted for Food and Drug Administration (FDA) approval: celecoxib (Celebrex) and rofecoxib (Vioxx). Two other osteoarthritis drugs are available that work on a totally different principle. These are hyaluronan (Hyalgan) and hylan G-F20 (Synvisc). Both are substitutes for hyaluronic acid, which appears to lubricate and increase the viscosity of joint fluid. As such, they must be injected directly into the joint in question, in a weekly series that typically costs from five hundred to seven hundred dollars. Large joints such as the knee fare best in this treatment; small joints are nearly impossible to inject with the large
98 ✧ Arthritis needle required for the viscous fluid. Relief is reported to last for six months to a year. The NSAIDs are used extensively in osteoarthritis treatment, although they may be recommended in any case where pain must be controlled. Drugs to treat rheumatoid arthritis have been less effective than the NSAIDs, often merely reducing inflammation and performing a holding action on development of the disease. Historically, the first of these was a corticosteroid. With its use, inflammation and pain were virtually eliminated, and the disease appeared to be arrested. Side effects soon occurred, however, and in ensuing decades have been well documented: possible ulcers, mental changes, fat accumulation in the body, muscular weakness and wasting, loss of bone calcium, and other symptoms. Steroids are now used sparingly and as a kind of last resort. A variety of treatments has sprung up to lessen swelling and ease other symptoms of rheumatoid arthritis: methotrexate, injectable gold salts, penicillamine, azsulfidine, and hydroxychloroquine, among others. Some of these have serious side effects, and in any case they do not reverse the effects of the disease; moreover, it is generally unclear whether they actually arrest the arthritic damage or merely slow it down. Three newer drugs may actually halt the disease. The first of these, leflunomide (Arava), is an immune suppressor that targets the cells of the joint. General immunosuppressors like methotrexate have been used, but leflunomide is the first that is tailored to the inflammatory cells that attack the synovium. Standard treatment costs about three thousand dollars per year, however, and requires careful monitoring by a physician and laboratory tests to observe effects on the body. The other two drugs are the anti-TNF (tumor necrosis factor) compounds infliximab (Remicade) and etanercept (Enbrel). TNF is a cytokine that seems to cause inflammation and bone damage, so a drug that suppresses it suppresses its effects. Both drugs are administered by injection— intravenous in the case of infliximab—and both are expensive, about ten thousand dollars per year for etanercept. One other new treatment for rheumatoid arthritis has been devised, involving blood-serum filtration with a protein called Prosorba, which seems to clear out inflammatory substances. This is a procedure prescribed for those who are getting no help from regular medication; it is very expensive (about twenty thousand dollars per year). None of these drugs or procedures had received FDA approval by the end of the 1990’s. Drugs and treatments for other types of arthritis are usually some combination of those given for osteoarthritis and rheumatoid arthritis. No herbal, naturopathic, homeopathic, or other “alternative” treatment has been shown by laboratory testing to give reproducible results other than occasional pain relief. —Robert M. Hawthorne, Jr.
Asbestos ✧ 99 See also Aging; Canes and walkers; Disabilities; Medications and the elderly; Mobility problems in the elderly; Nursing and convalescent homes; Pain management. For Further Information: Dunkin, Mary Ann. “The New Drugs: What to Expect.” Arthritis Today 12, no. 6 (November/December, 1998): 31-35. Fuller discussion of new drugs mentioned above. Arthritis Today, published by the Arthritis Foundation (http://www.arthritis.org), contains well-balanced popular articles on all aspects of the disease. Fries, James F. Arthritis: A Take-Care-of-Yourself Guide to Understanding Your Arthritis. 5th ed. Reading, Mass.: Addison-Wesley, 1999. Thorough discussion of types of arthritis, treatments, and prognoses, followed by an extensive guide to personal management methods and suggestions for problem-solving. Gordon, Neil F. Arthritis: Your Complete Exercise Guide. Champaign, Ill.: Human Kinetics, 1993. The author is eminently qualified to discuss and illustrate the various types of exercise modalities; he suggests a schedule of frequencies and durations for each. The illustrations are easily understood and followed. Lorig, Kate, and James F. Fries. The Arthritis Helpbook: A Tested Self-Management Program for Coping with Your Arthritis. 5th ed. Reading, Mass.: AddisonWesley, 2000. Gives a brief introduction to the disease along with much valuable advice on exercise, pain management by self-suggestion, sleep, depression, nutrition, medication, working with one’s physician, and other topics. Less technical than the preceding text. Sands, Judith K., and Judith H. Matthews. “Medications: Arthritis Drugs Hit Their Mark.” Harvard Health Letter 24, no. 4 (February, 1999): 4-5. Evaluates new arthritis drugs.
✧ Asbestos Type of issue: Environmental health, industrial practices, occupational health, public health Definition: The industrial term for certain silicate minerals that occur in the form of long, thin fibers. The adverse health effects of breathing high concentrations of asbestos over many years have been known since the early 1970’s. The Clean Air Act classified asbestos as a carcinogenic material, and in 1990 the U.S. Environmental Protection Agency (EPA) established a broad ban on the manufacture, processing, importation, and distribution of asbestos products.
100 ✧ Asbestos Asbestos-form minerals are natural substances that are common in many types of igneous and metamorphic rocks found over large areas of the planet. Erosion continually releases these fibers into the environment; most people typically inhale thousands of fibers each day, or more than 100 million over a lifetime. Asbestos fibers also enter the body through drinking water. Drinking water supplies in the United States typically contain almost 1 million fibers per quart, but water in some areas may have as many as 100 million or more fibers per quart. Many silicate minerals occur in fibrous form, but only six have been commercially produced as asbestos. In order of decreasing commercial importance, these are chrysotile (white asbestos), crocidolite (blue asbestos), amosite (brown asbestos), anthophyllite, tremolite, and actinolite. All the minerals except chrysotile are members of the amphibole group of minerals, which have a chainlike arrangement of the atoms. In contrast, chrysotile, as a member of the serpentine family, has atoms arranged in a sheetlike fashion. Uses and Hazards Although these minerals differ greatly from one another in individual properties, they share several characteristics that make them useful and cost-effective. These include great resistance to heat, flame, and acid attack; high tensile strength and flexibility; low electrical conductivity; resistance to friction; and a fibrous form, which allows them to be used for the manufacture of protective clothing. Therefore, asbestos was widely used until the 1970’s in a great variety of building and industrial products. Such common materials as vinyl floor tiles, appliance insulation, patching and joint compounds, automobile brake pads, hair dryers, and ironing board covers all might have contained asbestos. Most such products now contain one or more of several substitutes for asbestos instead of asbestos itself. However, many of the substitutes may not be hazard-free, a fact that is starting to be recognized by legislators. For example, in 1993 the World Health Organization (WHO) stated that all substitute fibers must be tested to determine their carcinogenicity. Germany now classifies glass, rock, and mineral wools as probable carcinogens. The U.S. Department of Health and Human Services classifies asbestos as a carcinogen. Studies leading to this determination were mostly based on asbestos workers who were exposed to extremely high levels of fibers for many years. These studies concluded that the asbestos workers have increased chances of developing two types of cancer: mesothelioma (a cancer of the thin membrane surrounding the lungs) and cancer of the lung tissue itself. These workers were also at increased risk of developing asbestosis, an accumulation of scarlike tissue in the lungs that can cause great difficulty in breathing and permanent disability. None of these diseases develops immediately; instead, they have long latency periods, typically fifteen to forty
Asbestos ✧ 101 years. Despite the common misconception, exposure to asbestos does not cause muscle soreness, headaches, or any other immediate symptoms. The effects typically are not noticed for many years. Degrees of Risk It is generally agreed that the risk of developing disease depends on the number of fibers in a person’s body, how long the fibers have been in the body, and whether one is a smoker, since smoking greatly increases the risk of developing disease. There is no agreement on the risks associated with low-level, nonoccupational exposure. The EPA has concluded that there is no safe level of exposure to asbestos fibers, but the Occupational Safety and Health Administration (OSHA) allows up to one thousand fibers per cubic meter during an eight-hour work day. Another area of controversy stems from scientific studies showing that all forms of asbestos are not equally dangerous. Evidence has shown that the amphibole forms of asbestos, and particularly crocidolite, are hazardous, but the serpentine mineral chrysotile—accounting for 95 percent of all asbestos used in the past and 99 percent of current production—is not. For example, one case study involved a school that was located next to a 150,000-ton rock dump containing chrysotile. Thousands of children played on the rocks over a one-hundred-year period, but not a single case of asbestos-related disease developed in any of the children. The difference seems to be in how the human body responds to amphibole compared to chrysotile. The immune system can eliminate chrysotile fibers much more readily than amphibole, and there is also evidence that chrysotile in the lungs dissolves and is excreted. This remains a controversial area, and the U.S. government still treats all forms of asbestos the same. This is not true of some European governments. The risk of developing any type of disease from exposure to normal levels of asbestos fibers in outdoor air or the air in closed buildings is extremely low. Melvin Benarde’s 1990 calculations show that the risk of dying from nonoccupational exposure to asbestos is one-third the risk of being killed by lightning. The Health Effects Institute made similar calculations in 1991 and found that the risk of dying from asbestos is less than 1 percent the risk of dying from exposure to secondary tobacco smoke. —Gene D. Robinson See also Cancer; Environmental diseases; Lung cancer; Occupational health. For Further Information: Benarde, Melvin, ed. Asbestos: The Hazardous Fiber. Boca Raton, Fla.: CRC Press, 1990.
102 ✧ Asthma Harben, Peter W., and Robert L. Bates. Industrial Minerals: Geology and World Deposits. London: Industrial Minerals Division, Metal Bulletin, 1990. A good general discussion of asbestos. McDonald, J. C., et al. “The Health of Chrysotile Asbestos on Mine and Mill Workers of Quebec.” Archives of Environmental Health 28 (1974). An example of a study conducted to determine the health effects of chrysotile. Skinner, H. Catherine W., Malcolm Ross, and Clifford Frondel. Asbestos and Other Fibrous Minerals. New York: Oxford University Press, 1988. A balanced look at the health effects of asbestos.
✧ Asthma Type of issue: Children’s health, environmental health, public health Definition: A chronic inflammatory obstructive pulmonary disease that obstructs the airways to the lungs and makes it difficult or, in severe attacks, nearly impossible to breathe. Asthma is a Greek word meaning “gasping” or “panting.” It is a chronic obstructive pulmonary (lung) disease that involves repeated attacks in which the airways in the lungs are suddenly blocked. The disease is not completely understood, but asthma attacks cause the person to experience tightening of the chest, sudden breathlessness, wheezing, and coughing. Death by asphyxiation is rare but possible. Fortunately, the effects can be reversed with proper medication. The severity of symptoms and attacks varies greatly among individuals, and sufferers can be located on a continuum running from mild to severe. Mild asthmatics have fewer than six minimal attacks per year, with no symptoms between attacks, and they require no hospitalizations and little or no medication between attacks. Severe asthmatics have more than six serious attacks each year, have symptoms between attacks, lose more than ten school days or workdays, and require two or more hospitalizations per year. Attacks are typically spaced with symptom-free intervals but may also occur continuously. Rather than focusing only on the specific attacks, one should view and treat asthma as a chronic disease, a nagging, continuing condition that persists over a long period of time. The Mechanism of an Asthma Attack During inhalation, air travels into the nose and mouth and then into the trachea (windpipe); it then divides into the two tubes called bronchi and enters the lungs. Inside each lung, the tubes become smaller and continue to divide. The air finally moves into the smallest tubes, called bronchioles,
Asthma ✧ 103 and then flows into the millions of small, thin-walled sacs called alveoli. Vital gas exchange occurs in the alveoli. This gas exchange involves two gases in particular, oxygen and carbon dioxide. Oxygen must cross the membrane of the alveoli into the blood and then travel to all the cells of the body. Within the cells, it is used in chemical reactions that produce energy. These same reactions produce carbon dioxide as a by-product, which is returned by the blood to the alveoli. This gas is removed from the body through the same pathway that brought oxygen into the lungs. The parts of this airway that are involved in asthma are the bronchioles. These tubes are wrapped with smooth, involuntary muscles that adjust the amount of air that enters. The lining of the bronchioles also contains many cells that secrete a substance called mucus. Mucus is a thick, clear, slimy fluid produced in many parts of the body. Normal production of mucus in the lungs catches foreign material and lubricates the pathway to allow smooth airflow. People suffering from asthma have very sensitive bronchioles. Three pathological processes in the bronchioles contribute to an asthma attack. One is an abnormal sensitivity and constriction of the involuntary muscles surrounding the airways, which narrows the diameter of the airway. Another is an inflammation and swelling of the tissues that make up the bronchioles themselves. The third is an increased production of mucus, which then blocks the airways. These three mechanisms may work in combination and are largely caused by the activation of mast cells in the airways. The result can be extreme difficulty in taking air into the lungs until the attack subsides. The characteristic “wheeze” of asthma is caused by efforts to exhale, which is more difficult than inhaling. In the most serious attacks, the airways may close down to the point of suffocating the patient if medical help is not given. Attacks can vary in severity at different times because of variations in tension within the bronchiole muscles. Although there is still debate about the general function of these muscles, they probably help to distribute the air entering the alveoli evenly. Control of the tension in these smooth muscles is involuntary and follows a circadian (twenty-four-hour) rhythm influenced by neurohormonal control. Accordingly, for most people this cycle causes maximum constriction to occur at about 6:00 a.m. and maximum relaxation to occur at about 6:00 p.m. Hence, asthma attacks tend to be more severe in the late night and early morning. Following a given asthma attack, patients are sometimes susceptible to additional, more severe attacks. This period of high risk, called a late-phase response, occurs five or six hours after the initial symptoms pass and may last as long as several days. Some researchers believe that the increase in deaths from asthma in the United States may be tied to this danger, which often goes unrecognized.
104 ✧ Asthma Asthma Triggers The initial cause and mechanism of an asthma attack can vary from person to person. Accordingly, asthma is usually divided into two types. One type is extrinsic, that is, caused by external triggers that bring about an allergic response. Allergic reactions involve the immune system. Normal functioning of the immune system guards the body against harmful substances. With an allergy, the body incorrectly identifies a harmless substance as harmful and reacts against it. This substance is then called an allergen. If the symptoms of this reaction occur in the lungs, the person has extrinsic or allergic asthma. Pollens, dust, dust mites, animal dander, molds, cockroaches, and feathers are common allergens. When allergens enter the body, the white blood cells make specific IgE antibodies that can bond with the invaders. Next, the IgE antibodies attach to the surfaces of mast cells; these cells are found all over the body and are numerous in the lungs. The allergens attach to the IgE antibodies located on the mast cells, and the mast cells are stimulated to produce and release chemicals called mediators, such as histamine, prostaglandin D2, and leukotrienes. These mediators cause sneezing, tighten the muscles in the bronchioles, swell the surrounding tissues, and increase mucus production. The second type of asthma is intrinsic and does not involve allergies. People who suffer from intrinsic asthma have hyperactive or twitchy airways that overreact to irritating factors. The mechanism for this form is not always understood, but no IgE antibodies for the irritant are placed on the mast cells. Examples of such nonallergic stimuli are cigarette smoke, house dust, artificial coloring, aspirin, ozone, or cold air. Odors from insecticides, cleaning fluids, cooking foods, and perfume can also trigger attacks. Also included in this category are attacks that are caused by viral infections (including colds and flu), stress, and exercise. Asthma can be triggered by many different substances and events in different people. While the symptoms are the same whether the asthma is intrinsic or extrinsic, asthmatics need to identify what substances or events trigger their attacks in order to gain control of the disease. Causes of Asthma Why people develop asthma is not well understood. Asthma can begin at any age, but it is more likely to arise in childhood. While it is known that heredity predisposes an individual to asthma, the pattern of inheritance is not a simple one. Most geneticists now regard allergies as polygenic, which means that more than one pair of genes is involved. Height, skin color, and intelligence are other examples of polygenic traits. Exposure to particular external conditions may also be important. The children who develop asthma are more likely to be boys, while girls are more likely to show signs of the disease at puberty (about age twelve). Childhood asthma is also most
Asthma ✧ 105 likely to disappear or to be “outgrown” at puberty; about half of the cases of childhood asthma eventually disappear. Early exposures to some triggers may be a key in the development of asthma. Smoking by mothers can cause children with a genetic disposition to develop asthma. Apparently, the early exposure to secondhand smoke develops an allergy. Early studies in this area were confusing until the data were sorted by level of education. Lung specialist Fernando Martinez of the University of Arizona believes that less-educated women who smoke are more likely to cause this effect because their homes are likely to be smaller and therefore expose the children to more smoke. Another study, this one in Great Britain, indicated that more frequent and thorough housecleaning might keep children from developing asthma. Early exposure by genetically susceptible children to dust and the mites that thrive in dust may also cause some to develop asthma. Controlling Asthma The key to gaining control of asthma is discovering the particular factors that act as triggers for an attack in a given individual. These factors vary and at times can be surprising; for example, one person found that a mint flavoring in a particular toothpaste was a trigger for his asthma. Nevertheless, most common triggers fall in the following groups: allergies; irritants, including dust, fumes, odors, and vapors; air pollution, temperature, and dryness; colds and flu; and stress. Even types of food may be important. Diets low in vitamin C, fish, or a zinc-to-copper ratio, as well as diets with a high sodium-to-potassium ratio, seem to increase the risk of asthma attacks and bronchitis. There have also been correlations between low niacin levels in the diet and tight airways and wheezing. Various medications are available to keep the airways open and to lower their sensitivity. In an emergency, drugs may be injected, but medications are usually either inhaled or taken orally as pills. Because inhaling transports the medication directly to the lungs, lower doses can be used. Many asthmatics carry inhalers, which allow them to breathe in the medication during an attack. Because this action requires a person to coordinate inhaling with the release of the spray, young children are sometimes better off with a device that requires them to wear a mask. The choice and dosage of medicine vary with the patient, and physicians need to determine what is safest and most effective for each individual. Self-treatment with nonprescription drugs should be avoided. Some of the most commonly prescribed drugs are bronchodilators, inflammation reducers, and trigger-sensitivity reducers. The bronchodilators include albuterol, metaproterenol, and terbutaline. They are betaagonists that mimic the way in which the body’s nervous system relaxes or dilates the airways. (Any drug that functions as a beta-blocker should be
106 ✧ Asthma avoided by asthmatics because of its opposite effects.) Another bronchodilator is adrenaline (or epinephrine), but it is a less specific drug that also affects the heart and pulse rate. Theophylline, a stimulant chemically related to caffeine, relaxes the airways and also helps clear mucus. The use of corticosteroids (or steroids) for asthma has been increasing because they reduce inflammation and relax airways. Initially, corticosteroids were used if other drugs were ineffective, but in 1991 they were strongly recommended for long-term preventive use. As another way of addressing asthma as a long-term problem, cromolyn sodium is sometimes inhaled on a daily basis to prevent attacks by decreasing sensitivity to triggers. The concern for safety with these medications increases when asthmatics use high doses (more than two hundred inhalations monthly) of betaagonist inhalers. A higher risk of fatal or near-fatal attacks has been found with a high usage of fenoterol, a beta-agonist that is not used in the United States. Paul Scanlon, a chest physician at the Mayo Clinic, warns that individuals should not exceed their prescribed dosage when using an inhaler. An individual who feels the need to use an inhaler more often to obtain adequate relief should see a doctor. The increased need is a sign of worsening asthma, and a doctor needs to investigate and perhaps change the treatment. Some doctors have improved their diagnosis of asthma with a tool called the peak flow meter. The meter can also be used by patients at home to predict impending attacks. This inexpensive device measures how fast air can be moved out of the lungs. Therefore, it can be discovered that airways are beginning to tighten before other symptoms occur. The early warning allows time to adjust medications to head off attacks. This tool can help asthmatics take charge of their disease. Over-the-counter drugs are often used by asthmatics to treat their symptoms. These drugs often use ephedrine, metaraminol, phenylephrine, methoxamine, or similar chemicals. All these drugs are structurally related to amphetamine or adrenaline. Unfortunately, some people may be getting relief without discovering the cause of their asthma. The National Asthma Education Panel (NAEP) maintains that self-treatment without a doctor’s guidance is risky. Asthma is a major health problem in the United States. As many as 20 million Americans may have the disease, and the number has been mysteriously increasing since 1970. While attacks can cause complications, there is no permanent damage to the lungs themselves, as there is in emphysema. Complications include possible lung collapse, infections, chronic dilation, rib fracture, a permanently enlarged chest cavity, and respiratory failure. Furthermore, millions of days of work and school are lost as victims recuperate; asthma is the leading cause of missed school days. Even though attacks can be controlled by medication, occasionally fatalities do occur. The total number of deaths from asthma in the United States reached 4,600 in 1987. —Paul R. Boehlke; updated by Shih-Wen Huang, M.D.
Attention-deficit disorder (ADD) ✧ 107 See also Allergies; Children’s health issues; Environmental diseases; Secondhand smoke; Smog; Smoking. For Further Information: American Medical Association Essential Guide to Asthma. New York: Pocket Books, 1998. Although sparsely illustrated, this handy book presents the essential details on asthma from diagnosis to treatment and prevention, as well as a chapter covering alternative therapies, a glossary, and a resources list. Barnes, Peter J., et al., eds. Asthma. 2 vols. London: Martin Dunitz, 2000. This text, the core resource in the field, offers a comprehensive overview, incorporating current information related to asthma’s pathobiology and clinical aspects. The 148 chapters range from the basic sciences to management of the disease in both adults and children. Haas, François, and Sheila Sperber Haas. “Living with Asthma.” In The World Book Medical Encyclopedia. Chicago: World Book, 1988. This special report carefully explains the disease and encourages asthmatics to take control of their lives. A chart details how a house can be asthma-proofed. Side effects and drawbacks of various drugs are charted. Krementz, Jill. How It Feels to Fight for Your Life. Boston: Little, Brown, 1989. A collection of fourteen case studies of children who have serious chronic diseases. In one chapter, Anton Broekman, a ten-year-old, describes what living with asthma is like. Ostrow, William, and Vivian Ostrow. All About Asthma. Morton Grove, Ill.: Albert Whitmany, 1989. A children’s book written to inform and encourage. The writers, a boy and his mother, tell about his experience with asthma. He explains causes, symptoms, and ways to lead a normal life. A must for children with asthma.
✧ Attention-deficit disorder (ADD) Type of issue: Children’s health, mental health Definition: A condition characterized by an inability to focus attention or to inhibit impulsive, hyperactive behavior; it is associated with poor academic performance and behavioral problems in children. Most experts think that 2 to 5 percent of children may have attention-deficit disorder (ADD), which is also known as attention-deficit hyperactivity disorder (ADHD). The cause of ADD is unknown, although the fact that it often occurs in families suggests some degree of genetic inheritance. The condition is more common in boys, but it does occur in girls. ADD is usually diagnosed when a child enters school, but it may be discovered earlier.
108 ✧ Attention-deficit disorder (ADD) Adolescents and even adults who escaped earlier detection may be diagnosed when their symptoms cause particularly severe problems. Some causes of ADD that have been suggested, but never proved, include low blood sugar, food additives, the sweetener aspartame, allergies, and vitamin deficiencies. The Symptoms of ADD Children who do not have ADD may, at times, have some of the symptoms of this disorder, but children who can be diagnosed with ADD must have most of the symptoms most of the time—in school, at home, or during other activities. The symptoms are usually grouped into three main categories: inattention, hyperactivity, and impulsiveness. Children who have symptoms of inattention often make careless mistakes at school or do not pay close attention to details in play or work. They may have problems sustaining attention over time and frequently do not seem to listen when spoken to, especially in groups. Children with ADD have difficulty following instructions and often fail to finish chores or schoolwork. They do not organize well and may have messy rooms and desks at school. They also frequently lose things necessary for play or school. Because they have trouble sustaining attention, children with ADD dislike tasks that require this skill and will try to avoid them. One of the key symptoms is distractibility, which means that children with ADD are often paying attention to extraneous sights, sounds, smells, and thoughts rather than focusing on the task that they should be doing. Particularly frustrating to parents is the symptom of forgetfulness in daily activities, in spite of numerous reminders from parents about such common, everyday activities as dressing, hygiene, manners, and other behaviors. Children with ADD have a poor sense of time; they are frequently late or think that they have more time to do a task than they really do. Not all children with ADD have symptoms of hyperactivity, but many have problems with fidgeting, or squirming. It is common for these children to be constant talkers, often interrupting others. Other symptoms of hyperactivity include leaving their seat in school, church, or similar settings and running around excessively in situations where they should be still. Children with ADD have difficulty playing quietly, although they may watch television or play video games for long periods of time. Some of these children seem to be driven by a motor, or are continuously on the go. All children with ADD will have some symptoms of impulsiveness, such as blurting out answers before questions are completed or intruding on others by “butting in.” They often have difficulty standing in lines or waiting for their turn in games. Several other neurologic or psychiatric disorders have symptoms that can overlap with ADD, so diagnosis is often difficult. When a child is suspected
Attention-deficit disorder (ADD) ✧ 109 of having ADD, he or she should have a thorough medical interview with, and physical examination by, a physician familiar with child development, ADD, and related conditions. A psychological evaluation to determine intelligence quotient (IQ) and areas of learning and performance strengths and weaknesses should be obtained. School records need to be reviewed, and teachers may be asked to submit rating forms or similar instruments to document school performance. A thorough family history and a discussion of family problems such as divorce, violence, alcoholism, or drug abuse should be part of the evaluation. Other conditions that might be found to exist along with ADD, or to be the underlying cause of symptoms thought to be ADD, include oppositional defiant disorder, conduct disorder (usually seen in older children), depression, or anxiety disorder. Some physicians, teachers, psychologists, and parents do not believe that ADD is a “real” condition, but this disorder is usually widely accepted in the United States as a credible diagnosis for a child who demonstrates many of the above symptoms at home, at play, and at school. An Inability to Focus Children with ADD often make the same mistakes repeatedly because they lack hindsight and forethought. Their primary problem is not that they cannot pay attention but that they pay attention to everything. Consequently, they cannot focus on the most important sensory input, such as a parent’s order or a teacher’s assignment. It is important to recognize that children with ADD are not bad children who are hyperactive, impulsive, and inattentive on purpose. Rather, they are usually bright children who would like to behave better and to be more successful in school, in social life with peers, and in family affairs, but they simply cannot. One way to think about ADD is to consider it a disorder of the ability to inhibit impulsive, off-task, or undesirable attention. Consequently, the child with ADD cannot separate important from unimportant stimuli and cannot sort appropriate from inappropriate responses to those stimuli. It is easy to understand how someone whose brain is trying to respond to a multitude of stimuli, rather than sorting stimuli into priorities for response, will have difficulty focusing and maintaining attention to the main task. It is also important to remember that it is not only the presence of symptoms that categorizes a child as having ADD but also the intensity and prevalence of the symptoms in more than one setting. For example, a child may not seem to pay attention in school and often may be disruptive in class but be a normal child at home, playing Little League baseball, and in church school. This child may have a learning disability without ADD or a specific conflict with the teacher. Children most likely to be diagnosed correctly with ADD will have many
110 ✧ Attention-deficit disorder (ADD) of the following characteristics. They will have a short attention span, particularly for activities that are not fun or entertaining. They will be unable to concentrate because they will be distracted by peripheral stimuli. They will have poor impulse control so that they seem to act on the spur of the moment. They will be hyperactive and usually rather clumsy, resulting in their being labeled “accident-prone.” They will certainly have school problems, especially when classwork requires more thinking and planning—often seen about third grade and beyond. They may display attention-demanding behavior and/or show resistant or overpowering social behaviors. Last, children with ADD often act as if they were younger, and “immaturity” is a frequent label. Along with this trait, they have wide mood swings and are seen as very emotional. ADD as a Developmental Problem Many experts think that ADD is a developmental problem, caused by the failure of the brain and nervous system to grow and mature normally. Most people would agree that an average, normal two-year-old child is a perfect definition for ADD: short attention span, impulsive, distracted by almost anything new, highly emotional, demanding, often clumsy and reckless, unable to plan well, and sometimes aggressive. All these characteristics are acceptable for the toddler. When those symptoms persist into and beyond kindergarten, however, an unusually slow brain and nervous system development seems likely. This slow development may improve during childhood or may persist into adolescence. Adolescents who have ADD are usually not hyperactive, although they may have problems with impulsive talking and behavior. They have considerable difficulty complying with rules and following directions. They may be poorly organized, causing problems both with starting projects and with completing them. Their inability to monitor their own behavior leads to problems making and keeping friends and causes them to have conflicts with parents and teachers beyond those normally seen in teenagers. Adolescents with ADD usually have problems in school in spite of average or above-average potential. They may have poor self-esteem and a low frustration tolerance. The Controversy over Treatment The medical treatment of ADD is one of the most controversial issues in education and in medicine. Although scientific studies clearly show the value of certain medications, and scores of parents and teachers have noticed remarkable improvement with treatment, some people take issue with using medications to change a child’s behavior. Clearly, medications alone are not the answer for ADD. Families and children need guidance and
Attention-deficit disorder (ADD) ✧ 111 support in the form of counseling, as well as considerable information about the condition. Special accommodations can be arranged with most schools and are mandated by federal law. Once educational adjustments have been made and counseling is in place, however, medications can play an important role. The most frequently prescribed medications are stimulants; they include dexedrine, methylphenidate (Ritalin), and a combination of dexedrine salts (Adderall). A similar medication, pemoline (Cylert), has been related to side effects, which may limit its usefulness. The stimulant medications may function by influencing chemicals in the brain called neurotransmitters, which help transmit messages among brain and nerve cells. In ADD, it is thought that the medications improve the function of cells that direct the brain to focus attention, resist distraction, control behavior, and perceive time correctly. These medications are generally thought to be safe and effective, although they can have such adverse effects as headache, stomachache, mood changes, heart rate changes, appetite suppression, and interference with going to sleep. All children receiving medication must be monitored at regular intervals by a physician. Other medications that may be used for ADD include antidepressants and antianxiety medications. Some children are treated with combinations of two medications; in unusual circumstances, there may be even more than two. Some of these medications are Imipramine and Desipramine, antidepressants that act mainly to control impulsiveness and hyperactivity; Bupropion, an antidepressant, and Buspar, an antianxiety medicine, both of which have been used largely in older children and adolescents; and clonidine and guanfacine, which work on brain nerve message transmitters and are sometimes helpful in calming aggressive behavior. —Robert W. Block, M.D. See also Children’s health issues; Health problems and families; Learning disabilities; Stress. For Further Information: Barkley, Russell A. Taking Charge of ADHD. Rev. ed. New York: Guilford Press, 2000. A comprehensive guide for parents that discusses how to understand ADD, how to be a successful parent, how to cope with the child at home and at school, and how to evaluate medications. Block, Robert W., and Elaine King Miller. “The Maladroit Adolescent: Learning Disorders and Attentional Deficits.” In Advances in Pediatrics. Vol. 33. Chicago: Year Book Medical Publishers, 1986. This article was written for parents as well as for medical and educational professionals. It describes ADD and several learning disabilities and recommends appropriate interventions. Wender, Paul H. The Hyperactive Child, Adolescent, and Adult. New York:
112 ✧ Autism Oxford University Press, 1987. This book offers concise information about ADD in children, adolescents, and adults. Clearly defines the characteristics of individuals with symptoms of ADD and discusses the reasons for using medications. Zeigler Dendy, Chris A. Teenagers with ADD: A Parents’ Guide. Bethesda, Md.: Woodbine House, 1995. This resource is a workbook for parents and teachers of adolescents who have ADD. Includes useful lists of problem behaviors at home and at school, with practical solutions to these problems.
✧ Autism Type of issue: Children’s health, mental health Definition: A lifelong mental disability characterized by difficulty with social relationships, difficulty with language and communication, preoccupation with repetitive or stereotyped behaviors and interests, and a general resistance to changes in routine. Autism is a psychological and behavioral disorder that is characterized by a cluster of symptoms. In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (4th ed., 1994, DSM-IV), the primary diagnostic handbook used by physicians and psychologists, autism is grouped with Asperger’s syndrome and Rett’s syndrome under the general classification of pervasive developmental disorder. Children who are diagnosed as having autism can demonstrate a wide range of symptoms; for this reason, physicians and psychologists often refer to “autistic spectrum disorders” to capture the range of symptoms that can be classified as autism. Despite evident differences, all children diagnosed with autism show three basic symptoms: some level of impairment in social functioning, delayed and/or abnormal language development, and a marked participation or interest in restricted and repetitive behaviors or activities. Austism and Social Interaction The social interactions of children with autism are strikingly abnormal, ranging from total isolation to inappropriate social behavior. Many autistic children refuse eye contact, show little if any facial expressiveness, and do not engage in social gesturing or body language. While the majority of autistic children develop attachments to their parents and/or other caregivers, there is a marked aloofness and lack of social reciprocity in interactions with autistic children. It is often said that autistic children do not relate to other people as people. They show no empathy for others’ emotional
Autism ✧ 113 expressions; they do not smile in response to others’ expressions of happiness, nor do they attempt to comfort others who show distress. Autistic children may treat other people as if they were objects; in so doing, they might produce inappropriate social behaviors such as touching people’s bodies, grabbing objects from other people, or bumping into or sitting on people. The language of autistic children can range from mutism to somewhat deviant speech. Between 25 and 30 percent of children diagnosed with autism never develop spoken language, despite having normal hearing abilities. Those autistic children who do develop language often evidence linguistic disorders such as echolalia, persistent use of neologisms, limited vocabularies, and/or grammatical anomalies. Autistic children who develop fluent speech demonstrate poor conversational skills related to the general lack of social reciprocity seen in autism. Autistic speech is often flat, monotonous, and boring, with autistic speakers tending to focus on their own concerns and showing little regard for the interest or understanding of their conversational partners. Children with autism also evidence deficits in receptive communication. There is reduced attention to human voices in general; poor understanding of nonverbal language, including gesture and vocal intonation; and generalized difficulties with nonliteral language such as metaphors, jokes, and irony. Autistic Behaviors Children with autism show a preoccupation with restricted and repetitive behaviors, interests, and activities. This focus on repetition can take a range of forms, from performance of stereotypies to compulsive insistence on daily routines to an intense focus on specific, narrow topics of interest. Common stereotypies seen in autistic children include hand flapping, head banging, and other, more complex whole-body movements. Autistic children sometimes show self-injurious behaviors (such as biting or hair pulling) and/or self-soothing behaviors (such as rocking or stroking). More compulsive, ritualistic behavior patterns might include hand washing, counting, or the arrangement of possessions. This aspect of autism can also include intense preoccupation with highly restricted topics, such as water or pencils. Some children with autism also develop pica, the eating of such nonfood items as paper, paper clips, or dirt. Another defining characteristic of autism is a lack of imaginative or pretend play. This symptom may be related to the general literalness seen in autistic communication. Autistic children’s play tends to be solitary and to involve the repetitive manipulation of objects. The one-sidedness of autistic children’s play and their generally impaired social interactions result in a failure to develop peer relationships appropriate to their developmental level. Autistic children are therefore often cut off from their peer groups,
114 ✧ Autism which can cause feelings of loneliness and depression, especially as autistic children approach adolescence. Up to three-quarters of children with autism are also mentally retarded, with an intelligence quotient (IQ) below 70. The mental profiles of autistic children can be unusual, however, with particularly low verbal IQ scores but normal or near-normal scores on measures of mathematical and spatial IQ. According to the DSM-IV, autism is diagnosed if there is evidence of delay in normal functioning of social interaction, communicative language, or imaginative/symbolic play prior to age three. In some cases, children diagnosed with autism have seemed to develop normally until age two and then apparently lost the beginnings of linguistic and social skills that had been developed up to that point. The Rise in Autism In the late 1990’s, the incidence of autism was approximately two to three per thousand. Some researchers suggested that the incidence of autism rose over the course of the twentieth century, citing studies from the 1950’s and 1960’s that listed the incidence of autism at four to five per thousand. It has also been suggested that the apparent rise in the incidence of autism simply reflects a rise in awareness of the disorder and an increase in the accuracy with which the disorder is now diagnosed. Autism is more common in males than in females, with a ratio of 3:1 or 4:1. Autism appears to run in some families, and the concordance of autism or autistic-like symptoms in identical twins is around 50 percent. By the end of the twentieth century, however, autism had not been linked to a single gene. Asperger’s syndrome is thought to represent a subclassification of autism. The psychological and behavioral profiles of children with Asperger’s syndrome are very similar to those of children with autism; however, children with Asperger’s syndrome evidence normal or above-normal IQ scores and normal language development. Some children with Asperger’s syndrome have particular talents, although in restricted domains such as calculation, memorization, or drawing. Children with Asperger’s syndrome show the same lack of social awareness and restricted interests that are characteristic of autism. Forms of Treatment There is no cure or universal treatment for autism. Because children with autism can show such a wide range of symptoms, the range of available treatments is also wide. In dealing with autism, physicians, psychologists, and other health professionals focus on alleviating the symptoms that are the most disruptive to a particular child. Available treatments include behavior modification, social skills training, speech/language therapy, occupational
Autism ✧ 115 therapy, music therapy, vitamin therapy, and prescribed medications. Often, a combination of these treatments will be used with a particular autistic child. One of the most successful treatments for autism has been intensive behavior modification therapy. In his book The Autistic Child: Language Development Through Behavior Modification (1977), Dr. O. Ivar Lovaas described a program of intensive, one-on-one behavior modification therapy that was highly effective in alleviating disturbing symptoms and in engendering positive social behaviors in autistic children. Lovaas’s technique is controversial because it involves both rewards for such appropriate behaviors as making eye contact or maintaining conversation and punishments for such inappropriate behaviors as self-damaging acts, stereotypies, or pica. In a well-publicized legal case, the state of Massachusetts banned the use of punishment in a school for autistic children. As a result, the children’s levels of self-injurious behavior increased, to the extent that the parents petitioned for punishment to be reinstated in the school’s behavior modification program. While the utility of punishment is generally acknowledged, many behavior modification therapists now suggest that the positive reinforcement of rewarding appropriate behavior is effective enough that punishment for inappropriate behavior is not necessary. Despite variations in philosophy and technique, behavior modification aimed at increasing social responsiveness and decreasing inappropriate behaviors is generally an essential component of therapy for autistic children. Social skills training involves direct teaching of the rules of social interaction. This training encourages autistic children to develop basic interpersonal skills, such as maintaining eye contact, waiting for a turn in conversation, listening to another person’s words, and saying “please” and “thank you.” Besides working on basic skills, social skills training techniques attempt to educate autistic children about the significance of the behavior, feelings, and thoughts of other people. Speech therapy has been shown to be effective in improving the communicative and linguistic skills of children with autism. Occupational therapy focuses on teaching skills that allow autistic children to participate in daily life: crossing a street, preparing simple meals, making purchases, or answering the telephone. Music therapy has been used to draw emotional responses from children with autism, with varied levels of success, and vitamin therapy and/or dietary restrictions have also been found in certain cases to alleviate some of the symptoms of autism. While no drug is specifically prescribed for autism, various medications are sometimes used to treat its symptoms. Stimulants may be used to treat the inattentiveness of autistic children who are particularly isolated and unresponsive. Tranquilizers may be prescribed to manage obsessivecompulsive behaviors that are disruptive to normal functioning. Antidepressants are also sometimes prescribed for autistic children in order to
116 ✧ Autism heighten emotional responsiveness and/or to stabilize mood. As many as one-third of children with autism develop seizures, often in adolescence, that are similar to epileptic seizures. These seizures are usually treated with medication. Children with autism may lead different sorts of lives, depending upon the severity of the symptoms. Autistic children with mild impairments can live at home, learn to participate in family and social life, and go to mainstream schools. Children with more profound autistic symptoms or significant mental retardation may go to special schools or live in residential school settings. Whatever the setting, children with autism respond most positively to a highly structured environment that includes a good deal of one-to-one interaction. Parents, siblings, and friends of autistic children also benefit from therapy. Life with autistic children can be rewarding, especially when progress is made, but it can also be frustrating and depressing. Often parents, siblings, and friends, as well as medical professionals, feel rejected by autistic children despite continual attempts to make contact. Most professionals suggest that anyone who spends extended periods of time with an autistic child would benefit from some form of training and/or emotional support. The most recent work on autism has focused on physiological and cognitive aspects of the disorder. Brain studies utilizing magnetic resonance imaging (MRI) and positron emission tomography (PET) scanning have suggested that the cerebellum is abnormal in individuals with autism. A large number of cognitive studies conducted in the 1990’s focused on the “theory of mind” hypothesis, which holds that autism results from a congenital inability to understand the minds of others. —Virginia Slaughter See also Children’s health issues; Learning disabilities. For Further Information: Aarons, Maureen, and Tessa Gittens. The Handbook of Autism: A Guide for Parents and Professionals. New York: Routledge, 1999. Written by professional speech therapists, this book is a thorough introduction to autism, covering diagnosis, assessments, history, prognosis, and methods of education. It is intended for a British audience. Cohen, Donald J., and Fred R. Volkmar, eds. Handbook of Autism and Pervasive Developmental Disorders. 2d ed. New York: John Wiley & Sons, 1997. This is a scholarly work presenting current information, diverse approaches, and some new areas of investigation that have not been addressed in other sources. There is an extensive review of the literature in all of the chapters and well-documented references based on the research. Happe, Francesca. Autism: An Introduction to Psychological Theory. London: UCL Press, 1994. This readable book gives a historical overview of autism
Biofeedback ✧ 117 and presents various theories that have been proposed to explain the disorder, including the “theory of mind” hypothesis. Hart, Charles A. A Parent’s Guide to Autism. New York: Pocket Books, 1993. A thorough discussion of important issues relevant to parents of autistic children, including chapters on diagnosis, treatment, education, and life choices. McClannahan, Lynn E., and Patricia J. Krantz. Activity Schedules for Children with Autism: A Guide for Parents and Professionals. Bethesda, Md.: Woodbine House, 1999. The authors cover one method of helping autistic children learn: activity schedules. These schedules teach autistic youngsters to follow words, pictures, or other nonverbal prompts to complete all varieties of tasks.
✧ Biofeedback Type of issue: Medical procedures, mental health, treatment Definition: The learned self-regulation of the autonomic nervous system through monitoring of the physiological activity occurring within an individual. Biofeedback has been utilized in both research and clinical applications. The term itself denotes the provision of information (feedback) about a biological process. It has been found that individuals (laboratory animals included), when given feedback that is reinforcing, are able to change physiological processes in a desired direction; homeostatic processes being what they are, these changes are in a positive direction. In the case of humans, the feedback is provided about a physiological function of which the individual would not otherwise be aware if it were not for the provision—via a biodisplay—of information about that process. A classic example of biofeedback being used to correct a physiological problem would be the employing of electromyograph (EMG) biofeedback for the correction of a simple tension (or psychophysiologic) headache. The headache is caused by inappropriately high muscle tension in the neck, head, or shoulders. In surface electromyographic biofeedback, the biofeedback practitioner attaches electronic sensors to the muscles of the forehead, neck, or shoulders of the patient. The electronic sensors pick up signals from electrochemical activity at the surface of the skin in the area of the involved muscle groups. The behavior of the muscles being monitored is such that minute changes in the electrochemical activity in the muscles— tension and relaxation—occur naturally.
118 ✧ Biofeedback Biofeedback Instruments The sensitivity of the biofeedback instrument (the magnification of the signal may be as high as one thousand times) and the display of the signal make the individual aware of these changes via sound or visual signals (biodisplays). When the biofeedback signal indicates that the muscle activity is in the direction of relaxation, the individual makes an association between that muscle behavior and the corresponding change in the strength of the signal. The individual can then increase the duration, strength, and frequency of the relaxation process. Having learned to relax the involved muscles, the individual is able to prevent or abort headache activity. An electromyograph is an instrument that is capable of monitoring and displaying information about electrochemical activity in a group of muscle fibers. Common applications of surface electromyography (in which sensors are placed on the surface of the skin, as opposed to the insertion of needles into the muscle itself) include stroke rehabilitation. Surface electromyography is also used in the treatment of tension headaches and fibromyalgia. An electrodermal response (EDR) biofeedback instrument is capable of monitoring and displaying information about the conductivity of the skin. An increase in the conductivity of the skin is a function of moisture accumulating in the space recently occupied by blood. The rate of blood flow depends on the amount of autonomic nervous system arousal present within the organism at the time of measurement. The higher the level of autonomic nervous system arousal, the greater the amount of skin conductivity. Common applications of EDR biofeedback are the reduction of anxiety caused by phobic reactions, the control of asthma (especially in young children), and the treatment of sleep disorders. For example, many insomniacs are unable to drop off to sleep because of higher-than-appropriate autonomic nervous system activity. An instrument that is capable of monitoring and displaying the surface temperature of the skin, as correlated with an increase in vascular (blood flow) activity in the area of the skin in question, can also be used for biofeedback. Such an instrument is helpful in the treatment for high blood pressure and migraine headaches. Electroencephalographic (EEG) biofeedback involves the monitoring and displaying of brain wave activity as a correlate of autonomic nervous system activity. Different brain waves are associated with different levels of autonomic nervous system arousal. Common applications of EEG biofeedback are in the treatment of substance abuse disorders, epilepsy, attentiondeficit disorders, and insomnia. Common Uses of Biofeedback Biofeedback is gaining in popularity because of a number of factors. One of the principal reasons is a growing interest in alternatives to the lifetime use
Biofeedback ✧ 119 of medications to manage a disorder. The more common usages of biofeedback treatment techniques include migraine headaches, tension headaches, digestive disorders, high blood pressure, low blood pressure, cardiac arrhythmias, Raynaud’s disease, epilepsy, and paralysis. One example worth noting—in terms of the magnitude of the problem—is the treatment of cardiovascular disorders. Myocardial infarctions, commonly known as heart attacks, are one of the major health problems in the industrialized world and an area of special concern to those practitioners with a psychophysiological orientation. In the United States alone, approximately 700,000 persons die of heart attacks each year. One of the principal causes of heart attacks is hypertension (high blood pressure). Emotions have much to do with the manifestation of high blood pressure (hypertension), which places this condition in the category of a psychophysiological disorder. Researchers have demonstrated that biofeedback is an effective methodology to correct the problem of high blood pressure. The data reveal that many individuals employing biofeedback have been able to decrease (or eliminate entirely) the use of medication to manage their hypertension. Studies also show that these individuals maintain normal blood pressure levels for as long as two years following the completion of biofeedback training. Because of its noninvasive properties and its broad applicability in the clinical setting, biofeedback is also increasingly becoming one of the more commonly utilized modalities in many fields, such as behavioral medicine. Researchers have provided documented evidence showing that biofeedback is effective in the treatment of so-called stress-related disorders. It is recognized that the four major causes of death and disability in the United States fall into the “stress-related” category. Research has also shown that biofeedback has beneficial applications in the areas of neuromuscular rehabilitation (working with stroke victims to help them develop greater control and use of afflicted muscle groups) and myoneural rehabilitation (working with victims of fibromyalgia and chronic pain to help them obtain relief from debilitating pain). Research in the 1960’s pointed to the applicability of EEG biofeedback for seizure disorders (such as epilepsy). Advanced technology and later research findings, however, have demonstrated EEG biofeedback to be effective in the treatment of attention-deficit disorder, hyperactivity, and alcoholism as well. Biofeedback appears to have particular applicability for children. Apparently, there is an innate ability on the part of the young to learn selfregulation skills much more quickly than older persons, such as the lowering of autonomic nervous system activity. Since this activity is highly correlated with respiratory distress, biofeedback is often used in the treatment of asthma in prepubescent children. Biofeedback is also being successfully used as an alternative to prescription medications (such as Ritalin) for youngsters with attention-deficit disorder.
120 ✧ Biofeedback Biofeedback and Sports The use of biofeedback is also found in the field of athletics and human performance. Sports psychologists and athletic coaches have long recognized that there is an inverted “U” pattern of performance where autonomic nervous system activity and performance are concerned. In the field of sports psychology, this is known as the Yerkes-Dobson law. The tenets of this law state that as the level of autonomic nervous system arousal rises, performance will improve—but only to a point. When autonomic nervous system arousal becomes too high, a corresponding deterioration in performance occurs. At some point prior to an athletic competition, it may be desirable for an athlete to experience an increase (or a decrease) in the level of autonomic nervous system activity (the production of adrenaline, for example). Should adrenaline levels become too high, however, the athlete may “choke” or become tense. To achieve physiological autoregulation (often referred to in this athletic context as self-regulation), athletes have used biofeedback to assist them with establishing better control of a variety of physiologic processes. Biofeedback applications have ranged from hand-warming techniques for crosscountry skiers and mountain climbers to the regulation of heartbeat for sharpshooters (such as biathletes and archers) to the lowering of adrenaline levels for ice-skaters, gymnasts, and divers. The Acceptance of Biofeedback The evolution of biofeedback as a treatment modality has its historical roots in early research in the areas of learning theory, psychophysiology, behavior modification, stress reactivity, electronics technology, and biomedical engineering. The emerging awareness—and acceptance by the general public—that individuals do in fact have the potential to promote their own wellness and to facilitate the healing process gave additional impetus to the development of both the theory and the technology of biofeedback treatment. Several other factors have combined to produce the climate within which biofeedback has gained recognition and acceptance. One of these was widespread recognition that many of the disorders that afflict humankind today have, as a common basis, some disruption of the natural feedback processes. Part of this recognition is attributable to the seminal work of Hans Selye on stress reactivity. Developments in the fields of electronics, physiology, psychology, endocrinology, and learning theory produced a body of knowledge which spawned the evolution and growth of biofeedback. Further refinement and an explosion of technology have resulted in procedures and techniques that have set the stage for the use of biofeedback as an effective intervention with wide applications in the treatment of numerous disorders. The practice of biofeedback has extended to a number of disciplines. Included in the membership of the Association of Applied Psychophysiology
Birth control and family planning ✧ 121 and Biofeedback (formerly the Biofeedback Society of America) are representatives from the fields of medicine, psychology, physical therapy, social work, occupational therapy, and chiropractic. —Ronald B. France See also Alternative medicine; Asthma; Attention-deficit disorder (ADD); Cardiac rehabilitation; Exercise; Headaches; Heart attacks; Hypertension; Hypnosis; Meditation; Pain management; Physical rehabilitation; Preventive medicine; Sleep disorders; Stress. For Further Information: Basmajian, John V., ed. Biofeedback: Principles and Practice for Clinicians. 3d ed. Baltimore: Williams & Wilkins, 1989. A collection of writings dealing with the uses of biofeedback for various disorders. This work contains chapters on instrumentation and theory as well. Olton, David S., and Aaron R. Noonberg. Biofeedback: Clinical Applications in Behavioral Medicine. Englewood Cliffs, N.J.: Prentice Hall, 1980. A practical overview of the applicability of biofeedback in the practice of behavioral medicine. This reference contains a basic overview of the development of biofeedback, as well as fundamental clinical applications in the treatment of various disorders. Robbins, Jim. A Symphony in the Brain: The Evolution of the New Brain Wave Biofeedback. New York: Atlantic Monthly Press, 2000. This work discusses brain-wave biofeedback (or neurofeedback), in which an electroencephalograph measures brain waves, and patients are trained to control them consciously. Robbins interviews many key researchers for this book. Schwartz, Mark S. Biofeedback: A Practitioner’s Guide. 2d ed. New York: Guilford Press, 1995. One of the more recent references in the field of biofeedback. The chapters contain updated information concerning the fundamentals of and (as of 1987) state-of-the-art methodologies concerning biofeedback. Schwartz, Mark S., and Les Fehmi. Applications Standards and Guidelines for Providers of Biofeedback Services. Wheatridge, Colo.: Biofeedback Society of America, 1982. A statement of the professional and ethical foundations for the practice of biofeedback. An important reference for anyone considering the employment of biofeedback in a clinical setting.
✧ Birth control and family planning Type of issue: Public health, women’s health Definition: The use of various methods to choose if and when conception will take place, and subsequently the number of children.
122 ✧ Birth control and family planning Without the ability to determine if they will bear children, women lack self-determination; thus access to safe and reliable birth control and family planning are essential elements in improving their status. Throughout history, societies have sought to control human fertility. In traditionally agricultural areas, where children represent a source of potential labor and care for aged parents, desired family size has been larger, especially when infant and childhood mortality rates remain high. By contrast, in modern industrialized and urbanized countries where childhood mortality is low and education extends into early adulthood, desired family size is smaller. Methods of Birth Control One way that societies affect the size of families is by encouraging either early or late marriages. Another is by persuading mothers to nurse their infants for extended periods of time; this is not a reliable method of birth control on an individual basis but does lower fertility for groups as a whole. The banning of conjugal relations between spouses during certain times also reduces birthrates. In the United States in the nineteenth century, for example, many couples confined intercourse to a period when they believed women were infertile. This method had limited value, because doctors lacked a clear understanding of the human fertility cycle until 1924. Some couples still use a similar technique, known as the rhythm method, based on careful monitoring of a woman’s menstrual cycle and variations in her body temperature. Whatever the Many different kinds of devices have been designed to success of individual couprevent pregnancy, from barrier methods such as conples, any method that incordoms and diaphragms to hormonal methods such as birth control pills. Each method has its own advantages porates periods of abstiand disadvantages, and failure rates. (Hans & Cas- nence lowers the overall birthrate. Finally, many sosidy, Inc.)
Birth control and family planning ✧ 123 cieties have resorted to abortion and infanticide when other methods of birth control have failed. One common form of birth control has been the use of contraception in an attempt to prevent conception in the first place. Perhaps the most widely used method prior to the twentieth century has been male withdrawal before ejaculation, or coitus interruptus. Women, however, often relied on barrier methods such as pessaries, instruments or suppositories placed in the vagina to prevent impregnation. These were more effective when combined with ingredients such as the tips of the acacia shrub. This is a source of lactic acid, an ingredient used in many modern spermicides. Less common until the nineteenth century were douches after intercourse to prevent impregnation. Although men in primitive tribes sometimes wore sheaths over their penises, scholars believe these served as protection or decoration. By the sixteenth century, however, European men were using the condom, made of silk or from animal bladders or intestines, to prevent the spread of venereal disease. Despite their contraceptive value, these devices were not widely used because they were expensive. By the mid-nineteenth century, the vulcanization of rubber allowed manufacturers to produce condoms at reasonable prices. Throughout history, individuals have turned to sterilization to prevent conception, a method that is still widely used. Thus, excluding the hormone suppressors developed in the latter part of the twentieth century, the major forms of contraception are centuries old. The Fight for Birth Control in North America In North America, the dissemination of birth control information has a controversial history. The U.S. Congress passed a law in 1873 barring the distribution of all matter termed “obscene, lewd, [or] lascivious.” Known as the Comstock Law, it had been suggested by Anthony Comstock (1844-1915) and his followers, who feared that urban environments were corrupting youths. They also believed that middle-class women were bearing too few children, and, given the rising tide of immigration from Central and Eastern Europe, the older “Yankee stock” was seen as facing “race suicide.” Because of the Comstock Law, any person seeking to mail information about birth control or abortion faced stiff fines and prison sentences. Twenty-two states passed “little Comstock Laws,” among them Connecticut. Its 1879 law forbade the use of contraceptive devices and penalized anyone, including physicians, who supplied such devices. In 1892, Canada modified its criminal code by forbidding the dissemination of birth control information, a ban that was not lifted until 1969. Nevertheless, during the latter decades of the nineteenth century, the Voluntary Motherhood movement came into being, made up of free-love advocates, moral reformers warring against prostitution, and suffragists
124 ✧ Birth control and family planning concerned with raising the status of women. The conviction that wives, as childbearers, had the right to determine when a couple would engage in conjugal relations tied this group together. While Voluntary Motherhood marked the beginning of a true birth control movement in the United States, it opposed contraception. Its adherents believed that separating sexual relations from procreation would expose women to greater exploitation. Margaret Sanger (1879-1966) initiated the next stage in the drive for freer dissemination of contraceptive information. Sanger, who coined the phrase “birth control,” challenged the Comstock Law directly through articles on sexuality in the socialist newspaper, The Call, and her own journal, The Woman Rebel. Finally, her pamphlet Family Limitation, containing explicit information on birth control methods and techniques, led to her arrest in 1914. After a preliminary hearing, Sanger fled to Europe where she learned the technique of fitting women with diaphragms in Dutch clinics. When she returned to the United States, the groundswell of support for her cause led the government to drop its case against her. New charges were brought after she opened a clinic in Brooklyn. The New York Court of Appeals upheld her conviction in 1918 but affirmed the right of physicians to give contraceptive advice or devices for preventing disease to married persons where not specifically forbidden by law. In the past, doctors had given such information only to men, but now women could also receive it. Many physicians were willing to extend the idea of preventing disease to preventing pregnancy, especially if they were serving middle- and upper-class patients. When the United States entered World War I, the military, seeking to reduce the incidence of venereal disease, issued condoms for the first time. Afterward, many veterans introduced their wives to contraceptive methods. Nevertheless, by 1930, many poorer women still lacked access to birth control information. During the Great Depression, social workers and health care professionals championed birth control as a way of aiding families on relief. States, beginning with North Carolina, staffed their own clinics, and a 1936 Gallup Poll found that most Americans favored allowing physicians to dispense information on contraception. Similar changes occurred in Canada in this period. In 1942, an organization that Sanger had founded in 1921 to promote greater acceptance of birth control became the Planned Parenthood Federation of America. As the new name suggested, many now saw birth control as a way for couples to space children and achieve their optimum family size. By giving women the power to limit their families, the organization helped lay the foundation for a revived women’s movement. In 1965, the Supreme Court of the United States, in Griswold v. Connecticut, overturned the state’s “little Comstock Law,” passed almost a century earlier. The Court ruled that married couples enjoyed a right to privacy that
Birth control and family planning ✧ 125 included access to birth control. Seven years later, in Eisenstadt v. Baird, the Court, invoking the same right of privacy, extended similar access to unmarried couples. The appearance in 1960 of Enovid-10, the first pill that suppressed ovulation, gave women a more effective means of preventing pregnancy while allowing them to separate contraception from sexual intercourse itself. Many women experienced disturbing side effects from the birth control pill, however, including weight gain, rashes, nausea, bloating, and cardiovascular problems. Barbara Seaman, in The Doctor’s Case Against the Pill (1969), publicized these problems, and a reenergized women’s movement pressured the drug companies to manufacture a safer pill. The pharmaceutical companies complied by lowering the dosage of estrogen and progestin, but many women have continued to harbor health concerns about the pill and its long-term usage. Other birth control methods that initially were promising have since proved problematical. The intrauterine device (IUD), which is inserted into a woman’s uterus in order to prevent impregnation, caused serious physical problems for many women, and some types were taken off the market in the United States. Depo-Provera is a synthetic progesterone that prevents pregnancy for several months through injections. Collaboration between a Finnish pharmaceutical company and the nonprofit Population Council resulted in Norplant, a contraceptive implant that releases hormones over time. Although all these methods are highly effective in preventing pregnancy, there are questions about their long-term effects on health. Continuing Problems and Prospects At the beginning of the twenty-first century, many women still relied on the older barrier methods, such as improved diaphragms, cervical caps, spermicides, and even a female condom. These methods are considered to be safer than hormonal treatments but are not as effective. It is not surprising that about half of all unplanned pregnancies occur among women who are using birth control. In that light, the development of RU-486 (first manufactured by the French firm Roussell Uclaf) is germane. It has been used in Europe since 1982 as a way of terminating early pregnancy, and it was finally approved for use in the United States in 2000. RU-486 functions by blocking the body’s production of progesterone, the hormone that prepares the uterus to accept the fertilized egg. Other researchers are working on vaccines to cause immune system reactions that would prevent fertilization from occurring in the first place. Although more governmental and private resources are needed to develop new forms of contraception, technology is only part of the answer. Women usually attain a large measure of control over reproduction only after society has achieved certain necessary preconditions. These include
126 ✧ Birth defects lessening poverty, so individuals gain hope that the future can be different from the past; decreases in infant and childhood mortality; greater educational opportunities for women; and improvements in the status of women so they have chances for achievement beyond the bearing of children. —Shirley A. Leckie See also Abortion; Abortion among teenagers; Condoms; Infertility in men; Infertility in women; Morning-after pill; Pregnancy among teenagers; Prenatal care; Sexual dysfunction; Sexually transmitted diseases (STDs). For Further Information: Chesler, Ellen. Woman of Valor: Margaret Sanger and the Birth Control Movement in America. New York: Simon & Schuster, 1992. This exhaustively researched biography brings this strong-willed birth control pioneer vividly to life, along with the individuals and movements that influenced her work. Garrow, David J. Liberty and Sexuality: The Right to Privacy and the Making of “Roe v. Wade.” New York: Macmillan, 1994. More than the title indicates, this prodigiously researched work is invaluable for tracing the fight for reproductive freedom in the United States. Gordon, Linda. Woman’s Body, Woman’s Right: Birth Control in America. New York: Penguin Books, 1990. Revised and updated edition of Gordon’s 1976 work, it places birth control in the context of social history. Hatcher, Robert A., et al. Contraceptive Technology. 17th ed. New York: Irvington, 1998. This frequently revised book offers a thorough and readable discussion of most aspects of contraception. McLaren, Angus, and Arlene Tigar McLaren. The Bedroom and the State: The Changing Practices and Politics of Contraception and Abortion in Canada, 1880-1980. Toronto: McClelland and Stewart, 1986. A valuable overview on the fight for reproductive freedom in Canada.
✧ Birth defects Type of issue: Children’s health, mental health Definition: Congenital malformations or structural anomalies and their accompanying functional disorders which originate during embryonic development; they are involved in up to 6 percent of human live births. As the human embryo develops, it undergoes many formative stages from the simple to the complex, most often culminating in a perfectly formed newborn infant. The formation of the embryo is controlled by both genetic factors and interactions between the various embryonic tissues. Because the
Birth defects ✧ 127 genes play a vital role as the blueprint for the developing embryo, they must be accurate and the cellular mechanisms that allow the genes to be expressed must also work correctly. In addition, the chemical and physical communications between cells and tissues in the embryo must be clear and uninterrupted. The development of the human embryo into a newborn infant is infinitely more complex than the design and assembly of the most powerful supercomputer or the largest skyscraper. Because of this complexity and the fact that development progresses without supervision by human eye or hand, there are many opportunities for errors that can lead to malformations. Errors in development can be caused by both genetic and environmental factors. Genetic factors include chromosomal abnormalities and gene mutations. Both can be inherited from the parents or can occur spontaneously during gamete formation, fertilization, and embryonic development. Environmental factors, called teratogens, include such things as drugs, disease organisms, and radiation. Chromosomal Abnormalities Chromosomal abnormalities account for about 6 percent of human congenital malformations. They fall into two categories, numerical and structural. Numerical chromosomal abnormalities are most often the result of nondisjunction occurring in the germ cells that form sperm and eggs. During the cell division process in sperm and egg production deoxyribonucleic acid (DNA) is duplicated so that each new cell receives a complete set of chromosomes. Occasionally, two chromosomes fail to separate (nondisjunction), such that one of the new cells receives two copies of that chromosome and the other cell none. Both of the resulting gametes (either sperm or eggs) will have an abnormal number of chromosomes. When a gamete with an abnormal number of chromosomes unites with a normal gamete, the result is an individual with an abnormal chromosome number. The missing or extra chromosome will cause confusion in the developmental process and result in certain structural and functional abnormalities. For example, persons with an extra copy of chromosome number 21 suffer from Down syndrome, which often includes mental deficiency, heart defects, facial deformities, and other symptoms. Abnormal chromosome numbers may also result from an egg’s being fertilized by two sperm, failure of cell division during gamete formation, and nondisjunction in one or more cells of the early embryo. Structural chromosomal abnormalities result from chromosome breaks. Breaks occur in chromosomes during normal exchanges in material between chromosomes (crossing over). They also may occur accidentally at weak points on the chromosomes, called fragile sites, and can be induced by chemicals and radiation. Translocations occur when a broken-off piece of chromosome at-
128 ✧ Birth defects taches to another chromosome. For example, an individual who has the two usual copies of chromosome 21 and, as the result of a translocation, carries another partial or complete copy of 21 riding piggyback on another chromosome will have the symptoms of Down syndrome. Deletions occur when a chromosome break causes the loss of part of a chromosome. The cri du chat syndrome is caused by the loss of a portion of chromosome number 5. Infants affected by this disorder have a catlike cry, are mentally retarded, and have cardiovascular defects. Other structural chromosomal abnormalities include inversions (in which segments of chromosomes are attached in reverse order), duplications (in which portions of a chromosome are present in multiple copies), and isochromosomes (in which chromosomes separate improperly to produce the wrong configuration). Mutations Gene mutations (defective genes) are responsible for about 8 percent of birth defects. Mutations in genes occur spontaneously because of copying errors or can be induced by environmental factors such as chemicals and radiation. The mutant genes are passed from parents to offspring; thus certain defects may be present in specific families and geographical locations. Two examples of mutation-caused defects are polydactyly (the presence of extra fingers or toes) and microcephaly (an unusually small cranium and brain). Mutations can be either dominant or recessive. If one of the parents possesses a dominant mutation, there will be a 50 percent chance of this mutant gene being transmitted to the offspring. Brachydactyly, or abnormal shortening of the fingers, is a dominantly inherited trait. Normally, the parent with the dominant gene also has the disorder. Recessive mutations can remain hidden or unexpressed in both parents. When both parents possess the recessive gene, there is a 25 percent chance that any given pregnancy will result in a child with a defect. Examples of recessive defects are the metabolic disorders sickle-cell anemia and hemophilia. Environmental Factors Environmental factors called teratogens are responsible for about 7 percent of congenital malformations. Human embryos are most sensitive to the effects of teratogens during the period when most organs are forming (organogenetic period), that is, from about fifteen to sixty days after fertilization. Teratogens may interfere with development in a number of ways, usually by killing embryonic cells or interrupting their normal function. Cell movement, communication, recognition, differentiation, division, and adhesion are critical to development and can be easily disturbed by teratogens. Teratogens can also cause mutations and chromosomal abnormalities in
Birth defects ✧ 129 embryonic cells. Even if the disturbance is only weak and transitory, it can have serious effects because the critical period for development of certain structures is very short and well defined. For example, the critical period for arm development is from twenty-four to forty-four days after fertilization. A chemical that interferes with limb development such as the drug thalidomide, if taken during this period, may cause missing arm parts, shortened arms, or complete absence of arms. Many drugs and chemicals have been identified as teratogenic, including alcohol, aspirin, and certain antibiotics. Other environmental factors that can cause congenital malformations include infectious organisms, radiation, and mechanical pressures exerted on the fetus within the uterus. Certain infectious agents or their products can pass from the mother through the placenta into the embryo. Infection of the embryo causes disturbances to development similar to those caused by chemical teratogens. For example, German measles (rubella virus) causes cataracts, deafness, and heart defects if the embryo is infected early in development. Exposure to large doses of radiation can result in death and damage to embryonic cells. Diagnostic X rays are not known to be a cause of birth defects. Some defects such as hip dislocation may be caused by mechanical forces inside the uterus; this could happen if the amnion is damaged or the uterus is malformed, thus restricting the movement of the fetus. About 25 percent of congenital defects are caused by the interaction of genetic and environmental factors (multifactorial), and the causes of more than half (54 percent) of all defects are unknown. Preventing Birth Defects Because many birth defects have well-defined genetic and environmental causes, they often can be prevented. Preventive measures need to be implemented if the risk of producing a child with a birth defect is higher than average. Genetic risk factors for such defects include the presence of a genetic defect in one of the parents, a family history of genetic defects, the existence of one or more children with defects, consanguineous (samefamily) matings, and advanced maternal age. Prospective parents with one or more of these risk factors should seek genetic counseling in order to assess their potential for producing a baby with such defects. Also, parents exposed to higher-than-normal levels of drugs, alcohol, chemicals, or radiation are at risk of producing gametes that may cause defects, and pregnant women exposed to the same agents place the developing embryo at risk. Again, medical counseling should be sought by such prospective parents. Pregnant women should maintain a well-balanced diet that is about 200 calories higher than normal to provide adequate fetal nutrition. Women who become anemic during pregnancy may need an iron supplement, and the U.S. Public Health Service recommends that all women of childbearing age consume 0.4 milligram of folic acid (one of the B vitamins) per day to
130 ✧ Birth defects reduce the risk of spina bifida and other neural tube defects. Women at high risk for producing genetically defective offspring can undergo a screening technique whereby eggs taken from the ovary are screened in the laboratory prior to in vitro fertilization and then returned to the uterus. Some couples may decide to use artificial insemination by donor if the prospective father is known to carry a defective gene. Detecting Birth Defects The early detection of birth defects is crucial to the health of both the mother and the baby. Physicians commonly use three methods for monitoring fetal growth and development during pregnancy. The most common method is ultrasound scanning. High-frequency sound waves are directed at the uterus and then monitored for waves that bounce back from the fetus. The return waves allow a picture of the fetus to be formed on a television monitor, which can be used to detect defects and evaluate the growth of the fetus. In amniocentesis, the doctor withdraws a small amount of amniotic fluid containing fetal cells; both the fluid and the cells can be tested for evidence of congenital defects. Amniocentesis generally cannot be performed until the sixteenth week of pregnancy. Another method of obtaining embryonic cells is called chorionic villus sampling and can be done as early as the fifth week of pregnancy. A tube is inserted into the uterus in order to retrieve a small sample of placental chorionic villus cells, identical genetically to the embryo. Again, these cells can be tested for evidence of congenital defects. The early discovery of fetal defects and other fetal-maternal irregularities allows the physician time to assess the problem and make recommendations to the parents regarding treatment. Many problems can be solved with therapy, medications, and even prenatal surgery. If severe defects are detected, the physician may recommend termination of the pregnancy. Treating Birth Defects Children born with defects often require highly specialized and intense medical treatment. For example, a child born with spina bifida may have lower-body paralysis, clubfoot, hip dislocation, and gastrointestinal and genitourinary problems in addition to the spinal column deformity. Spina bifida occurs when the embryonic neural tube and vertebral column fail to close properly in the lower back, often resulting in a protruding sac containing parts of the spinal meninges and spinal cord. The malformation and displacement of these structures result in nerve damage to the lower body, causing paralysis and the loss of some neural function in the organs of this area.
Birth defects ✧ 131 Diagnostic procedures including X rays, computed tomography (CT) scans, and urinalysis are carried out to determine the extent of the disorder. If the sac is damaged and begins to leak cerebrospinal fluid, it needs to be closed immediately to reduce the risk of meningitis. In any case, surgery is done to close the opening in the lower spine, but it is not possible to correct the damage done to the nerves. Urgent attention must also be given to the urinary system. The paralysis often causes loss of sphincter muscle control in the urinary bladder and rectum. With respect to the urinary system, this lack of control can lead to serious urinary tract infections and the loss of kidney function. Both infections and obstructions must be treated promptly to avoid serious complication. Orthopedic care needs to begin early to treat clubfoot, hip dislocation, scoliosis, muscle weakness, spasms, and other side effects of this disorder. The medical treatment of birth defects requires a carefully orchestrated team approach involving physicians and specialists from various medical fields. When the abnormality is discovered (before birth, at birth, or after birth), the primary physician will gather as much information as possible from the family history, the medical history of the patient, a physical examination, and other diagnostic tests. This information is interpreted in consultation with other physicians in order to classify the disorder properly and to determine its possible origin and time of occurrence. This approach may lead to the discovery of other malformations, which will be classified as primary and secondary. When the physician arrives at a specific overall diagnosis, he or she will counsel the parents about the possible causes and development of the disorder, the recommended treatment and its possible outcomes, and the risk of recurrence in a subsequent pregnancy. Certain acute conditions may require immediate attention in order to save the life of the newborn. In addition to treating the infant with the defect, the physician needs to counsel the parents in order to answer their questions. The counseling process will help them to understand and accept their child’s condition. In order to promote good parent-infant bonding, the parents are encouraged to maintain close contact with the infant and participate in its care. Children born with severe chronic disabilities and their families require special support. When parents are informed that their child has limiting congenital malformations, they may react negatively and express feelings of shock, grief, and guilt. Medical professionals can help the parents deal with their feelings and encourage them to develop a close and supportive relationship with their child. Physicians can provide a factual and honest appraisal of the infant’s condition and discuss treatments, possible outcomes, and the potential for the child to live a happy and fulfilling life. Parents are encouraged to learn more about their child’s disorder and to seek the guidance and help of professionals, support groups, family, and friends. With the proper care and home environment, the child can
132 ✧ Birth defects develop into an individual who is able to interact positively with family and community. —Rodney C. Mowbray See also Amniocentesis; Childbirth complications; Cleft lip and palate; Diabetes mellitus; Disabilities; Down syndrome; Fetal alcohol syndrome; Gene therapy; Genetic counseling; Genetic diseases; Health problems and families; Hydrocephalus; Mental retardation; Phenylketonuria (PKU); Premature birth; Screening; Spina bifida. For Further Information: Bloom, Beth-Ann, and Edward Seljeskog. A Parent’s Guide to Spina Bifida. Minneapolis: University of Minnesota Press, 1988. Designed to assist the parents of children with spina bifida. The book includes chapters on the nature of the disorder and how it is treated, the medical problems associated with spina bifida, and how to help the afflicted child while he or she is growing up. Also includes a useful glossary, a list of organizations and support groups, and an extensive bibliography. Moore, Keith L., and T. V. N. Persaud. The Developing Human. 6th ed. Philadelphia: W. B. Saunders, 1998. An outstanding textbook on human embryonic development. Chapter 8 deals specifically with the causes of congenital malformations, and several other chapters include more detailed information about common defects occurring in each of the body’s systems. The book is easy to understand and well illustrated. Nixon, Harold, and Barry O’Donnel. The Essentials of Pediatric Surgery. 4th ed. Boston: Butterworth Heinemann, 1992. Describes in laypersons’ terms the surgical treatment of many congenital abnormalities, including birth injuries, imperforate anus, spina bifida, hydrocephalus, pyloric stenosis, birthmarks, cleft lip and palate, hernias, urinary and digestive tract deformities, undescended testis, intersex problems, limb malformations, and congenital heart disease. The book is well illustrated with descriptive line diagrams and includes a thorough discussion of each procedure. Stray-Gundersen, Karen, ed. Babies with Down Syndrome. Kensington, Md.: Woodbine House, 1986. A complete guide for parents with a Down syndrome child, written by doctors, nurses, educators, lawyers, and parents. The book includes a complete medical description of the disorder and extensive coverage of care concerns, child development, education, and legal rights. Contains an extensive glossary, reading list, and resource guide. Warkany, Josef, Ronald J. Lemire, and Michael Cohen. Mental Retardation and Congenital Malformations of the Central Nervous System. Chicago: Year Book Medical Publishers, 1981. A medical reference book that gives complete descriptions of congenital malformations of the nervous sys-
Breast cancer ✧ 133 tem and their effects on the eyes, ears, heart, skeleton, and skin. The authors also include a thorough discussion of congenitally caused mental illness. The book is technical in nature but informative and authoritative. Well illustrated; includes extensive listings of technical articles.
✧ Breast cancer Type of issue: Women’s health Definition: The growth of abnormal cells in the breast, which can spread throughout the body and prevent organs from functioning normally. It is estimated that one in eight women in the United States will develop breast cancer during her lifetime. Each year, approximately 175,000 new cases of breast cancer are diagnosed, and about 45,000 women die of the disease annually. Although genetic predisposition plays a role in the development of cancer, as many as 80 percent of the women who get the disease have no known risk factor (such as early onset of puberty, having a mother or sister with the disease, or not having given birth before age thirty). Breast cancer is a common cancer in women. Cancer is caused when normal cells become abnormal and begin to grow out of control. The abnormal cells can spread throughout the body and prevent organs from functioning normally. Breast cancer itself is not fatal; only cancer that has spread outside the breast (to the bones, liver, or brain, for example) can kill. Types and Staging The most common type of breast cancer, about 86 percent of all cases, begins in the drainage ducts of the mammary glands (ductal carcinoma); 12 percent of breast cancers are lobular, meaning they begin in the breast lobules (milk glands). The remainder begin in surrounding tissues. Cancer can also be described as “infiltrating” or “invasive,” meaning it has traveled into surrounding tissue from its original site. Invasive breast cancer is graded from stages 1 to 4 in order to assess treatment possibilities. A number of tests are performed to determine the stage of the disease: chest X rays, blood tests, and a variety of scans (usually of the bones, liver, lungs, and brain). Tumor size, skin swelling, whether the cancer has spread to lymph nodes (lymph node involvement), and results of such tests as hormone receptors and flow cytometry are also considered. Because of more extensive use of mammograms and breast self-examination (BSE), most cancers found are stage 1 or 2, which respond best to treatment. Stage 1 is a tumor up to two centimeters in size with no lymph node
134 ✧ Breast cancer involvement, while stage 2 is a tumor between two and five centimeters with or without lymph node involvement or a tumor larger than five centimeters with no lymph node involvement. Stage 3 cancers have a large (more than five centimeters) tumor with lymph node involvement, and stage 4 describes a tumor that has metastasized, or spread to distant sites in the body (most commonly the liver, lungs, bones, or brain). Breast cancer is detected in several ways: through mammography, needle biopsy (the insertion of a needle to draw out fluid or tissue), and surgical biopsy (the removal of some of the tissue of the breast). Treatment and Prognoses Local and systemic treatments are most commonly prescribed for breast cancer. Surgery, including mastectomy and lumpectomy, is generally the first treatment, though research on chemotherapy and/or radiation before surgery continues. Modified radical mastectomy has become the most common treatment for early-stage breast cancer, though an increased number of women opt for lumpectomy, with or without follow-up radiation and chemotherapy. Surgery is used to remove the cancer from the breast; most of the time, underarm lymph nodes are removed and examined to determine whether the disease has spread. Lymph node involvement generally means that radiation and/or chemotherapy are recommended. Radiation therapy uses high-energy X rays to kill cancer cells; radiation can be given externally by a machine or internally through implants. Chemotherapy, a systemic treatment (able to kill cancer cells outside the breast area) is given by injection, through pills, or both. Hormone therapy can include the use of drugs such as tamoxifen or the removal of hormonemaking organs. The aim of adjuvant therapies such as these is to kill any cancer cells that remain after surgery. Immunotherapy, or biological therapy, was under investigation in clinical trials in the mid-1990’s; it uses materials to heighten the body’s natural defenses against disease. High-dose chemotherapy followed by bone marrow transplantation (necessary because the chemotherapy destroys the body’s bone marrow) has also undergone testing as a new treatment. Complementary treatments can include visualization, diet, exercise, meditation, or alternative therapies and are often used in hopes of strengthening the immune system in its fight against cancer. Prognoses for breast cancer vary greatly depending on the cancer’s stage at detection, the treatment options chosen, and the individual patient. Of stage 1 patients, 85 percent were still alive five years after diagnosis, as opposed to 66 percent of stage 2 patients, 41 percent of stage 3 patients, and 10 percent of stage 4 patients. Mortality rates are difficult to estimate because of constant updating and are highly dependent on a number of variables. Sources tend to disagree given that most survival statistics were
Breast cancer ✧ 135 compiled before chemotherapy became commonly prescribed as a postsurgery treatment. The most accurate information available suggests very good survival rates for stage 1 and 2 patients, and survival rates for all stages improve over time. In the United States, for many years the standard treatment was to perform a biopsy, followed immediately by a radical mastectomy if the biopsy results showed cancer. For most of the twentieth century, radical mastectomy, which removes the entire breast, underlying muscles, and lymph nodes, was performed (in more than 90 percent of cases in 1960). This procedure finally began to be questioned, and in Canada and England, surgeons began to perform far less radical procedures. In 1979, the National Cancer Institute (NCI) recommended that the biopsy and follow-up surgery be performed separately, so that women could discuss treatment options and decide on the best course of action to follow. The NCI also declared that radical mastectomy should no longer be the treatment of choice for breast cancer. The courage of several prominent women who “went public” with their breast cancer played a major role in women’s advocacy about the disease and led to widespread questioning of traditional methods of treatment, as well as a dramatic increase in the number of women having mammograms and performing BSE. Many women opt for lumpectomy, usually followed by chemotherapy and/or radiation, in order to preserve their breasts. Numerous studies have shown that survival rates are nearly identical for lumpectomy and mastectomy; in Canada and Europe, statistics show that they have equivalent survival rates for twenty-five years past diagnosis. Increasingly, women are taking a strong role in their treatment: They obtain second and third opinions, assimilate all available information, and make informed decisions. Emotional Impact Women’s reactions to a diagnosis of breast cancer vary greatly. Some suggest that a woman’s first concern is often cosmetic—the possible loss of a breast and the effects of chemotherapy and/or radiation on appearance—whereas others note that a cancer diagnosis is devastating regardless of the area of the body affected. It is certain that rising awareness of breast cancer and support groups for cancer survivors have lessened the stigma of the disease and much of the fear, shame, and isolation felt by breast cancer patients. Society’s stress on perfection of the female body and the Western emphasis on the breasts as an area of eroticism contribute greatly to women’s worries about the physical effects of the disease. Losing a breast, or greatly changing its appearance, is one of the biggest fears women face and could be a factor in their apparent reluctance to perform BSE (fewer than 40 percent of women do so). A mastectomy or lumpectomy, by making a
136 ✧ Breast cancer woman realize the seriousness of her disease, can also greatly change her self-image. Breast cancer patients often suffer doubts about how this change will affect the rest of their lives, especially regarding intimacy, lifestyle, and personal relationships. Many studies have shown that the attitude of a spouse during a partner’s illness has a great impact on the partner’s adjustment to the situation. One of the most common concerns is how a woman’s partner will react to her changed body after her surgery. Most sources agree that the specter of a life-threatening illness can have a dramatic impact on a relationship but that, for the most part, the changes are positive, resulting in heightened appreciation of each partner. Another concern springs from the changes in the body wrought by chemotherapy, radiation, and hormonal therapy: nausea, vomiting, hair loss, and mood changes. Hair loss in particular can be a traumatic event, again because of stereotyped ideas of the ideal woman in Western society. Programs such as Look Good, Feel Better, sponsored by the American Cancer Society, can help women deal with their changed appearance. Many women wear a prosthesis, and increasing numbers have reconstructive surgery to restore their appearance. Although some women are reluctant to put themselves through another surgery, they see reconstruction as an essential step in their recovery, and an increasing number of options are available. Programs such as Reach to Recovery, a peer-visitor organization that provides information and support, and ENCORE, a national discussion and exercise program for breast cancer survivors sponsored by the Young Women’s Christian Association (YWCA), are designed to help women cope with the feelings and physical effects of the disease. These programs and I Can Cope, sponsored by the American Cancer Society and the Y-Me National Organization for Breast Cancer Information and Support, emphasize the practical and emotional aspects of dealing with cancer. Breast cancer support groups are common in the United States and are often organized by cancer centers, hospitals, or social service agencies; they are usually led by a nurse or social worker and provide support for cancer survivors and, increasingly, their families. Many women, after facing treatment and recovery, feel the need to help others and join volunteer organizations. Prevention and Awareness Breast self-examination is recommended by most physicians to help women detect breast cancer. Many women’s groups conduct seminars on this possibly lifesaving skill, given that 85 percent of lumps are found by women themselves. BSE has helped many women detect breast cancer in its early stages. Mammograms (X rays of the breast) are widely used and have been shown to reduce mortality by 30 to 50 percent in women over age fifty. Research efforts have been aided by the Pink Ribbon Campaign, modeled on the awareness campaign on behalf of acquired immunodeficiency
Breast-feeding ✧ 137 syndrome (AIDS). Wearing a pink ribbon represents awareness of breast cancer and activism for funding research. Sponsored by Avon, Self magazine, and other organizations, the Pink Ribbon Campaign has been joined by Race for the Cure, sponsored by the Susan G. Komen Breast Cancer Foundation and the National Alliance of Breast Cancer Organizations, both of which provide information and assistance to breast cancer patients and lobby for heightened public awareness of breast cancer. —Michelle L. Jones See also Breast surgery; Cancer; Cervical, ovarian, and uterine cancers; Chemotherapy; Hospice; Mammograms; Mastectomy; Pain management; Screening; Women’s health issues. For Further Information: Berger, Karen, and John Bostwick III. A Woman’s Decision: Breast Care, Treatment and Reconstruction. 3d rev. ed. St. Louis: Quality Medical Publishing, 1998. Discusses various treatment options with regard to quality of life; combines physicians’ perspectives with those of patients. Especially valuable is a section detailing surgical options for breast reconstruction. Berman, Joel, ed. Comprehensive Breast Care: Surviving Breast Cancer. Boston: Branden Books, 2000. A popular work about breast cancer. Includes an index. Davies, Kevin. Breakthrough: The Race to Find the Breast Cancer Gene. New York: John Wiley & Sons, 1996. Chronicles the search for BRCA1, the gene that appears to cause the inheritable form of breast cancer. Higgins-Lee, Charlotte. Surviving Breast Cancer. Pittsburgh: Dorrance, 1997. Written by a psychologist who survived breast cancer. Using a composite client she names Charlie, Higgins-Lee illustrates her therapeutic method as she takes the reader through the emotional stages associated with breast cancer. Love, Susan, with Karen Lindsey. Dr. Susan Love’s Breast Book. 3d rev. ed. Reading, Mass.: Perseus Books, 2000. Written by a breast surgeon. A reliable and highly readable analysis of the physical, social, historical, and emotional aspects of breast cancer.
✧ Breast-feeding Type of issue: Children’s health, social trends Definition: The preferred feeding method for infants, providing optimal nutrition for the infant (including immunologic protection), motherinfant bonding, and enhanced maternal health.
138 ✧ Breast-feeding The terms “breast-feeding,” “nursing,” and “lactation” all refer to the bestknown method of infant feeding. Although there are a few rare exceptions, almost every mother can breast-feed and thereby provide low-cost, nutritional support for her infant. Although it is often thought otherwise, the size of the mother’s breast has no relationship to successful lactation. In fact, the physiology of successful lactation is determined by the maturation of breast tissue, the initiation and maintenance of milk secretion, and the ejection or delivery of milk to the nipple. This physiology is dependent on hormonal control, and all women have the required anatomy for successful lactation unless they have had surgical alteration of the breast. Breast and Milk Development Hormonal influence on breast development begins in adolescence. Increased estrogen causes the breast ducts to elongate and duct cells to grow. (The ducts are narrow tubular vessels that run from the segments of the breast into the tip of the nipple.) More fibrous and fatty tissue develops, and the nipple area matures. As adolescence progresses, regular menstrual cycle hormones cause further development of the alveoli, which are the milkproducing cells. The elevated levels of estrogen present during pregnancy promote the growth and branching of milk ducts, while the increase in progesterone promotes the development of alveoli. Throughout pregnancy and especially during the first three months, many more milk ducts are formed. Clusters of milk-producing cells also begin to enlarge, while at the same time placental hormones promote breast development. Shortly before labor and delivery, the hormone prolactin is produced by the pituitary gland. Prolactin, which is necessary for starting lactation and sustaining milk production, reaches its peak at delivery. Another hormone, oxytocin, which is also produced by the pituitary, stimulates the breast to eject milk. This reaction is called the “let-down reflex,” which causes the milk-producing alveoli to contract and force milk to the front of the breast. Oxytocin serves an important function after delivery by causing the uterus to contract. Initially, the let-down reflex occurs only when the infant suckles, but later on it may be initiated simply by the baby’s cry. An efficient let-down reflex is critical to successful breast-feeding. Emotional upset, fatigue, pain, nervousness, or embarrassment about lactation can interrupt this reflex; these psychological factors, rather than breast size or physiology, are predictive of successful lactation. The Nutritional Value of Breast Milk Not only is breast-feeding a natural response to childbirth, but the nutrient content is tailor-made for the human infant as well. More than one hundred
Breast-feeding ✧ 139 constituents of breast milk, both nutritive and nonnutritive, are known. Although the basic nutrient content is a solution of protein, sugar, and salts in which fat is suspended, those concentrations vary depending on the period of lactation and even within a given feeding. Colostrum, often called “first milk,” is produced in the first few days after birth. It is lower in fat and Calories (kilocalories) and higher in protein and certain minerals than is mature breast milk. Colostrum is opaque and yellow because it contains a high concentration of the vitamin A-like substances called carotenes. It also has a high concentration of antibodies and white blood cells, which pass on immunologic protection to the infant. Within a few days after birth, the transition is made from colostrum to mature milk. There are two types of mature milk. Foremilk is released first as the infant begins to suckle. It has a watery, bluish appearance and is low in fat and rich in other nutrients. This milk accounts for about one-third of the baby’s intake. As the nursing session progresses, the draught reflex helps move the hindmilk, with its higher fat content, to the front of the breast. It is important that the nutrient content of breast milk be determined from a sample of both types of milk in order to make an adequate assessment of all nutrients present. Breast milk best meets the infant’s needs and is the standard from which infant formulas are judged. Several nutrient characteristics make it the ideal infant food. Lactose, the carbohydrate content of breast milk, is the same simple sugar found in any milk, but the protein content of breast milk is uniquely tailored to meet infant needs. An infant’s immature kidneys are better able to maintain water balance because breast milk is lower in protein than cow’s milk. Most breast milk protein is alpha-lactalbumin, whereas cow’s milk protein is casein. Alpha-lactalbumin is easier to digest and provides two sulphur-containing amino acids that are the building blocks of protein required for infant growth. The fat (lipid) content of breast milk differs among women, and even from the same woman, from day to day. The types of fatty acids that make up most of the fat component of the milk may vary in response to maternal diet. Mothers fed a diet containing corn and cottonseed oil produce a milk with more polyunsaturated fatty acids, which are the predominant fatty acids in those oils. Breast milk is higher in the essential fatty acid called linoleic acid than is cow’s milk, and it also contains omega-3 fatty acids. About 55 percent of human milk Calories come from fat, compared with about 49 percent of Calories found in infant formulas. In addition, enzymes in breast milk help digest fat in the infant’s stomach. This digested fat is more efficiently absorbed than the products that result from digesting cow’s milk. Breast milk contains more cholesterol than cow’s milk, which seems to stimulate development of the enzymes necessary for degrading cholesterol, perhaps offering protection against atherosclerosis in later life. Cholesterol is also needed for proper development of the central nervous system.
140 ✧ Breast-feeding Vitamin and Mineral Content The vitamin and mineral content of breast milk from healthy mothers supplies all that is needed for growth and health except for vitamin D and fluoride, and these are easily supplemented. Breast milk and the infant’s intestinal bacteria also supply all the necessary vitamin K, but since no bacteria are present at birth, an injection of vitamin K should be given to prevent deficiencies. Breast milk mineral content is balanced to promote growth while protecting the infant’s immature kidneys. Breast milk has a low sodium content, which helps the immature kidneys to maintain water balance. No type of milk is a good source of iron. Although breast milk contains relatively small amounts of iron, about 50 percent of this iron can be absorbed by the body, compared with only 4 percent from cow’s milk. This phenomenon is called bioavailability. Because of the high bioavailability of breast milk iron, the introduction of solids, which are given to replace depleted iron stores, can be delayed until six months of age in most infants; this delay may help to reduce the incidence of allergies in susceptible infants. There is also evidence that zinc is better absorbed from breast milk. The vitamin content of milk can vary and is influenced by maternal vitamin status. The water-soluble vitamin content of breast milk (the B vitamins and vitamin C) will change more because of maternal diet than the fat-soluble vitamin content (vitamins A, E, and K). If women have diets that are deficient in vitamins, their levels in breast milk will be lower. Yet even malnourished mothers can breast-feed, although the quantity of milk is decreased. As the maternal diet improves, the level of water-soluble vitamins in the milk increases. There is a level, however, above which additional diet supplements will not increase the vitamin content of breast milk. Nonnutritive Advantages of Breast-Feeding There are many nonnutritive advantages to breast-feeding. A major advantage is the immunologic protection and resistance factors that it provides to the infant. Bifidus factors, found in both colostrum and mature milk, favor the growth of helpful bacteria in the infant’s digestive tract. These bacteria in turn offer protection against harmful organisms. Lactoferrin, another resistance factor, binds iron so that harmful bacteria cannot use it. Lysozyme, lipases, and lactoperoxidases also offer protection against harmful bacteria. Immunoglobulins are present in large amounts in colostrum and in significant amounts in breast milk. These protein compounds act as antibodies against foreign substances in the body called antigens. Generally, the resistance passed to the infant is from environmental antigens to which the mother had been exposed. The concentration of antibodies in colostrum is highest in the first hour after birth. Secretory IgA is the major immunoglobulin that provides protection against gastrointestinal organisms. Breast
Breast-feeding ✧ 141 milk also contains interferon, an antiviral substance which is produced by special white blood cells in milk. Protection against allergy is another advantage of breast-feeding. It is not known, however, whether less exposure to the antigens found in formula or some substance in the breast milk itself provides this protection. Normally, a mucous barrier in the intestine prevents the absorption of whole proteins, the root of an allergic reaction. In the newborn, this barrier is not fully developed to allow whole immunologic proteins to be absorbed. The possibility that whole food proteins will be absorbed as well is greater if cow’s milk or early solids are given, and this absorption increases the potential for allergic reactions. Milk from mothers delivering preterm infants is higher in protein and nonprotein nitrogen, calcium, IgA, sodium, potassium, chloride, phosphorus, and magnesium. It also has a different fat composition and is lower in lactose than mature milk of mothers delivering after a normal term. These concentrations support more rapid growth of a preterm infant. Advantages for the Mother Breast-feeding is not only good for the baby but also good for the mother. There is an association between reduced breast cancer rates and breastfeeding, although the reason is not known. In addition, the hormonal influences caused by suckling the infant help to contract the uterus, returning it to prepregnancy size and controlling blood loss. Breast-feeding also helps to reduce the mother’s weight. Calories required to make milk are drawn from the fat stores that were deposited during pregnancy. Nevertheless, breast-feeding should be viewed not as a quick weight loss program but as a healthful, natural weight loss process. If a woman breast-feeds completely, which means that no supplements or solid foods are given until the baby is six months of age, often she will not menstruate. Many women find this lack of menstrual periods psychologically pleasant while not realizing the physiological benefit of restoring the iron stores that were depleted during pregnancy and delivery. An important advantage to breast-feeding in developing countries is that it can help to space pregnancies naturally. Most infant malnutrition occurs when the second child is born, because breast-feeding is stopped for the first child. The first child is weaned to foods that do not supply enough nutrients. By spacing pregnancies out, the first child has a chance to nurse longer. Complications and Disorders Some special problems or circumstances can make breast-feeding difficult. The breasts may become engorged—so full of milk that they are hard and sore—making it difficult for the baby to latch onto the nipple. Gentle massaging of the breasts, especially with warm water or a heating pad, will
142 ✧ Breast-feeding allow release of the milk and reduce pain in the breast. This situation is common during the first few weeks of nursing but will occasionally recur if a feeding is missed or a schedule changes. Sometimes a duct will become plugged and form a hard lump. Massaging the lump and continuing to nurse will remedy the situation. If influenza-like symptoms accompany a plugged duct, the cause is probably a breast infection. Since the infection is in the tissue around the milk-producing glands, the milk itself is safe. The mother must apply heat, get plenty of rest, and keep emptying the breast by frequent feedings. Stopping nursing would plug the duct further, making the infection worse. Of concern to many mothers are reports of contaminants in breast milk. Drugs, environmental pollutants, viruses, caffeine, alcohol, and food allergens can be passed to the infant through breast milk. Drug transmission depends on the administration method, which influences the speed with which it reaches the blood supply to the breast. Whether that drug can remain functional after it is subjected to the acid in the baby’s digestive tract varies. Large amounts of caffeine in breast milk can produce a wakeful, hyperactive infant, but this situation is corrected when the mother stops her caffeine consumption. Large amounts of alcohol produce an altered facial appearance which is reversible; however, some psychomotor delay in the infant may remain even after the mother’s drinking has stopped. Nicotine also enters milk, but the impact of secondhand smoke may pose more of a health threat than the nicotine content of breast milk. Since the human immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS), can also pass through breast milk, HIV-positive mothers should not breast-feed their infants. Of greater concern is the presence of contaminants that cannot be avoided, such as pesticide residues, industrial waste, or other environmental contaminants. Polychlorinated biphenyls (PCBs) and the pesticide DDT have received the most attention. Long-term exposure to contaminants promotes their accumulation in the mother’s body fat, and the production of breast milk is one way to rid the body of these contaminants. Concentrations present in the breast milk vary. Ordinarily, these substances are in such small quantities that they pose no health risk. Women who have consumed large amounts of fish from PCB-contaminated waters or have had occupational exposure to this chemical, however, need to have their breast milk tested. It is also possible for these substances to enter the infant’s food supply from other sources. There are very few instances in which a woman should not breast-feed her infant. Babies with a rare genetic disorder called galactosemia cannot nurse since they lack the enzyme to metabolize milk sugar. Phenylketonuria (PKU), another genetic disorder, requires close monitoring of the infant’s blood phenylalanine level, but the infant can be totally or at least partially breastfed. Breast-feeding is contraindicated for women suffering from AIDS,
Breast surgery ✧ 143 alcoholism, drug addiction, malaria, active tuberculosis, or a chronic disease that results in maternal malnutrition. The presence of other conditions, from diabetes to the common cold, are not reasons to avoid breast-feeding. —Wendy L. Stuhldreher, R.D. See also Children’s health issues; Malnutrition among children; Nutrition and children; Nutrition and women; Phenylketonuria (PKU); Women’s health issues. For Further Information: Huggins, Kathleen. The Nursing Mother’s Companion. 4th ed. Boston: Harvard Common Press, 1999. This personable book provides comprehensive information about breast-feeding. Topics include preparation, special situations, returning to work, and nursing the older infant. Mason, Diane, and Diane Ingersoll. Breastfeeding and the Working Mother. Rev. ed. New York: St. Martin’s Griffin, 1997. This book, written by women who have personal experience in the area, provides a host of practical tips for the working mother who wishes to breast-feed her baby. How-to basics as well as suggestions for practically every job situation are addressed. Rolfes, Sharon Rady, and Linda Kelly DeBruyne. Life Span Nutrition: Conception Through Life. 2d ed. Edited by Eleanor Noss Whitney. St. Paul, Minn.: West, 1998. Chapter 5 of this textbook contains a comprehensive section on breast-feeding. Covers societal support, special medical conditions, physiology, the nutritional characteristics of breast milk, and the nutrient requirements for nursing mothers. An easy-to-read text with illustrations of the physiology of breast-feeding. Stanway, Penny, and Andrew Stanway. Breast Is Best. Rev. ed. London: Pan Books, 1996. Written by two doctors who are also parents, this book provides practical, yet medically sound information about many aspects of breast-feeding. Chapters on etiquette, working, special situations, and readers’ questions and answers cover issues not discussed in other books. The Womanly Art of Breastfeeding. 5th rev. ed. Franklin Park, Ill.: La Leche League International, 1997. This bible of breast-feeding covers preparation, the advantages of breast-feeding, and how to overcome problems. This illustrated manual provides the most up-to-date, comprehensive information, supported by an advisory board of medical experts. A must-read for all nursing mothers.
✧ Breast surgery Type of issue: Medical procedures, social trends, women’s health Definition: Procedures performed for aesthetic enhancement of the breasts,
144 ✧ Breast surgery which may be undertaken on an elective basis, following surgery to correct defects resulting from a pathological process such as cancer, or to correct genetic deformities. Breast augmentation, reduction, and reconstruction are procedures that are undertaken for different but related reasons. These procedures are almost always performed using general anesthesia. Augmentation procedures increase the size of breasts and are performed electively to correct hypomastia (abnormally small breasts). Reduction procedures decrease the size and shape of breasts. This is called reductive mammoplasty. Most commonly, reductions are performed on an elective basis for aesthetic reasons, but they can be indicated to relieve back, shoulder, and neck pain. Such abnormally large breast size is called mammary hyperplasia. Reconstruction involves the use of tissues from other parts of the body or prosthetic devices to restore a normal shape and contour. Surgical Techniques There are alternative sites for incisions to augment breasts. The site selected depends on the size and shape of the implant to be used. The safest surgical approach is from the underside of the breast (inframammary), with the incision being made in the skin fold formed by the bottom margin of the breast. A small scar will result. A second incision site is around the outer edge of the areola of the nipple (circumareolar). Scarring is minimal and hardly noticeable. A third approach is through an incision under the armpit (axillary). This leaves no scar on the breast but is technically more difficult. The underlying pectoralis major muscle is separated from the fascia beneath it, creating a pocket for the implant. The implant is inserted and attached to adjacent tissue. The pocket is closed with sutures that will dissolve and do not have to be removed; the skin is carefully closed. The patient is seen approximately a week after surgery for a check-up and removal of any skin sutures. Surgical reduction involves the removal of tissue. The amount and location of tissue to be removed depends on the initial size of the breast. Commonly, tissue is removed from the most dependent (lowest) portion of the breast. It is important to preserve the nipple and immediately underlying structures: the nerves and lactic ducts. Vertical incisions are made in the underside of the breast. The excess tissue is removed, preserving the nipple, areola, nerves, and connecting ducts. A wedge-shaped portion of skin is also removed. After all bleeding is stopped, the remaining breast tissue is sutured together and the skin carefully closed. Care in closure and immediate postoperative activity will minimize scarring. The breast should be adequately supported, and stretching should be avoided for the first few weeks after surgery. The patient returns in a week so that the surgeon can monitor healing and remove skin sutures.
Breast surgery ✧ 145 Reconstruction of breast tissue for reasons other than those described above is similar. In cases of trauma, damaged tissue is debrided, underlying tissues are replaced and sutured together, and the skin is carefully closed. The nipple, areola, and nerves are protected and preserved to the greatest extent possible. Skin closure may require assistance from a plastic surgeon to minimize scarring. Uses and Complications Breast surgery is useful to correct breast ptosis (sagging). Sagging occurs with normal aging and the influence of gravity. The extent and severity of this condition are functions of the size of the breast, the adequacy of undergarment support, and position of the nipple. With minimal ptosis, a prosthesis can be inserted to provide internal support. With severe ptosis, a combination of tissue removal and relocation of the nipple and areola are performed simultaneously. These procedures can usually be done using local anesthesia on an outpatient basis. Two potential complications of all breast surgery are infection and scarring. Infections are infrequent but must be treated aggressively when they occur. If a prosthesis is involved, it is usually removed and reinserted three to six months later. Scarring is of concern because breast surgery is most often undertaken for cosmetic or aesthetic reasons. The placement of incisions along skin folds and careful skin closure help to minimize scarring. Restricting immediate postoperative activities, especially those that require stretching, also reduces untoward scarring. Two potential problems exist with the use of prostheses: contracture and leakage. Contracture occurs when the tissue immediately surrounding the prosthesis shrinks and pulls the prosthesis out of position, detracting from the normal appearance of the breast. This condition formerly occurred in approximately 25 percent of cases but has been largely eliminated through the use of a textured outer envelope. Microscopic surface variations provide anchoring points for tissue and deter contracture formation. When both inner and outer envelopes rupture, the implant material can reach adjacent tissues. Silicone is irritating and can lead to the formation of nodules. Saline is now the material of choice for filling breast prostheses. Such leaks have received widespread attention in the media, but they are uncommon. In recent years, the legal climate has led to the virtual withdrawal of all silicone-based products from use in North America. Saline implants have been widely and safely used. Social Contexts of Breast Surgery With the exception of repairing the effects of unexpected trauma, most breast surgery is undertaken for cosmetic or aesthetic reasons. Individuals
146 ✧ Breast surgery are influenced by those around them and by messages received from the media concerning what breast size and shape are desirable. Although these values change over time, it is more difficult to alter breast tissue. Aging plays a role. Supportive elements within tissues break down with age, resulting in unwanted but inevitable sagging of tissues. Breast size, shape, and integrity are intimately related to feelings of self-worth and confidence. Reduction is indicated for massively oversized breasts. Augmentation is indicated in instances of pathology that require removal of a portion of breast tissue. Enlarging genetically small breasts is not a medical reason for augmentation. —L. Fleming Fallon, Jr., M.D., M.P.H. See also Aging; Breast cancer; Cancer; Cosmetic surgery and aging; Cosmetic surgery and women; Mammograms; Mastectomy; Women’s health issues. For Further Information: Ball, Adrian Shervington, and Peter M. Arnstein. Handbook of Breast Surgery. London: Edward Arnold, 1999. Provides a concise description of the full range of surgical procedures that constitute the practice of a specialist breast surgeon. Bostwick, John. Aesthetic and Reconstructive Breast Surgery. St. Louis: Matthew Medical Books, 1990. This textbook presents an excellent discussion of cosmetic and reconstructive breast surgery. Georgiade, Nicholas G., ed. Aesthetic Breast Surgery. 7th ed. Philadelphia: W. B. Saunders, 1990. This book describes procedures for cosmetic breast surgery. It is written by internationally recognized authorities and well illustrated. Guthrie, Randolph, and Doug Podolsky. The Truth About Breast Implants. New York: John Wiley & Sons, 1994. This book helps to clear away the confusion and anxiety surrounding the silicone implant controversy. The author is a plastic surgeon who details the safest techniques now available to women, tells how to find the right doctor, and explains what women should expect at every step for both breast reconstruction and enlargement. Stewart, Mary White. Silicone Spills: Breast Implants on Trial. Westport, Conn.: Praeger, 1998. Stewart details the experiences of women who suffered devastating, sometimes fatal consequences of silicone breast implants at the hands of doctors and manufacturers seeking monetary gain. Uses sources ranging from medical and court records to face-to-face interviews with survivors.
Broken bones in the elderly ✧ 147
✧ Broken bones in the elderly Type of issue: Elder health Definition: A break in the continuity of a bone. A fracture is a break in the continuity of a bone. Fractures can occur at any age, but there are certain causes and types of fractures that are more common in older people. Internal and external factors influence the development of a fracture. The internal factors include the strength of the bone and whether it is affected by disease. For example, osteoporosis, which is common in the elderly, makes the bone thin and fragile and more likely to break with minimal trauma. External factors include the type of trauma that occurs. In the elderly, falls are the major cause of trauma leading to fractures. Fractures may be complete or incomplete. Complete fractures involve a break across the entire section of the bone. In incomplete fractures, the break occurs in only a part of the bone. Open, or compound, fractures involve a break in the bone as well as a break in the skin, with an increased risk of acquiring an infection in the wound. In closed, or simple, fractures, the bone is broken but does not pierce the skin. Fractures that occur with minimal but repeated stress on a bone, such as in running, are called stress fractures. Fractures that occur in diseased bones are referred to as “pathologic.” Fractures are also named according to the bone affected, such as the femur (thigh bone), humerus (upper arm bone), or vertebra (back bone). Broken bones begin to heal as soon as they are injured. Bleeding from the blood vessels inside the bone occurs first. Then a clot forms, which later develops into a callus. The callus serves as a bridge or framework in which new bone cells begin to develop. The length of time for complete healing varies with the age of the person and the type of bone injured. In general, older people take longer to heal. Fractures in Older Adults Older people are at special risk for certain types of fractures, including those of the wrist, upper arm, and ankle. Hip fractures frequently occur as a result of injury caused by falls; complications may lead to additional problems and even death. The number of hip fractures that occur each year is expected to increase as the baby-boom population ages. Crush or compression fractures in the backbone may occur with minimal trauma and are related to weakening of the bone because of osteoporosis. The presence of osteoporosis increases the risk of fractures in women after the menopause, as well as in elderly men. Many factors increase the risk of accidental injury in the elderly. Older adults with mental impairment or other health problems affecting their
148 ✧ Broken bones in the elderly balance are more likely to fall. The chance of falls increases with the use of tranquilizers and medications to lower blood pressure, and also increases in people who are poorly nourished or do not exercise regularly. Decreases in both mobility and independence that accompany fractures lessen the individual’s quality of life. The medical costs related to fractures measure in the billions of dollars each year. Treatment of Fractures Prompt recognition and treatment of a fracture increases the likelihood of a better outcome for healing. One of the most common signs of a broken bone is pain in the affected part. The ability to use the injured part may or may not be affected. If a bone in the arm or leg is broken, swelling will become noticeable in the painful area. The extremity may appear abnormal in shape or position because of the break in the normal alignment of the bone. Some fractures do not displace the bones, so the extremity may not appear abnormal except for swelling. The immediate treatment of fractures involves measures to protect the injured part and person from further injury. If a fracture is suspected after a fall, the most important concern is to watch for signs of shock, including pale, cool, and moist skin. The person may become light-headed or may seem less alert. If these signs are present, it will be necessary to call for emergency assistance; the injured person should remain quiet and should not be moved. A fractured body part should not be moved. Attempts to put the part back into normal position may cause further injury and pain. If a broken bone is suspected, the injured part should not be used. Ice may be applied to reduce swelling and discomfort. If the suspected fracture is in an arm or a leg, the extremity should be elevated to reduce swelling. People with suspected fractures should be examined by a health professional who can confirm the diagnosis with specialized testing, such as X rays or bone scans. Fractures must be treated to restore correct position and function of the affected part. A physician who specializes in broken bones is called an orthopedic surgeon or an orthopedist. The physician can diagnose the fracture and determine the best method for treatment. The fractured bone must be properly aligned for proper healing. The physician will return the bone to its normal position if necessary. The bone must be immobilized to prevent movement while healing occurs. Methods of immobilizing the bone include casts, which may be made of plaster or fiberglass. Some fractures may require surgery to insert different types of metal devices into the bone to stabilize the fracture. The healing time varies according to the type of fracture and the age of the individual. Older people generally require a longer time to heal. Rehabilitation after a fracture may involve physical or occupational therapy to help the individual regain maximum function of the affected part.
Burns and scalds ✧ 149 Prevention of Fractures Prevention of fractures is extremely important for older people. The development of osteoporosis is one of the major factors related to fractures in the elderly. Measures that may be taken to reduce the effect of this disease include regular weightbearing exercise such as walking, dancing, or stair climbing; sufficient calcium intake; and avoiding smoking. Screening tests are available that measure the density of the bone. Medications and hormones may be ordered by the health care provider for those who are particularly at risk for osteoporosis. Measures to reduce the chance of falls include safety precautions in the home. The chance of tripping may be reduced by applying nonskid backing to throw rugs and keeping electrical cords or other small objects out of walking areas. The more medications a person takes, the greater the chance that he or she may experience side effects that may affect balance or judgment. Individuals should be aware of these side effects and exercise caution when moving about. The physician should be informed about these side effects to see if changes in the medication could be made. —Bobbie Siler See also Aging; Exercise and the elderly; Falls among the elderly; First aid; Foot disorders; Injuries among the elderly; Mobility problems in the elderly; Osteoporosis; Safety issues for the elderly; Smoking. For Further Information: American Academy of Orthopedic Surgeons, Public Information, Patient Education Brochures. http://www.aaos.org/wordhtml/home2.htm Horan, Michael Arthur, and Rod A. Little, eds. Injury in the Aging. New York: Cambridge University Press, 1998. Preventing Falls and Fractures. Bethesda, Md.: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Aging, 1998. Siegel, Irwin M. All About Bone: An Owner’s Manual. New York: Demos Medical Publishing, 1998.
✧ Burns and scalds Type of issue: Children’s health, occupational health, public health Definition: Damage to tissue caused by exposure to heat, chemicals, electricity, or radiation. Burns and scalds are caused by exposure to heat, chemicals, electricity, or radiation. Scalds refer specifically to burns caused by hot liquid. Burns are
150 ✧ Burns and scalds often the result of accidents or carelessness. It is estimated, however, that perhaps as many as 20 percent of all pediatric burns are the result of deliberate abuse. About 97 percent of all pediatric burns are thermal, or caused by heat; of these, between 65 and 85 percent are scalds. Burns and scalds are one of the leading causes of death among children. Neal D. Uitvlugt and Daniel J. Ledbetter report in Pediatric Trauma: Initial Care of the Injured Child (1995) that in 1985, for example, burns killed 1,461 children under age nineteen in the United States. Further, about 500,000 children need medical attention each year for burns and scalds, with between 23,000 and 60,000 requiring hospitalization. The average age of children treated for burns is thirty-two months. Sources of Burns Common causes of burns in children include defective wiring, cigarettes and matches, defective heating equipment, spilled containers of hot liquids or food, and flammable clothing. Electrical burns in children may be caused by chewing on an exposed electrical cord or sucking on the outlet end of an extension cord. Burns deliberately inflicted on a child are most common in toddlers, and these injuries tend to be more severe than those received accidentally. Uitvlugt and Ledbetter report a five times greater mortality rate for inflicted burns than for pediatric burns in general. The severity of a burn can be determined by classifying it according to degree and size. A first-degree burn is red and painful, affecting the epidermis. It is a superficial, partial thickness burn. The surface area is unbroken and dry. A second-degree burn affects both the epidermis and the dermis. It can be a superficial or a deep partial thickness burn. The skin is pink or mottled red and blistered, and it is often moist and weeping. Second-degree burns are very painful. Third-degree burns may affect tissue to the bone, damaging or destroying the full thickness of the skin. A third-degree burn may appear charred, white, waxy, or very deep red. The surface area is dry and leathery, with charred vessels apparent. Because such burns do so much nerve damage, it is likely that the victim will not feel pain. Third-degree burns are caused by prolonged exposure to heat or chemicals or short exposure to electricity. Burn Treatment Most pediatricians agree that first-degree burns can be treated at home by removing the source of the burning and then dousing the burned area with cold water for about ten minutes. Any jewelry or belts should be removed. A first-degree burn should heal on its own in two to three days. In the past, caregivers often coated the burn area with butter or grease; doctors, however, strongly advise against this practice.
Burns and scalds ✧ 151 Most doctors also agree that minor second-degree burns smaller than a quarter can be treated at home in the same manner. Nearly all sources agree, however, that any burn affecting the face, hands, feet, or genitals should be treated at a hospital. Likewise, burns caused by smoke inhalation or electricity should be treated at a hospital. Electrical burns are notoriously difficult to assess; the body can conduct the electricity to internal organs, and a wound that has a minor surface appearance can mask a very serious internal injury. Doctors also agree that a victim whose burns total 10 to 15 percent of his or her total body surface area should be hospitalized. In cases of third-degree burns or where the burn or scald appears to have been inflicted, the victim must be hospitalized. Hospital treatment varies according to the severity of the injury. Generally, emergency personnel remove any remaining clothing or jewelry, debride the wound, and monitor the lungs and the heart. Often, oxygen is administered. If at least 15 percent of the body surface is affected, medical personnel put an intravenous line in place for the replacement of lost body fluids. Doctors also check blood gases in the case of smoke inhalation. In addition, doctors administer a topical therapy designed to reduce the chance of bacterial or fungal infection. Depending on the severity of the injury, a patient might have to undergo several skin grafts, in which sections of the patient’s undamaged skin is transplanted over the injured site. Appropriate and effective treatment of burns has long been of concern to doctors. In 1944, the Lund and Browder chart was developed to regularize the assessment of burn size to the size of the victim’s body. An accurate assessment of the burn size helped doctors better determine appropriate treatment. Also, in the early twentieth century, doctors recognized that burn patients have large fluid requirements. Some sources claim that this recognition contributed more to the survival of burn patients than any previous discovery. Doctors continue to research burn treatment, often focusing their attention on the development of an appropriate covering for burn wounds until the patient is ready for a skin graft. They have tested both frozen cadaver skin and temporary skin substitutes grown in laboratories from human cells. —Diane Andrews Henningfeld See also Child abuse; Children’s health issues; Electrical shock; First aid; Safety issues for children; Sunburns. For Further Information: Clayman, Charles B., ed. American Medical Association Encyclopedia of Medicine. New York: Random House, 1989. A concise presentation of numerous medical terms and illnesses. A good general reference. Glanze, Walter D., Kenneth N. Anderson, and Lois E. Anderson, eds. The Signet Mosby Medical Encyclopedia. New York: Signet, 1996. Excellent general reference for the layperson. Offers a concise but clear presentation of numerous medical topics.
152 ✧ Cancer Hendin, David. Save Your Child’s Life! New rev. ed. New York: Pharos Books, 1986. Miller, Benjamin, and Claire B. Keane. Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health. 6th ed. Philadelphia: W. B. Saunders, 1997. A good, concise presentation of the topic of burns. Uitvlugt, Neal D., and Daniel J. Ledbetter. “Treatment of Pediatric Burns.” In Pediatric Trauma: Initial Care of the Injured Child, edited by Robert M. Arensman et al. New York: Raven Press, 1995.
✧ Cancer Type of issue: Environmental health, occupational health, public health Definition: Inappropriate and uncontrollable cell growth within one of the specialized tissues of the body, threatening normal cell and organ function and in serious cases traveling via the bloodstream to other areas of the body. Cancer is a disease of abnormal growth. All growing cells pass through a strictly regulated series of events called the cell cycle. Most structures of the cell are duplicated during this sequence. At the end of the cycle, one cell is separated into two “daughter cells,” each of which receives one copy of the duplicated cellular structures. The most important structures that must be exactly duplicated are the genes, the master blueprints that govern all cellular activities. Human life starts with a single microscopic cell—a fertilized egg. This cell divides again and again; the adult human body is composed of more than a trillion cells, each with a very specific job to perform. After adulthood is reached, most cells of the body stop duplicating themselves. Some cell types, however, do need to continue dividing to replace worn-out cells; these include cells of the blood, skin, intestine, and some other tissues. Such growth is very accurately controlled so that excess cells are not produced. It is in these cell types, those that normally grow in the adult body, that cancer most often occurs. A small defect arises in one gene so that the cells are able to progress through the cell cycle even though more cells are not needed. This is the start of cancer. Such cancer cells do not need to grow faster than do their normal neighbors; their key feature is simply that they continue growing when no more cells should be produced. At first, these cells very closely resemble their neighbors. For example, newly altered blood cells still look very much like normal blood cells, and in most respects they are.
Cancer ✧ 153 Cancerous Defects The first defect that gets cancer started is called initiation. It is typically the result of a mutation in one of the genes whose job it is to control some feature of the cell cycle. There are probably several hundred such genes, each of which regulates a different aspect of the cell cycle. These genes have perfectly normal jobs in the life of the cell until they become damaged. When there is a mutation in a controlling gene, the gene functions improperly: It does not govern the cell cycle quite right, and the cell cycle therefore proceeds when it should instead be halted. Such cancer-causing genes are called oncogenes. After the initiation of cancer, additional mutations and other defects begin to pile up, and the defective cells become increasingly abnormal. Tumor suppressor genes, which normally function to keep cell division from becoming disorganized, are the site of these second-stage mutations. Those cells whose cell division and growth genes have mutated (oncogenes) and whose cell division and growth inhibitor genes (tumor suppressor genes) have also been mutated will become cancer cells. Typically, a second change, called promotion, must take place before cancer cells begin really growing freely. The promotion step typically allows the initiated cell to escape some policing activity of the body. For example, various hormones provide cells with instructions about how to behave; a promotion-type change may allow a cell to ignore such instructions. Both initiation and promotion occur randomly. Many cells that are initiated, however, fail to grow into tumors. It is only those relatively few cells that happen to acquire both defects that become a problem. Fortunately, very few cells will have both their oncogenes turned “on” and their tumor suppressor genes turned “off.” Benign and Malignant Tumors At this point, the new cancer cell is dividing and collecting in large numbers. These excess cells make up a mass called a tumor (except in the blood and lymph cancers, in which the cancer cells circulate individually). Nevertheless, all these cells are fairly “normal.” Indeed, at this early stage, cancer is relatively easy to control using methods such as surgery. The excess cells may not cause much harm—warts, for example, are excess numbers of growing cells. Such relatively harmless tumors are called benign. If the cancer is detected at this early stage, while it is still relatively harmless, effective treatment and even a cure are still quite possible, which is why early diagnosis is so important in cancer medicine. Unfortunately, more and more defects accumulate in these cells as they grow, and some of these defects (again by chance) will be particularly harmful. The most harmful changes make the growing cells capable of causing damage to other parts of the body. For example, cancer cells may acquire the ability to digest their way through nearby tissues, a process called
154 ✧ Cancer invasion. Eventually, the functions of organs containing such cells become impaired. Such an invasion of body parts can be extremely painful as well. Other cancer cells may come loose from the tumor and travel to other parts of the body in the circulatory or lymphatic system: This process is called metastasis. In advanced stages of cancer, a patient may actually have dozens or hundreds of tumors, all of which have developed from a single parent tumor. Cells that can invade or metastasize are called malignant. It becomes increasingly difficult to eradicate cancer cells as they become more malignant. Pathologists are highly skilled at distinguishing benign from malignant cancer cells based on their appearance in a microscope and can provide accurate diagnosis of how far a case of cancer has progressed. Such information is crucial for deciding how best to treat the cancer. Tendencies Toward Cancer Most kinds of cancer typically occur during old age. Because each of the events that leads to tumor development is rather uncommon, it takes years for the several required mistakes to accumulate in a single cell, which then grows into a tumor. A few kinds of cancer occur most commonly in children. Such children usually have inherited one or more of the genetic defects that lead to cancer (already mutated oncogenes or tumor suppressor genes) from their parents. It then takes less time before the additional required defects are likely to occur. Thus, a tendency toward certain kinds of cancer can be inherited in families, as with other genetic traits (such as hair and eye color, height, and nose shape). Cancer occurs when anything causes oncogenes and tumor suppressor genes to function abnormally, allowing cells to continue growing when they should not. The delicate genes in an individual’s cells can be modified chemically by a number of different highly active and dangerous chemicals known collectively as carcinogens. Several kinds of radiation also pose a threat to genes. The best-known example is ultraviolet radiation from the sun, which can damage genes of the skin and lead to skin cancer. Finally, certain kinds of viruses can cause oncogenes to function improperly. Surgery and Chemotherapy The cancer treatments used most commonly are of three kinds: surgery, chemotherapy, and radiation therapy. First, and most straightforward, is the surgical removal of tumors. If done at an early stage, before cancer has spread, this method can be highly successful. Even so, surgery is much easier and less dangerous for some cancers (for example, skin cancer) than for others (such as brain tumors, which can be difficult to reach and remove safely). Naturally, surgery is much less successful with widely spread cancers such as leukemia (a cancer of blood cells) and in more advanced stages of cancer.
Cancer ✧ 155 The second type of cancer treatment is chemotherapy. Patients are treated with chemicals that prevent cells from duplicating themselves, or at least limit or slow that process. Such drugs, which are usually injected, reach all parts of the body and so are much more effective than surgery when cancer has reached a later stage of spreading. Different kinds of chemicals work in very different ways to achieve this result. These chemicals can be roughly divided into four categories. First are chemicals that react directly with the substances required for cells to survive and function. Many such agents directly attack a cell’s genes, preventing them from passing along information required for a cancer cell to stay alive. Second are antimetabolites, which prevent the chemical reactions that allow cells to produce energy (energy must also be available for cells to stay alive). The third category consists of steroid hormones. Cancer cells in some organs of the body respond to these hormones, which can therefore be used to regulate their growth. Thus estrogens, the female sex steroid hormones, are often used for treatment of breast cancer, whereas the male sex steroids, or androgens, may influence prostate cancer. Fourth are miscellaneous drugs, a few other chemicals that affect cancer cells in some different way. For example, drugs called vinca alkaloids stop the mechanical process of one cell dividing into two, in this way preventing growth. A derivative of the insecticide DDT (dichloro-diphenyl-trichloroethane) prevents unwanted steroid-hormone production and has been useful for treating tumors of the adrenal gland. Addressing the Side Effects of Chemotherapy The most common and difficult problem with the chemotherapeutic approach to cancer management is that normal cells that happen to be growing are also affected by the same drugs that halt the growth of cancer cells. This reaction causes many difficulties for patients, some serious and some less so. Probably the most serious problems are in the immune system. The growth of blood cells that make antibodies, called lymphocytes, is necessary before antibodies can be produced in response to an infectious disease. Because these cells cannot grow, patients in chemotherapy are much more vulnerable to illnesses caused by bacteria and viruses. Other blood cells, including those that carry oxygen, are also affected, causing additional problems. Skin cells and cells lining the digestive tract stop dividing, causing additional difficulties for the patients. A less serious problem for such patients is hair loss, as hair cells also are prevented from growing. Designing drug treatments that kill cancer cells while minimizing these problems is a demanding and precise task for oncologists (physicians who specialize in cancer research and treatment). Some drugs affect different cell types in somewhat different ways, allowing normal cells to continue their functions while killing tumor cells. Doses and timing of treatments can be
156 ✧ Cancer adjusted to maximize the effect of the drugs. It is typical for several drugs that act in different ways to be given in the same treatment, to assure that all cancer cells are halted; this approach is called combination chemotherapy. It is of critical importance that all cancer cells be stopped because a single unaffected cancer cell at any place in the body can begin growing after chemotherapy and develop into a cancer, a process known as relapse. Another useful approach for improving chemotherapy is drug targeting. The chemical structure of tumor cells is subtly different from that of normal cells, and it is sometimes possible to make use of this difference. For example, a drug can be attached to an antibody molecule that reacts with a tumor protein (antigen) that is not found on normal cells. In this way, most of the drug will be directed to the tumor cells, while normal cells will receive a much lower dose. Hormones and other molecules also attach to specific molecules on cells, and this fact can sometimes be exploited to target drugs if the tumor cells have a particularly high number of such molecules. Another problem with drug delivery is that the most effective drugs are rapidly degraded by the body’s defense systems and secreted from the body. The actual period of exposure to an active drug in the body can be quite brief (a few minutes) for this reason. Methods have been developed for hiding or disguising drugs so they are not removed so rapidly. For example, some drugs can be placed inside fat droplets, and in this way they can escape detection by the immune system and breakdown in the liver. Radiation Therapy The third type of cancer treatment is radiation therapy. The radiation of choice is X rays, which can penetrate the body to reach a tumor and which can be produced at very high dosages using modern equipment. X rays can be focused on a specific small area or can be given over the whole body in the case of metastasized cancer. Therapeutic radiation damages genes to such an extent that they become physically fragmented and nonfunctional, ending the life of the target cell. Radiation therapy has some of the same drawbacks as chemotherapy. Again, the most serious problem is that normal cells in the pathway of the radiation will also be killed. Bone marrow, the source of blood cells, is destroyed by whole-body cancer treatments. This problem can be overcome after radiation therapy by transplanting new bone marrow to the patient from close relatives, so that a treated patient can begin to remanufacture blood cells. Ironically, radiation designed to kill cancer cells can also turn normal cells into new cancer cells. Some normal cells may receive a reduced exposure of X rays. The dosage may be just sufficient to damage oncogenes of normal cells, causing them to become cancerous. Thus radiation therapy must be carried out with great care and precision. —Howard L. Hosick; updated by Connie Rizzo, M.D.
Canes and walkers ✧ 157 See also Breast cancer; Cervical, ovarian, and uterine cancers; Chemotherapy; Colon cancer; Environmental diseases; Hospice; Hysterectomy; Living wills; Lung cancer; Mammograms; Mastectomy; Prostate cancer; Radiation; Screening; Secondhand smoke; Skin cancer; Smoking; Terminal illnesses. For Further Information: Levenson, Frederick B. The Causes and Prevention of Cancer. New York: Stein & Day, 1985. A very personal attempt to give an overview of cancer and how it fits into health maintenance in general. Presented as a storylike narrative with the emphasis ultimately on the author’s unproved ideas about cancer prevention and its relationship to human life. Murphy, G., L. Morris, and D. Lange. Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery. New York: Viking Press, 1997. This text from the American Cancer Society is intended for the layperson. It is exemplary in its discussion of cancer. Prescott, D. M., and Abraham S. Flexer. Cancer: The Misguided Cell. Sunderland, Mass.: Sinauer Associates, 1986. The authors focus primarily on how cells change during cancer. This book describes more basic biology than most of the other publications listed. Siegel, Mary-Ellen. The Cancer Patient’s Handbook: Everything You Need to Know About Today’s Care and Treatment. New York: Walker, 1986. Siegel is a physician who explains concepts in simple terms. A very practical discussion of medical procedures related to cancer, including diagnosis and therapy. Provides descriptions of the various kinds of cancer and a useful glossary. Tierney, Lawrence M., Jr., et al., eds. Current Medical Diagnosis and Treatment: 2001. New York: McGraw-Hill, 2000. This text, updated yearly, is the point of reference for physicians and other health care practitioners. It incorporates each year’s biomedical research discoveries that have immediate, relevant, and applicable use for the patient.
✧ Canes and walkers Type of issue: Elder health, treatment Definition: Devices for temporary or long-term assistance in walking. Many types of canes and walkers are available for purchase in drugstores and variety stores. Many older individuals using these assistive devices purchased them in such stores or borrowed one from a friend or family member. Often, these devices are prescribed by a physician or therapist for either temporary or long-term use. Regardless of how the device was obtained, proper choice and fit are important for many reasons. A poor choice or fit can result in
158 ✧ Canes and walkers
A home care professional instructs a patient in the proper use of a walker. (Digital Stock)
decreased stability, increased energy expenditure needed to walk, and unsafe walking. A cane or walker properly fit for an individual results in the handgrip of the device being level with the user’s wrist crease when the user is standing with arms at the sides. The fit can also be checked by ensuring that the elbow is bent approximately twenty to thirty degrees when the user stands and holds the device. (For individuals with decreased leg strength, walkers may be fit a bit lower to allow greater use of the arms.) A combination of these methods should be used to check for proper fit, since individuals sometimes have proportionally long or short arms. In addition, the device should be measured with the user in the footwear normally worn, since shoe height will affect the fit. Types of Canes and Walkers The choice of device should be made considering the user’s needs and abilities. Canes are more functional on stairs and in confined areas, and they are easier to transport than are walkers. Canes do not provide as much support, however, and are not recommended for use with any weightbearing restrictions, such as after total knee or hip replacement surgery.
Canes and walkers ✧ 159 Walkers offer maximal support and stability, but mobility is somewhat restricted because of their size. Walkers are often prescribed for mobility with weight-bearing restrictions, with the goal of advancing to a cane or another assistive device as healing progresses. Several styles of canes and walkers are available, and the choice should depend on the user’s needs and abilities. Standard J canes are inexpensive; most are wooden and can be cut to the proper height. They are not the most stable choice, however, since the user’s hand is not directly over the foot of the cane. Offset canes have a bend in the shaft that places the user’s hand over the cane’s foot, thereby increasing stability. Often, these canes are also adjustable in length and, therefore, can be used with varying footwear or by different individuals. Quad canes have four feet and offer the most stability. They are more difficult to use, however, and can be very unstable if all four feet do not come in contact with the ground with each step. Standard walkers are the most inexpensive type, but they are relatively awkward and difficult to transport since they do not fold. This problem is solved with folding walkers, but these devices can collapse if they are not set up properly. Wheeled varieties are available for individuals without the arm strength to pick up and advance a walker with each step. They also allow increased speed and provide good stability if used with brakes that activate when the user pushes down with each step. —Mary Ann Holbein-Jenny See also Aging; Broken bones in the elderly; Falls among the elderly; Foot disorders; Injuries among the elderly; Mobility problems in the elderly; Osteoporosis; Safety issues for the elderly; Wheelchair use among the elderly. For Further Information: Means, K. M., D. E. Rodell, and P. S. O’Sullivan. “Obstacle Course Performance and Risk of Falling in Community-Dwelling Elderly Persons.” Archives of Physical Medicine and Rehabilitation 79, no. 12 (1998): 1570-1576. Murray, Ruth Beckmann, and Judith Proctor Zentner. Health Assessment and Promotion Strategies Through the Life Span. 7th ed. Englewood Cliffs, N.J.: Prentice Hall, 2000. Ryan, J. W., and A. M. Spellbring. “Implementing Strategies to Decrease Risk of Falls in Older Women.” Journal of Gerontological Nursing 22, no. 12 (1996): 25-31. Walker, Bonnie L. “Preventing Falls.” RN 61 (May, 1998).
160 ✧ Cardiac rehabilitation
✧ Cardiac rehabilitation Type of issue: Medical procedures, prevention, treatment Definition: The activities that ensure the physical, mental, and social conditions necessary for returning cardiac patients to good health. Cardiovascular disease (CVD), or heart disease, is the leading cause of death and disability in most of the industrialized nations of the world. For those persons who survive a cardiac event, discharge from a hospital or medical setting without further assistance may lead to financial, physical, and mental incapacity. Just as interventional procedures and medical care are important for the initial treatment of acute cardiac events, such as a myocardial infarction (heart attack) or angina (chest pain), cardiac rehabilitation influences long-term morbidity and mortality. Such preventive cardiology assists persons with CVD in three main areas: education, behavior modification, and patient and family support. The two primary goals of the rehabilitation program are to help increase the patient’s functional capacity (the ability to perform activities of daily living) and to counteract or arrest the patient’s disease process using a multidisciplined educational approach. Modifying Risk Factors In order to provide direction in prevention and rehabilitation, research studies have clearly defined several modifiable risk factors for heart disease, which are presented to patients. Among the most significant are smoking, high serum cholesterol, hypertension, and physical inactivity. Assistance with education about and modification of these risk factors, through risk factor counseling and participation in physical activity, is provided in modern cardiac rehabilitation programs. Methods for providing education on risk factor modification can vary greatly from program to program, but include such means as didactic lecturing, slide presentations, printed material for patients to read, demonstrations (such as cooking and stress reduction techniques), providing loaner books, and one-on-one counseling. The exercise portion of the cardiac rehabilitation is most often the time-consuming element of the program. It involves controlling and monitoring four major variables: mode (type of activity, such as bicycling, walking, or stair-stepping), duration (length of time the patient exercises), frequency (number of times per week that exercise is performed), and intensity (exertion level of the patient, usually assessed by the heart rate response). To become involved in the cardiac rehabilitation program, a patient is initially screened by a physician, nurse, or other clinical specialist and
Cardiac rehabilitation ✧ 161 directed to the appropriate level (or phase) of intervention. There are three to four clinical phases involved with cardiac rehabilitation, as various groups categorize them differently. The Exercise and Cardiac Rehabilitation Committee of the American Heart Association outlines three phases; the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) outlines four phases. Combating Bed Rest Phase 1 occurs while the patient is still in the hospital. It begins when the patient’s condition is stabilized, sometimes as soon as forty-eight hours after the coronary event or procedure. This phase can begin in the coronary care unit (CCU) or the intensive care unit (ICU). Phase 1 incorporates several disciplines, including physical therapy, nursing, psychiatry, dietetics, occupational therapy, and exercise science. It is designed to prevent the deleterious physiological effects of bed rest. The physical components of this phase include maintaining a range of motion and gradually returning to activities of daily living. Patients gradually advance through stages until they are able to walk up to 200 or 400 feet. Before discharge, patients are encouraged to walk up and down one flight of stairs while accompanied by a physical therapist or other clinician who monitors heart rate and blood pressure. The level of exertion during the early portion of this phase is normally 1 to 2 METs. Thus, in phase 1, the mode of exercise focuses on motion (sitting, standing, and finally walking), the frequency is seven days per week, the duration of exercise is usually five to ten minutes at a time, and the intensity of activity should not cause the heart rate to exceed twenty beats above the resting rate while standing. For coronary artery bypass graft (CABG) patients who have not experienced a myocardial infarction, progress during this phase is usually faster than for heart attack patients. Percutaneous transluminal coronary angioplasty (PTCA) patients may receive only a few days of rehabilitation, as they are usually discharged from the hospital sooner than heart attack or CABG patients. The mental components of phase 1 include risk factor modification education and an introduction to rehabilitation concepts. Exposure to Exercise Phase 2 customarily begins within three weeks of discharge from the hospital and lasts for four to twelve weeks. During phase 2, patients are exposed to a level of exertion commensurate with several criteria: the patient’s clinical status (stable or unstable, depending on whether the patient is experiencing problems related to the disease); the patient’s functional capacity, or fitness level; orthopedic limitations, such as muscle or joint problems; the goals for
162 ✧ Cardiac rehabilitation functional capacity (what tasks the patient wants to be able to perform); and any other special circumstances or situations. In a given phase 2 program, there are a variety of patients, all with varying levels of physical fitness. Through variations in the mode, duration, frequency, or intensity of exercise, these differing levels of fitness can be accommodated. A variety of exercise modes are presented in the phase 2 program, including walking, stationary cycling, stationary rowing, simulated stair-climbing, water aerobics, swimming, and upper-body ergometry. The exercise for this phase frequency is three to six days per week, the duration consists of twenty to forty-five minutes of continuous aerobic activity, and the intensity should produce a heart rate that is 60 to 85 percent of the symptom-limited maximal heart rate. Exercises are monitored by an exercise specialist and a cardiovascular fitness nurse. Exercise intensity is determined in most cases by heart rate and may be monitored by electrocardiogram (EKG or ECG) telemetry on a number of patients simultaneously. Outpatient Supervision and Maintenance Patients move into phase 3 of cardiac rehabilitation, a community-based outpatient program, when cardiovascular and physiological responses to exercise have been stabilized and the patient has achieved the goals initially set. Phase 3 is generally considered to be an extended, supervised program which usually lasts from four to six months but which can continue indefinitely. Participants in phase 3 programs become more involved in and in charge of their own exercises. Typically, these programs do not include EKG monitoring. Individuals are given more responsibility with respect to maintaining their own heart rates in their training heart rate range. Usually, an exercise specialist, nurse, or physician is available to oversee the exercises. The mode, frequency, duration, and intensity of exercise in this phase is similar to that of phase 2. Phase 4 is a maintenance program. Although many rehabilitation settings label this a phase 3 program, the phase 4 program is considered to be the longest-term, ongoing phase and is of indefinite length. Many phase 2 cardiac rehabilitation program graduates remain in phase 3 or phase 4 programs for years. The mode, frequency, duration, and intensity of the exercise program for phase 4 is also similar to that of phase 2. Expanding Participation Increasing numbers of cardiac rehabilitation programs are accepting unconventional patient populations. These patients now include heart transplant recipients, congestive heart failure patients, individuals suffering from ischemic heart disease, and those with arrhythmias and/or pacemakers.
Cardiac rehabilitation ✧ 163 Although most of the prescribed exercise regimens for these patients parallel those for the conventional cardiac patient, there are subtle differences. In the heart transplant population, for example, heart rate response differs from nontransplant patients. The adjustment of heart rate to various workloads lags in acute heart transplant recipients; that is, the heart rate does not increase as rapidly as it does for normal patients. To accommodate this difference, researchers have suggested that, in place of heart rate response, clinicians use a “rating of perceived exertion” scale to monitor the patients’ responses to exercise. Even patients who have orthopedic limitations, such as arthritis or chronic injuries, may be accommodated in the exercise portion of the cardiac rehabilitation program. Exercises can be adjusted to allow participants to derive cardiovascular benefits without causing them unnecessary discomfort. Although cardiac rehabilitation is safe in general, several factors may emerge during graded exercise testing (a screening for entry into a cardiac rehabilitation program) that can identify those patients who may be at increased risk. These factors include a significant depression or elevation of the S-T wave segment from a resting EKG, angina, extensive left ventricular dysfunction and severe myocardial infarction, ventricular dysrhythmias, inappropriate blood pressure response to exercise, achieving a peak heart rate of less than 120 beats per minute (if not taking a negative chronotropic medication, which slows down the heart rate), and a functional exercise capacity of less than 4 to 5 METs. Inclusion in one of these categories does not preclude participation in a cardiac rehabilitation program, but it may warrant specific exercise guidelines and close monitoring. Among the criteria for exclusion from a cardiac rehabilitation program are unstable angina, acute systemic illness, uncontrolled arrhythmias, tachycardia, diabetes, symptomatic congestive heart failure, a resting systolic blood pressure over 200 millimeters of mercury (mm Hg) or a resting diastolic blood pressure over 110 mm Hg, third-degree heart block without a pacemaker, and moderate to severe aortic stenosis. Assessment and Risk Stratification For those who meet the criteria for inclusion in a cardiac rehabilitation program, risk stratification (low, moderate, or high) may be employed. This allows an appropriate amount of supervision to be in place based on each patient’s goals and condition. Clinical observations and tests allow each patient to be assessed individually. Within each phase, levels of risk may be established. Various proposals have been made for risk stratification prior to entry into a cardiac rehabilitation program, including stratification based on several factors: the degree of left ventricular dysfunction, presence or absence of myocardial ischemia, extent of myocardial injury, and presence of ventricular arrhythmias.
164 ✧ Cardiac rehabilitation Some of the most widely examined noninvasive assessment tools include the extent of QRS wave abnormalities on a resting EKG and the results of exercise stress testing, twenty-four-hour ambulatory EKG monitoring, radionuclide ventriculography, and echocardiography. A combination of these test results may be used to determine the course of action provided to an individual. As with any effective therapy, exercise as a form of cardiac rehabilitation is neither without hazard nor always beneficial. If appropriate clinical guidelines are utilized, however, the benefit-risk ratio can be very favorable. In a 1986 study of 51,303 patients from 142 outpatient cardiac rehabilitation programs in the United States (representing 2,351,916 patient-hours of exercise), the incidence rate for fatal and nonfatal cardiac events was 1 in 111,996. This low incidence of cardiac-related events during participation in programs is probably attributable to improved risk stratification, the use of appropriate medical and surgical therapies, and improved exercise guidelines. On the rare occasions when cardiac events occur, reports have indicated that up to 90 percent of all patients with exercise-related cardiac arrest are successfully resuscitated when the patient experiences the event in a properly equipped and supervised program. —Frank J. Fedel See also Exercise; Exercise and the elderly; Heart attacks; Heart disease; Heart disease and women; Physical rehabilitation; Preventive medicine; Stress. For Further Information: American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation Programs. 2d ed. Champaign, Ill.: Human Kinetics Books, 1995. This short text is laid out well, with many citations of research studies and books on cardiac rehabilitation. A broad-based book that provides information for existing rehabilitation programs and proposes new programs. Blocker, William P., and David Cardus, eds. Rehabilitation in Ischemic Heart Disease. New York: SP Medical & Scientific Books, 1983. Thoroughly researched, this text is almost a bible for any cardiac rehabilitation program. Provides a broad base of background information, in addition to the history and philosophy of the rehabilitation process. Gordon, Neil F., and Larry W. Gibbons. The Cooper Clinic Cardiac Rehabilitation Program. New York: Simon & Schuster, 1990. Provides a wide array of anecdotes for the layperson, as well as a good foundation for the clinician. Includes personal stories from former cardiac patients regarding the intimate process of cardiac rehabilitation, lending credibility to the book. Written by clinicians who care about their patients, one of the intangible attributes of cardiac rehabilitation.
Carpal tunnel syndrome ✧ 165 McGoon, M. The Mayo Clinic’s Heart Book. New York: William Morrow, 1993. The most respected text for laypeople on heart disease. Covers all aspects of anatomy, physiology, diagnosis, treatment, and prevention. Pryor, J. A., and B. A. Webber, eds. Physiotherapy for Respiratory and Cardiac Problems. 2d ed. Edinburgh, Scotland: Churchill Livingstone, 1998. Provides therapists with a great deal of useful information regarding the treatment of individuals with respiratory or cardiac conditions. The appendix offers normal values for vital signs, arterial and venous blood gases, blood chemistry, and pressures in the circulatory and respiratory systems, as well as common medical abbreviations.
✧ Carpal tunnel syndrome Type of issue: Occupational health Definition: A common disorder that causes discomfort and decreased hand dexterity via excessive pressure on the median nerve at the wrist, often caused by repetitive wrist and hand movements. Carpal tunnel syndrome, also known as median nerve palsy, is caused by the transverse carpal ligament compressing the median nerve. This nerve passes through the carpal tunnel alongside nine tendons attached to the muscles that enable the hand to close and the wrist to flex. The tendons have a lubricating lining called the synovium, which normally allows the tendons to smoothly glide back and forth through the tunnel during wrist and hand movements. The median nerve is the softest component within the tunnel and becomes compressed when the tendons are stressed and become swollen. Median nerve compression most often results when the synovium becomes thick and sticky as a result of the wear and tear of aging or repeatedly performing stressful motions with the hands while holding them in the same position for extended periods. The roots of carpal tunnel syndrome can be traced back to the 1860’s, when meatpackers complained of pain and loss of hand function, which physicians initially attributed to reduced circulation. Modern occupations that require repetitive motions for extended periods—such as typing on a computer keyboard, construction and assembly-line work, and jackhammer operation—have caused a dramatic rise in cumulative trauma disorders such as carpal tunnel syndrome, while other workplace injuries have leveled off. Entrapment of the median nerve is less commonly caused by rheumatoid arthritis, diabetes mellitus, poor thyroid gland function, excessive fluid retention such as during pregnancy or by medications, vitamin B6 or B12 deficiency, or bone protruding in the tunnel from previous dislocations or fractures of the wrist.
166 ✧ Carpal tunnel syndrome Symptoms and Diagnosis Initial symptoms of carpal tunnel syndrome include tingling and numbness in the hands, often beginning in the thumb and index and middle fingers, that causes the hand to feel as though it were asleep and shooting pain from the thenar region radiating as far up as the neck. Later symptoms include burning pain from the wrist to the fingers, changes in touch or temperature sensation, clumsiness in the hands, and muscle weakness creating an inability to grasp, pinch, and perform other thumb functions. Swelling of the hands and forearms and changes in sweat gland functioning in the hands may also be noted. Symptoms can be intermittent or constant and often progress to the point of regularly awakening the patient at night. Temporary relief is sometimes available by elevating, massaging, and shaking the hand. Although very treatable if diagnosed early, carpal tunnel syndrome can escalate into persistent pain, which can become so crippling that workplace duties and such simple tasks as holding a cup, writing, and buttoning a shirt are compromised. A clinical examination for confirmation of median nerve impingement includes wrist examination, an X ray for previous injury and arthritis, assessment of swelling and sensitivity to touch or pinpricks, and the reproduction of symptoms by tapping of the median nerve (Tinel’s test) and holding the wrist in a flexed position for several minutes (Phalen’s test). Nerve conduction tests, which measure nerve transmission speed by electrodes placed on the skin, and electromyogram evaluation, which notes muscle function abnormalities, may also assist in a diagnosis. Treatment and Therapy Early diagnosis and the taking of appropriate preventive measures, such as ergonomic modifications in the way that upper extremity movements are performed, often reduce the risk of developing advanced carpal tunnel syndrome. The need to compensate for weak muscles with an inappropriate wrist position can be reduced by maintaining a neutral (straight) wrist position instead of a flexed, extended, or twisted wrist position; utilizing the entire hand and all the fingers to grasp and lift objects, instead of gripping solely with the thumb and index finger; minimizing repetitive movements; allowing the upper extremities regular rest periods; using power tools, instead of hand tools; alternating work activities; switching hands; reducing movement speed; and stretching and using strengthening exercises for the hand, wrist, and arm. Keeping the hands warm to maintain good blood circulation and avoiding smoke-filled environments, which reduce peripheral blood flow, are also recommended. Treatment generally begins with splinting of the wrist and medication, but surgery may be required if symptoms do not subside within three months. Both nocturnal splints and job-specific occupational splints can
Cervical, ovarian, and uterine cancers ✧ 167 effectively keep the wrist in a neutral position, thus avoiding the extreme wrist flexion or extension that narrows the carpal tunnel. Wrist supports lying on the desk in front of a computer keyboard are often helpful, but the benefit of strapping on wrist splints while typing is controversial because disuse atrophy may result, potentially creating a muscle imbalance. Aspirin and other oral nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce swelling and inflammation, relieving some nerve pressure. Corticosteroids and cortisone-like medications injected directly into the carpal tunnel can help confirm diagnosis if the symptoms are relieved. Diuretics and vitamin supplementation may also be beneficial. If initial symptoms do not subside, pain increases, or the risk of permanent nerve and muscle damage exists, then surgery may be necessary, with subsequent rehabilitation and ergonomic counseling with a physical or occupational therapist. An outpatient surgical procedure called carpal tunnel release involves dividing the transverse ligament to open the carpal tunnel to relieve pressure and removing thickened synovial tissue, with recovery expected in six to ten weeks. An endoscopic procedure utilizing a much smaller incision and a fiberoptic camera holds considerable promise for alleviating the median nerve pressure that causes carpal tunnel syndrome. —Daniel G. Graetzer See also Disabilities; Occupational health; Pain management. For Further Information: Johansson, Philip. Carpal Tunnel Syndrome and Other Repetitive Strain Injuries. Berkeley Heights, N.J.: Enslow, 1999. Katz, R. T. “Carpal Tunnel Syndrome: A Practical Review.” American Family Physician 51, no. 1 (1995): 48-57. Kulick, R. G. “Carpal Tunnel Syndrome.” Orthopaedic Clinics of North America 27, no. 2 (1996): 345-354. Rosenbaum, Richard B., and Jose L. Ochoa. Carpal Tunnel Syndrome and Other Disorders of the Median Nerve. Boston: Butterworth-Heinemann, 1993.
✧ Cervical, ovarian, and uterine cancers Type of issue: Public health, women’s health Definition: The primary cancers of the female reproductive system. Tumors of the reproductive tract occur in relatively high rates in women. Cervical cancer accounts for 6 percent, ovarian cancer 5 percent, and cancer
168 ✧ Cervical, ovarian, and uterine cancers of the lining of the uterus (endometrial cancer) 7 percent of all cancers in women. A variety of treatments are available for patients with cancers of the reproductive tract: surgical removal of the organ, hormonal therapy, chemotherapy, or radiation therapy. Cervical Cancer Cervical cancer is most frequently found in women who are between forty and forty-nine years of age, but the incidence has been steadily increasing in younger women. Several factors appear to be involved in initiating this cancer: young age at first intercourse, number of sexual partners (as well as the number of the partner’s partners), infection with sexually transmitted diseases such as herpes simplex type 2 and human papilloma virus, and cigarette smoking. Since most patients do not experience symptoms, regular checkups are necessary. The Pap (Papanicolaou) smear performed in a physician’s office will detect the presence of cervical cancer. In this procedure, the physician obtains a sample of the cervix by swabbing the area and placing the cells on a microscope slide for examination. The treatment of cervical cancer depends on the size and location of the tumor and whether the cells are benign or malignant. If the patient is no longer capable of or interested in childbearing, then she may choose to have her uterus, including the cervix, removed in the procedure known as hysterectomy. The physician may also use a laser, cryotherapy (use of a cold instrument), or electrocautery (use of a hot instrument) to destroy the tumor without removing the uterus. Malignant tumors may require a total hysterectomy as well as the removal of associated lymph nodes, which can trap metastatic cells. This surgery may be followed by radiation or chemotherapy if there is a possibility that all cancer cells have not been removed. Cervical cancer diagnosed in a pregnant patient can complicate the treatment. Fortunately, only about 1 percent of cervical cancers are found in pregnant women. If the cancer is restricted to the cervix (that is, it has not metastasized), treatment is usually delayed until after childbirth. It is interesting to note that a normal vaginal delivery may occur without harming the mother or the infant. Malignant cervical cancer must be treated in a similar way as in nonpregnant women. If the cancer is found in the first trimester, a hysterectomy or radiation therapy or both is used to help eradicate the malignancy. Obviously, these approaches terminate the pregnancy. During the second trimester, the uterus must be emptied of the fetus and placenta, followed by radiation therapy or removal of the affected reproductive organs. In the third trimester, the physician will typically try to delay treatment until he or she believes that the fetus has developed sufficiently to stay alive when delivered by cesarean section. A vaginal delivery is not recommended, as it has been shown to lower the cure rate of malignant
Cervical, ovarian, and uterine cancers ✧ 169 cervical cancer. Treatment after delivery consists of surgery, radiation therapy, and chemotherapy. The prognosis in patients who have elected surgical removal of the tumor is a five-year survival rate of up to 90 percent. Cure rates for patients undergoing radiation therapy are between 75 and 90 percent. Chemotherapeutic agents have not had as much effect, as they significantly reduce only 25 percent of tumors. It is important to note that the best outcomes are achieved with early diagnosis. Ovarian Cancer Ovarian cancer accounts for more deaths than any other cancer of the female reproductive system. While the cause of ovarian cancer is unknown, the risk is greatest for women who have not had children. Ovarian cancer does not appear to run in families, and its incidence is slightly decreased in women who use oral contraceptives for many years. Ovarian tumors generally affect women over fifty years of age. There are two major types of ovarian cancer: epithelial and germ cell neoplasms. About 90 percent of ovarian cancers are epithelial and develop on the surface of the ovary. These tumors often are bulky and involve both ovaries. Germ cell tumors are derived from the eggs within the ovary and, if malignant, tend to be highly aggressive. Malignant germ cell neoplasms tend to occur in women under the age of thirty. Ovarian cancer is generally considered a silent disease, as the signs and symptoms are vague and often ignored. Abdominal pain is the most obvious symptom, followed by abdominal swelling. Some patients also report gastrointestinal disorders such as changes in bowel habits. Abnormal vaginal bleeding may occur but like the other symptoms is not specific for the disease. Diagnosis is made using imaging techniques such as ultrasound, computed tomography (CT) scanning, and magnetic resonance imaging (MRI). Ovarian cancers are treated with a similar approach. Surgery may involve the removal of the ovaries, uterine tubes, and uterus, as well as associated lymph nodes depending upon the extent of malignancy. Radiation and chemotherapy are usually employed but oftentimes are not effective. The drug taxol is a relatively new agent which shows some promise in treating ovarian cancers. This drug was isolated from the bark of the yew tree and shows some specificity for ovarian tumors. Taxol prevents cell division in ovarian tumors, slowing the progression of the disease. The outcome for ovarian cancer is usually not as good as for cervical and endometrial cancers, since the disease is usually in an advanced stage by the time that it is diagnosed. The overall survival rate without evidence of recurrence in patients with epithelial ovarian cancers is between 15 and 45 percent. The more uncommon germ cell ovarian cancers have a much more
170 ✧ Cervical, ovarian, and uterine cancers variable prognosis. With early diagnosis, aggressive surgery, and the use of newer chemotherapeutic agents, the long-term survival rate for all ovarian cancer patients approaches 70 percent. Uterine Cancer Uterine cancer, also known as endometrial cancer, most frequently affects women between the ages of fifty and sixty-five. Like most cancers, the cause of endometrial cancer is not clear. Nevertheless, relatively high levels of estrogens have been identified as a risk factor. For example, obese women, women who have an early onset of their first period (menarche), and women who never became pregnant tend to have high estrogen levels for longer durations than those without these conditions. Medical scientists believe not only that it is estrogens that are important but also that the other ovarian hormone, progesterone, must be lower than normal for the cancer to develop. Therefore, progesterone appears to have a protective effect in endometrial cancer. Detection of endometrial cancer is accomplished by having a physician take a small tissue sample (biopsy) from the lining of the uterus. The sample can be examined under the microscope to determine if the cells are cancerous. Surgery is often the treatment of choice for endometrial cancer. As with cervical cancer, however, treatment depends upon the extent of the disease and the patient’s wishes relative to reproductive capabilities and family planning. A hysterectomy—removal of the uterine tubes, ovaries, and surrounding lymph nodes—is usually indicated. Chemotherapy and radiation therapy are occasionally utilized as adjunctive therapy, as is progesterone. Progesterone (medroxyprogesterone or hydroxyprogesterone) may benefit patients with advanced disease, as it seems to cause a decrease in tumor size and regression of metastases. In fact, progesterone therapy in patients with advanced or recurrent endometrial cancer leads to regression in about 40 percent of cases. Progesterone therapy also has produced regression in tumors that have metastasized to the lungs, vagina, and chest cavity. The outcome of endometrial cancer is influenced by the aggressiveness of the tumor, the age of the woman (older women tend to have a poorer prognosis), and the stage at which the cancer was detected. Almost twothirds of all patients live without evidence of disease for five or more years after treatment. Unfortunately, 28 percent die within five years. For cancer identified and treated early, almost 90 percent of patients are alive five years after treatment. Increasing Preventive Measures Scheduling regular checkups with a health care provider may increase the likelihood of detecting cervical, ovarian, and uterine cancers early, even if
Cervical, ovarian, and uterine cancers ✧ 171 no symptoms are present. Pelvic examinations should be performed every three years for women under the age of forty and yearly thereafter. Pap smear tests for cervical cancer should be undertaken yearly from the time that a woman becomes sexually active. Some physicians will take an endometrial tissue biopsy from women at high risk and at the time of the menopause. Some data suggest that modifying lifestyle may help reduce the incidence of cervical cancer. The cervix is exposed to a variety of factors during intercourse, including infections and physical trauma. Multiple sexual partners increases the risk of sexually transmitted diseases which may predispose the cervix to cancer. This factor is compounded by the fact that infectious agents and other carcinogens can be transmitted from one individual to another. Therefore, theoretically the cervix can be exposed to carcinogens from a partner’s sexual partners. Regular intercourse begun in the early teens also predisposes one to cervical cancer, as the tissue of the cervix may be more vulnerable at puberty. Barrier methods of contraception, mainly the condom, reduce the risk of developing cervical cancer by reducing the exposure of the cervix to potential carcinogens. Smoking also increases the risk of cervical cancer, perhaps because carcinogens in tobacco enter the blood which in turn has access to the cervix. Women who are twenty or more pounds over ideal body weight are twice as likely to develop endometrial cancer, and the risk increases with increased body fat. Some estrogens are produced in fat tissue, and this additional estrogen may play a role in the development of endometrial cancer. Therefore, reduction of excess body fat through diet and exercise would be important for a woman who wished to reduce her chances of developing uterine cancer. —Matthew Berria See also Cancer; Chemotherapy; Hysterectomy; Pap smears; Radiation; Screening; Women’s health issues. For Further Information: Epps, R., and the American Medical Women’s Association, eds. The Women’s Complete Handbook. New York: Dell Books, 1995. This book, by the oldest organization of female physicians in the United States, is an invaluable guide for the layperson on female-specific diseases. Fox, Stuart I. Perspectives on Human Biology. Dubuque, Iowa: Wm. C. Brown, 1991. Chapter 14 provides the nonscientist with a basic understanding of cancer biology. Fox explains how oncogenes are thought to act in the formation of neoplasms and how antioxidant vitamins may protect against certain forms of cancer. Hales, Dianne. An Invitation to Health. 9th ed. Belmont, Calif.: Wadsworth Thomson Learning, 2000. This text should be read by anyone who wishes
172 ✧ Chemotherapy an overview of health topics. Particularly important reading for those interested in the prevention of cancer. Mader, Sylvia S. Human Biology. 5th ed. Dubuque, Iowa: Wm. C. Brown, 1997. Chapter 20 is devoted to a discussion of cancer and provides an excellent overview of cancer biology. This text was written for the nonscientist yet details contemporary theories on cancer formation and treatment. Murphy, G., L. Morris, and D. Lange. Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery. New York: Viking Press, 1997. This text from the American Cancer Society is intended for the lay reader. It is exemplary in its discussion of cancer.
✧ Chemotherapy Type of issue: Medical procedures, treatment Definition: The treatment of a disease, especially cancer, by the use of drugs. The term “chemotherapy” is used to refer to the use of chemical agents in the treatment of any disease. It is employed most often, however, in reference to the treatment of cancer. Some drugs are capable either of stopping the undesirable spreading of cancer cells or of preventing cancer from occurring at all. These drugs, called chemotherapeutic agents, destroy cells by interfering with their life-sustaining functions. For example, one type of drug prevents cells from forming the proteins and enzymes that keep them alive. Another type kills by disrupting a step in the process of cell division, while a third type upsets the balance of hormones in a patient’s body, creating conditions unsuitable for cancer survival. Unfortunately, all drugs that kill cancer cells also kill normal cells. On the other hand, they selectively kill more cancer cells than normal cells. Chemotherapy is used when cancerous cells have spread through the body, so that their location cannot be precisely determined. Neither surgery nor radiation therapy can destroy widespread cancer, but drugs can circulate throughout the entire body and kill the cells that surgery and radiotherapy miss. Typically, a cancer cell develops resistance or spreads so extensively that an effective drug dose would kill the patient. Even when a cure is not achieved, however, chemotherapeutic agents can be useful in extending the life of patients, in sensitizing a tumor to radiation treatment, and as an adjuvant or precautionary method when doctors cannot determine whether a cancer has spread. Immediately after a malignancy is diagnosed, it must be appropriately classified before therapy can be delivered. Out of classification comes an appropriate treatment prescription. The crucial decision in pretreatment planning is whether a cure is feasible. If a cure is possible, aggressive therapy
Chemotherapy ✧ 173 is indicated and certain risks are worth taking. If a cure is not possible, then the therapeutic goal is the prolongation of life, the relief of symptoms, and the maintenance of as near-normal function as possible. The Course of Treatment The route of administration is an important variable in the delivery of the required dose of chemotherapy. Administration can be oral, intravenous, by continuous infusion, or by intracavity instillation. The optimum drug dosage is also a critical variable. The objective is to provide the patient with the maximum therapeutic benefit and the minimum side effects. For the large majority of anticancer drugs, administered singly or in combination, bone marrow suppression represents the most important dose-limiting factor, and close monitoring of the patient is critical. The choice of drugs to be used is dependent on the primary site of origin of the malignancy. Over the years, a database has been established that links specific primary tumor types with drugs that have demonstrated reproducible clinical activity. If combination therapy is chosen, the choice of drugs follows the following empirical guidelines: Each drug should be active when used alone against the disease in question; the drugs should have different postulated or known mechanisms of action; and the drugs should not have overlapping toxicity patterns. Types of Chemotherapy Alkylating agents are reactive organic compounds that transfer alkyl groups in chemical reactions. Their effectiveness as anticancer drugs is attributable to the transfer of these alkyl groups to biologically important cell constituents whose function is then impaired. Examples of alkylating agents are cyclophosphamide, used in the treatment of lymphomas, different types of leukemia, and lung cancer; chlorambucil and melphalan, used in the treatment of multiple myeloma and ovarian cancer; and the nitrosoureas, such as carmustine and lomustine, which are useful in the treatment of brain neoplasms, gastrointestinal carcinomas, and malignant melanomas. Antimetabolites are structurally similar to the naturally occurring compounds required for synthesis of purines, pyrimidines, and nucleic acids. They interfere with DNA synthesis by inhibiting key enzymes in the purine or pyrimidine synthetic pathways or by misincorporation in the DNA, leading to strand breaks or premature chain termination and slow cell division. An example of antimetabolites is 5-fluorouracil, which inhibits the formation of a thymine-containing nucleotide necessary for DNA synthesis; it is used in the treatment of breast cancer. Methotrexate is another antimetabolite; it binds to the enzyme responsible for the reduction of folic acid in the first step of the synthesis of nucleic acids, and is commonly used to treat
174 ✧ Chemotherapy leukemia. Other antimetabolites used for the treatment of leukemia are 6-thioguanine and 6-mercaptopurine. Antitumor antibiotics are natural products of microbial metabolism. The singular purpose of these compounds is to afford these microbial organisms a selective advantage in hostile environments by interfering with the growth or proliferation of competing life-forms—therefore their usefulness in destroying cancer cells. Some of these antibiotics have been synthesized, but the naturally occurring ones have proven to be more effective. Antitumor antibiotics are effective against leukemia, lymphomas, sarcomas, carcinomas of most organs, and germ cell tumors. They are normally used as part of a multiagent chemotherapy regimen and also as part of adjuvant protocols. These compounds show a wide array of structures because of the variety of fungal organisms that are their source. They also exhibit a great diversity in mechanisms of action. For example, doxorubicin has been reported to have at least seven different mechanisms of action, and it is very difficult to determine which is the most effective. Daunorubicin acts by inhibition of DNA and ribonucleic acid (RNA) enzymes, idarubicin acts by the generation of oxygen-free radicals, and mitoxantrone’s mechanisms of action include single-strand and double-strand DNA breaks, the peroxidation of cell membranes, and cell surface action. Vinka alkaloids represent natural or semisynthetic drugs derived from the periwinkle plant, and the epipodophyllotoxins are semisynthetic products derived from the roots of the mayapple or mandrake plant. Of the vinka alkaloids, the most important are vincristine and vinblastine. Their general mechanism of action is the binding to dimers of tubulin, a protein subunit of microtubules. Microtubules perform many critical functions in the cell, such as the maintenance of cell shape, mitosis, meiosis, secretion, and intracellular transport. The binding of vinka alkaloids to tubulin causes the microtubule structures to disappear and the cell to die. They are useful in the treatment of Hodgkin’s lymphomas and leukemia. Etoposide and teniposide, two of the epipodophyllotoxins, show good clinical activity, although their mechanism of action is not fully understood. Apparently involved in the mechanism are the breakage of single-strand and double-strand DNA and DNA protein cross-links. These compounds are useful in treating pediatric malignancies. Hormonal therapy is an important and effective means to treat hormonally sensitive tumors, such as breast, endometrium, prostate, ovarian, and renal tumors. Although it is very hard to explain the mechanism of action, it is assumed that the initial step is the binding to a specific cell surface receptor. This can result in the inhibition of the production of factors necessary for tumor growth, the induction of growth inhibitory proteins, or the inhibition of oncogene expression. Examples of compounds employed in this type of therapy are the adrenocorticoids, used to treat leukemia; estrogens, used in breast cancer therapy; progestins, used for breast and
Chemotherapy ✧ 175 endometrial cancer treatment; and androgens, used against breast cancer. Immune modulation, or biological response modification against malignant disease, has been a long-sought goal. Developments in molecular biology and immunology and refinements in recombinant methodologies have set the stage for this approach to cancer treatment. It involves the modification of the relationship between the tumor and the host, primarily by modifying the host’s response to tumor cells, with resultant therapeutic benefit. Among the substances studied is interferon, a simple glycoprotein with profound immunomodulatory, antiviral, and antiproliferative characteristics. There are three types of interferons, which attach themselves to receptors in the cell surface. This receptor-interferon complex initiates a variety of processes that affect DNA synthesis; it may also render a cell as foreign, facilitating the immune system’s job of getting rid of it. In adoptive immunotherapy, immune-activated cells (or tumor killer cells) are administered to a host with advanced cancer in an attempt to mediate tumor regression. Tumor necrosis factor also exhibits antitumor activity and has also shown a synergistic effect with interferon. Platinum analogues such as cisplatin produce high response rates in patients with small cell carcinoma of the lung, bladder cancer, and ovarian cancer. Most of the data are consistent with the hypothesis that the major target of the drug is DNA, although the type of lesions produced in the DNA structure is not clearly established. Side Effects In addition to being highly toxic, most of the useful chemotherapy agents are themselves carcinogenic. Often, very high doses are necessary for effective treatment. As a result, combination therapy has increased in use because of the success of additive or even synergistic effects when two or more drugs are used, allowing the use of lower doses and reducing side effects. Side effects of chemotherapy include nausea, vomiting, and diarrhea resulting from damage to the stomach and intestines; dryness and soreness of the mouth from damage to the mucous membranes; and partial loss of hair from damage to the hair follicles. When damage to the bone marrow occurs, the marrow ceases to supply the blood with a normal amount of white blood cells, platelets, and red blood cells, so that the body cannot properly control infection, bruising, or fatigue. Patients may also experience muscular weakness, loss of appetite, rashes, discoloration of the skin, irregular menstrual periods, and sterility. Most of these effects disappear when chemotherapy ends. Unfortunately, cancer chemotherapy fails to cure most cancer patients because of the growth of resistant cells. Tumor cells are either intrinsically resistant or become resistant to individual drugs. A given chemotherapy regimen is followed until indication of the overgrowth of resistant cells, at
176 ✧ Child abuse which point treatment is ineffective. The development of effective drugs for treating cancer has been a landmark achievement of medical research. The hope for the eventual cure and prevention of malignancy rests with the development of safer agents with enhanced antitumor spectrums, as well as in the study of the synergistic effect of chemotherapy and biological response modifiers. —Maria Pacheco See also Breast cancer; Cancer; Cervical, ovarian, and uterine cancers; Colon cancer; Lung cancer; Mastectomy; Pain management; Radiation; Skin cancer. For Further Information: Carter, Stephen K., Mary T. Bakowski, and Kurt Hellmann. Chemotherapy of Cancer. 3d ed. New York: John Wiley & Sons, 1987. A good reference book with sections on general cancer treatment, clinical trials, drug development, anticancer drugs, treatment of specific types of cancer. Very complete. Chabner, Bruce A., and Jerry M. Collins, eds. Cancer Chemotherapy: Principles and Practice. 2d ed. Philadelphia: J. B. Lippincott, 1996. A compilation of works by more than thirty expert authors in the field of cancer chemotherapy. The book provides both an in-depth reference and a rapid source of critical information. An excellent reference work. Joesten, Melvin D., David O. Johnston, John Netterville, and James L. Wood. The World of Chemistry. 2d ed. Philadelphia: W. B. Saunders College, 1999. A basic chemistry book with a good section on cancer and its treatments. Good for a quick reference. Murphy, G., L. Morris, and D. Lange. Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery. New York: Viking Press, 1997. This text from the American Cancer Society is intended for the layperson. It is exemplary in its discussion of cancer. Perry, Michael C., ed. The Chemotherapy Source Book. 2d ed. Baltimore: Williams & Wilkins, 1996. A compilation of essays by experts in this field. Deals with the practical principles of chemotherapy, commercially available drugs by class (emphasizing their mechanisms of action), chemotherapy drug toxicity, combination therapy programs, and the therapy methods for specific tumors. A complete, thorough reference.
✧ Child abuse Type of issue: Children’s health, ethics, mental health Definition: A series of problems that may include child neglect, physical
Child abuse ✧ 177 abuse, sexual abuse, emotional abuse, failure to thrive, and Münchausen syndrome by proxy. Physical abuse may involve children of any age, but those at greatest risk for death are children under the age of three, especially infants under the age of one. Fatal abuse most often follows head trauma, often with the injuries inflicted during a violent shaking and/or a blunt impact to the head. Shaken Infant Syndrome Injuries related to shaking assume a classic pattern that allows physicians and other health care workers to recognize the abusive situation. Generally, the shaking episode is precipitated by an event such as inconsolable crying that angers and frustrates the caretaker. Often, the caretaker is a male companion of the mother or an inexperienced young babysitter. The infant is usually shaken with rapid successive movements, with the perpetrator’s hands encircling the infant’s chest. Sometimes, the infant sustains rib fractures. Intracranial injuries follow the rapid centrifugal movement of the infant’s head back and forth through an arc. There is both axonal injury to the brain and subsequent bleeding, as small bridging blood vessels are disrupted. The bleeding is usually subdural or subarachnoid in location. In addition, there are hemorrhages into the infant’s retinas. The mechanism of formation of these hemorrhages is unclear, although they may form directly as a result of the force being exerted on the retinal blood vessels. Cerebral edema and infarction (brain death) are additional sequelae of the shaking. Several different clinical patterns may develop as a result of the shaking. The infant may experience apnea, seizures, or signs of increased intracranial pressure such as vomiting. Frequently, there has been a brief interval (sometimes about an hour) between the shaking and when the infant is reevaluated by the caretaker, who then fails to connect the earlier episode with the subsequent symptoms. Paramedics may be summoned, and the caretaker expresses puzzlement that the infant who was sleeping peacefully suddenly experienced medical problems. At the hospital, an evaluation should include imaging studies such as computed tomography (CT) scanning and magnetic resonance imaging (MRI) of the head, which may reveal the presence of intracranial hemorrhages. A careful fundoscopic examination of the retina of the eye usually also shows hemorrhages. A skeletal survey may reveal the presence of fractures. Classically, rib fractures may be present, especially in younger infants. The absence of either retinal hemorrhages or rib fractures does not preclude the diagnosis of shaken infant syndrome. Other appropriate studies usually include coagulation panels to ensure that there are no underlying blood-clotting problems. Spinal taps, undertaken to exclude meningitis,
178 ✧ Child abuse may reveal the presence of yellow (xanthochromatic) fluid or shrunken (crenated) red blood cells. Skull fractures, when present, usually denote an impact injury, such as would occur if an infant were slammed against a solid surface during or after the shaking episode. Injuries Due to Blows The second leading cause of death among abused children is abdominal trauma, usually following a direct blow to the abdomen. There may be laceration of the liver or spleen, with subsequent intra-abdominal hemorrhage and shock. Other injuries include rupture of the intestine or laceration of the mesentery (a layer of the peritoneum). In these cases, peritonitis may develop, with death occurring from this complication if medical intervention does not take place. Hematomas of the duodenum are another specific abdominal injury. In this case, the child may experience uncontrollable vomiting such as is seen with pyloric stenosis. An X ray of the abdomen would reveal a “double bubble” pattern as is seen in duodenal atresia (absence of an opening in the duodenum). Occasionally, trauma to the pancreas also occurs. In the absence of overt trauma or the use of medications that are harmful to the pancreas, inflicted injury is the leading cause of pancreatitis in children. The clinical picture in each of these cases may be confusing because of the absence of an overt history or any visual findings on the abdominal wall. The latter is a classic finding because of the force of the blow and the absorption of the impact internally. A high index of suspicion about inflicted abdominal trauma is essential to ensure the appropriate intervention. External bruising is another manifestation of child abuse. Injuries may take various forms and need to be differentiated from accidental injuries. Normal bruises are noted over bony prominences, including the shins and forehead. Concern should be present when multiple bruises of different ages are present over soft tissue areas. The dating of bruises is somewhat controversial. In general, bruises follow a predictable pattern as they resolve, going from purple-blue (a classic black-and-blue mark) to green, then yellow and brown. The time course for the resolution of bruises is usually about two weeks, and some bruises do not make an appearance until one to two days after the injury. The size and depth of the bruise will affect the rate of resolution, and deeper, larger bruises may take longer to resolve. Certain bruise patterns are clues to what induced the injury. Slap marks, grip marks, belt marks, paddling, cords, and bind and gag marks are some examples of these patterned injuries. Sometimes, unusual patterns are noted that may represent specific objects such as hairbrushes or wall molding. A search of the home may uncover such objects.
Child abuse ✧ 179 Burns, Bites, and Broken Bones Burn injuries are also seen in abused children. Some of these injuries have characteristic patterns that occur because of immersion injuries. These injuries may involve the hands, feet, buttocks, or genitals. Injuries to the latter two areas usually occur in children between the ages of eighteen months and three years, when they are being toilet trained. Accidents during this period may be met with anger by a caretaker who cleans children in a punitive manner by immersing them in a tub filled with hot water. Other burn injuries may occur when a heated object is held in direct contact with the child’s skin. The pattern of the object, such as a heating grid, is imposed on the skin. Cigarette burns also produce characteristic injuries. Sometimes, impetigo or resolving chickenpox may be mistaken for an inflicted burn, especially if there is superinfection with Staphylococcus aureus. Culturing the skin lesion is helpful in detecting such an infection. Bites may also be an inflicted injury. Human bites, particularly if the skin is broken, carry the risk of serious infection. Differentiating child from adult bite marks can be facilitated by measuring the distance between the lateral incisors. The space between the lateral incisors in adults is at least 3 centimeters, while in children it is less than 3 centimeters. Additionally, forensic dentists can identify a perpetrator by the bite marks on the victim’s skin. Fractures may involve any bone, particularly long bones. While spiral or oblique fractures are highly suggestive of an inflicted injury (especially in the absence of a credible history), transverse fractures may also be inflicted. Other fractures include injuries to the metaphysis, leading to bucket handle or metaphyseal chip fractures. These injuries usually result from a twisting motion. Accidental fractures that are common during childhood include clavicular fractures, transverse long bone fractures, and supracondylar fractures which are incurred when a child falls from a height. The presence of multiple fractures of different ages is highly suspicious of inflicted injury. Child Neglect Sometimes, a child is injured as a result of neglect. Neglect includes withholding from the child basic needs such as food, clothing, housing, medical care, and education. The issue of medical care is somewhat complex. Some parents do not obtain medical care because of an alternative belief system. Other times, the family has not been compliant in following medical recommendations. For example, some children with asthma or diabetes require hospitalization in an intensive care unit because they do not take their medicines as prescribed. Neglect can also have fatal consequences. An infant left in a bathtub unattended even for a moment can drown. Children left unattended in a home may die as a result of a house fire that sometimes they are responsible for starting. An infant left in a car may overheat and die from hyperthermia. Sometimes, the parent’s actions are even more blatant.
180 ✧ Child abuse A mother may place her unwanted infant in a trash dumpster, where the infant dies as a result of exposure and lack of nutrition. Sexual and Psychological Abuse Sexual abuse differs from physical abuse in that the injuries are often not readily apparent. Sexual abuse can occur in many different ways, and for certain situations it would not be expected that the abuse would result in any findings. In general, concern about sexual abuse is raised because of a disclosure by a child or the presence of medical or behavioral problems. In the past, often a long time interval existed between when the abuse occurred and when the child revealed the details of the events. This was in part related to the fact that children were frequently not believed, and no intervention occurred. With greater investigation and understanding of the nature of the sexual use of children, most adults now accept these disclosures as true, or at least believe that they warrant further evaluation. Disclosures may be made to different individuals. In school-age children, the disclosure may be made to a teacher. Sometimes, children disclose the abuse to a close friend. Interviewing a child about the possibility of prior sexual abuse requires a skilled interviewer. Such interviews should be kept to a minimum, involve the most expert professionals, and allow for observation by legal agencies such as law enforcement and the district attorney’s office. Children may recant their disclosures because of fear or embarrassment. The emotional turmoil associated with disclosure has been described in the writings of Dr. Roland Summit. Some sexually abused children are brought to medical attention because of behavioral symptoms that they are experiencing. The specific symptoms are age-dependent but include sleep difficulties, bed-wetting (enuresis), soiling (encopresis), acting out behavior, masturbation, and sexually inappropriate behavior. In adolescents, school problems, running away, promiscuity, suicide gestures, and eating disorders (particularly bulimia) have also been reported. None of these problems is specific for prior sexual abuse and may be associated with other stressors, such as parental divorce or familial dysfunction. Medical conditions may also bring sexually abused children to medical attention. In a child who has been recently abused, genital injuries may be present, and the child will have pain or bleeding in either the genital or anal areas. Sexually transmitted diseases (STDs) may develop in children who have been sexually abused. They may include gonorrhea, chlamydia, herpes, genital warts, and human immunodeficiency virus (HIV). Suspicion about an STD is usually aroused by the presence of lesions in the anogenital area or the appearance of a vaginal discharge. Not all discharges are caused by sexually transmitted conditions, however, and careful laboratory assessment is needed to ensure a correct diagnosis.
Child abuse ✧ 181 The medical assessment of the sexually abused child calls for a careful interview and a full medical evaluation. The examination of the anogenital area is frequently done with the use of magnifying equipment, most commonly a colposcope. Colposcopes usually include recording devices such as a video or still camera. The value of magnification is that it permits the examiner to differentiate normal variation from changes attributable to scarring and prior injuries. Most children with a history of prior sexual abuse have normal anogenital examinations because many abusive acts, such as fondling or oral-genital contact, do not produce physical injuries and because injuries to the anogenital area may heal without leaving residual findings. In girls, a hymen that has been injured may show evidence of disruptions, be reduced in amount, or have scars. There are also medical conditions that affect the anogenital area which are not related to abuse. Accidental injuries, including straddle injuries, may cause bleeding in the genital area. Skin conditions can cause changes that may be mistaken for trauma. Other medical conditions that have been mistakenly diagnosed as sexual abuse include urethral prolapse (in which the urethra extrudes through the urethral orifice) and inflammatory bowel disease. Treating Child Abuse In all cases where an injured child is suspected of having been abused, an assessment must be made about the possibility of accidental trauma or some medical condition contributing to the findings. Such a determination is made after obtaining a full history, performing a comprehensive physical examination, and reviewing the appropriate diagnostic studies. In cases of head trauma, a history of a minor fall or an unwitnessed event is often elicited. Simple falls do not result in significant intracranial hemorrhage. Occasionally, an epidural hemorrhage will occur following a minor fall, especially if there is an associated parietal skull fracture with disruption of the middle meningeal artery. The classic symptoms in this situation include a period of clearheadedness following the fall, after which the child becomes increasingly lethargic. Surgical intervention is essential and lifesaving. Similar surgical intervention with evacuation of a blood clot is sometimes needed with hemorrhages related to shaking. Management of cerebral edema is complicated and requires placement in an intensive care unit. In children with multiple bruises, a medical condition that could account for easy bruising needs to be eliminated. In general, coagulation studies should include a complete blood count, including a platelet count and blood smear, a prothrombin time (PT), an activated partial thromboplastin time (aPTT), and a bleeding time. These studies will detect most, but not all, bleeding disorders, in addition to leukemia and thrombocytopenic conditions. Other medical conditions, such as Henoch-Schönlein purpura, may be misdiagnosed as inflicted trauma by the inexperienced clinician.
182 ✧ Child abuse Children with bruises related to conditions other than abuse need to be managed accordingly. In cases of abuse involving children under the age of two, there is consensus that skeletal surveys should be obtained to detect occult fractures. Such fractures are clinically apparent in older children, although some experts recommend trauma series in cases of abuse involving children up to the age of five. Children with fractures resulting from abuse need to have their fractures evaluated by orthopedists and then managed like fractures that result from accidental injuries, usually with casting, traction, and/or open reduction. Children who have been sexually abused sometimes have medical problems that need to be addressed. Such problems may include the presence of STDs that warrant the use of antibiotics. Acute genital injuries may require surgical repair in the operating room. In all cases of inflicted injuries, documentation of the findings is critical. The examiner should record carefully all physical findings, as well as diagnostic studies, in the medical records. In addition, photographs should be obtained. If law enforcement is available, a police photographer should photograph the child using a color index recorded on the photograph. Alternatively, a hospital photographer or the examiner should obtain photos of the injuries. Long-term management of a child who has been abused needs to address the psychological trauma that has been experienced. As a rule, such children should be given counseling, which may include group sessions with other abused children, individual counseling, and family sessions. Another component of the child abuse process involves the interaction with the legal system. The child, family, and physician may be called upon to testify in court about the events surrounding the alleged abuse. Testifying in court may be a stressful event for the child, but preparation, including speaking to the attorney ahead of time, may make the experience less traumatic. The Prevalence of Child Abuse Child abuse was initially reported by American pediatrician John Caffey in 1946, when he described a series of children with chronic subdural hematomas and multiple fractures in long bones. The battered child syndrome was first reported by Henry Kempe and colleagues in 1962 in a classic article in which they described the multiple types of injuries that could be inflicted on a child. The pervasiveness of abuse is evidenced by the fact that in the United States in 1996, there were approximately 1 million cases of abuse and an additional 1 million cases of neglect that were identified through the National Incidence Survey. It is unclear how many additional cases are not recognized through this surveillance mechanism.
Child abuse ✧ 183 Although many would choose to believe that child maltreatment is restricted to poor and inner-city populations, this is not the case. Children from all socioeconomic classes may be the victims of abuse. Some of the most publicized cases involve families not affected by the stresses of poverty and unemployment. The understanding and knowledge of the nature of child abuse has grown since the 1960’s, but areas remain that need further research and assessment. The mechanism of injury in shaken infant syndrome is still being evaluated. The resiliency of some children to abuse and neglect is being assessed in a longitudinal follow-up study. There are many unanswered questions related to child sexual abuse. What are the long-term medical effects of sexual abuse? Studies have suggested that women with functional bowel disease, chronic pelvic pain, and obesity have a higher incidence of having been abused as children. What happens to boys who are sexually abused? Do they experience medical problems or sexual dysfunction as adults? The area of child abuse prevention is a challenging one to address. While the ability to recognize abuse and intervene has improved, no evidence exists that society has made any progress in the arena of child abuse prevention. This issue is very much linked to violence and how pervasive it has become in society. While poverty, substance abuse, and unemployment all have a role in predisposing people to child abuse, the ability of individuals to care for and parent children is also a contributing factor. The challenge for society is to interrupt the cycle of abuse and empower parents with the skills to nurture their children in a safe and caring environment. —Carol D. Berkowitz, M.D. See also Burns and scalds; Children’s health issues; Domestic violence; Ethics; Falls among children; Malnutrition among children; Münchausen syndrome by proxy. For Further Information: Brodeur, Armand E., and James A. Monteleone. Child Maltreatment: A Clinical Guide and Reference. 2 vols. St. Louis: G. W. Medical Publishing, 1994. A complete and comprehensive guide to all aspects of child abuse. Contains numerous photographs and X rays that illustrate injuries sustained by abused children. Gellert, George A. Confronting Violence: Answers to Questions About the Epidemic Destroying America’s Homes and Communities. Boulder, Colo.: Westview Press, 1997. A comprehensive guide to all types of violence in society, including child abuse. The information is laid out in a logical format that is easy to read and follow. Goulding, Regina A., and Richard C. Schwartz. The Mosaic Mind: Empowering the Tormented Selves of Child Abuse Survivors. New York: W. W. Norton, 1995.
184 ✧ Childbirth complications A fascinating account of how a multiple personality disorder developed in a woman who had been sexually abused and how therapy attempted to help her overcome the trauma of her past. Heger, Astrid, and S. Jean Emans. Evaluation of the Sexually Abused Child. New York: Oxford University Press, 1992. A medical textbook and photographic atlas that details the various aspects of the comprehensive evaluation of sexually abused children. Reece, Robert M., ed. Child Abuse: Medical Diagnosis and Management. Philadelphia: Lea & Febiger, 1994. A basic reference book for anyone dealing with child abuse. The book details various aspects of abuse and is written in an authoritative and scholarly manner by many of the nation’s experts on child abuse.
✧ Childbirth complications Type of issue: Children’s health, women’s health Definition: The difficulties that can occur during childbirth, either for the mother or for the baby. With medical monitoring and diagnostic tests, about 5 to 10 percent of pregnant women can be diagnosed as high-risk pregnancies, and appropriate precautions and preparations for possible complications can be made prior to labor. Yet up to 60 percent of complications of labor, childbirth, and the postpartum period (immediately after birth) occur in women with no prior indications of possible complications. Difficulties in childbirth can be placed into two general categories—problems with labor and problems with the child—and encompass a wide range of causes and possible treatments. Complications of Labor Cesarean birth (also called cesarean section, C-section, or a section) is the surgical removal of the baby from the mother. About one in ten infants is delivered by cesarean birth. In this procedure, one incision is made through the mother’s abdomen and a second through her uterus. The baby is physically removed from the mother’s uterus, and the incisions are closed. This type of surgery is very safe but carries with it the general risks of any major surgery and requires approximately five days of hospitalization. In some cases, diagnosed preexisting conditions suggest that a cesarean birth is necessary and can be planned; in the majority of cases, unexpected difficulties during labor dictate that an emergency cesarean section be performed. Some conditions leave no question about the necessity of a cesarean
Childbirth complications ✧ 185 section. These absolute indications include a variety of physical abnormalities. Placenta previa is a condition in which the placenta has implanted in the lower part of the uterus instead of the normal upper portion, thereby totally or partially blocking the cervix. The baby could not pass down the birth canal without dislodging or tearing the placenta, thereby interrupting its blood and Breech birth, one of several complications that may oxygen supply. Placenta pre- occur during childbirth, is the emergence of the invia is frequently the cause of fant buttocks-first rather than head-first; such a birth bleeding after the twentieth is risky for the child, and often birth is accomplished week of pregnancy, and it can by cesarean section, a surgical procedure to eliminate be definitively diagnosed by ul- risk. (Hans & Cassidy, Inc.) trasound. For women with this condition, bed rest is prescribed, and the baby will be delivered by cesarean birth at the thirty-seventh week of pregnancy. Placental separation, also known as placenta abruptio, is the result of the placenta partially or completely separating from the uterus prior to the normal separation time after birth. This condition results in bleeding, with either mild or extreme blood loss depending on the severity of the separation. If severe, up to four pints of blood may be lost, and the mother is given a blood transfusion. If the pregnancy is near term, an emergency cesarean section is indicated to deliver the child. Occasionally, as the baby begins traveling down the birth canal, the umbilical cord slips and lies ahead of the baby. This condition, called prolapsed cord, is very serious because the pressure of the baby against the cord during a vaginal delivery would compress the cord to the extent that the baby’s blood and oxygen supply would be cut off. This condition necessitates an emergency cesarean section. Some conditions that occur during labor are judged for their potential for causing harm to either the mother or the baby. The physician’s decision to proceed with vaginal delivery will be based on the severity of the complication and consideration of the best option for the mother and baby. A few of the more common indicators for possible cesarean section which occur during labor include a fetal head size that is too large for the mother’s birth canal; fetal distress, evidenced by insufficient oxygen supply reaching the baby; rupturing of the membranes without labor commencing or prolonged labor after membranes burst (usually twenty-four hours); and inelasticity of the pelvis in first-time mothers over forty years of age.
186 ✧ Childbirth complications Other maternal conditions are diagnosed prior to the onset of labor, and the physician may or may not recommend a cesarean birth based on the severity of the complication. These include postmaturity, in which the onset of labor is at least two weeks overdue and degeneration of the placenta may compromise the health of the baby; maternal diseases, such as diabetes mellitus and toxemia, in which the stress of labor would be highly risky to the mother; and previous cesarean section. Complications with the Baby Premature labor can occur between twenty and thirty-six weeks gestation, and a premature infant is considered to be any infant whose birth weight is less than 5.5 pounds. Certain maternal illnesses or abnormalities of the placenta can lead to premature birth, but in 60 percent of the cases there is no identifiable cause. If labor begins six weeks or more prior to the due date, the best chance of infant survival is to be delivered and cared for at a hospital with a perinatal center and specialized intensive care for premature infants. Prior to twenty-four weeks development, a premature infant will not survive as a result of inadequate lung development. The survival rate of premature infants increases with age, weight, and body system maturity. In about 4 percent of births, the baby is in the breech position—buttocks first or other body part preceding the head—rather than in the normal head-down position. Delivery in this position is complicated because the cervix will not dilate properly and the head may not be able to pass through the cervix. Other complications of breech position are prolapse or compression of the umbilical cord and trauma to the baby if delivered vaginally. Manual techniques may be used to rotate the baby into the correct position. Vaginal delivery may be attempted, frequently aided by gentle forceps removal of the baby. Breech babies are frequently born by cesarean section. Cephalopelvic disproportion is a condition in which the baby’s head is larger than the pelvic opening of the mother. This can only be determined after labor has begun, because the mother’s muscles and joints expand to accommodate the baby’s head. If at some point during labor the doctor determines that the baby will not fit through the mother’s pelvic opening, a cesarean section will be performed. —Karen E. Kalumuck See also Amniocentesis; Birth defects; Diabetes mellitus; Genetic counseling; Miscarriage; Multiple births; Natural childbirth; Postpartum depression; Pregnancy among teenagers; Premature birth; Prenatal care; Women’s health issues. For Further Information: Carlson, Karen J., Stephanie A. Eisenstat, and Terra Ziporyn. The Harvard
Childhood infectious diseases ✧ 187 Guide to Women’s Health. Cambridge, Mass.: Harvard University Press, 1996. Gonik, Bernard, and Renee A. Bobrowski. Medical Complications in Labor and Delivery. Cambridge, Mass.: Blackwell Scientific, 1996. Hotchner, Tracie. Pregnancy and Childbirth. Rev. ed. New York: Avon Books, 1997. Sears, William, and Martha Sears. The Birth Book. Boston: Little, Brown, 1994. Stoppard, Miriam. Conception, Pregnancy, and Birth. Rev. ed. London: Dorling Kindersley, 2000.
✧ Childhood infectious diseases Type of issue: Children’s health, epidemics, public health Definition: A group of diseases including diphtheria, tetanus, measles, polio, rubella (German measles), mumps, and pertussis (whooping cough). Acute communicable diseases occur primarily in childhood because most adults have become immune to such diseases, either by having acquired them as children or by having been inoculated against them. For example, prior to the use of vaccine for measles—a highly contagious disease found in most of the world—the peak incidence of the disease was in five- to ten-year-olds. Most adults were immune. Before a vaccine was developed and used against measles, epidemics occurred at two- to four-year intervals in large cities. Today, most cases are found in nonimmunized preschool children or in teenagers or young adults who have received only one dose of the vaccine. Measles A person infected with red measles (also known as rubeola) becomes contagious about ten days after exposure to the disease virus, at which time the prodromal stage begins. Typically, the infected person experiences three days of slight to moderate fever, a runny nose, increasing cough, and conjunctivitis. During the prodromal stage, Koplik’s spots appear inside the cheeks opposite the lower molars. These lesions—grayish white dots about the size of sand particles with a slightly reddish halo surrounding them that are occasionally hemorrhagic—are important in the diagnosis of measles. After the prodrome, a rash appears, usually accompanied by an abrupt increase in temperature (sometimes as high as 104 or 105 degrees Fahrenheit). It begins in the form of small, faintly red spots and progresses to large, dusky red confluent areas, often slightly hemorrhagic. The rash frequently begins behind the ears but spreads rapidly over the entire face, neck, upper
188 ✧ Childhood infectious diseases arms, and upper part of the chest within the first twenty-four hours. During the next twenty-four hours, it spreads over the back, abdomen, entire arms, and thighs. When it finally reaches the feet after the second or third day of the rash, it is already fading from the face. At this point, the fever is usually disappearing as well. The chief complications of measles are middle-ear infections, pneumonia, and encephalitis (a severe infection of the brain). There is no correlation between the severity of the case of measles and the development of encephalitis, but the incidence of the infection of the brain runs to only one or two per every thousand cases. Measles can also exacerbate tuberculosis. Rubella The incubation period for rubella (German measles) lasts between fourteen and twenty-one days, and the disease occurs primarily in children between the ages of two and ten. Like the initial rash of measles, the initial rash of rubella usually starts behind the ears, but children with rubella normally have no symptoms save for the rash and a low-grade fever for one day. Adolescents may have a three-day prodromal period of malaise, runny nose, and mild conjunctivitis; adolescent girls may have arthritis in several joints that lasts for weeks. The red spots begin behind the ears and then spread to the face, neck, trunk, and extremities. This rash may coalesce and last up to five days. Temperature may be normal or slightly elevated. Complications from rubella are relatively uncommon, but if pregnant women are not immune to the disease and are exposed to the rubella virus during early pregnancy, severe congenital anomalies may result. Because similar symptoms and rashes develop in many viral diseases, rubella is difficult to diagnose clinically. Except in known epidemics, laboratory confirmation is often necessary. Mumps The patient with mumps is likely to have fever, malaise, headache, and anorexia—all usually mild—but “neck swelling,” a painful enlargement of the parotid gland near the ear, is the sign that often brings the child to a doctor. Maximum swelling peaks after one to three days and begins in one or both parotid glands, but it may involve other salivary glands. The swelling pushes the earlobe upward and outward and obscures the angle of the mandible. Drinking sour liquids such as lemon juice may increase the pain. The opening of the duct inside the cheek from the affected parotid gland may appear red and swollen. The painful swelling usually dissipates by seven days. Abdominal pain may be caused by pancreatitis, a common complication but one that is usually mild. The most feared complication, sterility, is not as common as most
Childhood infectious diseases ✧ 189 believe. Orchitis rarely occurs in prepubertal boys and occurs in only 14 to 35 percent of older males. In 30 percent of patients with orchitis, both testes are involved, and a similar percentage of affected testes will atrophy. Surprisingly, impairment of fertility in males is only about 13 percent; absolute infertility is rare. Ovary involvement in women, with pelvic pain and tenderness, occurs in only about 7 percent of postpubertal women and with no evidence of impaired fertility. Measles, rubella, and mumps are all viral illnesses, but Hemophilus influenzae type B is the most common cause of serious bacterial infection in the young child. It is the leading cause of bacterial meningitis in children between the ages of one month and four years, and it is the cause of many other serious, life-threatening bacterial infections in the young child. Bacterial meningitis, especially from Hemophilus influenzae and pneumococcus, is the major cause of acquired hearing impairment in childhood. Polio Poliomyelitis(polio), an acute viral infection, has a wide range of manifestations. The minor illness pattern accounts for 80 to 90 percent of clinical infections in children. Symptoms, usually mild in this form, include slight fever, malaise, headache, sore throat, and vomiting but do not involve the central nervous system. Major illness occurs primarily in older children and adults. It may begin with fever, severe headache, stiff neck and back, deep muscle pain, and abnormal sensations, such as of burning, pricking, tickling, or tingling. These symptoms of aseptic meningitis may go no further or may progress to the loss of tendon reflexes and asymmetric weakness or paralysis of muscle groups. Fewer than 25 percent of paralytic polio patients suffer permanent disability. Most return in muscle function occurs within six months, but improvement may continue for two years. Twenty-five percent of paralytic patients have mild residual symptoms, and 50 percent recover completely. A long-term study of adults who suffered the disease has documented slowly progressive muscle weakness, especially in patients who experienced severe disabilities initially. Tetanus, Diphtheria, and Whooping Cough Tetanus is a bacterial disease which, once established in a wound of a patient without significant immunity, will build a substance that acts at the neuromuscular junction, the spinal cord, and the brain. Clinically, the patient experiences “lockjaw,” a tetanic spasm causing the spine and extremities to bend with convexity forward; spasms of the facial muscles cause the famous “sardonic smile.” Minimal stimulation of any muscle group may cause painful spasms.
190 ✧ Childhood infectious diseases Diphtheria is another bacterial disease that produces a virulent substance, but this one attacks heart muscle and nervous tissue. There is a severe mucopurulent discharge from the nose and an exudative pharyngitis (a sore throat accompanied by phlegm) with the formation of a pseudomembrane. Swelling just below the back of the throat may lead to stridor (noisy, high-pitched breathing) and to the dark bluish or purplish coloration of the skin and mucous membranes because of decreased oxygenation of the blood. The result may be heart failure and damaged nerves; respiratory insufficiency may be caused by diaphragmatic paralysis. Clinically, pertussis (whooping cough) can be divided into three stages, each lasting about two weeks. Initial symptoms resembling the common cold are followed by the characteristic paroxysmal cough and then convalescence. In the middle stage, multiple, rapid coughs, which may last more than a minute, will be followed by a sudden inspiration of air and a characteristic “whoop.” In the final stage, vomiting commonly follows coughing attacks. Almost any stimulus precipitates an attack. Seizures may occur as a result of hypoxia (inadequate oxygen supply) or brain damage. Pneumonia can develop, and even death may occur when the illness is severe. Chickenpox and Hepatitis Varicella (chickenpox) produces a generalized itchy, blisterlike rash with low-grade fever and few other symptoms. Minor complications, such as ear infections, occasionally occur, as does pneumonia, but serious complications such as infection in the brain are thankfully rare. It is a very inconvenient disease, however, requiring the infected person to be quarantined for about nine days or until the skin lesions have dried up completely. Varicella, a herpes family virus, may lie dormant in nerve linings for years and suddenly emerge in the linear-grouped skin lesions identified as herpes zoster. These painful skin lesions follow the distribution of the affected nerve. Herpes zoster is commonly known as shingles. Hepatitis Hepatitis type B is much more common in adults than in children, except in certain immigrant populations in which hepatitis B viral infections are endemic. High carrier rates appear in certain Asian and Pacific Islander groups and among some Inuits in Alaska, in whom perinatal transmission is the most common means of perpetuating the disease. Having this disease in childhood can cause problems later in life. An estimated five thousand deaths in the United States per year from cirrhosis or liver cancer occur as a result of hepatitis B. Carrier rates of between 5 and 10 percent result from disease acquired after the age of five, but between 80 and 90 percent will be carriers if they are infected at birth.
Children’s health issues ✧ 191 The serious problems of hepatitis B occur most often in chronic carriers. For example, 50 percent of carriers will ultimately develop liver cancer. The virus is fifty to one hundred times more infectious than human immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS). Health care workers are at high risk of contracting hepatitis B, but virtually everyone is at risk for contracting this disease because it is so contagious. —Wayne R. McKinny, M.D. See also AIDS and children; Antibiotic resistance; Children’s health issues; Epidemics; Herpes; Immunizations for children; Influenza; Lice, mites, and ticks; Meningitis; Reye’s syndrome; Tonsillectomy; Tuberculosis; Worms. For Further Information: Behrman, Richard E., ed. Nelson Textbook of Pediatrics. 15th ed. Philadelphia: W. B. Saunders, 1996. This standard pediatrics textbook contains complete discussions of all common (and uncommon) causes of infectious disease in children. Many chapters are well written and easily understood by the nonspecialist. Berkow, Robert, and Andrew J. Fletcher, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Rahway, N.J.: Merck Sharp & Dohme Research Laboratories, 1999. Published since 1899, this classic work is well indexed and easy to use. Discussions of the various infectious diseases of childhood are usually brief but thorough. Burg, Fredric D., ed. Treatment of Infants, Children, and Adolescents. Philadelphia: W. B. Saunders, 1990. One can quickly find specific information about vaccine dosages and other valuable information in this text. Korting, G. W. Diseases of the Skin in Children and Adolescents. Philadelphia: W. B. Saunders, 1970. An older textbook that contains color photographs of skin lesions in many childhood infectious diseases, matched by brilliant discussions of clinical patterns and signs. Robbins, Stanley L., Ramzi S. Cotran, and Vinay Kumar, eds. Robbins’ Pathologic Basis of Disease. 5th ed. Philadelphia: W. B. Saunders, 1999. An excellent textbook that combines the clinical and the pathological beautifully.
✧ Children’s health issues Type of issue: Children’s health Definition: The special health care needs of children and adolescents; at each stage of development, children experience different needs and have different abilities to be actively involved in good health practices.
192 ✧ Children’s health issues The healthy growth and development of children are influenced by genetic and environmental elements. Yet, genetic and environmental elements can also contribute to unhealthy growth and development, as can be seen by infant mortality rates and the incidence of preventable diseases and abnormal development. Health and Infant Mortality Infant mortality in the United States has been declining, but it is still higher than in many other countries, including Japan, the Scandinavian countries, Great Britain, and Canada. In the United States there are nearly twice as many infant deaths among African Americans as among whites. Infant deaths among Hispanics approximately equal those among whites. Individual states vary greatly in their infant mortality rates. Teenage pregnancies and out-of-wedlock births are believed to be important factors in infant mortality, primarily because of associated risk factors such as poverty, substance abuse, or low levels of education. Preventable diseases such as tuberculosis and measles can contribute to infant mortality, but their effect can be decreased through access to primary health care. The same relationship exists for abnormal development, as seen in birth defects. The causes of health problems or deaths in infants and older children are related to factors in society at large. These range from poor maternal health during pregnancy, to the decline in immunizations for some preventable diseases, to the presence and the use of health-threatening substances in the environment, to the lack of availability and use of health care, to the lack of family support resulting in accidents or death. Knowledge of these factors can affect the ability of parents and caregivers to provide an environment for infants and children that promotes healthy growth and development. Prenatal Health Sound prenatal health is an important factor in the development of healthy infants and children. The total dependence of unborn children on their mothers for nourishment and healthy development emphasizes the importance of a thoughtful approach to pregnancy at any age. Unplanned or unrecognized pregnancies can affect the health of infants and children if expectant mothers engage in activities that may prevent normal healthy development. Pregnancy in teenagers can create special problems, because growing mothers will compete with their fetuses for nutrients such as calcium, phosphorus, and iron. In addition, teenagers with low body weight are in danger of having infants with low birth weight, which is one of the leading causes of infant mortality. The thoughtful approach to pregnancy requires that mothers stop and think about what they are doing to themselves and how their behavior will affect their unborn children.
Children’s health issues ✧ 193 For example, foods and medicines ingested by mothers will be passed on to their unborn babies. Some substances pass quickly to fetuses while others pass on to them slowly. Still others concentrate in unborn children. The wrong drug or medicine during the first twelve weeks of pregnancy, when most birth defects are caused, could damage babies’ development. Medical professionals generally agree that the use of drugs, alcohol, tobacco, and caffeine during pregnancy may have a harmful effect on fetuses, but they disagree on how much is too much. Expectant mothers can discuss these matters with health care providers to determine the appropriate approach to each individual pregnancy. If women take drugs during pregnancy, either prescription or illicit drugs, their children can be born with drug dependencies or birth defects. Prenatal exposure to drugs such as cocaine and heroin has been associated with retarded growth, drug withdrawal, abnormal behavior, and drug dependency in infants. Prematurity and low birth weight have also been associated with drug exposure during pregnancy. Alcohol consumed during pregnancy is associated with fetal alcohol syndrome, which is characterized by a pattern of physical and mental defects. These include growth deficiencies, heart defects, and malformed facial features. Mental retardation is also associated with this syndrome. Fetal alcohol syndrome is considered to be an acute health problem, because it is associated with increased alcohol consumption in adolescents, who have a relatively high birth rate. Smoking tobacco during pregnancy can cause nicotine and carbon monoxide to decrease the flow of blood and oxygen to unborn children. Infants of mothers who smoke may be born prematurely, have low birth weights, and be more susceptible to respiratory infections after birth. Caffeine in coffee, tea, chocolate, and soft drinks acts as a stimulant, but it builds up in concentrated amounts in the placenta. The effects of this are not completely known, but studies on animals have linked caffeine to bone deformities and the development of cleft palate. Spina bifida is another condition that may be caused by unfavorable environmental patterns. This birth defect of the lower spinal cord develops shortly after conception and results in muscle paralysis, spine and limb deformities, and bowel and bladder problems. Spina bifida is believed to be caused by a combination of genetic and environmental factors, but the American Medical Association has noted that the children of women who use hot tubs are almost three times more likely to have this defect than the children of women who do not. Women who intend to become pregnant are thus encouraged to restrict their use of hot tubs and saunas. Preventable Disease Control One of the major factors in the health of infants and children is access to immunizations. A vaccine, a substance made of dead or weakened bacteria
194 ✧ Children’s health issues or virus cells, is given either by injection (shot) or orally so that infants’ and children’s bodies may build defenses against preventable diseases. Immunizations cause the body to produce antibodies that fight against particular diseases and continue to protect against future exposures. Infants must be vaccinated against mumps, measles, polio, German measles, diphtheria, pertussis (whooping cough), tetanus, chickenpox, and Hib disease (associated with bacterial meningitis). In addition to protecting infants and children against specific diseases, immunizations help to ensure that they will not suffer from the side effects of these diseases, which can include hearing loss and damage to the nervous system or heart. Older children may require booster shots for some diseases. The American Academy of Pediatrics has worked with the U.S. Centers for Disease Control (CDC) to establish a schedule for immunization of infants and children. Children’s primary health care givers should be consulted on the appropriate schedule of immunizations. Regardless of the particular immunization schedule, it is important that children be immunized in order to prevent disease outbreak before they begin kindergarten at ages four to six and when they are in middle or junior high school at ages eleven to twelve. Primary health care givers should also be consulted about the possibility of adverse reactions to vaccines. The chance of adverse reactions is slight, but in some instances mild fever or soreness may be experienced. When compared with the greater danger posed by the diseases against which vaccines guard, such reactions are minor. In addition to immunizations before starting school, children should be tested for tuberculosis. There has been a resurgence of tuberculosis in the United States, causing serious concern in child care or educational settings. This disease can cause lymph node infection, pulmonary complications, and possibly a form of meningitis. Because early symptoms resemble those associated with the common cold, tuberculosis has the potential to spread to other children or adults working with children. Exposure to Health-Threatening Substances Many substances in the environment can pose a threat to the health of infants and children. Because of their less developed immune systems and small body size, children have lower resistance to toxic substances and may be at greater health risk than adults. Exposure can take different forms, such as inhalation of secondhand smoke or dust, absorption of chemicals that come in contact with the skin, or ingestion of solids or liquids. Secondhand smoke from cigarettes, pipes, or cigars can be released into the air from two sources. Mainstream smoke is first inhaled into a smoker’s mouth and nasal passages before being exhaled. Sidestream smoke is more dangerous for nonsmokers, because it goes directly into the air from burning tobacco. It has higher concentrations of harmful compounds such as benzene and
Children’s health issues ✧ 195 formaldehyde than mainstream smoke and has carbon monoxide levels that may be two to fifteen times higher than in mainstream smoke. Studies have shown that secondhand smoke is detrimental to infants and children. Smoking by pregnant women may cause premature babies to be susceptible to respiratory distress syndrome. Babies of parents who smoke have a higher rate of lung diseases, such as bronchitis and pneumonia, in their first two years of life than babies of nonsmoking parents. Studies have also shown that babies of smokers may have problems with speech, intelligence, and attention span. Children ages five to nine years old have shown impaired lung function from secondhand smoke. Asthma attacks can be triggered by secondhand smoke. It is apparent that smokeless environments will give infants and children the best possible opportunity for healthy growth and development. Infants and children are also at risk of exposure to toxic chemicals that may be used in households. Cleaning agents and insecticides may be absorbed through the skin if infants and children are accidentally exposed to them. The potential for absorption through the skin may be higher with those substances that contain organic solvents to maintain the chemicals’ liquid form or to boost cleaning power. Acute exposure to toxic chemicals may have less severe results, such as nausea, dizziness, or fever, but chronic exposure could lead to the development of multiple chemical sensitivities or life-threatening diseases such as cancer. It is important to keep toxic chemicals out of the reach of children as well as to limit children’s exposure to them. The use of more natural cleaning products and insecticides may help reduce the possible development of long-term health problems. Environmental Hazards As infants and children develop, so does their tendency to put objects and substances into their mouths. Those objects that are small enough can pose a health threat if they are swallowed or lodged in the esophagus or lungs. Other substances that can be swallowed may pose a long-term health threat because of their chemical effects on the body. This is especially the case with lead, which may be present in paint and water pipes in older homes as well as in the soil in and around homes. Lead, whether swallowed or inhaled through dust, can build up in the blood and cause long-term effects such as learning disabilities, decreased growth, hyperactivity, impaired learning, and possibly brain damage. These effects can be reduced by medical treatment if lead poisoning is diagnosed early enough. Parents should have their children tested for lead poisoning if their homes contain paint that is more than thirty years old. Other ways to reduce the likelihood of lead exposure include keeping toys and pacifiers clean and preventing children from chewing on painted surfaces such as window sills, cribs, or playpens. Finally, parents should remember that good eating habits can help reduce the
196 ✧ Children’s health issues effects of lead; a diet with the appropriate amounts of iron and calcium will decrease the ability of the body to absorb lead. —Cherilyn Nelson See also Abortion among teenagers; AIDS and children; Alcoholism among teenagers; Asthma; Attention-deficit disorder (ADD); Autism; Birth defects; Breast-feeding; Burns and scalds; Child abuse; Childbirth complications; Childhood infectious diseases; Circumcision of boys; Circumcision of girls; Cleft lip and palate; Colic; Dental problems in children; Depression in children; Disabilities; Drowning; Drug abuse by teenagers; Exercise and children; Failure to thrive; Falls among children; Fetal alcohol syndrome; Hydrocephalus; Immunizations for children; Lead poisoning; Learning disabilities; Malnutrition among children; Münchausen syndrome by proxy; Nutrition and children; Obesity and children; Phenylketonuria (PKU); Physical fitness tests for children; Poisoning; Poisonous plants; Pregnancy among teenagers; Premature birth; Prenatal care; Reye’s syndrome; Safety issues for children; Spina bifida; Sports injuries among children; Sudden infant death syndrome (SIDS); Suicide among children and teenagers; Sunburns; Tattoos and body piercing; Teething; Tobacco use by teenagers; Tonsillectomy; Well-baby examinations. For Further Information: Behrman, Richard E., ed. Nelson Textbook of Pediatrics. 14th ed. Philadelphia: W. B. Saunders, 1992. Standard pediatrics textbook that is written to be understood by nonspecialists and covers both common and uncommon causes of infectious disease in children. Edelstein, Sari F. The Healthy Young Child. Minneapolis/St. Paul: West, 1995. Discusses infants from birth to one year old, toddlers and preschoolers from one to five years old, and elementary-age children from six to eight years old in terms of growth, development, physical activity, nutrition, safety, hygiene, and modern health issues. Gravelle, Karen. Understanding Birth Defects. New York: Franklin Watts, 1990. Discusses the nature of birth defects, how to prevent them, and what to do for children who have them. Reuben, Carolyn. The Healthy Baby Book: A Parent’s Guide to Preventing Birth Defects and Other Long-Term Medical Problems Before, During, and After Pregnancy. New York: Jeremy P. Tarcher/Perigee, 1992. Straightforward guidebook on children’s health written for parents. Trahms, Christine M., and Peggy L. Pipes, eds. Nutrition in Infancy and Childhood. 6th ed. New York: McGraw-Hill, 1997. Comprehensive overview, written for both professionals and nonprofessionals, of the nutritional needs of both healthy and sick children from infancy through adolescence, the development of food habits, and the prevention of chronic diseases through dietary intervention.
Chlorination ✧ 197
✧ Chlorination Type of issue: Environmental health, industrial practices, prevention, public health Definition: The practice of disinfecting water by the addition of chlorine. Although the chlorination of public water in the United States has helped reduce outbreaks of waterborne disease, it has raised concerns about the possible formation of chloro-organic compounds in treated water. Drinking water, waste waters, and water in swimming pools are the most common water sources where chlorination is used to kill bacteria and prevent the spread of diseases. Viruses are generally more resistant to chlorination, but they can be eliminated by increasing the chlorine levels needed to kill bacteria. Common chlorinating agents include elemental chlorine gas and sodium or calcium hypochlorite. In water these substances generate hypochlorous acid, which is the chemical agent responsible for killing microorganisms by inactivating bacteria proteins or viral nucleoproteins. Public drinking water was chlorinated in most large U.S. cities by 1914. The effectiveness of chlorination in reducing outbreaks of waterborne diseases in the early twentieth century was clearly illustrated by the drop in typhoid deaths: 36 per 100,000 in 1920 to 5 per 100,000 by 1928. Chlorination has remained the most economical method to purify public water, although it is not without potential risks. Chlorination has also been widely used to prevent the spread of bacteria in the food industry. Potential Hazards of Chlorination In its elemental form, high concentrations of chlorine are very toxic, and solutions containing more than 1,000 milligrams per liter are lethal to humans. Chlorine has a characteristic odor that is detectable at levels of 2 to 3 milligrams per liter of water. Most public water supplies contain chlorine levels of 1 to 2 milligrams per liter, although the actual concentrations of water reaching consumer faucets fluctuates and is usually around 0.5 milligram per liter. Consumption of water containing 50 milligrams per liter has produced no immediate adverse effects. The greatest environmental concern from chlorination is not usually from the chlorine itself, but from the potential toxic compounds that may form when chlorine reacts with organic compounds present in the water. Chlorine, which is an extremely reactive element, reacts with organic material associated with decaying vegetation (humic acids), forming chloroorganic compounds. Trihalo-methanes (THMs) are one of the most common chloro-organic compounds. At least a dozen THMs have been identi-
198 ✧ Choking fied in drinking water since the 1970’s, when health authorities came under pressure to issue standards for the identification and reduction of THM levels in drinking water. Major concern has focused on levels of chloroform because of its known carcinogenic properties in animal studies. Once used in cough syrups, mouthwashes, and toothpastes, chloroform in consumer products is now severely restricted. A 1975 study of chloroform concentrations in drinking water found levels of more than 300 micrograms per liter in some water, with 10 percent of the water systems surveyed having levels of more than 105 micrograms per liter. In 1984, the World Health Organization used a guideline value of 30 micrograms per liter for chloroform in drinking water. Although there are risks associated with drinking chlorinated water, it has been estimated that the risk of death from cigarette smoking is two thousand times greater than that of drinking chloroform-contaminated water from most public sources. However, as water sources become more polluted and require higher levels of chlorination to maintain purity, continual monitoring of chloro-organic compounds will be needed. —Nicholas C. Thomas See also Environmental diseases; Epidemics; Fluoridation of water sources; Water quality. For Further Information: Connell, Gerald F. The Chlorination/Chloramination Handbook. Denver: American Water Works Association, 1996. De Zuane, John. Handbook of Drinking Water Quality. 2d ed. New York: Van Nostrand Reinhold, 1997. Jolley, Robert L., and Lyman W. Condie. Water Chlorination: Chemistry, Environmental Impact, and Health Effects. Boca Raton, Fla.: Lewis, 1990. White, George Clifford. Handbook of Chlorination and Alternative Disinfectants. 4th ed. New York: John Wiley & Sons, 1998.
✧ Choking Type of issue: Children’s health, public health Definition: A condition in which the breathing passage (windpipe) is obstructed; it is one of the most common causes of death in young children. A person who is choking may cough, turn red in the face, clutch his or her throat, or any combination of the above. If the choking person is coughing, it is probably best to do nothing; the coughing should naturally clear the airway. The true choking emergency occurs when a bit of food or other
Choking ✧ 199 foreign object completely obstructs the breathing passage. In this case, there is little or no coughing—the person cannot make much sound. This silent choking calls for immediate action. Performing the Heimlich Maneuver An individual witnessing a choking emergency should first call for emergency help and then perform the Heimlich maneuver. The choking person should never be slapped on the back. The Heimlich maneuver is best performed while the choking victim is standing or seated. If possible, the person performing the Heimlich maneuver should ask the victim to nod if he or she wishes the Heimlich maneuver to be performed. If the airway is totally blocked, the victim will not be able to speak and may even be unconscious. The individual performing the Heimlich maneuver positions himself or herself behind the choking victim and places his or her arms around the victim’s waist. Making a fist with one hand and grasping that fist with the other hand, the rescuer positions the thumb side of the fist toward the stomach of the victim—just above the navel and below the ribs. The person performing the maneuver pulls his or her fist upward into the abdomen of the victim with several quick thrusts. This action should expel the foreign object from the victim’s throat, and he or she should begin coughing or return to normal breathing. The Heimlich maneuver is not effective in dislodging fish bones and certain other obstructions. If the airway is still blocked after several Heimlich thrusts, a finger sweep should be tried to remove the obstruction. First the mouth of the victim must be opened: The chin is grasped, and the mouth is pulled open with one hand. With the index finger of the other hand, the rescuer sweeps through the victim’s throat, pulling out any foreign material. One sweep should be made from left to right, and a second sweep from right to left. The Heimlich maneuver may then be repeated if necessary. Treating a Choking Child Although it is possible for a child to choke when suffering from a disease such as croup, which involves swelling of the airways as a result of a viral infection, most children choke when foreign objects become lodged in the esophagus. Children frequently swallow and choke on coins, small batteries, balloons, marbles, small balls, and other toys. Almost any food can cause choking as well. Most experts agree that the most dangerous food items include hot dogs, carrots, grapes, cherries, raisins, nuts, popcorn, apples, pears, hard candy, celery, peanut butter, beans, chickpeas, marshmallows, and chunks of meat. A child who is eating may choke by suddenly inhaling while talking, laughing, or crying out in surprise. Parents can lessen the risk
200 ✧ Cholesterol of choking by childproofing the environment, by closely monitoring play and other activities, by teaching safe eating habits, and by restricting the intake of dangerous foods. A child who is choking but trying to cough up a swallowed object should be monitored. Intervention should take place only if the child is unable to make a sound, indicating that the airway is fully obstructed. At this point, the procedure for treatment varies. An infant under the age of one should be balanced facedown against an adult’s forearm and given five quick and firm blows between the shoulder blades. If this does not dislodge the object, the infant should be turned face up and the adult should deliver five quick thrusts to the chest. Most experts agree that a child between one and three years of age should be placed on the back while an adult presses quickly and firmly upward and into the abdomen up to five times. The Heimlich maneuver can be performed on children over three. These procedures usually dislodge the object. If not, cardiopulmonary resuscitation (CPR) should be performed and help summoned. —Steven A. Schonefeld; Cassandra Kircher See also Children’s health issues; First aid; Resuscitation; Safety issues for children; Safety issues for the elderly. For Further Information: Anderson, Kenneth N., et al., eds. Mosby’s Medical, Nursing, and Allied Health Dictionary. 5th ed. St. Louis: C. V. Mosby, 1998. Castleman, Michael. “Emergency! Fifty-four Ways to Save Your Life.” Family Circle 107, no. 4 (March 15, 1994): 37. Heimlich, H. J., and E. A. Patrick. “The Heimlich Maneuver: The Best Technique for Saving Any Choking Victim’s Life.” Postgraduate Medicine 87, no. 6 (May 1, 1990): 38-48, 53. Stern, Loraine. “Your Child’s Health: Mom, I Can’t Breathe!” Woman’s Day 57, no. 6 (March 15, 1994): 18.
✧ Cholesterol Type of issue: Prevention, public health, social trends Definition: A fatlike substance found in certain foods and manufactured in the liver. The body needs cholesterol for a variety of purposes. It is a component of cell membranes, for example, and is needed for the production of bile and certain hormones (estrogen, testosterone, and adrenal hormones). It is a component of brain and nerve cells.
Cholesterol ✧ 201 Cholesterol circulates in the blood attached to proteins called lipoproteins. Major lipoproteins include chylomicrons, which carry digested and absorbed dietary fats in the blood; very low-density lipoproteins (VLDLs); low-density lipoproteins (LDLs), which are also called “bad” cholesterol; and high-density lipoproteins (HDLs), also called “good” cholesterol because HDLs seem to have protective functions. The liver manufactures about half of the cholesterol needed by the body; the rest comes from foods. Dietary sources of cholesterol include animal fats and oils such as egg yolk, whole milk, butter, cream, cheeses, ice cream, sour cream, lard, and meats, especially fatty meats. Dietary cholesterol raises LDLs and total cholesterol in the blood, but to a lesser extent than foods high in saturated fatty acids. Saturated fats are found in many of the same foods as cholesterol as well as in some vegetable oils, including coconut, palm, and palm kernel oils. Despite the body’s need for cholesterol, excessive amounts over long periods of time can accumulate in blood vessels, increasing the risk of atherosclerosis, coronary artery disease, or carotid artery disease. These increase the risk of heart attack or stroke. The American Heart Association recommends a blood cholesterol level of 200 milligrams per deciliter or less to lower the risk of heart disease. Elevated levels of LDLs increase the risk the most and should be below 130 milligrams per deciliter in the general population. Blood cholesterol levels increase with age, especially LDL levels. Cholesterol levels are generally higher in men than in women until women reach the menopause, when their levels begin to increase. For both men and women, heart disease is the number one cause of death in the United States. Cholesterol and Nutrition Both people with elevated blood cholesterol levels and the general population are advised to reduce their consumption of cholesterol (300 milligrams daily or less), of total fat (30 percent of dietary calories or less), of saturated fat (8 to 10 percent of total calories), and trans fats (or transfatty acids) in hydrogenated foods such as margarines and shortenings. One should choose lean cuts of meats with the fat trimmed, limit meat portions to 6 ounces daily, choose low-fat dairy products, use small amounts of monounsaturated vegetable oils such as olive and canola oils, and eat increased amounts of fruits, vegetables, and whole grains. Reading the nutrition labels on foods to learn the grams of total fat, saturated fat, and cholesterol the foods contain is helpful in selecting appropriate foods. Increasing exercise, losing weight if overweight, and stopping smoking are also recommended for those with high levels of blood cholesterol. In addition, some people with high levels of blood cholesterol may need to take lipid-lowering drugs. —Betsy B. Holli
202 ✧ Chronic fatigue syndrome See also Arteriosclerosis; Heart attacks; Heart disease; Heart disease and women; Malnutrition among the elderly; Nutrition and aging; Obesity; Obesity and aging; Smoking; Strokes. For Further Information: Dietschy, John M. “Physiology in Medicine: LDL Cholesterol: Its Regulation and Manipulation.” Hospital Practice 25 (June 15, 1990): 67-78. Grundy, Scott M. Cholesterol and Atherosclerosis. Philadelphia: J. B. Lippincott, 1990. Nesto, N. W., and Lisa Christenson. Cholesterol-Lowering Drugs: Everything You and Your Family Need to Know. New York: William Morrow, 2000. Yeagle, Philip L. Understanding Your Cholesterol. San Diego: Academic Press, 1991.
✧ Chronic fatigue syndrome Type of issue: Public health, women’s health Definition: Chronic fatigue syndrome is a multifaceted disease state characterized by debilitating fatigue. Chronic fatigue syndrome is a heterogenous disease state that has been difficult to define, diagnose, and treat because of poorly understood causeand-effect relationships. The disease can be best described in terms of long-lasting and debilitating fatigue, the etiology of which has been linked to such external factors as microbial agents, stress, and lifestyle as well as such internal factors as genetic makeup and the body’s immune response. The fact that it is a physical disease with psychological components has also caused confusion in the medical community. Among the many names that have been used for the disease, the three that demonstrate the many factors that contribute to chronic fatigue syndrome are chronic Epstein-Barr virus syndrome, chronic fatigue immune dysfunction syndrome, and “Yuppie flu.” Because of the marked immunological aspects of the disease and the fact that different viruses have been found in patients with chronic fatigue, the disease is referred to as chronic fatigue immune dysfunction syndrome by many involved in the study. The Centers for Disease Control (CDC) continues to refer to it as chronic fatigue syndrome (CFS). Although the disease is not specific by race, sex, or age group, there is demographic evidence that young white females make up two-thirds of the known cases. It is estimated by the CDC that between 1 and 10 of every 10,000 people in the United States have CFS. The disease has also been identified as a problem in Europe and Australia.
Chronic fatigue syndrome ✧ 203 Acute and Chronic Phases CFS can manifest itself in acute and chronic phases, although some patients do not remember an acute phase presentation. Acute phase symptoms are general and flulike, with a low-grade fever, sore throat, headache, muscle pain, painful lymph nodes, and overall fatigue. Unlike with a bout of influenza, the symptoms do not subside with time, instead intensifying into a chronic phase. The fatigue can become disabling, with severe muscle and joint pain, swollen and painful lymph nodes, and the inability to develop proper sleep patterns. Some researchers blame psychological and emotional stress, with a viral infection having triggered the initial acute phase. Although the psychological description does not fit all cases, problems of concentration, attention, and depression have been implicated to the point that researchers recognize both psychological and physical components. The working definition from both a research and a clinical perspective requires that the fatigue cause at least 50 percent incapacitation and last at least six months. The ineffectiveness of treatment, compounded by the inability to provide a concrete diagnosis, further complicates the psychological aspects of the disease for the patient. Environmental or Viral Agents? Although the environment provides an array of agents that could trigger the physical condition of CFS, the hypothesis for a viral cause is supported by the flulike symptoms, occasional clustering of cases, and the presence of antiviral antibodies in the patient’s serum. The involvement of the EpsteinBarr virus in CFS seems likely because of its role as the etiological agent of mononucleosis and Burkitt’s lymphoma, which are similar diseases. In both of these diseases, the Epstein-Barr virus has a unique and harmful effect on the immune system because it directly invades B lymphocytes, the antibodyproducing cells of the body, using them to grow new virus particles while disrupting the proper functioning of the immune system. Like CFS, mononucleosis is characterized by flulike symptoms and fatigue, but the disease is self-limiting and the patient eventually recovers. Despite this seeming difference in outcome, the Epstein-Barr virus can cause a chronic condition. The viruses that infect humans can become dormant within the cells that they infect. The nucleic acid of a virus can become incorporated into the DNA of its host cell, and the body no longer shows physical signs of their presence. A virus can become active at times of physical or emotional stress and can once again trigger the physical symptoms of disease. For example, herpes simplex virus 1 remains dormant in its host cell but periodically, in response to environmental factors, causes a cold sore lesion. Some patients with CFS have also been infected with two retroviruses, human T cell lymphotropic virus type II (HTLV-II) and a Spumavirus. Both
204 ✧ Chronic fatigue syndrome are related to the human immunodeficiency virus (HIV), the causative agent of acquired immunodeficiency syndrome (AIDS). Retrovirus genes are made of ribonucleic acid (RNA) rather than deoxyribonucleic acid (DNA), as are the genes of herpes-type viruses such as Epstein-Barr and herpes simplex virus 1. Retroviruses must convert their RNA into complementary DNA (cDNA) when they infect a host cell in order to incorporate their genes into the host cell genes. Although the two viruses are associated with some CFS patients, diagnostic tests developed to detect their presence have not confirmed that the CFS condition depends on their presence. This same finding is true of herpesvirus 6 and other viruses. Although viruses may play a role in CFS, they are not the only factors involved and are not substantive evidence to define a clinical or research case. Immunological dysfunction has been observed in CFS patients because they demonstrate increased allergic sensitivity to skin tests when compared with normal individuals. Cells and cellular chemicals directly involved with protective immunity and the regulation of the immune response have been found in these patients in abnormal concentrations. For example, they have abnormal numbers of the natural killer cells and suppressor T cells that are essential to cell-mediated immunity. Cellular chemicals such as gamma interferon and interleuken II that regulate the activities of the cells in the cell-mediated and humeral immune responses are seen in abnormal concentrations in some CFS patients. Infectious agents, bacteria, viruses, yeasts, parasites, and even cancer cells are eliminated from the body when humeral and cell-mediated immune systems are operating properly. When the immune system is not working properly, however, not only is the body more susceptible to a variety of infectious agents but the immune system can actually begin to destroy normal body tissues, such as the thyroid gland and other vital organs. Such disease states are referred to as autoimmune diseases. Allergic reactions are also examples of uncontrolled immune responses. The component immune dysfunction of CFS is thought to be significant enough for some researchers to recommend that new and worsening allergies be added as minor criteria to the case definition for the disease. The psychological and emotional aspects of CFS are also in question. Some studies indicate that the brain is physically affected by inflammation and hormonal changes. Other studies demonstrate that some of the known viral infective agents can have neurological effects. Psychiatric studies give ample evidence that depression, memory loss, and concentration are significant problems for some CFS patients. The extent to which stress is a factor in the disease is unknown. Defining the Symptoms In 1993, a meeting at the CDC attempted to evaluate what had been learned over the previous five-year period and to make recommendations regarding
Chronic fatigue syndrome ✧ 205 a case definition. It was suggested that the case definition format involve inclusion and exclusion criteria that would increase the number and range of cases being studied because of the heterogeneous nature of the disease. The cases should also be subcategorized to provide a homogeneity that would allow for subgroup identification and comparison. The inclusion evidence should be simple, with a descriptive interpretation of the fatigue being essential and having objective criteria to define a 50 percent reduction of physical activity. Symptoms that are specific to unexplained fatigue should be used, while the physical exam information should not be included. It was also suggested that exclusion of any cases should involve an in-depth history (both medical and psychiatric), a physical examination, and standardized testing that would involve medical, laboratory, and psychiatric information. Because it appears that CFS overlaps with many other medical and psychiatric conditions that can be identified and treated, there is debate as to how to interpret CFS as it relates to patient care and research. Some believe that an in-depth history is fundamental to the understanding of CFS and that CFS could be the final pathway that occurs from a variety of biological and psychosocial insults to the body. The minor criteria used to define CFS involve both symptom and physical criteria that have not been proved adequate to validate or define the condition. In fact, the conflicting data have only served to emphasize further the clinical heterogeneity of the disease and suggest a heterogeneity of cause. Suggestions have been made to drop the concept of minor criteria, use symptoms that are specific for the unexplained fatigue, and drop all physical examination criteria. The argument for eliminating physical criteria is that more specific criteria exist for a case definition. Because physical symptoms are inconsistent or periodic, it is believed that a documented patient history would provide more case-specific information. Although symptom criteria have widespread support in the case definition of CFS, symptoms with the greatest sensitivity and specificity are also being debated. Night sweats, cough, gastrointestinal problems, and new and worsening allergies are not presently considered and are believed by some to be more specific than fever or chills and sore throat. Others have proposed that symptoms should be reduced to chills and fever, sore throat, neck or axilla adenopathy, and sudden onset of a main symptom complex. The most prevalent symptoms are believed to be muscle weakness and pain, problems in concentration, and sleep disturbance. The importance of the psychiatric component in CFS continues to be a problem in case definition. Some believe that the neurological component is a major criterion in case definition and that behavior symptoms, including stress and psychiatric illness, must be emphasized in clinical diagnosis as well as in therapy. It has been recommended that objective neuropsychological testing be used to determine cognitive dysfunction and depression. There is agreement that CFS patients have impaired concentration and attention,
206 ✧ Chronic fatigue syndrome but forgetfulness and memory problems are questioned. There is also evidence that the duration and severity of myalgia are closely associated with psychological distress and that psychotherapy improves physical symptoms. Finally, it has been argued that the psychiatric component of the case definition is essential because there is evidence that the disease directly affects the brain and that CFS can cause both isolation and limitation of the patient’s normal lifestyle. Testing for the Disease Whatever the case definition, the second major criterion will be expressed in some form. Proper patient care necessitates extensive evaluation in order to identify the biological or psychological reasons for the problem. Proper CFS patient care demands the elimination of other serious disease possibilities that may appear superficially similar. Primary care physicians may find it difficult to make a diagnosis without a team of specialists in the areas of hematology, immunology, and psychiatry. Numerous laboratory tests must be made available. Although there are no specific recommended tests, those that must be performed should be tailored to specific patients and used by the team of specialists for their care. The possibility of infectious disease, either as part of CFS (as in the case of certain viral agents) or as an autonomous infection having no relation to CFS, requires a variety of antibody tests to detect such viruses as Epstein-Barr or HIV. Skin tests such as the purified protein derivative (PPD) test for tuberculosis are used. Polymerase chain reaction and tissue culture for cytopathic effects have been developed to detect certain retroviruses for ultimate use in diagnosis at the clinical level. The immune system is so intimately interactive with the entire body that most disease conditions are affected by or affect its function. The measure of its components provides a clue to the identity of the disease that is operating because they indicate whether normal protection activity or immune dysfunction (or a combination) is occurring in the patient. The components of the immune system can be measured in numerous ways, from methodologies used in standard clinical laboratory procedures to research protocols used to study immune function and disease treatment. Tests are available that can measure total antibody concentration and the various subgroups IgG, IgM, IgA, IgE, IgD; cytokines such as interleuken II and gamma interferon; cellular components such as T cells and their subtypes (such as suppressor T cells and natural killer cells), and B cells. Autoimmune diseases and allergies are immune dysfunction diseases in their own right. Because there is an immune dysfunction component to CFS, tests for these conditions are important considerations. An antinuclear antibody (ANA) test determines the presence of antibodies that attack the tissues of the patient, as in systemic lupus erythematosus. The type and
Chronic fatigue syndrome ✧ 207 extent of allergic reactions can be measured using the radioimmunosorbent (RIST) tests for total IgE concentration and radioallergosorbent (RAST) tests for IgE concentration for particular antigens. Systemic disease states, including CFS, often involve generalized inflammation that is considered part of the body’s protective response. While inflammation is important to the elimination of various infective agents, it is also involved in neurological and muscle tissue damage. C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) tests measure the intensity of the inflammatory response. A variety of other tests provide information that indicates the extent of muscle, liver, thyroid, and other vital organ damage. No Standard Treatment Although a diagnosis can be made for CFS, there is no standard treatment. Clinical treatment essentially takes the form of alleviating the symptoms. Antidepressants such as doxepin (Sinequan) are useful in the treatment of depression and are also used to control muscle pain, lethargy, and sleeping problems. Nonsteroidal anti-inflammatory drugs (NSAIDs) provide relief for headache and muscle pain. Two drugs that have demonstrated antiviral activities are acyclovir and ampligen; ampligen can also modulate the immune response. An example of research to develop therapies that might alleviate other symptoms of CFS involves the treatment of a number of patients with dialyzable leukocyte extract and psychologic treatment in the form of cognitive-behavioral therapy. The patients’ cell-mediated immune response after therapy was evaluated by peripheral blood T cell subset analysis and delayed hypersensitivity skin testing. Psychologic analysis was performed using numerous cognitive tests. Both therapies proved to be inconclusive. Because of the systemic nature of the disease, including its psychoneurological component, consideration must be given to holistic medical treatment. Any treatment protocol must be able to address the interactive factors of CFS that are still being defined in terms of cause and effect. Some researchers believe that therapeutic treatment should comprise diet, exercise, vitamins, and homeopathic medicine. They further believe that psychoemotional treatment should allow patients to be responsible for their own recovery and help them to develop a personal lifestyle that provides general good health. —Patrick J. DeLuca See also Allergies; Environmental diseases; Influenza; Memory loss; Sleep disorders; Stress; Women’s health issues. For Further Information: Collinge, William. Recovering from Chronic Fatigue Syndrome: A Guide to Self-
208 ✧ Circumcision of boys Empowerment. New York: Body Press/Perigee, 1993. An excellent book written for the general public that speculates on the multifaceted nature of the disease. Offers information for those who have CFS, such as suggested diets and treatments. Also provides addresses for support groups. National Institutes of Health. Chronic Fatigue Syndrome: Information for Physicians. Bethesda, Md.: Author, 1997. A brief, concise description of what is known about CFS. Although printed for physicians, this pamphlet can be read and understood by nonspecialists. Stoff, Jesse A., and Charles Pellegrino. Chronic Fatigue Syndrome. Rev. ed. New York: HarperPerennial, 1992. An excellent book describing the biological aspects of the disease in layperson’s terms. Essential reading for anyone suffering from the disease because of its diary-like accounts, anecdotal data, emphasis on holistic treatment, and inspirational tone. Wessely, S., M. Hotopf, and M. Sharpe. Chronic Fatigue and Its Syndromes. Oxford, England: Oxford University Press, 1999. The authors consider chronic fatigue to be similar to any other illness in that its onset and course are influenced by physical, psychological, and social factors. Chapters review these topics as well as the history of chronic fatigue and neurasthenia and the influence of social circumstances. Yehuda, Shlomo, and David I. Mostofsky, eds. Chronic Fatigue Syndrome. New York: Plenum Press, 1997. Provides an updated description of CFS, the medical conditions from which it must be distinguished, and current treatment approaches.
✧ Circumcision of boys Type of issue: Children’s health, ethics, medical procedures, men’s health Definition: The removal of the foreskin (prepuce) covering the head of the penis. Routine circumcision of the newborn male—in which the foreskin of the penis is stretched, clamped, and cut—is becoming an increasingly controversial procedure. Famed pediatrician Benjamin Spock once contended that circumcision is a good idea, especially if most of the boys in the neighborhood are circumcised; then a boy feels “regular.” Yet many wonder if that is justification for circumcision. Allowing routine circumcision of newborns as a religious and cultural rite still leaves the debate over medical necessity. The United States is the only country in the world that circumcises a majority of newborn males without a religious reason. In fact, circumcision has been termed a “cultural surgery.”
Circumcision of boys ✧ 209 Indications and Contraindications True medical indications for the surgery are seldom present at birth. Such conditions as infections of the head and/or shaft of the penis may be indications for circumcision; an inability to retract the foreskin in the newborn is not an indication. Some argue that circumcision should be delayed until the foreskin has become retractable, making an imprecise surgical procedure presumably less traumatic. In 96 percent of infant boys, however, the foreskin is not fully retractable; it is normally so tight and adherent that it cannot be pulled back and the penis cleaned. By age three, that percentage decreases to 10 percent. There are other definite contraindications to newborn circumcision. Circumcising infants with abnormalities of the penal head or shaft makes treatment more difficult because the foreskin may later be needed for use in reconstruction. Prematurity, instability, or a bleeding problem also preclude early circumcision. The foreskin is a natural protective membrane, representing 50 to 80 percent of the skin system of the penis, having 240 feet of nerve fibers, more than 1,000 nerve endings, and 3 feet of veins, arteries, and capillaries. It keeps the sensitive head protected, facilitating intercourse, and prevents the surface of the glans from thickening and becoming desensitized. Also, within the inner surface of the foreskin are a series of tiny ridged bands that contribute significantly to stimulating the glans. Risks of Infection and Cancer The two most persistent arguments for the operation, however, are the risks of infection and cancer in the uncircumcised. Without circumcision, smegma accumulates beneath the base of the covered head of the penis. This cheeselike material of dead skin cells and secretions of the sweat glands is thought to be a cause of cancer of the penis and prostate gland in uncircumcised men and cancer of the cervix in their female partners. Doctors who argue against circumcision, however, say that the presence of smegma in the uncircumcised is simply a sign of poor hygiene and that poor sexual hygiene, inadequate hygienic facilities, and sexually transmitted diseases cause an increased incidence of cancer in ethnic groups or populations that do not practice circumcision. Doctors who argue against circumcision also point out that complete circumcision is found as often in male partners of women without cancer of the cervix as in male partners of women who have cervical cancer. In Sweden, moreover—where newborn circumcision is not routinely practiced but where good hygiene is practiced—the rates of these cancers are essentially the same as those found in Israel, where ritual circumcision is practiced. The increased incidence of urinary tract infections and sexually transmitted diseases (STDs) in uncircumcised males sufficiently argue for circumcision, say its proponents. They warn that the intact foreskin invites bacterial
210 ✧ Circumcision of boys colonization, which leads to urethral infection ascending to the bladder that ultimately may spread upward to the kidneys and sometimes cause permanent kidney damage. On the other hand, no proof exists that uncircumcised male infants who sustain urinary tract infections will have future urologic problems. Furthermore, the operation is not a simple procedure and is not without peril. Penile amputation, life-threatening infections, and even death have been well documented. Slightly increased rates of infection with sexually transmitted diseases in the uncircumcised argue the case for some proponents, but it is acquired immunodeficiency syndrome (AIDS) that they most fear. In Africa, where circumcision is seldom practiced, the acquisition of AIDS by heterosexual men from infected women during vaginal intercourse is the most common mode of transmission. Proponents say that infection with human immunodeficiency virus (HIV), the virus that leads to AIDS, depends on a break or an abrasion of the skin to gain entry. The intact foreskin provides a site for transfer of infected cervical secretions. In Africa, doctors at the University of Nairobi noted a relationship of HIV infection to genital ulcers and lack of circumcision. Uncircumcised men had a history of genital ulcers more often than did the circumcised, and they were more often HIV-positive. They were also more frequently HIV-positive even if they did not have a history of genital ulcer disease. Potential Complications In 1989, the American Academy Pediatrics Task Force on Circumcision concluded that “newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained.” This neutral statement does not lessen the anxiety of parents who are trying to weigh the pros and cons of routine newborn circumcision, but examination of the evidence does allow parents to weigh the individual benefits and risks and see if the scale tips in either direction. Worldwide studies of predominantly uncircumcised populations have shown a higher incidence of urinary tract infection in boys during the first few months of life, which is the reverse of what is found in older infants and children, where girls predominate. In 1986, Brooke Army Medical Center in Fort Sam Houston, Texas, took a closer look. The doctors found the incidence of urinary tract infection in circumcised infant males to be 0.11 percent but 1.12 percent in the uncircumcised. Even without proof that the uncircumcised male infants who get urinary tract infections will have future urologic problems, the proponents for the surgical procedure claim about a 1 percent advantage.
Circumcision of boys ✧ 211 The evidence for an increase in sexually transmitted diseases (such as genital herpes, gonorrhea, and syphilis) among the uncircumcised is conflicting. Furthermore, apparent correlations between circumcision status and these diseases do not reflect confounding genetic and environmental variables. It is also difficult to factor in the risk from HIV infections. The studies from Africa do not look at any variables in the transmission of HIV except circumcision status and previous history of genital ulcers. The nutritional and economic status of the men was not examined, even though it is known that malnourishment suppresses the immune systems. Moreover, if everyone practiced “safe sex,” the argument for circumcision would be moot. Almost all the surgical complications of circumcision can be avoided if doctors performing the procedure adhere to strict asepsis, are properly trained and experienced in the procedure, remove the appropriate and correct amount of tissue, and provide adequate hemostasis. The variety of circumstances, populations, and physicians affects the incidence of complications. In the larger, teaching hospitals, often the newest physicians with the least experience or supervision perform the operation. As a result, complications may arise. Excessive bleeding is the most frequent complication. The incidence of bleeding after circumcision ranges from 0.1 percent to as high as 35 percent in some reports. Most of the episodes are minor and can be controlled by simple measures, such as compression and suturing, but some of these efforts can lead to diminished blood supply to the head and shaft of the penis with necrosis of the affected part. Chordee can result if improper technique or bad luck intervenes, and such penile deformity begets the risk of emotional distress. The urethral opening on the end of the penis can become infected or ulcerated when the glans is no longer protected by foreskin; such infection rarely occurs in the uncircumcised. Finally, any surgical procedure runs the risk of infection. These localized infections rarely spread to the blood, but death from sepsis and its sequelae has been documented. Overall, the surgical complication rate after circumcision runs around 0.19 percent, which could be lowered with strict protocols, meticulous technique, strict asepsis, and well-trained, experienced physicians. Strict protocols, it is hoped, would ensure that absolute contraindications to the procedure—such as anomalies of the penis, prematurity, instability, or a bleeding disorder—were honored. In part because of an additional cost that arises with anesthesia, the vast majority of infant circumcisions are performed without pain control. The surgery is painful, and yet some physicians claim that the minute that the operation ends, the circumcised baby no longer cries and frequently falls asleep. Continuing pain, therefore, is probably not present.
212 ✧ Circumcision of boys Changing Attitudes Toward Routine Circumcision Routine newborn circumcision originated in the United States in the 1860’s, ostensibly as prophylaxis against disease. Some medical historians, however, believe that nonreligious circumcision was a deliberate surgical procedure to desensitize and debilitate the penis to prevent masturbation. Eventually, a general change in attitude occurred, notably in Great Britain and New Zealand, which virtually have abandoned routine circumcision. Rates of circumcision have also fallen dramatically in Canada, Australia, and even the United States. As recently as the mid-1970’s, approximately 90 percent of U.S. male babies were circumcised. Not until 1971 did the American Academy of Pediatrics determine that circumcision is not medically valid. By 1995, the incidence of newborn circumcision had declined to 59 percent. In 1971, the American Academy of Pediatrics’ Committee on the Fetus and Newborn issued an advisory that said, “There are no valid medical indications for routine circumcision in the neonatal period.” In 1978, when the American College of Obstetricians and Gynecologists affirmed this statement, the circumcision rate had already declined to an estimated 70 percent of newborn males, compared to previous rates of between 80 and 90 percent. In response to the critics who were worried about increased urinary tract infections in the uncircumcised, the 1989 American Academy of Pediatrics’ Task Force on Circumcision concluded that “newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained.” Undoubtedly, the future will bring improved surgical techniques. More emphasis will be placed on avoiding surgical complications by more rigid monitoring of the operation and who performs the procedure. It is unlikely that circumcision will disappear completely. Organizations such as Doctors Opposing Circumcision and the National Organization to Halt the Abuse and Routine Mutilation of Males, however, are actively proposing an end to routine neonatal circumcision. Some nursing groups and concerned mothers have formed local groups to oppose circumcision. They argue that subjecting a baby to this procedure may impair mother-infant bonding. Another question posed by some physicians and parents is the ethics involved in the unnecessary removal of a functioning body organ, particularly without the patient’s consent. Others claim that the baby’s rights are being violated, noting that it is the child who must live with the outcome of the decision to perform a circumcision. —Wayne R. McKinny, M.D.; updated by John Alan Ross See also Children’s health issues; Circumcision of girls; Ethics. For Further Information: Behrman, Richard E., ed. Nelson Textbook of Pediatrics. 16th ed. Philadelphia:
Circumcision of girls ✧ 213 W. B. Saunders, 2000. This standard pediatric textbook briefly covers the medical risks and benefits of routine newborn circumcision fairly and without bias or excessive medical jargon. Draws no conclusions. Berkow, Robert, and Andrew J. Fletcher, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Rahway, N.J.: Merck Sharp & Dohme Research Laboratories, 1999. This classic textbook does say that circumcision “is rarely indicated medically.” In contrast with longer review articles, however, The Merck Manual states that bleeding disorders in infants should include a history of the mother’s taking medication for bleeding disturbances, such as anticoagulants or aspirin. Bigelow, Jim. The Joy of Uncircumcising!: Exploring Circumcision—History, Myths, Psychology, Restoration, Sexual Pleasure, and Human Rights. Rev. ed. Aptos, Calif.: Hourglass, 1998. This book provides an alternative view of this controversial procedure. King, L. R., ed. Urologic Surgery in Neonates and Young Infants. Philadelphia: W. B. Saunders, 1998. J. W. Duckett’s contribution, “The Neonatal Circumcision Debate,” is an excellent review of the controversies surrounding this operation. Although written for doctors, it will present minimal difficulty for laypersons. Snyder, Howard M. “To Circumcise or Not.” Hospital Practice 26 (January 15, 1991): 201-207. This widely available medical journal article examines in detail the medical evidence for and against circumcision. With a minimum of medical jargon, the author also states his own personal bias against the routine use of the procedure.
✧ Circumcision of girls Type of issue: Children’s health, ethics, medical procedures, women’s health Definition: The partial or complete surgical removal of the clitoris, labia minora, and labia majora for cultural reasons. The 1989-1990 Demographic Health Survey of Circumcision stated that circumcision is performed annually on an estimated 80 to 114 million women; 85 percent of these procedures involve clitoridectomy, while approximately 15 percent involve infibulation. Certain contemporary cultures of Africa, the Middle East, and parts of Yemen, India, and Malaysia continue these practices. Contemporary Middle Eastern countries practicing female circumcision and genital mutilation are Jordan, Iraq, the two Yemens, Syria, and southern Algeria. In Africa, it is practiced in the majority of the countries, including Egypt, Ivory Coast, Kenya, Mali, Mozambique, Sudan, and Upper Volta. It has been estimated that 99 percent of northern Sudanese women, aged fifteen to forty-nine, are circumcised. In and around
214 ✧ Circumcision of girls Alexandria, Egypt, 99 percent of rural and lower income urban women are circumcised. Types of Female Circumcision Cross-culturally, there are essentially four types of female genital circumcision and female genital mutilation. Circumcision or sunna circumcision is removal of the prepuce or hood of the clitoris, with the body of the clitoris remaining intact. Sunna means “tradition” in Arabic. Excision circumcision or clitoridectomy is the removal of the entire clitoris (both prepuce and glans) and all or part of the adjacent labia majora and the labia minora. Intermediate circumcision is the removal of the clitoris, all or part of the labia minora, and sometimes part of the labia majora. Infibulation or pharaonic circumcision is the removal of the clitoris, the labia minora, and much of the labia majora; on occasion, the remaining sides of the vulva are stitched together to close up the vagina, except for a small opening maintained for the passage of blood and urine. All types of female genital mutilation frequently create severe, long-term effects, such as pelvic infections that usually lead to infertility; chronic recurrent urinary tract infections; painful intercourse; obstetrical complications; and, in some cases, surgically induced scars that can cause tearing of the tissue, and even hemorrhaging, during childbirth. In fact, it is not unusual for women who have been infibulated to require surgical enlargement of the vagina on their wedding night or when delivering children. Unfortunately, babies born to infibulated women frequently suffer brain damage because of oxygen deprivation (hypoxia) caused by a prolonged and obstructed delivery. The baby may die during the painful birthing process because of a damaged birth canal. Other physical and psychological difficulties for the circumcised woman may be sexual dysfunction, delayed menarche, and genital malformation. Cultural Contexts From a cultural perspective, there are numerous reasons for these surgical procedures. It is a rite of passage and proof of adulthood. It raises a woman’s status in her community, because of both the added purity that circumcision brings and the bravery that initiates are called upon to demonstrate. It is also thought to confer maturity and inculcate positive character traits, such as the ability to endure pain and to be submissive. In some cultures, the circumcision ritual is a positive one in which the girl is the center of attention and receives presents and moral instruction from her elders. It creates a bond between the generations, as all women in the society must undergo the procedure and thus have shared an important experience. It is thought that a girl who has been circumcised will not have her
Circumcision of girls ✧ 215 conscience troubled by lustful thoughts or sensations or by physical temptations such as masturbation. Therefore, there is less risk of premarital relationships that can end in the stigma and social difficulties of illegitimate birth. The bond between husband and wife may be closer because one or both of them will never have had sex with anyone else. The relationship may be motivated by love rather than lust because there will be no physical drive for the wife, only an emotional one. There is little incentive for extramarital sex for the wife; hence, the marriage may be more secure. Children may be better cared for because the husband can be more confident that they are his. Generally, a girl who is not circumcised is considered “unclean” by local villagers and therefore unmarriageable. In some societies, a girl who is not circumcised is believed to be dangerous, even deadly, if her clitoris touches a man’s penis. Unfortunately, female genital circumcision and female genital mutilation surgeries are invariably conducted in unsanitary conditions in which a midwife or close female relative uses unsterile sharp instruments, such as pieces of glass, razor blades, kitchen knives, or scissors. The induction of tetanus, septicemia, hemorrhaging, and even shock are not uncommon. Human immunodeficiency virus (HIV) can be transmitted. No anesthesia is used. These procedures usually are experienced by the child at approximately three years of age, although the actual age depends upon the customs of the particular society or village. In order to minimize the risk of the transmission of viruses, countries such as Egypt have made it illegal for female genital mutilation to be practiced by anyone other than trained doctors and nurses in hospitals. Female Circumcision as a Violation of Human Rights Because of the high number of female genital mutilations and the deaths that this procedure has caused, it is now prohibited in Great Britain, France, Sweden, Switzerland, and some countries of Africa, such as Egypt, Kenya, and Senegal. The National Organization of Circumcision Information Resource Centers (NOCIRC) is opposed to the procedures, as well as to male circumcision. The United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) consider female genital mutilation to be a violation of human rights, recommending its eradication. In the United States, former Congresswoman Patricia Schroeder introduced a bill that would outlaw female genital mutilation. The bill, called the Federal Prohibition of Female Genital Mutilation of 1995, was passed in 1996. The Canadian Criminal Code was enacted to protect children who are ordinarily residents in Canada from being removed from the country and subjected to female genital mutilation. Both female genital circumcision and female genital mutilation perpetuate customs that seek to control female bodies and sexuality. It is hoped that
216 ✧ Cleft lip and palate with increasing legislation and attitude changes regarding bioethical issues, fewer girls and young women will undergo these mutilating surgical procedures. One problem in this campaign is the conflict between cultural selfdetermination and basic human rights. Feminists, physicians, and ethicists must work respectfully with, and not independently of, local resources for cultural self-examination and change. —John Alan Ross See also Circumcision of boys; Ethics; Health equity for women; Infertility in women; Menstruation; Sexual dysfunction. For Further Information: Elchala, U., B. Ben-Ami, R. Gillis, and A. Brezezinski. “Ritualistic Female Genital Mutilation: Current Status and Future Outlook.” Obstetrical and Gynecological Survey 52, no. 10 (1997): 643-653. Gollaher, David L. Circumcision: A History of the World’s Most Controversial Surgery. New York: Basic Books, 2000. James, Stephen A. “Reconciling International Human Rights and Cultural Relativism: The Case of Female Circumcision.” Bioethics 8, no. 1 (1994): 1-26. Kluge, E. W. “Female Genital Mutilation: Cultural Values and Ethics.” Journal of Obstetrics and Gynecology 16, no. 2 (1997): 71. Walker, Alice, and Pratibha Parmar. Warrior Marks: Female Genital Mutilation and the Sexual Blinding of Women. New York: Harcourt Brace, 1993.
✧ Cleft lip and palate Type of issue: Children’s health Definition: A fissure in the midline of the palate so that the two sides fail to fuse during embryonic development; in some cases, the fissure may extend through both hard and soft palates into the nasal cavities. Cleft palate is a congenital defect characterized by a fissure along the midline of the palate. It occurs when the two sides fail to fuse during embryonic development. The gap may be complete, extending through the hard and soft palates into the nasal cavities, or may be partial or incomplete. It is often associated with cleft lip or “hare lip.” About one child in eight hundred live births is affected with some degree of clefting, and clefting is the most common of the craniofacial abnormalities.
Cleft lip and palate ✧ 217 Development of Cleft Palate in the Fetus Cleft palate is not generally a genetic disorder; rather, it is a result of defective cell migration. Embryonically, in the first month, the mouth and nose form one cavity destined to be separated by the hard and soft palates. In addition, there is no upper lip. Most of the upper jaw is lacking; only the part near the ears is present. In the next weeks, the upper lip and jaw are formed from structures growing in from the sides, fusing at the midline with a third portion growing downward from the nasal region. The palates develop in much the same way. The fusion of all these structures begins with the lip and moves posteriorly toward, then includes, the soft palate. The two cavities are separated by the palates by the end of the third month of gestation. If, as embryonic development occurs, the cells that should grow together to form the lips and palate fail to move in the correct direction, the job is left unfinished. Clefting of the palate generally occurs between the thirtyfifth and thirty-seventh days of gestation. Fortunately, it is an isolated defect not usually associated with other disabilities or with mental retardation. If the interference in normal growth and fusion begins early and lasts throughout the fusion period, the cleft that results will affect one or both sides of the top lip and may continue back through the upper jaw, the upper gum ridge, and both palates. If the disturbance lasts only part of the time that development is occurring, only the lip may be cleft, and the palate may be unaffected. If the problem begins a little into the fusion process, the lip is normally formed, but the palate is cleft. The cleft may divide only the soft palate or both the soft and the hard palate. Even the uvula may be affected; it can be split, unusually short, or even absent. About 80 percent of cases of cleft lip are unilateral; of these, 70 percent occur on the left side. Of cleft palate cases, 25 percent are bilateral. The mildest manifestations of congenital cleft are mild scarring and/or notching of the upper lip. Beyond this, clefting is described by degrees. The first degree is incomplete, which is a small cleft in the uvula. The second degree is also incomplete, through the soft palate and into the hard palate. Another type of “second-degree incomplete” is a horseshoe type, in which there is a bilateral cleft proceeding almost to the front. Third-degree bilateral is a cleft through both palates but bilaterally through the gums; it results in a separate area of the alveolus where the teeth will erupt, and the teeth will show up in a very small segment. When the teeth appear, they may not be normally aligned. In addition to the lip, gum, and palate deviations, abnormalities of the nose may also occur. Cleft palate may be inherited, probably as a result of the interaction of several genes. In addition, the effect of some environmental factors that affect embryonic development may be linked to this condition. They might include mechanical disturbances such as an enlarged tongue, which prevents the fusion of the palate and lip. Other disturbances may be caused by
218 ✧ Cleft lip and palate toxins introduced by the mother (drugs such as cortisone or alcohol) and defective blood. Other associated factors include deficiencies of vitamins or minerals in the mother’s diet, radiation from X rays, and infectious diseases such as German measles. No definite cause has been identified, nor does it appear that one cause alone can be implicated. It is likely that there is an interplay between mutant genes, chromosomal abnormalities, and environmental factors. Problems Due to Cleft Palate Problems begin at birth for the infant born with a cleft palate. The most immediate problem is feeding the baby. If the cleft is small and the lip unaffected, nursing may proceed fairly easily. If the cleft is too large, however, the baby cannot build up enough suction to nurse efficiently. To remedy this, the hole in the nipple of the bottle can be enlarged, or a plastic obturator can be fitted to the bottle. Babies with cleft palate apparently are more susceptible to colds than other children. Since there is an open connection between the nose and mouth, an infection that starts in either location will easily and quickly spread to the other. Frequently, the infection will spread to the middle ear via the Eustachian tube. Other problems associated with cleft palate are those related to dentition. In some children there may be extra teeth, while in others the cleft may prevent the formation of tooth buds so that teeth are missing. Teeth that are present may be malformed; those malformations include injury during development, fusion of teeth to form one large tooth, teeth lacking enamel, and teeth that have too little calcium in the enamel. If later in development and growth the teeth are misaligned, orthodontia may be undertaken. Another possible problem met by patients with a cleft palate is maxillary (upper-jaw) arch collapse; this condition is also remedied with orthodontic treatment. Surgical Repair One of the first questions a parent of a child with a cleft palate will pose regards surgical repair. The purpose of surgically closing the cleft is not simply to close the hole—although that goal is important. The major purpose is to achieve a functional palate. Whether this can be accomplished depends on the size and shape of the cleft, the thickness of the available tissue, and other factors. When the child is scheduled for surgery, it is a tangible sign that the condition is correctable. When the lip is successfully closed, it is positive affirmation that a professional team can help the family. The goals of both the team and the family are extremely similar: Both want the patient to look as normal as possible and to have a functional palate.
Cleft lip and palate ✧ 219 Cleft lip surgery is performed when the healthy baby weighs at least seven pounds; it is done under a general anesthetic. If the cleft is unilateral, one operation can accomplish the closure, but a bilateral cleft lip is often repaired in two steps at least a month apart. When the lip is repaired, normal lip pressure is restored, which may help in closing the cleft in the gum ridge. It may also reduce the gap in the hard palate, if one is present. Successive operations may be suggested when, even years after surgery, scars develop on the lip. Surgery to close clefts of the hard and soft palate is typically done when the baby is at least nine months of age, unless there is a medical reason not to do so. Different surgeons prefer different times for this surgery. The surgeon attempts to accomplish three goals in the repair procedure. The surgeon will first try to ensure that the palate is long enough so that function and movement will result (this is essential for proper speech patterns). Second, the musculature around the Eustachian tube should work properly in order to cut down the incidence of ear infections. Finally, the surgery should promote the development of the facial bones and, as much as possible, normal teeth. This goal aids in eating and appearance. All this may be accomplished in one operation, if the cleft is not too severe. For a cleft that requires more procedures, the surgeries are usually spaced at least six months apart so that complete healing can occur. This schedule decreases the potential for severe scarring. Successful repair greatly improves speech and appearance, and the physiology of the oral and nasal cavities is also improved. Additional surgery may be necessary to improve appearance, breathing, and the function of the palate. Sometimes the palate may partially reopen, and surgery is needed to reclose it. Postsurgical Treatment When the baby leaves the operating room, there are stitches in the repaired area. Sometimes a special device called a Logan’s bow is taped to the baby’s cheeks; this device not only protects the stitches but also relieves some of the tension on them. In addition, the baby’s arms may be restrained in order to keep the baby’s hands away from the affected area. A parent of a child that has just undergone cleft palate repair should not panic at the sight of bleeding from the mouth. To curb it, gauze may be packed into the repaired area and remain about five days after surgery. As mucus and other body fluids accumulate in the area, they may be suctioned out. During the initial recovery, the child is kept in a moist, oxygen-rich environment (an oxygen tent) until respiration is normal. The patient will be observed for signs of airway obstruction or excessive bleeding. Feeding is done by syringe, eyedropper, or special nipples. Clear liquids and juices only are allowed. The child sits in a high chair to drink, when possible. After
220 ✧ Cleft lip and palate feeding, the mouth should be rinsed well with water to help keep the stitches clean and uncrusted. Peroxide mixed with the water may help, as well as ointment. Intake and output of fluids are measured. Hospitalization may last for about a week, or however long is dictated by speed of healing. At the end of this week, stitches are removed and the suture line covered and protected by a strip of paper tape. An alternative to surgery is the use of an artificial palate known as an obturator. It is specially constructed by a dentist to fit into the child’s mouth. The appliance, or prosthesis, is carefully constructed to fit precisely and snugly, but it must be easily removable. There must be enough space at the back so the child can breathe through the nose. While speaking, the muscles move back over this opening so that speech is relatively unaffected. Speech Therapy Speech problems are likely the most residual of the problems in the cleft palate patient. The speech of the untreated, and sometimes the treated, cleft palate patient is very nasal. If the soft palate is too short, the closure of the palate may leave a space between the nose and the throat, allowing air to escape through the nose. There is little penetrating quality to the patient’s voice, and it does not carry well. Some cleft palate speakers are difficult to understand because there are several faults in articulation. Certainly not all cleft lip or palate patients, however, will develop communication problems; modern surgical procedures help ensure that most children will develop acceptable speech and language without necessitating the help of a speech therapist. Psychological and Emotional Responses The problems accompanying clefting may alter family morale and climate, increasing the complexity of the problem. A team of specialists usually works together to help the patient and the family cope with these problems. This team may include a pediatrician, a speech pathologist, a plastic surgeon, an orthodontist, a psychiatrist, a social worker, an otologist, an audiologist, and perhaps others. The formation and cooperation of a team of professionals and the emotional support that they provide for an affected family hopefully will enable that family to perceive the baby more positively, to focus on the child’s potential rather than on the disability. The cooperating team should monitor feeding problems, family and friends’ reactions to the baby’s appearance, how parents encourage the child to talk or how they respond to poor speech, and whether the parents are realistic about the long-term outcome for their child. The grief, guilt, and shock that the parents often feel can be positively altered by how the professional team tackles the problem and by communication with the
Cleft lip and palate ✧ 221 parents. Usually the team does not begin functioning in the baby’s life until he or she is about a month old. Some parents have confronted their feelings, while others are still struggling with the negative feeling that the birth brought to bear. Therefore, the first visit that the parents have with the team is important, because it establishes the foundation of a support system which should last for years. —Iona C. Baldridge See also Birth defects; Children’s health issues; Disabilities; Speech disorders. For Further Information: Batshaw, Mark L. Children with Disabilities. Baltimore: Paul H. Brookes, 1997. This book first takes the reader through the basics of genetics. Based on this information, diagnoses and descriptions of birth defects are made relative to the various organ systems. Concludes by examining the emotional aspects of living with a handicapped child. Clifford, Edward. The Cleft Palate Experience. Springfield, Ill.: Charles C Thomas, 1987. This author writes from the perspective of a cleft palate team participant and incorporates the value of the team in his chapters. Much space is given to the child’s development of a positive self-image and the parents’ role, from birth, in forming this image. Dronamraju, Krishna R. Cleft Lip and Palate. Springfield, Ill.: Charles C Thomas, 1986. A compilation of research emphasizing population genetics, dental genetics, evolution, teratology, reproductive biology, and epidemiology. The purpose is to provide a basis for genetic counseling. An extensive bibliography is included. Lorente, Christine, et al. “Tobacco and Alcohol Use During Pregnancy and Risk of Oral Clefts.” American Journal of Public Health 90, no. 3 (March, 2000): 415-419. This study examines the relationship between maternal tobacco and alcohol consumption during the first trimester of pregnancy and oral clefts. Multivariate analyses showed an increased risk of cleft lip with or without cleft palate associated with smoking and an increased risk of cleft palate associated with alcohol consumption. Stengelhofen, Jackie, ed. Cleft Palate. Edinburgh, Scotland: Churchill Livingstone, 1989. Explores the various communication problems met by those with a cleft palate. An appeal to the entire team of professionals treating the patient and their partnership with parents. Case histories are discussed.
222 ✧ Colic
✧ Colic Type of issue: Children’s health Definition: As a general term, a paroxysm of acute abdominal pain caused by spasm, obstruction, or twisting of a hollow abdominal organ. As a specific entity, infantile colic is a group of behaviors displayed by young infants including crying, facial grimacing, drawing-up of the legs over the abdomen, and clenching of the fists. As a general term, colic can arise from any site in the abdomen. For example, cramplike pain caused by a stone obstructing the bile ducts or a stone obstructing the urinary tract are known as biliary colic and renal colic, respectively. More specifically, the term “colic,” when unmodified, generally refers to infantile colic. The crying of colicky infants tends to be more prominent in the evening, although they cry more than other infants at other times of day. The “rule of threes” of infantile colic holds that infants with colic cry for more than three hours per day for more than three days per week for more than three weeks. The associated gestures suggest to some that the infant is experiencing abdominal pain and is responsible for the use of the term “colic” to describe the condition. Possible Causes Several causes of infantile colic have been postulated, but conclusive evidence is lacking for any of them. This combination of behaviors has been interpreted as abdominal pain, leading to the idea that cramping somewhere in the intestine is the cause. Neurobehavioral explanations have been offered. The most common is that colic represents a state of agitation that may not require a noxious stimulus for agitation and crying to continue. Rarely is colic the result of organic disease, and the prevailing opinion is that it is a variant of normal infant behavior. It appears to be unrelated to caregiving style or intensity. Other proposed mechanisms include difficult temperament, sleep disturbance, diarrhea, child abuse, and irritable bowel syndrome. Some theories ascribe colic to hypersensitivity to dietary protein—usually proteins derived from cow’s milk, which can be secreted in breast milk—thus explaining the occurrence of colic in breast-fed infants. Intestinal gas, either from air swallowed during feeding or from fermentation of incompletely absorbed carbohydrates in the colon, has also been implicated. Parents of colicky infants frequently describe flatulence as an associated symptom.
Colic ✧ 223 Treating Colic The medical treatment of the infant with colic begins with a thorough medical history and a careful physical examination. While the likelihood of finding a cause of the infant’s symptoms are slight, the thoroughness of this approach provides an effective basis for reassurance and demonstrates that the parents’ complaint is taken seriously. Infantile colic virtually always resolves spontaneously, leaving the infant healthy and thriving. The essentials of therapy are demystification, reassurance, and support for the haggard and anxious parents. Demystification is the explanation of the source of the infant’s distress, which alleviates the anxiety attendant on diagnostic hypotheses that occur to or are suggested to the parents. It is important for pediatricians to deal with the anxiety aroused by the infant’s symptoms with reassurance, pointing out that the baby will be fine; the only risk of lasting damage is to the parents. Quick, superficial attempts to solve the problem with formula changes or medications, particularly when not accompanied by patient demystification and reassurance, reinforce the parents’ suspicion that there is something wrong with the child, ultimately increasing parental perception of the child’s vulnerability. The results of studies in the medical literature investigating the usefulness of switching formulas and using agents such as simethicone to deal with intestinal gas are mixed. Dicyclomine, an anticholinergic medication used in the past, should not be given to infants under six months of age because of the possibility that it will interfere with the baby’s breathing. More frequent, smaller feedings may help, as may increased carrying (called “walking the floor”) and rocking. One theory holds that mimicking the environment in the womb is reassuring—closeness to a warm person with a detectable heartbeat, swaddling (wrapping the baby in a blanket to restrict movement of the extremities), and rhythmic stimulation provided by background music and car or stroller rides. One commonly used method involves placing the baby in an infant seat on top of a running washer or dryer, thus exposing the infant to constant vibration. Care must be taken to stay with the baby or to secure the infant seat to prevent injury resulting from a fall off the appliance. Most colicky infants have excessive gas, and “gas pains” have long been suspected as responsible for colic. Since virtually all the gas in the intestine is swallowed air, minimizing air swallowing and maximizing burping after feedings are important measures in reducing colic. The use of cereal to ease the infant’s hunger and decrease the vigor with which he or she sucks on the nipple results in less air being swallowed. Unfortunately, many parents are advised to put the cereal in the bottle; this increases the negative pressure required to suck the slurry of milk and cereal and increases the amount of air swallowed. —Wallace A. Gleason, Jr., M.D. See also Children’s health issues; Lactose intolerance.
224 ✧ Colon cancer For Further Information: Balon, Angie Juszczyk. “Management of Infantile Colic.” American Family Physician 55, no. 1 (January, 1997): 235-242, 245-246. Berkowitz, C. D. “Management of the Colicky Infant.” Comprehensive Therapy 23, no. 4 (April, 1997): 277-280. Lehtonen, L. A., and P. T. Rautava. “Infantile Colic: Natural History and Treatment.” Current Problems in Pediatrics 26, no. 3 (March, 1996): 79-85. Sferra, T. J., and L. A. Heitlinger. “Gastrointestinal Gas Formation and Infantile Colic.” Pediatric Clinics of North America 43, no. 2 (April, 1996): 489-510. Waltman, Alicia Brooks. “The Crying Game.” Parenting 14, no. 3 (April, 2000): 128-132. Waltman offers information about the latest research on colic and the best ways to soothe a crying baby. For many babies, a surefire soother is a breast or a bottle.
✧ Colon cancer Type of issue: Public health Definition: Cancer occurring in the large intestine, which is the second deadliest type of this disease. With an estimated 60,000 deaths per year in the United States, cancer of the colon and rectum (also called large bowel or colorectal cancer) is the second most deadly cancer, ranking only behind lung cancer. About 90 percent of colorectal cancers arise from the glandular epithelium lining the inner surface of the large bowel and are termed adenocarcinomas. The cells of this layer are constantly being replaced by new cells. This fairly rapid cell division, along with the relatively hostile environment within the bowel, promotes internal cellular errors that lead to the formation of aberrant cells. These cells can become disordered and produce abnormal growths or tumors. Often, colorectal tumors protrude into the lumen (the spaces within the bowel), forming growths called polyps. Some polyps are benign and do not spread to other parts of the body, but they may still disturb normal bowel functions. Other polyps become malignant by forming more aggressive cell types, which allows them to grow larger and spread to other organs. The cancer can grow through the layers of the colon wall and extend into the body cavity and nearby organs such as the urinary bladder. Cancer cells can also break away from the main tumor and spread (metastasize) through the blood or lymphatic vessels to other organs, such as the lungs or liver. If not controlled, the spreading cancer eventually causes death by impairment of organ and system functions. The risk of colorectal cancer is increased by certain hereditary and
Colon cancer ✧ 225 environmental factors. The dietary intake of fat and fiber also influences colorectal cancer risk. Researchers believe that fiber reduces the exposure of colon cells to cancer-causing chemicals (carcinogens) by diluting them and causing them to move more rapidly through the colon. Fats may promote colorectal cancer by triggering the excess secretion of bile, which is known to be carcinogenic in animals. In addition, fat may be converted to carcinogens by bacteria that live in the colon. Diets high in protein or low in fruit and vegetables may also elevate the risk. The tendency to develop colorectal polyps and cancer can be inherited; this genetic predisposition may be responsible for about 5 to 7 percent of all colorectal cancers. One example is an inherited disorder called familial adenomatous polyposis (FAP), in which multiple polyps develop in the colon; it often leads to colorectal cancer. Some of the defective genes that cause this and other types of colorectal cancers have been identified and are being studied to determine their role. The interplay between the various oncogenes (mutated cell division and growth genes) and tumor suppressor genes (cell division and growth inhibitor genes) has been determined. Whether inherited or caused by carcinogens, damage to these specific genetic regions disrupts the delicate balance that regulates orderly and perfectly timed cell reproduction and development, producing cancer cells. Irritable bowel syndrome (IBS) and exposure to certain occupational carcinogens are also known to increase the risk. Treating Colon Cancer The chances for survival are greatly increased when colorectal cancer is detected and treated at an early stage. Early detection in the general population is possible with the use of three common medical tests: digital rectal examination, in which the physician checks the inner surface of the rectal wall with gloved finger for abnormal growths; fecal occult blood test, in which a stool sample is tested for hidden blood that may have emanated from a cancerous growth; and sigmoidoscopy, in which the physician examines the rectal and lower colon inner lining with a narrow tubular optical instrument inserted through the anus. If cancer is suspected, further tests will be done to arrive at a diagnosis. These tests may include a computed tomography (CT) scan, double-contrast barium enema X-ray series, and colonoscopy. The CT scan and contrast X rays reveal abnormal growths, and colonoscopy is similar to sigmoidoscopy but uses a longer, flexible tube in order to inspect the entire colon. During sigmoidoscopy and colonoscopy, the physician can remove polyps and obtain tissue samples for biopsy. Microscopic examination of the tissue samples by a pathologist can determine the stage or extent of growth of the cancer. This is important because it helps determine the type of treatment. In one type of staging, the following criteria are used: stage 0 (cancer confined to epithelium lining of the
226 ✧ Colon cancer bowel), stage 1 (cancer confined to the bowel wall), stage 2 (cancer penetrating through all layers of the bowel wall and possibly invading adjacent tissues), stage 3 (cancer invading lymph nodes and/or adjacent tissues), and stage 4 (cancer spreading to distant sites, forming metastases). Surgery is the primary treatment for colorectal cancer. Very small tumors in stage 0 can be removed surgically with the colonoscope. Tumors in more advanced stages require abdominal surgery in which the tumor is removed along with a portion of the bowel and possibly some lymph nodes. For cases in which the bowel cannot be reconnected, an opening is created through the abdominal wall (colostomy). This is usually a temporary procedure, and the hole will be closed when the bowel can be rejoined. Some advanced cancers cannot be cured by surgery alone. Adjuvant therapies—chemotherapy, radiation therapy, and biological therapy—may be used in combination with surgery. Chemotherapy drugs kill spreading cancer cells. The most common is 5-fluorouracil (5-FU), a chemical that interferes with the production of deoxyribonucleic acid (DNA) in dividing cells. 5-FU is more effective when given together with leucovorin (a compound similar to folic acid) and levamisole (an immune system stimulant). Levamisole and other treatments that reinforce the immune system are forms of biological therapy. Radiation therapy, given either before or after surgery, is helpful in killing undetected cancer cells near the site of the tumor. A Disease of Developed Societies More than 150,000 new cases of colorectal cancer are diagnosed in the United States each year, or roughly 15 percent of all cancers. The incidence of colorectal cancer is lower among females than males and rises dramatically after the age of fifty. Colorectal cancer is more common in developed countries such as the United States and in densely populated, industrialized regions. American mortality rates from colorectal cancer are higher in the Northeast and north-central regions of the country than in the South and Southwest. Populations moving from low-risk parts of the world, such as Asia or Africa, to high-risk areas, such as the United States or Europe, take on the higher risk within a generation or two, and vice versa. —Rodney C. Mowbray; updated by Connie Rizzo, M.D. See also Cancer; Chemotherapy; Nutrition and aging; Radiation. For Further Information: De Vita, Vincent T., Jr., Samuel Hellman, and Steven A. Rosenberg, eds. Cancer: Principles and Practice of Oncology. 5th ed. Philadelphia: J. B. Lippincott, 1997. Miles, Andrew, David Cunningham, and Daniel Haller, eds. The Effective Management of Colorectal Cancer. London: Aesculapius, 2000.
Condoms ✧ 227 Miskovitz, Paul, and Marian Betancourt. What to Do If You Get Colon Cancer: A Specialist Helps You Take Charge and Make Informed Choices. New York: Wiley, 1997. Murphy, G., L. Morris, and D. Lange. Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery. New York: Viking Press, 1997. Taylor, Irving, Stanley M. Goldberg, and Julio Garcia-Aguilar. Colorectal Cancer. Oxford, England: Oxford University Press, 1999.
✧ Condoms Type of issue: Men’s health, public health, women’s health Definition: The most commonly used form of barrier contraceptive; when used properly, they can prevent the sexual transmission of disease, as well as pregnancy. Condoms are included, along with the diaphragm, cervical cap, and contraceptive sponge, in the category of birth control devices called barrier methods; these devices reduce the probability of pregnancy by blocking the transmission of semen into the cervix, thus preventing sperm from reaching the egg. Because they prevent the exchange of body fluids, condoms also prevent the transmission of the viruses, bacteria, and other microorganisms that cause sexually transmitted diseases such as syphilis, chlamydia, genital warts, and acquired immunodeficiency syndrome (AIDS). Male condoms have been in existence for hundreds of years; made of animal or artificial membranes, they are put, like a sheath, over the erect penis. Female condoms are a relatively recent invention; also called the vaginal pouch, they are bag-shaped membranes inserted in the vagina. When used consistently and correctly, condoms are a highly effective method of preventing pregnancy and the transmission of sexual diseases. Correct usage means making sure the product has not passed its shelf life (it should be dated); has not been stored at high temperatures (including in a pocket or a wallet pressed close to the body); is used in conjunction with a spermicide (sold separately or included with the condom); is put on properly and at the proper time (not too tightly and before any fluid is present on the tip of the penis); and is not removed or allowed to slip off until after intercourse is completed. Unfortunately, many users do not follow all these rules or do not use condoms for every episode of intercourse. As a result, the actual failure rate for condom use is about 20 percent (measured in the percentage of couples per year using condoms as their only method of birth control who experience an unwanted pregnancy), compared to laboratory failure rates of only 1 to 2 percent. Human error and inconsistency also increase the actual rates of disease transmission above the near-zero meas-
228 ✧ Condoms ures of microbial passage through condom membranes as studied in the laboratory. Male condoms are relatively inexpensive and are easy to obtain, but many men do not like them because they reduce stimulation of the penis. This fact has resulted in many unwanted pregnancies and sexual diseases among women who do not have access to other forms of birth control and who have been unsuccessful in persuading their partners to use condoms. Because female condoms do not cause as much reduction in penile stimulation as do male condoms and because they cause very little change in female sensations, a woman is more likely to convince a male partner that the couple should use a female condom. Thus, the introduction of this option gives women more control over their health and reproductive choices. Controversy exists, however, regarding whether teenagers should be given easy access to condoms to protect against STDs and unwanted pregnancies. Advocates argue that condom availability, perhaps even in schools, would save many lives and promote health. Critics claim that providing condoms or other forms of contraception sends the wrong message about the appropriateness of sexual activity among minors. —Linda Mealey See also Abortion among teenagers; AIDS; AIDS and women; Birth control and family planning; Herpes; Morning-after pill; Pregnancy among teenagers; Sexually transmitted diseases (STDs). For Further Information: Covington, Timothy R., and J. Frank McClendon. Sex Care: The Complete Guide to Safe and Healthy Sex. New York: Pocket Books, 1987. Detailed information on how to use contraceptives. Sexually transmitted diseases and other reproductive health problems are also covered. Green, Shirley. The Curious History of Contraception. London: Ebury Press, 1971. A lighthearted account of contraceptive history, this book makes entertaining reading, with ample coverage of some of the more outlandish methods of contraception that people have used. Harlap, Susan, Kathryn Kost, and Jacqueline Darroch Forrest. Preventing Pregnancy, Protecting Health: A New Look at Birth Control Choices in the United States. New York: Alan Guttmacher Institute, 1991. This well-researched book presents information on the health impact of different forms of contraception, such as sexually transmitted diseases, cancer, and later infertility. Highly recommended. Hatcher, Robert A., et al. Contraceptive Technology. 17th ed. New York: Irvington, 1998. This frequently revised book offers a thorough and readable discussion of most aspects of contraception.
Cosmetic surgery and aging ✧ 229
✧ Cosmetic surgery and aging Type of issue: Elder health, medical procedures, social trends Definition: Plastic surgery intended to minimize the visible effects of aging, giving the person a more youthful, rested appearance. Plastic surgery can be divided into two basic types: reconstructive and cosmetic. Reconstructive surgery is done to restore function to a damaged body part, as with congenital abnormalities or traumatic lesions. Cosmetic surgery is done to remove blemishes or change contours. In some instances, such as traumatic injuries or cancer surgeries, plastic surgery may be used both to restore function and to remove blemishes or change contours. This entry focuses on cosmetic surgery that is done to counteract some of the effects of the aging process. Types of Cosmetic Surgeries Cosmetic surgery may be requested to counteract the normal changes of the skin that appear with aging. The area around the eye is the first to show signs of aging. The procedure that removes excess skin and fatty tissue from eyelids and eye area is called blepharoplasty. Areas involved can include one or both eyes and either upper or lower lids, or both. Incisions are made in the eyelid fold and extend out toward the smile lines. A later sign of aging is the gradual stretching downward of the cheeks and deep wrinkling of the forehead. Face lifts (rhytidectomy) and brow lifts are procedures to address these issues. Rhytidectomy tightens the skin of the face and neck. The face and neck are often done together because aging changes occur in both at the same time. A brow lift relieves sagging eyebrows and a wrinkling forehead. Tightness occurs after these procedures because skin and sometimes underlying tissue and muscles are moved. Extra skin is cut off. Incisions are made in existing creases and A “face lift” is the term used for the excision and pulling in the hairline around ears. upward of sagging skin on the face. This cosmetic proceWhile there are many rea- dure can smooth wrinkles and provide a more attractive sons for hair loss—severe profile, but there are drawbacks: The patient’s appearinfection, thyroid disease, ance may be changed too dramatically, and the procesome medications, chemo- dure must be repeated periodically to maintain the detherapy—the main reason is sired results. (Hans & Cassidy, Inc.)
230 ✧ Cosmetic surgery and aging heredity. Hair loss can begin in the twenties or thirties. It occurs both in men and women, but women seldom go bald. There are many treatments: systemic steroids or hormones, ointments, and antibiotics. Hair transplantation is another method. The older type of hair transplantation takes grafts from the back and side of the scalp and places them Blepharoplasty is the removal of excess, baggy skin around in the bald areas. Several sesthe eyes. (Hans & Cassidy, Inc.) sions are usually required. A disadvantage of this method is that it often gives the appearance of “doll’s hair.” A newer method is microtransplantation, or minigrafts, which takes a few hairs with each graft. The result is a more natural look. The surgeries outlined here are only a few of the numerous procedures that are offered. Many of the cosmetic surgeries can be done in an outpatient setting, while others can be done only in a hospital. The surgical time can last from thirty minutes to four or five hours. All procedures will produce some degree of swelling and bruising—which can last for several weeks. Opinions About Cosmetic Surgery There are two basic camps regarding cosmetic surgery: those who think that it is a waste of money and those who believe that it is the best thing offered. Those in the first group believe no cream, drug, or surgery can stop or reverse the aging process. They are quick to point out that cosmetic surgery is temporary and that the aging process continues, which means that wrinkles and sags will reappear. The money wasted on attempts to defy reality could be better used to meet more basic needs. Many also argue that American society tends to take the “quick fix” approach and jump at medication or surgeries to solve their problems. This group of people is more likely to avoid the sun, maintain proper nutrition, and not smoke as more natural methods to slow the signs of aging. Members of the other group acknowledge that cosmetic surgery does not stop the aging process but seem pleased at the temporary reversal of the process. These people believe there is a positive impact on their daily life. Studies have demonstrated that there is an increase in self-esteem, more self-confidence, more satisfaction with appearance, and less depression after a person undergoes cosmetic surgery.
Cosmetic surgery and women ✧ 231 Issues to Consider Before cosmetic surgery is performed, several issues need to be addressed. The first is the general health of the person considering surgery. With age and the natural decline of some body functions, there can be a greater likelihood of adverse reactions to anesthesia and a delay in healing. The desired results of the surgery need to be reviewed. Cosmetic surgery will not yield a “model-like” appearance. People with unrealistic expectations will not be satisfied with the results. It is important to remember that the results of surgery are not seen immediately. There can be extreme bruising and swelling for several weeks after most surgeries. It may take up to a year for healing to be complete. While cosmetic surgery is not the fountain of youth, it can be an effective method to aid people in looking their best. —Jennifer J. Hostutler See also Aging; Cosmetic surgery and women; Hair loss and baldness; Liposuction; Obesity and aging; Skin disorders with aging; Weight changes with aging. For Further Information: Henry, Kimberly A., and Penny S. Heckaman. The Plastic Surgery Sourcebook. Los Angeles: Lowell House, 1997. Marfuggi, Richard A. Plastic Surgery: What You Need to Know Before, During, and After. New York: Berkeley, 1998. Perry, Arthur W., and Robin K. Levinson. A Complete Question and Answer Guide. New York: Avon Books, 1997. Sarnoff, Deborah S., and Joan Swirsky. Beauty and the Beam: Your Complete Guide to Cosmetic Laser Surgery. New York: St. Martins Griffin, 1998. Wyer, E. Bingo. The Unofficial Guide to Cosmetic Surgery. New York: Simon & Schuster/Macmillan, 1999.
✧ Cosmetic surgery and women Type of issue: Medical procedures, social trends, women’s health Definition: The use of surgical techniques to reshape parts of a woman’s body. The term “plastic surgery” comes from the Latin plasticere, meaning “to mold”; the terms “plastic surgery” and “cosmetic surgery” have often been used interchangeably, although “cosmetic” implies procedures performed purely for aesthetic purposes. While cosmetic surgery could conceivably be performed on any part of the female body, the most common procedures are face and neck lifts, blepharoplasty (upper and lower eyelid tucks), breast
232 ✧ Cosmetic surgery and women enhancement and reduction, abdominoplasty (tummy tucks), and rhinoplasty (nose reshaping). Others include collagen injections, dermabrasion, chemical peels, cheek implants, and liposuction. A face and neck lift once simply pulled the skin and did not last more than five years, but new techniques involve changes in fat, tissue, and muscles, with results lasting between five and ten years. The surgeon makes cuts along the hairline above, in front of, and behind the ear and then removes fat deposits in the neck, frees up deep layers of tissues in the face, and pulls muscle layers in the face and neck so that they can be stitched behind the ears. Upper eyelid surgery removes loose skin, stretched muscle, and excess fat to correct droopy lids, while lower eyelid surgery smoothes out bulges, removes bags, and tightens the skin. Augmentation mammoplasty, or breast enlargement, has received the most publicity in recent years because the most common technique involves silicone implants. The implants may consist of semisolid, soft silicone in a solid silicone envelope or silicone covered with polyurethane; the latter is less common than it once was because of resulting infections and the difficulty involved in removing them. Implants may also consist of a waterfilled silicone envelope or a double-walled envelope. Breast enlargement surgery involves placing the implants either on top of or under the pectoral muscles. Reduction mammoplasty, or breast reduction surgery, is performed when overly large breasts cause medical problems and discomfort. Reduction can relieve backaches, shoulder aches, and breast crease irritation. In this procedure, excess breast tissue is removed, and the nipple is repositioned and sewn into the skin. Other stitches close the skin under the nipple, and another closes the gap between the skin and the breast crease. Techniques have improved in all areas of plastic surgery—for example, lasers can destroy spidery blood vessels, and endoscopic techniques can replace traditional incisions in face lifts—and the process has been streamlined. Surgery may be performed in a doctor’s office rather than in a hospital, and, depending on the procedure, patients may have a choice between regional and general anesthesia. They may be able to go home shortly after surgery. Risks and Controversy Most types of plastic surgery are major operations, and all cost considerable money. Depending on the procedure, the doctor, and the location, the costs range from a few thousand dollars to eight or ten thousand dollars. Medical insurance will not pay for cosmetic surgery. Recovery time may be a few days or a few weeks, or tissues may take several months to heal completely. In addition, physical risks accompany any surgery, and plastic surgery is no exception. In The Complete Book of Cosmetic Surgery (1988), Elizabeth
Cosmetic surgery and women ✧ 233 Morgan argues that after a face lift, minor surgery may be needed to correct scarring, nerves may be numb or bruised, and further surgery may be needed to stop bleeding. With breast enlargement surgery, the breasts may become permanently numb, the implants may leak and require removal, and infections (though unlikely) may occur. With breast reduction surgery, scar surgery or steroid injections may be needed, nipple feeling may not return, and the nipple may blister and become scarred or discolored. Many women object to such procedures because of the societal view that youth and beauty are paramount and that those women who fall short of perfection should alter themselves surgically. This view is reinforced in magazines, which are filled with pencil-thin models with perfect features and in businesses, where attractive women are often promoted more quickly than less attractive women. Many women are driven to plastic surgery by their own desires to correct what may or may not be actual flaws, others by the urging of parents or partners. Naomi Wolf, author of The Beauty Myth (1991), writes of a woman whose boyfriend rewarded her with breast implants for finishing her Ph.D. and of the trend in which some wealthy parents give their graduating daughters breast implants while their graduating sons receive trips to Europe. She complains, too, that women are not given enough information about the risks of surgery and are told there will be “some discomfort” rather than pain after the surgery. Wolf claims that such surgery is painful. In an apparent contradiction, women who had undergone such procedures, interviewed for an article in Hemisphere magazine, spoke of discomfort rather than of pain. Yet the article also quotes a plastic surgeon who says that women are accustomed to inconveniencing themselves in the pursuit of improving their looks, which is one reason that they make such good patients. —Kate L. Peirce See also Breast surgery; Cosmetic surgery and aging; Hair loss and baldness; Liposuction; Tattoos and body piercing; Women’s health issues. For Further Information: Adams, Jan R. Everything Women of Color Should Know About Cosmetic Surgery. New York: St. Martin’s Press, 2000. Chapkis, Wendy. Beauty Secrets: Women and the Politics of Appearance. Boston: South End Press, 1986. Davis, Kathy. Reshaping the Female Body: The Dilemma of Cosmetic Surgery. New York: Routledge, 1995. Sapiro, Virginia. Women in American Society. 4th ed. Mountain View, Calif.: Mayfield, 1998. Wolf, Naomi. The Beauty Myth. New York: William Morrow, 1991.
234 ✧ Death and dying
✧ Death and dying Type of issue: Ethics, mental health, public health, social trends Definition: The process and result of a major, irreversible failure in bodily systems. Medicine determines that death has occurred by assessing bodily functions in either of two areas. Persons with irreversible cessation of respiration and circulation are dead; persons with irreversible cessation of ascertainable brain functions are also dead. There are standard procedures used to diagnose death, including simple observation, brain-stem reflex studies, and the use of confirmatory testing such as electrocardiography (ECG or EKG), electroencephalography (EEG), and arterial blood gas analysis (ABG). The particular circumstances—anticipated or unanticipated, observed or unobserved, the patient’s age, drug or metabolic intoxication, or suspicion of hypothermia—will favor some procedures over others, but in all cases both cessation of functions and their irreversibility are required before death can be declared. A Physical and Psychological Process Between 60 and 75 percent of all people die from chronic terminal conditions. Therefore, except in sudden death (as in a fatal accident) or when there is no evidence of consciousness (as in a head injury which destroys cerebral, thinking functions while leaving brain-stem, reflexive functions intact), dying is both a physical and a psychological process. In most cases, dying takes time, and the time allows patients to react to the reality of their own passing. Often, they react by becoming vigilant about bodily symptoms and any changes in them. They also anticipate changes that have yet to occur. For example, long before the terminal stages of illness become manifest, dying patients commonly fear physical pain, shortness of breath, invasive procedures, loneliness, becoming a burden to loved ones, losing decision-making authority, and facing the unknown of death itself. Medicine has come to acknowledge that physicians should understand what it means to die. Indeed, while all persons should understand what their own deaths will mean, physicians must additionally understand how their dying patients find this meaning. Physicians who see death as the final calamity coming at the end of life, and thus primarily as something that only geriatric medicine has to face, are mistaken. Independent of beliefs about “life after life,” the life process on this planet inexorably comes to an end for everyone, whether as a result of accident, injury, or progressive deterioration.
Death and dying ✧ 235 Quality of Death In 1969, psychiatrist Elisabeth Kübler-Ross published the landmark On Death and Dying, based on her work with two hundred terminally ill patients. In it, she provided a framework which explained how people cope with and adapt to the profound and terrible news that their illness is going to kill them. Although other physicians, psychologists, and thanatologists have shortened, expanded, and adapted her five stages of the dying process, neither the actual number of stages nor what they are specifically called is as important as the information and insight that any stage theory of dying yields. As with any human process, dying is complex, multifaceted, multidimensional, and polymorphic. Denial, Anger, and Bargaining Denial is Kübler-Ross’s first stage, but it is also linked to shock and isolation. Whether the news is told outright or gradual self-realization occurs, most people react to the knowledge of their impending death with existential shock. Broadly considered, denial is a complex cognitive-emotional capacity which enables temporary postponement of active, acute, but in some way detrimental, recognition of reality. In the dying process, this putting off of the truth prevents a person from being overwhelmed while promoting psychological survival. Denial plays an important stabilizing role, holding back more than could be otherwise managed while allowing the individual to marshal psychological resources and reserves. It enables patients to consider the possibility, even the inevitability, of death and then to put the consideration away so that they can pursue life in the ways that are still available. In this way, denial is truly a mechanism of defense. Many other researchers, along with Kübler-Ross, report anger as the second stage of dying. The stage is also linked to rage, fury, envy, resentment, and loathing. Patients then begin to replace denial with attempts to understand what is happening to and inside them. When they do, they often ask, “Why me?” Though logically an unanswerable question, the logic of the question is clear. People, to remain human, must try to make intelligible their experiences and reality. The asking of this question is an important feature of the way in which all dying persons adapt to and cope with the reality of death. People react with anger when they lose something of value; they react with greater anger when something of value is taken away from them by someone or something. Rage and fury, in fact, are often more accurate descriptions of people’s reactions to the loss of their own life than anger. Anger is a difficult stage for professionals and loved ones, more so when the anger and rage are displaced and projected randomly into any corner and crevice of the patient’s world. An unfortunate result is that caretakers often experience the anger as personal, and the caretakers’ own feelings of guilt,
236 ✧ Death and dying shame, grief, and rejection can contribute to lessening contact with the dying person, which increases his or her sense of isolation. Bargaining is Kübler-Ross’s third stage, but it is also the one about which she wrote the least and the one that other thanatologists are most likely to leave unrepresented in their own models and stages of how people cope with dying. Nevertheless, it is a common phenomenon wherein dying people fall back on their faith, belief systems, or sense of the transcendent and the spiritual and try to make a deal—with God, life, fate, a higher power, or the composite of all the randomly colliding atoms in the universe. They ask for more time to help family members reconcile or to achieve something of importance. They may ask if they can simply attend their child’s wedding or graduation or if they can see their first grandchild born. Then they will be ready to die; they will go willingly. Often, they mean that they will die without fighting death, if death can only be delayed or will delay itself. Some get what they want; others do not. Depression and Acceptance The depression can take many forms, for indeed there are always many losses, and each loss individually or several losses collectively might need to be experienced and worked through. For example, dying parents might ask themselves who will take care of the children, get them through school, walk them down the aisle, or guide them through life. Children, even adult children who are parents themselves, may ask whether they can cope without their own parents. They wonder who will support and anchor them in times of distress, who will (or could) love, nurture, and nourish them the way that their parents did. Depression accompanies the realization that each role, each function, will never be performed again. Both the dying and those who love them mourn. Much of the depression takes the form of anticipatory grieving, which often occurs both in the dying and in those who will be affected most by their death. It is a part of the dying process experienced by the living, both terminal and nonterminal. Patients, family, and friends can psychologically anticipate what it will be like when the death does occur and what life will, and will not, be like afterward. The grieving begins while there is still life left to live. Bereavement specialists generally agree that anticipatory grieving, when it occurs, seems to help people cope with what is a terrible and frightening loss. It is an adaptive psychological mechanism wherein emotional, mental, and existential stability is painfully maintained. When depression develops, not only in reaction to death but also in preparation for it, it seems to be a necessary part of how those who are left behind cope in order to survive the loss themselves. Those who advocate or advise cheering up or looking on the bright side are either unrealistic or unable to tolerate the sadness in them-
Death and dying ✧ 237 selves or others. The dying are in the process of losing everything and everyone they love. Cheering up does not help them; the advice to “be strong” only helps the “helpers” deny the truth of the dying experience. Both preparatory and reactive depression are often accompanied by unrealistic self-recrimination, shame, and guilt in the dying person. Those who are dying may judge themselves harshly and criticize themselves for the wrongs that they committed and for the good that they did not accomplish. They may judge themselves to be unattractive, unappealing, and repulsive because of how the illness and its treatment have made them appear. These feelings and states of minds, which have nothing to do with the reality of the situation, are often amenable to the interventions of understanding and caring people. Disfigured breasts do not make a woman less a woman; the removal of the testes does not make a man less a man. Financial and other obligations can be restructured and reassigned. Being forgiven and forgiving can help finish what was left undone. Kübler-Ross’s fifth stage, acceptance, is an intellectual and emotional coming to terms with death’s reality, permanence, and inevitability. Ironically, it is manifested by diminished emotionality and interests and increased fatigue and inner (many would say spiritual) self-focus. It is a time without depression or anger. Envy of the healthy, the fear of losing all, and bargaining for another day or week are also absent. This final stage is often misunderstood. Some see it either as resignation and giving up or as achieving a happy serenity. Some think that acceptance is the goal of dying well and that all people are supposed to go through this stage. None of these viewpoints is accurate. Acceptance, when it does occur, comes from within the dying person. It is marked more by an emotional void and psychological detachment from people and things once held important and necessary and by an interest in some transcendental value (for the atheist) or his or her God (for the theist). It has little to do with what others believe is important or “should” be done. It is when dying people become more intimate with themselves and appreciate their separateness from others more than at any other time. Accepting Death as Natural All patients die—a fact that the actual practice of clinical Western medicine has too often discounted. Dealing with death is difficult in life, and it is difficult in medicine. As the ultimate outcome of all medical interventions, however, it is unavoidable. Dealing with the dying and those who care about them is also difficult. Patients ask questions that cannot be answered; families in despair and anger seek to find cause and sometimes lay blame. It takes courage to be with individuals as they face their deaths, struggling to find meaning in the time that they have left. It takes special courage simply to witness this struggle in a profession which prides itself on how well it
238 ✧ Death and dying intervenes. Working with death also reminds professionals of their own inevitable death. Facing that fact inwardly, spiritually, and existentially also requires courage. Cure and treatment become care and management in the dying. They should live relatively pain-free, be supported in accomplishing their goals, be respected, be involved in decision making as appropriate, be encouraged to function as fully as their illness allows, and be provided with others to whom control can comfortably and confidently be passed. The lack of a cure and the certainty of the end can intimidate health care providers, family members, and close friends. They may dread genuine encounters with those whose days are knowingly numbered. Yet the dying have the same rights to be helped as any of the living, and how a society assists them bears directly on the meaning that its members are willing to attach to their own lives. Today, largely in response to what dying patients have told researchers, medicine recognizes its role to assist these patients in working toward an appropriate death. Caretakers must determine the optimum treatments, interventions, and conditions which will enable such a death to occur. For each terminally ill person, these should be unique and specific. Caretakers should respond to the patient’s needs and priorities, at the patient’s own pace and as much as possible following the patient’s lead. For some dying patients, the goal is to remain as pain-free as is feasible and to feel as well as possible. For others, finishing whatever unfinished business remains becomes the priority. Making amends, forgiving and being forgiven, resolving old conflicts, and reconciling with self and others may be the most therapeutic and healing of interventions. Those who are to be bereaved fear the death of those they love. The dying fear the separation from all they know and love, but they fear as well the loss of autonomy, letting family and friends down, the pain and invasion of further treatment, disfigurement, dementia, loneliness, the unknown, becoming a burden, and the loss of dignity. —Paul Moglia See also Abortion; Abortion among teenagers; Aging; AIDS; AIDS and children; AIDS and women; Depression; Depression in children; Depression in the elderly; Ethics; Euthanasia; Hippocratic oath; Hospice; Hospitalization of the elderly; Law and medicine; Living wills; Stress; Sudden infant death syndrome (SIDS); Suicide; Suicide among children and teenagers; Suicide among the elderly; Terminal illnesses. For Further Information: Becker, Ernest. The Denial of Death. New York: Free Press, 1997. Written by an anthropologist and philosopher, this is an erudite and insightful analysis and synthesis of the role that the fear of death plays in motivating human activity, society, and individual actions. A profound work. Cook, Alicia Skinner, and Daniel S. Dworkin. Helping the Bereaved: Therapeutic
Dementia ✧ 239 Interventions for Children, Adolescents, and Adults. New York: Basic Books, 1992. Although not a self-help book, this work is useful to professionals and nonprofessionals alike as a review of the state of the art in grief therapy. Practical and readable. Of special interest for those becoming involved in grief counseling. Corr, Charles A., Clyde M. Nabe, and Donna M. Corr. Death and Dying, Life and Living. 3d ed. Belmont, Calif.: Wadsworth, 1999. This book provides perspective on common issues associated with death and dying for family members and others affected by life-threatening circumstances. Kübler-Ross, Elisabeth, ed. Death: The Final Stage of Growth. Reprint. New York: Simon & Schuster, 1986. A psychiatrist by training, Kübler-Ross brings together other researchers’ views of how death provides the key to how human beings make meaning in their own personal worlds. The author, who is regarded as the pioneer in death and dying studies, addresses practical concerns over how people express grief and accept the death of those close to them, and how they might prepare for their own inevitable ends. Kushner, Harold. When Bad Things Happen to Good People. New York: Summit, 1985. The first of Rabbi Kushner’s works on finding meaning in one’s life, it was originally his personal response to make intelligible the death of his own child. It has become a highly regarded reference for those who struggle with the meaning of pain, suffering, and death in their lives. Highly recommended.
✧ Dementia Type of issue: Elder health, mental health Definition: A generally irreversible decline in intellectual ability resulting from a variety of causes; differs from mental retardation, in which the affected person never reaches an expected level of mental growth. Dementia affects about four million people in the United States and is a major cause of disability in old age. Its prevalence increases with age. Dementia is characterized by a permanent memory deficit affecting recent memory in particular and of sufficient severity to interfere with the patient’s ability to take part in professional and social activities. Although the aging process is associated with a gradual loss of brain cells, dementia is not part of the aging process. It also is not synonymous with benign senescent forgetfulness, which is very common in old age and affects recent memory. Although the latter is a source of frustration, it does not significantly interfere with the individual’s professional and social activities because it tends to affect only trivial matters (or what the individual considers trivial).
240 ✧ Dementia Furthermore, patients with benign forgetfulness usually can remember what was forgotten by utilizing a number of subterfuges, such as writing lists or notes to themselves and leaving them in conspicuous places. Individuals with benign forgetfulness also are acutely aware of their memory deficit, while those with dementia—except in the early stages of the disease—have no insight into their memory deficit and often blame others for their problems. In addition to the memory deficit interfering with the patient’s daily activities, patients with dementia have evidence of impaired abstract thinking, impaired judgment, or other disturbances of higher cortical functions such as aphasia (the inability to use or comprehend language), apraxia (the inability to execute complex, coordinated movements), or agnosia (the inability to recognize familiar objects). Causes of Dementia Dementia may result from damage to the cerebral cortex (the outer layer of the brain), as in Alzheimer’s disease, or from damage to the subcortical structures (the structures below the cortex), such as white matter, the thalamus, or the basal ganglia. Although memory is impaired in both cortical and subcortical dementias, the associated features are different. In cortical dementias, for example, cognitive functions such as the ability to understand speech and to talk and the ability to perform mathematical calculations are severely impaired. In subcortical dementias, on the other hand, there is evidence of disturbances of arousal, motivation, and mood, in addition to a significant slowing of cognition and of information processing. Alzheimer’s disease, the most common cause of presenile dementia, is characterized by progressive disorientation, memory loss, speech disturbances, and personality disorders. Pick’s disease is another cortical dementia, but unlike Alzheimer’s disease, it is rare, tends to affect younger patients, and is more common in women. In the early stages of Pick’s disease, changes in personality, disinhibition, inappropriate social and sexual conduct, and lack of foresight may be evident—features that are not common in Alzheimer’s disease. Patients also may become euphoric or apathetic. Poverty of speech is often present and gradually progresses to mutism, although speech comprehension is usually spared. Pick’s disease is characterized by cortical atrophy localized to the frontal and temporal lobes. Vascular dementia is the second most common cause of dementia in patients over the age of sixty-five and is responsible for 8 percent to 20 percent of all dementia cases. It is caused by interference with the blood flow to the brain. Although the overall prevalence of vascular dementia is decreasing, there are some geographical variations, with the prevalence being higher in countries with a high incidence of cardiovascular and cerebrovas-
Dementia ✧ 241 cular diseases, such as Finland and Japan. About 20 percent of patients with dementia have both Alzheimer’s disease and vascular dementia. Several types of vascular dementia have been identified. Multiple infarct dementia (MID) is the most common type of vascular dementia. As its name implies, it is the result of multiple, discrete cerebral infarcts (strokes) that have destroyed enough brain tissue to interfere with the patient’s higher mental functions. The onset of MID is usually sudden and is associated with neurological deficit, such as the paralysis or weakness of an arm or leg or the inability to speak. The disease characteristically progresses in steps: With each stroke experienced, the patient’s condition suddenly deteriorates and then stabilizes or even improves slightly until another stroke occurs. In about 20 percent of patients with MID, however, the disease displays an insidious onset and causes gradual deterioration. Most patients also show evidence of arteriosclerosis and other factors predisposing them to the development of strokes, such as hypertension, cigarette smoking, high blood cholesterol, diabetes mellitus, narrowing of one or both carotid arteries, or cardiac disorders, especially atrial fibrillation (an irregular heartbeat). Somatic complaints, mood changes, depression, and nocturnal confusion tend to be more common in vascular dementias, although there is relative preservation of the patient’s personality. In such cases, magnetic resonance imaging (MRI) or a computed tomography (CT) scan of the brain often shows evidence of multiple strokes. Strokes are not always associated with clinical evidence of neurological deficits, since the stroke may affect a “silent” area of the brain or may be so small that its immediate impact is not noticeable. Nevertheless, when several of these small strokes have occurred, the resulting loss of brain tissue may interfere with the patient’s cognitive functions. This is, in fact, the basis of the lacunar dementias. The infarcted tissue is absorbed into the rest of the brain, leaving a small cavity or lacuna. Brain-imaging techniques and especially MRI are useful in detecting these lacunae. Treating Dementia It is estimated that dementia affects about 0.4 percent of the population aged sixty to sixty-four years and 0.9, 1.8, 3.6, 10.5, and 23.8 percent of the population aged sixty-five to sixty-nine, seventy to seventy-four, seventy-five to seventy-nine, eighty to eighty-four, and eighty-five to ninety-three years, respectively. Different surveys may yield different results, depending on the criteria used to define dementia. For physicians, an important aspect of diagnosing patients with dementia is detecting potentially reversible causes which may be responsible for the impaired mental functions. A detailed history followed by a meticulous and thorough clinical examination and a few selected laboratory tests are usually sufficient to reach a diagnosis. Various investigators have estimated that
242 ✧ Dementia reversible causes of dementia can be identified in 10 percent to 20 percent of patients with dementia. Recommended investigations include brain imaging (CT scanning or MRI), a complete blood count, and tests of erythrocyte sedimentation rate, blood glucose, serum electrolytes, serum calcium, liver function, thyroid function, and serum B12 and folate. Some investigators also recommend routine testing for syphilis. Other tests, such as those for the detection of HIV infection, cerebrospinal fluid examination, neuropsychological testing, drug and toxin screen, serum copper and ceruloplasmin analysis, carotid and cerebral angiography, and electroencephalography, are performed when appropriate. It is of paramount importance for health care providers to adopt a positive attitude when managing patients with dementia. Although at present little can be done to treat and reverse dementia, it is important to identify the cause of the dementia. In some cases, it may be possible to prevent the disease from progressing. For example, if the dementia is the result of hypertension, adequate control of this condition may prevent further brain damage. Moreover, the prevalence of vascular dementia is decreasing in countries where efforts to reduce cardiovascular and cerebrovascular diseases have been successful. Similarly, if the dementia is the result of repeated emboli (blood clots reaching the brain) complicating atrial fibrillation, then anticoagulants or aspirin may be recommended. Dealing with the Diagnosis The casual observer of the dementing process is often overwhelmed with concern for the patient, but it is the family that truly suffers. The patients themselves experience no physical pain or distress, and except in the very early stages of the disease, they are oblivious to their plight as a result of their loss of insight. Health care professionals therefore are alert to the stress imposed on the caregivers by dealing with loved ones with dementia. Adequate support from agencies available in the community is essential. When a diagnosis of dementia is made, the physician discusses a number of ethical, financial, and legal issues with the family, and also the patient if it is believed that he or she can understand the implications of this discussion. Families are encouraged to make a list of all the patient’s assets, including insurance policies, and to discuss this information with an attorney in order to protect the patient’s and the family’s assets. If the patient is still competent, it is recommended that he or she select a trusted person to have durable power of attorney. Unlike the regular power of attorney, the former does not become invalidated when the patient becomes mentally incompetent and continues to be in effect regardless of the degree of mental impairment of the person who executed it. Because durable power of attorney cannot be easily reversed once the person is incompetent, great care should be taken when selecting a person, and the specific powers
Dementia ✧ 243 granted should be clearly specified. It is also important for the patient to make his or her desires known concerning advance directives and the use of life support systems. Courts may appoint a guardian or conservator to have charge and custody of the patient’s property (including real estate and money) when no responsible family members or friends are willing or available to serve as guardian. Courts supervise the actions of the guardian, who is expected to report all the patient’s income and expenditures to the court once a year. The court may also charge the guardian to ensure that the patient is adequately housed, fed, and clothed and receiving appropriate medical care. Long-Term Prognoses Dementia is a very serious and common condition, especially among the older population. Dementia permanently robs patients of their minds and prevents them from functioning adequately in their environment by impairing memory and interfering with the ability to make rational decisions. It therefore deprives patients of their dignity and independence. Because dementia is mostly irreversible, cannot be adequately treated at present, and is associated with a fairly long survival period, it has a significant impact not only on the patient’s life but also on the patient’s family and caregivers and on society in general. The expense of long-term care for patients with dementia, whether at home or in institutions, is staggering. Every effort, therefore, is made to reach an accurate diagnosis and especially to detect any other condition that may worsen the patient’s underlying dementia. Finally, health care professionals do not treat the patient in isolation but also concern themselves with the impact of the illness on the patient’s caregivers and family. —Ronald C. Hamdy, M.D., Louis A. Cancellaro, M.D., and Larry Hudgins, M.D. See also Aging; Alzheimer’s disease; Arteriosclerosis; Hypertension; Malnutrition among the elderly; Medications and the elderly; Memory loss; Nursing and convalescent homes; Nutrition and aging; Parkinson’s disease; Reaction time and aging; Safety issues for the elderly; Sleep changes with aging; Strokes. For Further Information: Coons, Dorothy H., ed. Specialized Dementia Care Units. Baltimore: The Johns Hopkins University Press, 1991. A collection of articles reviewing the benefits and disadvantages of caring for patients with dementia in specialized care units. Several problems encountered when running such units are addressed.
244 ✧ Dental problems in children Hamdy, Ronald C., J. M. Turnbull, L. D. Norman, and M. M. Lancaster, eds. Alzheimer’s Disease: A Handbook for Caregivers. 3d ed. St. Louis: Mosby Year Book, 1998. A comprehensive discussion of the symptoms and characteristic features of Alzheimer’s disease and other dementias. Abnormal brain structure and function in these patients are discussed, and the normal effects of aging are reviewed. Gives caregivers practical advice concerning the encouragement of patients with dementia. Kovach, Christine, ed. Late Stage Dementia Care: A Basic Guide. Washington, D.C.: Taylor & Francis, 1997. Provides information on assessment and treatment management for individuals experiencing dementia. A valuable source for caregivers and family members of those affected. U.S. Congress. Office of Technology Assessment. Confused Minds, Burdened Families: Finding Help for People with Alzheimer’s and Other Dementias. Washington, D.C.: Government Printing Office, 1990. A report from the Office of Technology Assessment analyzing the problems of locating and arranging services for people with dementia in the United States. Also presents a framework for an effective system to provide appropriate services and discusses congressional policy options for establishing such a system. West, Robin L., and Jan D. Sinnott, eds. Everyday Memory and Aging. New York: Springer-Verlag, 1992. A review of issues relating to memory research and methodology, especially as they apply to aging.
✧ Dental problems in children Type of issue: Children’s health, public health Definition: Structures in the mouth that assist in the processing of food prior to swallowing and the diseases that can affect them. A tooth is composed of three parts: the crown, pulp, and root. The crown of the tooth is the portion exposed above the gums. Its surface is made of a hard, crystalline material called enamel. The rest of the crown is a substance known as dentin. At the center is pulp, which contains nerves and blood vessels. The root joins the crown to the jawbone. The outer surface of the root is a thin layer of cementum, with dentin underneath. Humans normally have twenty baby (deciduous or primary) teeth and thirty-two adult (permanent) teeth. The baby teeth begin to erupt through the gums in infancy. Most adult teeth develop below these baby teeth; as they grow, they push on the roots of the baby teeth, which are shed throughout childhood and into adolescence. The shape and size of permanent teeth are related to their functions. The four front incisors cut food like scissors. The four cuspids, or canines, are pointed; their primary function is to grasp and
Dental problems in children ✧ 245 tear food. The eight premolars are used for tearing and also to crush and grind food. The twelve molars grind food into even smaller portions. The third molars, commonly called wisdom teeth, are the last to develop, often appearing during adolescence. If the wisdom teeth are unable to erupt normally, then they may have to be removed. Teething Teething in infants is the time of primary incisor eruption, usually occurring between four and ten months of age. Symptoms associated with teething can include irritability, increased crying, restlessness, disturbed sleep, drooling, and decreased appetite but increased thirst. The gum around the erupting tooth is red, swollen, and tender. Sometimes, fever and/or diarrhea develops. Teething infants often like to put their fingers into their mouths. Some infants gain their baby teeth without any symptoms. A child who is teething may be given smooth, clean, hard, chewable objects on which to bite, such as water-filled “teethers” cooled in a refrigerator before use. To relieve pain, topical anesthetics can be applied, such as oral sugar-free choline salicylate dental gel, to be used every three to four hours. Parents should be informed that teething is normal and will resolve in time. If fever is persistent, the child should be treated by a pediatrician. Among some children, eruption cysts are observed as a complication of tooth eruption. An eruption cyst may develop a few weeks before the eruption of a primary or permanent tooth, often seen in the primary second molar or the first permanent molar regions. An eruption cyst appears as a bluish-purple elevated area of tissue, filled with fluid and blood. Sometimes, an eruption cyst is surrounded by inflammation. Usually within a few days the tooth breaks through the tissue, and the eruption cyst resolves itself. This process can be assisted with the usual teething aids, such as “teethers.” In rare cases, it may be necessary to open the cyst surgically. Under local anesthesia, the tissue of the cyst is cut away and the crown of the underlying tooth is exposed. Marginal Gingivitis Marginal gingivitis is a common periodontal disorder, or gum disease, in children of all ages. A published survey showed a rate of 87 percent of children having such a condition. It is more frequently seen in Asians and Africans than in Caucasians. The causes of this condition may be local oral or systemic factors. The major local oral cause is that the mouth contains a large number and variety of bacteria. Together with food, the bacteria form plaque. In the plaque, the bacteria create toxins, which irritate the gums. With poor oral hygiene, the plaque is not removed and hardens into calculus, which is occasionally seen in young children. Mouth breathing,
246 ✧ Dental problems in children tooth eruption, and other oral diseases may also increase the occurrence of marginal gingivitis. Systemic factors include diabetes mellitus, hematological disorders, vitamin C deficiency, and Down syndrome. Children with marginal gingivitis have an appearance of inflammatory gums that are red, tender, swollen, and bleed easily. The affected regions can be small or large, but the most commonly affected regions are the anterior segments. After the age of six, the risk of developing marginal gingivitis increases, reaching a peak at puberty (eleven years in girls and thirteen years in boys), which may be related to hormonal changes. Gingivitis leading to irreversible periodontal changes is rare in young children. However, after puberty, teenagers are more likely to have periodontal pockets and alveolar bone loss. Children should start brushing their teeth thoroughly twice a day with a fluoride toothpaste as soon as the primary teeth erupt. The toothbrush should be soft-bristled and replaced every three months. Use of dental floss may be started when the child can cooperate. From the age of six months, dental checkups every six months are necessary. The most common procedure performed for the treatment of gingivitis is cleaning and polishing. The frequency or need for semiannual prophylaxis for this age group is a topic of controversy. Frequent prophylaxis is beneficial to tissues, but the cost-benefit ratio may not justify providing such services to children at the community level. Developmental Defects Developmental defects associated with the teeth and oral structures may be caused by hereditary factors, infection, or metabolic disturbances during pregnancy or infancy. Congenital absence of teeth can be seen as anodontia or hypodontia. Anodontia implies complete failure of the development of the teeth. This condition may be related to a severe form of ectodermal dysplasia. In addition to the absence of all teeth, children with ectodermal dysplasia also have dry skin without sweat glands, thin hair and eyebrows, and a deficiency in salivary flow. Other ectodermal dysplasia features include protuberant lips, a saddle-nose appearance, and defects of the fingernails. Hypodontia represents a deficiency in tooth number or a developmental absence of some of the teeth. Familial heredity is commonly observed for the occurrence of hypodontia. This condition may also be associated with ectodermal dysplasia. The teeth that develop may be malformed. Hypodontia can occur for both the primary teeth and permanent teeth; those who have primary teeth with hypodontia are more likely to have permanent teeth with the same condition. In some cases, an excess number of teeth exists, which is described as hyperdontia or supernumerary teeth. Hyperdontia can occur in both the primary and permanent teeth and is often found in the
Dental problems in children ✧ 247 incisor, premolar, and occasionally molar regions. Boys are affected twice as frequently as girls. Amelogenesis imperfecta affects the enamel of both the primary and permanent teeth. The cause of amelogenesis imperfecta is generally accepted as a hereditary defect. However, some reports have indicated that a few children have had this condition without any hereditary background. There are three common types of amelogenesis imperfecta: hypoplastic, hypocalcified, and hypomatured. In the hypoplastic type, the enamel of the teeth is thin. The affected teeth appear small with open contacts. In the hypocalcified type, the enamel of the teeth is soft and fragile caused by poor calcification. The enamel of the affected teeth is easily fractured and the underlying dentin is exposed. Thus, children with hypocalcified enamel show an unaesthetic appearance. In the hypomatured type, the teeth have normal enamel thickness but a low value of mineral content. The enamel of the affected teeth chips away easily from the dentin. In the areas of the affected teeth where dentin is exposed, cavities can develop, but it is not always true that hypoplastic teeth are more susceptible to dental caries than normal teeth. The causes of environmental enamel hypoplasia are associated with varied environmental factors. Nutritional deficiencies, especially in vitamins A, C, and D and in calcium and phosphorus, can cause enamel hypoplasia. Research has shown that children with brain injuries and renal disease are more likely to have enamel hypoplasia than normal children are. There is also an observed correlation between enamel defects and the presence of severe allergies. The fetus of a lead-poisoned or rubella-infected mother has an increased risk of developing enamel hypoplasia. Other causes include severe infection, fevers, congenital syphilis, use of certain drugs, and excess fluoride. However, it is not always possible to identify environmental causes of enamel hypoplasia. Dentinogenesis imperfecta is an inherited dentin defect originating during the histodifferentiation stage of tooth development. This anomaly includes a defect of the predentin matrix that results in amorphic, disorganized, and atubular circumpulpal dentin. For both the primary and permanent teeth, dentinogenesis imperfecta is characterized by a reddish brown to gray opalescent color. There are three types of dentinogenesis imperfecta. Type I occurs with osteogenesis imperfecta, which is an inherited defect in collagen formation resulting in osteoporotic brittle bones, bowing of the limbs, bitemporal bossing, and blue sclera. Type I dentinogenesis imperfecta affects the primary teeth more than the permanent teeth. The affected teeth show an amber translucent color, periapical radiolucencies, bulbous crowns, obliteration of pulp chambers, and root fractures. Type II is known as hereditary opalescent dentin. The symptoms of this type are similar to that of type I, but type II affects the primary and the permanent teeth equally, although these two types are separate entities.
248 ✧ Dental problems in children Type III has the features described with a predominance of bell-shaped crowns, particularly seen in the permanent teeth. Affected teeth often have a shell-like appearance and multiple pulp exposures. Type III dentinogenesis imperfecta rarely occurs, and it has been suggested as a different expression of the same type II gene. Extremely high levels of fluoride ingested during the tooth formation stage can affect the ameloblasts. The appearance of fluorosis varies greatly, showing white or brown patches of discoloration on the affected teeth. Brown pigmentation is often seen in the maxillary anterior teeth. Children who have taken antibiotic tetracycline during the period of calcification of the primary or permanent teeth can have severe tooth discoloration. Tetracycline is bound to calcium and deposited in growing teeth (as well as bones). Affected teeth show bands of discoloration, ranging from gray to dark orange-brown. Research has indicated that when tetracycline is given in concentrations of 21 to 26 milligrams per kilogram or greater over a period as short as three days, both the primary and permanent teeth can be seriously affected. Tooth Decay Dental caries are the most common dental disorder. This condition affects both the primary and permanent teeth. The development of dental caries involves many factors, including bacteria, food, saliva, and poor oral hygiene. The predisposing risk factors for tooth decay include a frequent high sugar consumption in the diet, poor oral hygiene, lack of fluoride, and decreased flow of saliva. Dental caries are caused by acid produced from the action of bacteria on food, especially carbohydrates such as sugar. The caries-causing bacteria form a sticky film, called plaque, on tooth surfaces, and proliferate within plaque to produce both acid and enzymes. The acid and enzymes break down the calcified substances of the teeth, resulting in demineralization of the enamel surface. Sweets and other carbohydrate foods provide the caries-causing bacteria an excellent culture medium to produce such action. Saliva of healthy people contains immunoglobulins and other antibacterial substances, which can limit the activity of cariescausing bacterial. Thus, when the flow of saliva decreases, the risk of developing dental caries increases. A person’s susceptibility to dental caries is also determined by some other factors, such as heredity and tooth shape. As the acid produced by bacteria dissolves the tooth enamel, a cavity is formed. In the primary teeth, the sequence of caries follows a specific pattern: mandibular molars, maxillary molars, and maxillary anterior teeth. The second primary molars are much more susceptible to caries than the first primary molars, which erupt earlier. This difference in caries susceptibility between molars may be due to the differences of the occlusal surface. For the permanent teeth, caries are more likely to be seen in the mandibular
Dental problems in children ✧ 249 molars and maxillary molars. However, the maxillary lateral incisors often erupt with a defect in the lingual surface in many children. If caries occur in this area of the maxillary molars, the progression of the decay can be rapid, even involve the pulp before the awareness of the presence of the cavity. A lesion develops in the enamel initially, causing a cavity. If untreated, it will spread to the dentin, and sometimes, to an adjacent tooth, or to the pulp. Eventually, the infection will result in necrosis and abscess formation. The rate of caries progression is more rapid in the primary teeth than in the permanent teeth. Children with dental decay may feel pain, food impaction, and a sharp edge of tooth. However, these symptoms do not necessarily show themselves in all patients. Changes have been noticed for both the symptoms and the incidence of dental caries in the past decades. These changes are associated with the use of fluoride through fluoride toothpastes, dietary supplementation, and water supply augmentation. With the use of fluoride, the incidence rate of dental caries in adolescents decreased 50 percent. The progression of dental caries has become slower, and the changes in tooth structure usually are not observed in a short period of time. Before examination of dental caries, teeth should be dried well and viewed with a bright light. Fissures may be tested gently with a probe. Cavities may be detected by a fiber-optic light terminal placed against one wall of the tooth. Through this light, the cavity may be observed by the lack of light conduction. Rampant caries is a dental condition in which the child suffers from an acute onset of destructive lesions involving most of the erupted teeth, progressing rapidly to pulp. This condition can even affect those teeth usually regarded as immune to ordinary decay. Rampant caries is usually diagnosed when ten or more new lesions develop per year. Although it has been observed in all ages, young teenagers are most susceptible to rampant caries. The risk factors for rampant caries are similar to that of ordinary caries, but the mechanism of this condition is obscure. There is some evidence suggesting that emotional disturbances might be the cause in some children with rampant caries. These emotional disturbances could be stress, depression, anxiety, fear, dissatisfaction, and tension. Nursing caries is a condition seen in children with prolonged bottle feeding, beyond the time when most children are weaned from the bottle. Nursing caries occur among children aged two to four years old. These children often have been put to bed with a nursing bottle containing milk, formula, or juice. When the child falls asleep, the liquid from the nursing bottle remains in the mouth, especially pooling around the maxillary anterior teeth. Thus, there is a specific pattern for nursing caries: early caries development of the maxillary anterior teeth, the maxillary and mandibular first primary molars, and the mandibular canines. Nursing caries usually do not affect mandibular incisors.
250 ✧ Dental problems in children Treating Children’s Teeth For children with anodontia, the dental deficiencies can be overcome by the construction of dentures. The dentures should be constructed at an early age (two to three years old), and need to be remade from time to time to ensure facial growth. Children with a number of missing primary teeth (hypodontia) can have partial dentures constructed at an early age. A partial denture also needs to be adjusted and remade from time to time to allow the eruption of permanent teeth. Hyperdontia tends to cause orthodontic problems with adverse effects on adjacent teeth; thus, it often requires early extraction. Children with any problems related to tooth number need to have regular and closely monitored dental care. The treatment of amelogenesis imperfecta depends on the severity of the condition and the demands of aesthetic appearance. Porcelain jacket crowns can be used, as the dentin structure is normal. For some children with the hypoplastic and hypomatured types, bonded veneer restorations may provide a conservative alternative for the management of aesthetic appearance. Another reported successful treatment includes porcelain laminate veneer restorations. The treatment for hypoplastic teeth depends on the size of the affected areas. Small caries and precaries areas can be restored with amalgam, resin, or glass ionomer. The restoration is generally confined to the area of involvement of the teeth. Large areas of defective enamel and exposed dentin, which can be seen in both hypoplastic primary and permanent teeth, may become sensitive as soon as they erupt; however, the possibility of good restoration at this stage is rare. To reduce the sensitivity of the tooth, the topical application of fluoride is found useful, and can be repeated as often as necessary. The treatment of dentinogenesis imperfecta is quite difficult for both the primary and permanent teeth. The placement of stainless steel crowns on the primary posterior teeth may be used as a means of preventing gross abrasion of the tooth structure. Some approaches may be used to restore the teeth to functional and aesthetic standards, such as metal-ceramic restorations for the premolar teeth and those anterior to them and full cast crowns on the molars. For some patients, full coverage restorations may not be necessary; veneer restorations on anterior teeth can be helpful. In the case of teeth that have periapical rarefaction and root fracture, the affected teeth should be removed. However, the extraction of such teeth can be difficult because of the brittleness of the dentin. Correcting Tooth Color Several methods are available for the color correction of fluorosis. One technique is the use of 18 percent hydrochloric acid on the affected enamel surfaces. After careful isolation of tooth or teeth with the rubber dam and
Dental problems in children ✧ 251 proper preparations for safe use, the caustic agent, a slurry of fine pumice and hydrochloric acid, is applied under pressure, and abraded with a wooden stick. After each five seconds of such application, the slurry should be rinsed away with water. This procedure should be repeated till the desired color change has occurred. After a final rinsing, 1.1 percent neutral sodium fluoride gel is applied to the area for three minutes. Then, a fine fluoridated prophylaxis paste is applied with a rotating rubber cup. The final step is polishing the enamel with an aluminum oxide disk. Tetracycline should not be given to children under twelve years of age or to pregnant women. Observations have shown that the sensitive period for tetracycline induced discoloration for the primary teeth covers the fourmonth-old fetus to the three-month-old baby for maxillary and mandibular incisors, and the five-month-old fetus to the nine-month-old infant for maxillary and mandibular canines. The sensitive period for permanent maxillary and mandibular incisors and canines is from three months to seven years of age. Techniques are available for bleaching the teeth stained by tetracycline. Treating Cavities The treatment for dental caries varies depending on the extent of the decay. Restorations (fillings) are commonly done on living teeth. Under local anesthesia, decay is first completely removed; the resulting hole is then shaped and filled with material. Different filling materials are chosen to ideally match the tooth tissue in resistance, strength, and color. If the pulp is involved by the caries, and pulpitis (inflammation of the pulp) is observed, root canal therapy is often required. Root canal therapy is a multiphase procedure, including removing all traces of pulp tissue from the pulp chamber and the canals, cleaning out all bacteria, shaping the canals, and filling with filling material. A seal is placed to avoid reinfection. The tooth needs to be restored and protected after root canal therapy. For those permanently dead teeth where root canal therapy is not feasible, extraction is necessary. For children who have a primary tooth extracted and whose permanent tooth does not erupt for six or more months, space maintainers should be considered. A fixed bridge, a partial denture, or an implant supported prosthesis can be used to replace the extracted tooth. When rampant caries are diagnosed, the treatment of all cavities should be initiated immediately. As this condition develops rapidly, a plan of restoring one tooth at a time is impossible to achieve a full restoration. A more appropriate approach is the technique of gross excavation, gross caries removal, which can usually be accomplished in one appointment, except for some occasions where a second or third appointment is necessary for a large number of extensive caries. Following gross excavation there should be a systematic therapy for rampant caries, including taking a medical and dental
252 ✧ Dental problems in the elderly history, completing tests to determine the cause of the condition, and treatment of relevant medical and dental conditions. Parents should be educated about the cause of nursing caries. Infants should be held while bottle feeding, and should never be allowed to nap or sleep with the bottle propped in the mouth. Children need to begin brushing with a fluoride-enhanced paste once any teeth have erupted. Multiple vitamins containing fluoride can also be prescribed for a child by a pediatrician. —Kimberly Y. Z. Forrest See also Children’s health issues; Dental problems in the elderly; Fluoridation of water sources; Fluoride treatments in dentistry; Teething. For Further Information: McDonald, Ralph E., and David R. Avery. Dentistry for the Child and Adolescent. 6th ed. St. Louis: C. V. Mosby, 1994. This book is designed to help dental students provide efficient and superior comprehensive oral health care for infants, children, and teenagers. The newest edition provides current diagnostic and treatment recommendations for pediatric dental diseases based on research, clinical experience, and current literature. Parkin, Stanley F. Notes on Paediatric Dentistry. Boston: Wright, 1991. This book provides the main core subject matter of dental diseases in children. Each disease is discussed in a simple and clear context. Pinkham, J. R., ed. Pediatric Dentistry: Infancy Through Adolescence. 2d ed. Philadelphia: W. B. Saunders, 1994. This book initiates some basic information on pediatric dental problems pertinent to all age levels; the text is then divided into four large sections by developmental age. Dental diseases associated with specific age groups are described in detail. Taintor, Jerry F., and Mary Jane Taintor. The Complete Guide to Better Dental Care. Reprint. New York: Checkmark Books, 1999.
✧ Dental problems in the elderly Type of issue: Elder health, public health Definition: Treatment and prevention of diseases of the mouth, teeth, and gums. As the geriatric population increases in the United States, the provision of dental services for the elderly will have to expand to provide adequate regular dental follow-ups. This population will also need to be educated about how to care for their teeth, gums, and dentures in order to maintain good dental health and retain their natural teeth as long as possible.
Dental problems in the elderly ✧ 253 Normal Age-Related Changes Approximately 90 percent of the elderly have some form of mouth disorder. Normal age-related changes of the mouth have a minimal effect on overall functioning. Muscle weakening and decreased bone density in the jaw, decreased elasticity in the gums and cheeks, reduced secretion of saliva, and increased alkalinity in saliva make chewing foods more difficult. Thinning and staining of tooth enamel leads to chipping of teeth. The soft dentin in the teeth slowly and gradually dissolves as a result of exposure to the acid in saliva. Receding gums encourage the trapping of food in crevices between teeth and gums and in tooth borders. This accumulation of food and debris can promote gum irritation and tooth decay if proper dental hygiene, such as brushing and flossing, is not followed. Disorders of the Teeth Being toothless (edentulous) is not a normal part of aging. The major causes of tooth loss in adults are tooth decay and periodontal disease. Lack of water fluoridation, limited access to dental care, and inadequate dental hygiene are also causes of tooth loss in adults. Today, there are fewer cases of adults who are edentulous, owing to increased availability of preventive dental care and early diagnosis and intervention to prevent disease that causes tooth loss. Treatment for tooth loss includes bridges that replace one or more teeth and anchor onto teeth on either side of the bridge, partial dentures to replace missing teeth, full dentures to cover the entire gum of missing teeth, and dental implants to replace individual teeth by anchoring a post in the jaw and placing an artificial tooth over it. The wear-and-tear and potential for injury increase with Cavities (caries) are the age, making regular dental checkups crucial. (Photomajor cause of all tooth loss Disc)
254 ✧ Dental problems in the elderly in the United States. Because older adults have receding gums, most caries in older adults form at the gum line and the roots of teeth. Caries are areas in a tooth in which enamel has thinned (demineralized), causing weak areas in tooth enamel that eventually decay. This decay is a result of the acid in saliva, which increases during eating. Fluoride helps to slow enamel demineralization. Fluoride is present in many water supplies, toothpaste, and mouth rinses. Brushing the teeth at least twice daily and flossing between teeth help to prevent enamel demineralization. An abscessed tooth is an inflammation and infection in the pulp of a tooth. It most frequently results from a cavity that exposes the tooth pulp to bacteria. The major symptom is a constant, severe pain in the affected tooth. The pain increases when the tooth is exposed to heat and cold. Treatment includes drainage of the abscess by a dentist. If the pulp of the tooth is severely infected, a root canal may be the only means to save the tooth. A root canal is a procedure in which the diseased pulp is removed and the remaining space is filled with a compound that will maintain the integrity of the tooth. A fractured tooth is one that has cracked from trauma, poor health, or demineralized enamel. If the fracture is severe, a crown may be placed over the tooth to protect, strengthen, and prevent tooth loss. Malocclusion occurs when the teeth do not align in the mouth properly. This condition causes uneven wear on the teeth. Over time, it can create dental problems that require dental procedures to correct the damage that is caused. Common malocclusions are an overbite, in which the upper teeth greatly overhang the lower teeth, and an underbite, in which the lower teeth jut out beyond the upper teeth. When the gums recede or teeth are chipped or fractured, the dentin of the teeth allows the nerves to be exposed to irritants that cause pain or discomfort. The result is sensitive teeth. Frequently, these irritants are heat, cold, and sweet or sour foods and drinks. Using toothpaste for sensitive teeth and a soft toothbrush may help to relieve discomfort. Age-related color changes that occur in the teeth are normal. Years of exposure to coffee, tea, colas, fruit juices, and smoking gradually and steadily stain the teeth, causing color changes from whiter to more yellow. Professional bleaching by a dentist can help to restore some of the whiteness of teeth. Disorders of the Gums Periodontal disease, also called gum disease or pyorrhea, is a major cause of tooth loss in older adults. It results from an inflammatory process caused by the accumulation of plaque and tartar that destroys the bones supporting the teeth. Plaque is composed of sticky components of bacteria and saliva that adhere to the gum line and the crevices of the teeth. It forms constantly
Dental problems in the elderly ✧ 255 and must be brushed away to prevent tartar. Tartar is the hardened mineral deposits that are formed from plaque that is not removed. The accumulation of plaque and tartar may be the result of food impurities, malnutrition, vitamin deficiencies, endocrine disorders, certain medications, breathing through the mouth, poor dental hygiene, poor-fitting dentures, and inadequate access to dental care. The incidence of periodontal disease increases with age because of a reduction in saliva. Saliva aids in rinsing food particles from the teeth and gums and prevents plaque from forming. There are early and late stages in periodontal disease. Gingivitis is the earliest and least-invasive stage; it involves only the gums surrounding the teeth. The major cause of gingivitis is poor dental hygiene. Gingivitis produces bleeding, tender gums. Periodontitis is a more severe stage of periodontal disease in which the gums recede and separate from the teeth and the bone depletes. If this condition is left untreated, the gums recede and bone depletes even further. Food becomes trapped in the pockets that form between the gums and teeth; the resulting infection causes the teeth to loosen and fall out. Tobacco use also leads to periodontal disease, ulcerative gingivitis, tooth staining, delayed healing, and precancerous mouth tissue. Regular brushing of the teeth, gums, and tongue helps to fight periodontal disease. Receding gums shrink away from the gum line and expose the root of the tooth, which is normally covered. Improper tooth brushing techniques, firm-bristle toothbrushes, and periodontal disease cause the gums to shrink away from the gum line. Once the gums shrink, they do not grow back, even when there is an improvement in tooth brushing techniques and soft-bristle toothbrushes are used. Exposing the root of the tooth increases the chances for periodontal disease. Overgrowth of gum tissue (gingival hyperplasia) can result from irritation caused by plaque from poor dental hygiene or from physical or chemical irritant to the gums. Medications such as phenytoin and cyclosporine commonly cause gingival hyperplasia. Dentures Many older adults have the misconception that wearing dentures indicates that they no longer need to make regular visits to the dentist. This misconception causes many to experience dental problems that could be prevented. If identified in early stages of development, many dental problems are treatable or preventable. Denture wearers have 50 percent of the chewing and biting ability of those who have their natural teeth. Dentures that do not fit well can cause pain or discomfort that causes even more difficulty in chewing foods. Poor-fitting dentures may also cause speech problems because of the inability to enunciate words clearly. Poor-fitting dentures are an indication that a dentist visit is needed. Over time, the bone in the mouth
256 ✧ Depression that supports the dentures shrinks. Adjustments must be made to ensure that the denture fits properly and comfortably and to prevent additional dental problems. —Sharon W. Stark See also Aging; Cancer; Dental problems in children; Malnutrition among the elderly; Nutrition and aging. For Further Information: Academy of General Dentistry. AGD Impact 13 (August/September, 1998). Epidemiology and Oral Disease Prevention Program. National Institute of Dental Research. Oral Health of the United States Adults: The National Survey of Oral Health in U.S. Employed Adults and Seniors, 1985-1986—National Findings. NIH Publication no. 87-2868. Bethesda, Md.: U.S. Department of Health and Human Services, Public Service, National Institutes of Health, 1987. Little, James W., and Donald A. Falace, eds. Dental Management of the Medically Compromised Patient. 5th ed. St. Louis: Mosby Year Book, 1996.
✧ Depression Type of issue: Mental health Definition: The single most common psychiatric disorder, caused by biological and/or psychological factors; approximately 15 percent of cases result in suicide. The term “depression” is used to describe a fleeting mood, an outward physical appearance of sadness, or a diagnosable clinical disorder. It is estimated that 13 million Americans suffer from a clinically diagnosed depression, a mood disorder that often affects personal, vocational, social, and health functioning. The Diagnostic and Statistical Manual of Mental Disorders (4th ed., 1994, DSM-IV) of the American Psychiatric Association delineates a number of mood disorders that subsume the various types of clinical depression. Major Depressive Disorder A major depressive episode is a syndrome of symptoms, present during a two-week period and representing a change from previous functioning. The symptoms include at least five of the following: depressed or irritable mood, diminished interest in previously pleasurable activities, significant weight loss or weight gain, insomnia or hypersomnia, physical excitation or slowness, loss of energy, feelings of worthlessness or guilt, indecisiveness or a
Depression ✧ 257 diminished ability to concentrate, and recurrent thoughts of death. The clinical depression cannot be initiated or maintained by another illness or condition, and it cannot be a normal reaction to the death of a loved one (some symptoms of depression are a normal part of the grief reaction). In major depressive disorder, the patient experiences a major depressive episode and does not have a history of mania or hypomania. Major depressive disorder is often first recognized in the patient’s late twenties, while a major depressive episode can occur at any age, including infancy. Women are twice as likely to suffer from the disorder than are men. There are several potential causes of major depressive disorder. Genetic studies suggest a familial link with higher rates of clinical depression in first-degree relatives. There also appears to be a relationship between clinical depression and levels of the brain’s neurochemicals, specifically serotonin and norepinephrine. It is important to keep in mind, however, that 20 to 30 percent of adults will experience depression in their lifetime. Common causes of clinical depression include psychosocial stressors, such as the death of a loved one or the loss of a job, or any of a number of personal stressors; it is unclear why some people respond to a specific psychosocial stressor with a clinical depression and others do not. Finally, certain prescription medications have been noted to cause clinical depression. These drugs include muscle relaxants, heart medications, hypertensive medications, ulcer medications, oral contraceptives, and steroids. Thus there are many causes of clinical depression, and no single cause is sufficient to explain all clinical depressions. Bipolar Disorders Another category of depressive disorder is bipolar disorders, which affect approximately 1 to 2 percent of the population. Bipolar I disorder is characterized by one or more manic episodes along with persisting symptoms of depression. A manic episode is defined as a distinct period of abnormally and persistently elevated, expansive, or irritable mood. Three of the following symptoms must occur during the period of mood disturbance: inflated self-esteem, decreased need for sleep, unusual talkativeness or pressure to keep talking, racing thoughts, distractibility, excessive goal-oriented activities (especially in work, school, or social areas), and reckless activities with a high potential for negative consequences (such as buying sprees or risky business ventures). For a diagnosis of bipolar disorder, the symptoms must be sufficiently severe to cause impairment in functioning and/or concern regarding the person’s danger to himself/herself or to others, must not be superimposed on another psychotic disorder, and must not be initiated or maintained by another illness or condition. Bipolar II disorder is characterized by a history of a major depressive episode and current symptoms of mania.
258 ✧ Depression Patients with bipolar disorder will display cycles in which they experience a manic episode followed by a short episode of a major depressive episode, or vice versa. These cycles are often separated by a period of normal mood. Occasionally, two or more cycles can occur in a year without a period of remission between them, in what is referred to as rapid cycling. The two mood disorders can also occur simultaneously in a single episode. Bipolar disorder is often first recognized in adolescence or in the patient’s early twenties; it is not unusual, however, for the initial recognition to occur later in life. Bipolar disorder is equally common in both males and females. Genetic patterns are strongly involved in bipolar disorder. Brain chemicals (particularly dopamine, acetylcholine, GABA, and serotonin), hormones, drug reactions, and life stressors have all been linked to its development. Of particular interest are findings which suggest that, for some patients with bipolar disorder, changes in the seasons affect the frequency and severity of the disorder. These meteorological effects, while not well understood, have been observed in relation to other disorders of mood. Cyclothymia and Dysthymia Cyclothymia is another cyclic mood disorder related to depression; it has a reported lifetime prevalence of approximately 1 to 2 percent. This chronic mood disorder is characterized by manic symptoms without marked social or occupational impairment (“hypomanic” episodes) and symptoms of major depressive episode that do not meet the clinical criteria (less than five of the nine symptoms described above). These symptoms must be present for at least two years, and if the patient has periods without symptoms, these periods cannot be longer than two months. Cyclothymia cannot be superimposed on another psychotic disorder and cannot be initiated or maintained by another illness or condition. This mood disorder has its onset in adolescence and early adulthood and is equally common in men and women. It is a particularly persistent and chronic disorder with an identified familial pattern. Dysthymia is another chronic mood disorder affecting approximately 2 to 4 percent of the population. Dysthymia is characterized by at least a two-year history of depressed mood and at least two of the following symptoms: poor appetite, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or decision making, or feelings of hopelessness. There cannot be evidence of a major depressive episode during the first two years of the dysthymia or a history of manic episodes or hypomanic episodes. The patient cannot be without the symptoms for more than two months at a time, the disorder cannot be superimposed on another psychotic disorder, and it cannot be initiated or maintained by another illness or condition. Dysthymia appears to begin at an earlier age, as young as childhood, with symptoms typically evident by young adulthood. Dysthymia
Depression ✧ 259 is more common in adult females, equally common in both sexes of children, and with a greater prevalence in families. The causes of dysthymia are believed to be similar to those listed for major depressive disorder. Pharmacological Treatments Once a clinical depression (or a subclinical depression) is identified, there are at least four general classes of treatment options available. These options are dependent on the subtype and severity of the depression and include psychopharmacology (drug therapy), individual and group psychotherapy, light therapy, family therapy, electroconvulsive therapy (ECT), and other less traditional treatments. These treatment options can be provided to the patient as part of an outpatient program or, in certain severe cases of clinical depression in which the person is a danger to himself/herself or others, as part of a hospitalization. Three primary types of medications are used in the treatment of clinical depression: cyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and lithium salts. These medications are considered equally effective in decreasing the symptoms of depression, which begin to resolve in three to four weeks after initiating treatment. The health care professional will select an antidepressant based on side effects, dosing convenience (once daily versus three times a day), and cost. The cyclic antidepressants are the largest class of antidepressant medications. As the name implies, the chemical makeup of the medication contains chemical rings, or “cycles.” There are unicyclic (buproprion and fluoxetine, or Prozac), bicyclic (sertraline and trazodone), tricyclic (amitriptyline, desipramine, and nortriptyline), and tetracyclic (maprotiline) antidepressants. These antidepressants function to either block the reuptake of neurotransmitters by the neurons, allowing more of the neurotransmitter to be available at a receptor site, or increase the amount of neurotransmitter produced. The side effects associated with the cyclic antidepressants—dry mouth, blurred vision, constipation, urinary difficulties, palpitations, and sleep disturbance—vary and can be quite problematic. Some of these antidepressants have deadly toxic effects at high levels, so they are not prescribed to patients who are at risk of suicide. Monoamine oxidase inhibitors (isocarboxazid, phenelzine, and tranylcypromine) are the second class of antidepressants. They function by slowing the production of the enzyme monoamine oxidase. This enzyme is responsible for breaking down the neurotransmitters norepinephrine and serotonin, which are believed to be responsible for depression. By slowing the decomposition of these transmitters, more of them are available to the receptors for a longer period of time. Restlessness, dizziness, weight gain, insomnia, and sexual dysfunction are common side effects of the MAO inhibitors. MAO inhibitors are most notable because of the dangerous
260 ✧ Depression adverse reaction (severely high blood pressure) that can occur if the patient consumes large quantities of foods high in tyramine (such as aged cheeses, fermented sausages, red wine, foods with a heavy yeast content, and pickled fish). Because of this potentially dangerous reaction, MAO inhibitors are not usually the first choice of medication and are more commonly reserved for depressed patients who do not respond to the cyclic antidepressants. A third class of medication used in the treatment of depressive disorders consists of the mood stabilizers, the most notable being lithium carbonate, which is used primarily for bipolar disorder. Lithium is a chemical salt that is believed to effect mood stabilization by influencing the production, storage, release, and reuptake of certain neurotransmitters. It is particularly useful in stabilizing and preventing manic episodes and preventing depressive episodes in patients with bipolar disorder. Another drug occasionally used in the treatment of depression is alprazolam, a muscle relaxant benzodiazepine commonly used in the treatment of anxiety. Alprazolam is believed to affect the nervous system by decreasing the sensitivity of neuronal receptors believed to be involved in depression. While this may in fact occur, the more likely explanation for its positive effect for some patients is that it reduces the anxiety or irritability often coexisting with depression in certain patients. Psychotherapy, Shock Therapy, and Psychosurgery Psychotherapy refers to a number of different treatment techniques used to deal with the psychosocial contributors and consequences of clinical depression. Psychotherapy is a common supplement to drug therapy. In psychotherapy, the patients develop knowledge and insight into the causes and treatment for their clinical depression. In cognitive psychotherapy, cure comes from assisting patients in modifying maladaptive, irrational, or automatic beliefs that can lead to clinical depression. In behavioral psychotherapy, patients modify their environment such that social or personal rewards are more forthcoming. This process might involve being more assertive, reducing isolation by becoming more socially active, increasing physical activities or exercise, or learning relaxation techniques. Research on the effectiveness of these and other psychotherapy techniques indicates that psychotherapy is as effective as certain antidepressants for many patients and, in combination with certain medications, is more effective than either treatment alone. Electroconvulsive (or “shock”) therapy is the single most effective treatment for severe and persistent depression. If the clinically depressed patient fails to respond to medications or psychotherapy and the depression is life-threatening, electroconvulsive therapy is considered. It is also considered if the patient cannot physically tolerate antidepressants, as with elders who have other medical conditions. This therapy involves inducing a seizure
Depression ✧ 261 in the patient by administering an electrical current to specific parts of the brain. The therapy is quite sophisticated and safe, involving little risk to the patient. Patients undergo six to twelve treatments over a two-day to five-day period. Some temporary memory impairment is a common side effect of this treatment. A variant of clinical depression is known as seasonal affective disorder (SAD). Patients with this illness demonstrate a pattern of clinical depression during the winter, when there is a reduction in the amount of daylight hours. For these patients, phototherapy has proven effective. Phototherapy, or light therapy, involves exposing patients to bright light (greater than or equal to 2,500 lux) for two hours daily during the depression episode. The manner in which this treatment approach modifies the depression is unclear and awaits further research. Psychosurgery, the final treatment option, is quite rare. It refers to surgical removal or destruction of certain portions of the brain believed to be responsible for causing severe depression. Psychosurgery is used only after all treatment options have failed and the clinical depression is lifethreatening. Approximately 50 percent of patients who undergo psychosurgery benefit from the procedure. Rates and Risks of Depression The rates of clinical depression have increased since the early twentieth century, while the age of onset of clinical depression has decreased. Women appear to be at least twice as likely as men to suffer from clinical depression, and people who are happily married have a lower risk for clinical depression than those who are separated, divorced, or dissatisfied in their marital relationship. These data, along with recurrence rates of 50 to 70 percent, indicate the importance of this psychiatric disorder. While most psychiatric disorders are nonfatal, clinical depression can lead to death. Of the approximately 30,000 suicide deaths per year in the United States, 40 to 80 percent are believed to be related to depression. Approximately 15 percent of patients with major depressive disorder will die by suicide. There are, however, other costs of clinical depression. In the United States, billions of dollars are spent on clinical depression, divided among the following areas: treatment, suicide, and absenteeism (the largest). Clinical depression obviously has a significant economic impact on a society. —Oliver Oyama; updated by Nancy A. Piotrowski See also Addiction; Alcoholism; Alcoholism among teenagers; Alcoholism among the elderly; Child abuse; Death and dying; Dementia; Depression in children; Depression in the elderly; Domestic violence; Drug use among teenagers; Eating disorders; Elder abuse; Light therapy; Postpartum depression; Seasonal affective disorder (SAD); Sleep disorders; Stress; Suicide;
262 ✧ Depression in children Suicide among children and teenagers; Suicide among the elderly; Terminal illnesses. For Further Information: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Rev. 4th ed. Washington, D.C.: Author, 2000. This reference book lists the clinical criteria for psychiatric disorders, including the mood disorders that incorporate the depressions. DePaulo, J. Raymond, Jr., and Keith R. Ablow. How to Cope with Depression: A Complete Guide for You and Your Family. New York: McGraw-Hill, 1989. Written for patients diagnosed with depression and for their families and friends. The authors use case histories of patients seen at The Johns Hopkins University Hospital to highlight their clinical information. Includes a nice section on bipolar (manic-depressive) disorder. Greist, John H., and James W. Jefferson. Depression and Its Treatment. Rev. ed. Washington, D.C.: American Psychiatric Press, 1992. A patient’s guide to depression. The authors describe mood disorders and the identification of depression, and they review the various treatments that are available. The appendices offer a listing of national organizations concerned with depression and an excellent reading list. Matson, Johnny L. Treating Depression in Children and Adolescents. New York: Pergamon Press, 1989. This book, written by one of the leaders in the scientific study of depression, presents a guide to the evaluation and treatment of depression in children and adolescents. The author describes the assessment and treatment approaches that are unique for this nonadult population. Roesch, Roberta. The Encyclopedia of Depression. 2d. Ed. New York: Facts on File, 2000. This volume was written for both a lay and a professional audience. Covers all aspects of depression, including bereavement, grief, and mourning. The appendices include references, self-help groups, national associations, and institutes.
✧ Depression in children Type of issue: Children’s health, mental health Definition: A mood disorder in which children are unhappy, irritable, demoralized, self-derogatory, and bored. Depressed children feel worthless and hopeless. They fail to enjoy their usual activities. They may be unpopular, withdrawn from normal social interactions, and either agitated or lethargic. They cry easily and eat and sleep poorly. Cognitively, they have poor concentration, slowed thinking,
Depression in children ✧ 263 guilt, and recurrent thoughts of death or suicide. Their syndrome seriously impairs their well-being and everyday functioning. Depression is not simply an immediate reaction to a recent event but a long-term syndrome that has lasted for some time. Many features of childhood depression match those of depression in adulthood, although the features of childhood depression are often mixed with a broader array of behaviors. How Common Is Childhood Depression? The prevalence of depression in childhood is controversial. Some experts believe that symptoms of depression are rare in infants and preschool children. Others, in contrast, believe that depression is quite common, perhaps affecting 2 percent of the general child population and 15 to 20 percent of youngsters referred to clinics. Recorded statistics, however, may be lower because childhood depression can be obscured by other complaints and because young children have trouble talking about feelings of despair. Most experts agree that depression probably occurs less frequently in early childhood than in adolescence, when feelings of hopelessness and low self-esteem, and the incidence of suicide attempts, increase sharply. Episodes of major depression usually end after seven to nine months, but they may recur. Depression occurs at different rates for boys and girls. In childhood, depression is as common among boys as girls. In adolescence and adulthood, the ratio changes, with more girls and women reporting depression than boys and men. Children who have major depressive episodes sometimes experience no psychological problems as adults. Depressive disorders show the greatest continuity between childhood and adulthood when they first occur before puberty and are accompanied by other problems. Several factors probably contribute to childhood depression. First, depression seems to have a genetic component. Children with depressed parents are more likely to become depressed themselves. Researchers have also identified possible biochemical markers (lower levels of neurotransmitters and unusual reactions to drugs) in depressed children and teenagers, as well as in depressed adults. Second, depression seems to have a social support component. Depressed children may lack familial support for their psychological needs or may be insecurely attached to their parents. Parents of depressed children are often less warm, more controlling, and more punitive than parents of normal children. Third, severe environmental stress may contribute to depression. Children who are depressed are more likely than nondepressed children to live in poverty, to experience school problems, to come into contact with the police, and to have parents with alcohol problems. Thus, in addition to a genetic vulnerability, depressed children have problems at home, at school, and in their neighborhoods.
264 ✧ Depression in children Treating Depression A major problem in determining depression in children is the lack of practical, valid assessment instruments. Depression in adults is usually diagnosed from the sufferer’s own description of the symptoms. Young children, however, may be unable to describe their own pessimism, sadness, sense of failure, or other unhappy feelings. One common self-report measure of depression in children is the Children’s Depression Inventory, created by Maria Kovacs in 1992. It consists of twenty-seven items about depressive symptoms—for example, “I feel like crying every day,” “I feel like crying many days,” or “I feel like crying once in a while”—that describe the child’s mood in the previous two weeks. A warm, caring relationship with a parent or another adult acts as a protective factor against depression. Young adults who lost a parent before the age of sixteen experience more depression and suicide attempts than those adults who came from intact families. Consistent nurturance from another adult, however, can lessen these negative reactions. —Lillian M. Range See also Alcoholism among teenagers; Child abuse; Children’s health issues; Drug abuse by teenagers; Suicide among children and teenagers. For Further Information: Axline, Virginia Mae. Dibs, in Search of Self: Personality Development in Play Therapy. Boston: Houghton Mifflin, 1964. A case history of a withdrawn five-year-old boy and his struggle for identity through play therapy. Kovacs, Maria. The Children’s Depression Inventory. New York: Multi-Health Systems, 1992. A commonly used measure of depression in children. Matson, Johnny L. Treating Depression in Children and Adolescents. New York: Pergamon Press, 1989. This book, written by one of the leaders in the scientific study of depression, presents a guide to the evaluation and treatment of depression in children and adolescents. The author describes the assessment and treatment approaches that are unique for this nonadult population. Ollendick, Thomas H., and Michel Hersen, eds. Handbook of Child Psychopathology. 3d ed. New York: Plenum Press, 1998. In short, to-the-point chapters, this book covers all major topics from assessment to prevention and treatment. Most chapters about specific disorders end with a description of one case that illustrates the main points. Easy, interesting reading. Walker, C. Eugene, and Michael C. Roberts, eds. Handbook of Clinical Child Psychology. 2d ed. New York: John Wiley & Sons, 1992. An excellent reference work on nearly every aspect of child disorders and therapies.
Depression in the elderly ✧ 265
✧ Depression in the elderly Type of issue: Elder health, mental health Definition: A morbid sadness, dejection, or melancholy; more generally, a loss of affect or functionality. Community surveys have reported depressive symptoms in 30 percent to as many as 65 percent of people over the age of sixty. Depressions severe enough to warrant psychiatric intervention are generally estimated to affect 10 to 15 percent of the geriatric population, and depressive disorders are estimated to account for nearly one-half of the admissions of older adults to acute-care psychiatric hospitals in the United States. Demographic Aspects Strong associations have been found between geriatric depression and a number of demographic variables. Many of these variables involve decreases or losses in social, physical, and financial resources. Geriatric depression has been found to increase as financial status, the quality of interpersonal relationships, and general health decreases. Additional factors frequently associated with geriatric depression include marital discord, marital separation or divorce, living alone, lack of children (childlessness), the lack of a confiding relationship, decreases in social support, deaths of relatives and friends, physical disabilities affecting employment, high levels of stress, physical pain, chronic medical conditions, and lower levels of attained education. Considered together, these factors suggest that quality-of-life issues are crucial in understanding the onset, severity, and chronicity of geriatric depression. These factors do not cause geriatric depression per se but, in general, make the older individual much more vulnerable to its occurrence. On an individual basis, the effects of any one of these factors may be significantly mitigated by the attitude and psychological resources of a given individual. Specifically, greater overall coping with social, medical, and environmental stressors seems to be related to a given individual’s overall mental health before the onset of the stressors. Those older individuals who manifest more extensive psychological strengths and a greater repertoire of social and interpersonal skills tend to succumb to stressors much less frequently than individuals with histories of poor coping or impaired social functioning. Psychological Aspects Susceptibility to geriatric depression has been linked to a number of psychological variables. Extensive research has focused on the areas of self-esteem,
266 ✧ Depression in the elderly engagement in general life activities, and learned helplessness. Lowered self-esteem has been consistently associated with geriatric depression. Many elderly feel stigmatized or marginalized, especially after leaving positions of importance or prominence. The elderly in Western societies lack the high levels of respect and reverence shown toward the elderly of Eastern societies and many tribal cultures. Poor adjustment to retirement can often result in newly acquired feelings of inferiority or uselessness. Low self-esteem in elderly individuals has also been associated with overall poor coping following the death of a spouse. In addition to its association with geriatric depression, low self-esteem has been linked with greater levels of reported pain, lower levels of self-reported health, higher levels of physical disability, and increased anxiety. Investigation into the relationship between geriatric depression and “engagement” has produced fairly consistent results. Engagement theory conceptualizes geriatric depression as resulting from an overall “disengagement” from general life activities, especially social activities, recreational activities, volunteer work, and meaningful interactions within the larger community. According to this theory, many older individuals “withdraw inside themselves,” increasingly narrowing their personal worlds and levels of activity, eventually reaching a psychological state of stagnation and boredom resulting in depression. Depressed geriatric individuals do report a greater use of avoidance coping behaviors than their nondepressed peers. However, older individuals who engage in volunteer work have been found to manifest higher levels of life satisfaction, stronger desires to live, and overall fewer symptoms of anxiety and bodily complaints. In addition, nursing home residents who volunteer in a range of activities within their facilities have been found to manifest significant reductions in perceived hopelessness and depression. Overall, general activity and age-appropriate work appear to result in greater social contacts, reduced boredom, and increased sense of usefulness and satisfaction. A theoretical framework that has been quite influential in explaining the cognitive, motivational, and psychological deficits associated with depression is the learned helplessness model proposed by Martin Seligman. According to this model, depression is often the result of a perceived condition of “independence” between one’s actions and the results of one’s actions. A “helpless” individual is one who increasingly sees aspects of life as uncontrollable. It is this very feature of uncontrollability that, over time, leads to the perception of personal helplessness; the perception of helplessness, in turn, leads to depression. A factor that has been thought to encourage perceptions of noncontrol and helplessness in the aged is the widespread stereotyping of this population as infirm and fragile. It has been found that nurses who view their aged patients as dependent reinforce helplessness and “sick role” behaviors. It has also been found that residents from private retirement homes who were given control of both the frequency and dura-
Depression in the elderly ✧ 267 tion of the visits they received were consistently superior on measures of physical and psychological well-being to residents who had not been given this control. Medical Issues Given the psychological, cultural, and medical issues frequently faced by the elderly, the phenomenon of depression is highly complicated and frequently not detected. Adding to this complication is the phenomenon of pseudodementia, in which an elderly individual is incorrectly evaluated as manifesting severe cognitive impairments while the true diagnosis of depression is missed. The relatively extensive number of medical issues faced by the elderly often focuses the attention of medical professionals and the elderly themselves on bodily and pain-oriented complaints. What is often missed is a coexisting depression that preceded the onset of medical issues or occurred during the onset of medical issues but is unrelated to medical issues; a coexisting depression that is the elderly individual’s reaction to medical issues; or both. Nondetection of geriatric depression may also result from the hesitation of many elderly individuals to discuss psychological or emotional issues. The stigma sometimes associated with psychological issues is often a forceful factor in the elderly individual’s tendency to minimize them in favor of a wholly medical or pain-oriented presentation of symptoms. A medical or mental health professional who accepts this presentation without inquiring about issues related to emotional well-being may fail to uncover a coexisting depression underlying medical issues or even a depression unaccompanied by true medical difficulties. Another phenomenon involving the nondetection of geriatric depression is pseudodementia, in which the elderly individual is diagnosed as manifesting significant deficits in memory and intellectual processing typical of true dementia victims. This misdiagnosis can result from the unrecognized fact that depressions of all kinds, affecting individuals of all age groups, typically involve temporary deficits in memory processing, concentration, and general intellectual functioning; the fact that temporary deficits in memory and cognitive functioning are often brought on by prescriptions of drug dosages beyond the delicate physiological needs of the elderly; or the inaccurate assumption that severe memory and intellectual deficits are a normal part of aging. —John Monopoli See also Aging; Alcoholism among the elderly; Death and dying; Dementia; Depression; Depression in children; Disabilities; Light therapy; Medications and the elderly; Memory loss; Overmedication; Stress; Suicide among the elderly; Terminal illnesses.
268 ✧ Diabetes mellitus For Further Information: Billig, Nathan. To Be Old and Sad: Understanding Depression in the Elderly. Lexington, Mass.: Lexington Books, 1987. Birren, James E., R. Bruce Sloane, and Gene D. Cohen, eds. Handbook of Mental Health and Aging. 2d ed. San Diego: Academic Press, 1992. Brink, Terry L. Clinical Gerontology: A Guide to Assessment and Intervention. New York: Haworth Press, 1986. Gallagher, Dolores, and Larry W. Thompson. Depression in the Elderly: A Behavioral Treatment Manual. Los Angeles: University of Southern California, Ethel Percy Andrus Gerontology Center, 1981. Knight, Bob G. Psychotherapy with Older Adults. Thousand Oaks, Calif.: Sage Publications, 1996.
✧ Diabetes mellitus Type of issue: Public health, social trends Definition: A hormonal disorder in which the pancreas is not able to produce sufficient insulin to process and maintain proper blood sugar levels; if left untreated, it leads to secondary complications such as blindness, dementia, and eventually death. Diabetes mellitus is by far the most common of all endocrine (hormonal) disorders. The disease has been depicted as a state of starvation in the midst of plenty. Although there is plenty of sugar in the blood, without insulin it does not reach the cells that need it for energy. Glucose, the simplest form of sugar, is the primary source of energy for many vital functions. Deprived of glucose, cells starve and tissues begin to degenerate. The unused glucose builds up in the bloodstream, which leads to a series of secondary complications. Effects of Insulin Insufficiency The acute symptoms of diabetes mellitus are all attributable to inadequate insulin action. The immediate consequence of an insulin insufficiency is a marked decrease in the ability of both muscle and adipose (fat) tissue to remove glucose from the blood. In the presence of inadequate insulin action, a second problem manifests itself. People with diabetes continue to make the hormone glucagon. Glucagon, which raises the level of blood sugar, can be considered insulin’s biological opposite. Like insulin, glucagon is released from the pancreatic islets. The release of glucagon is normally inhibited by insulin; therefore, in the absence of insulin, glucagon action elevates concentrations of glucose. For this reason, diabetes may be
Diabetes mellitus ✧ 269 considered a “two-hormone disease.” With a reduction in the conversion of glucose into its storage forms of glycogen in liver and muscle and lipids in adipose cells, concentrations of glucose in the blood steadily increase (hyperglycemia). When the amount of glucose in the blood exceeds the capacity of the kidney to reabsorb this nutrient, glucose begins to spill into the urine (glucosuria). Glucose in the urine then drags additional body water along with it so that the volume of urine dramatically increases. In the absence of adequate fluid intake, the loss of body water and accompanying electrolytes (sodium) leads to dehydration and, ultimately, death caused by the failure of the peripheral circulatory system. Insulin deficiency also results in a decrease in the synthesis of triglycerides (storage forms of fatty acids) and stimulates the breakdown of fats in adipose tissue. Although glucose cannot enter the cells and be used as an energy source, the body can use its supply of lipids from the fat cells as an alternate source of energy. Fatty acids increase in the blood, causing hyperlipidemia. With large amounts of circulating free fatty acids available for processing by the liver, the production and release of ketone bodies (breakdown products of fatty acids) into the circulation are accelerated, causing both ketonemia and an increase in the acidity of the blood. Since the ketone levels soon also exceed the capacity of the kidney to reabsorb them, ketone bodies soon appear in the urine (ketonuria). Insulin deficiency and glucagon excess also cause pronounced effects on protein metabolism and result in an overall increase in the breakdown of proteins and a reduction in the uptake of amino acid precursors into muscle protein. This leads to the wasting and weakening of skeletal muscles and, in children who are diabetics, results in a reduction in overall growth. Unfortunately, the increased level of amino acids in the blood provides an additional source of material for glucose production (gluconeogenesis) by the liver. All these acute metabolic changes in carbohydrates, lipids, and protein metabolism can be prevented or reversed by the administration of insulin. Types of Diabetes There are two distinct types of diabetes mellitus. Type I, or insulin-dependent diabetes mellitus (IDDM), is an absolute deficiency of insulin that accounts for approximately 10 percent of all cases of diabetes. Until the discovery of insulin, people stricken with Type I diabetes faced certain death within about a year of diagnosis. In Type II or non-insulin-dependent diabetes mellitus (NIDDM), insulin secretion may be normal or even increased, but the target cells for insulin are less responsive than normal (insulin resistance); therefore, insulin is not as effective in lowering blood glucose concentrations. Although either type can be manifested at any age, Type I diabetes has a greater prevalence in children, whereas the incidence of Type II diabetes increases markedly after the age of forty and is the most
270 ✧ Diabetes mellitus common type of diabetes. Genetic and environmental factors are important in the expression of both types of diabetes mellitus. Type I diabetes is an autoimmune process that involves the selective destruction of the insulin-producing beta cells in the islets of Langerhans (insulitis). The triggering event that initiates this process in genetically susceptible persons may be a virus or, more likely, the presence of toxins in the diet. The body’s own T lymphocytes progressively attack the beta cells but leave the other hormoneproducing cell types intact. T lymphocytes are white blood cells that normally attack virus-invaded cells and cancer cells. For up to ten years, there remains a sufficient number of insulin-producing cells to respond effectively to a glucose load, but when approximately 80 percent of the beta cells are destroyed, there is insufficient insulin release in response to a meal and the deadly spiral of the consequences of diabetes mellitus is triggered. Insulin injection can halt this lethal process and prevent it from recurring but cannot mimic the normal pattern of insulin release from the pancreas. It is interesting that not everyone who has insulitis actually progresses to experience overt symptoms of the disease, although it is known that the incidence of Type I diabetes around the world is on the increase. Type II diabetes is normally associated with obesity and lack of exercise as well as with genetic predisposition. Family studies have shown that as many as 25 to 35 percent of persons with Type II diabetes have a sibling or parent with the disease. The risk of diabetes doubles if both parents are affected. Because there is a reduction in the sensitivity of the target cells to insulin, people with Type II diabetes must secrete more insulin to maintain blood glucose at normal levels. Because insulin is a storage, or anabolic, hormone, this increased secretion further contributes to obesity. In response to the elevated insulin concentrations, the number of insulin receptors on the target cell gradually decreases, which triggers an even greater secretion of insulin. In this way, the excess glucose is stored despite the decreased availability of insulin binding sites on the cell. Over time, the demands for insulin eventually exceed even the reserve capacity of the “genetically weakened” beta cells, and symptoms of insulin deficiency develop as the plasma glucose concentrations remain high for increasingly larger periods of time. Because the symptoms of Type II diabetes are usually less severe than those of Type I diabetes, many persons have the disease but remain unaware of it. Unfortunately, once the diagnosis of diabetes is made in these individuals, they also exhibit symptoms of long-term complications that include atherosclerosis and nerve damage. Hence, Type II diabetes has been called the “silent killer.” Insulin Treatments for Type I Diabetes Insulin is the only treatment available for Type I diabetes, and in many cases it is used to treat individuals with Type II diabetes. Insulin is available in
Diabetes mellitus ✧ 271 many formulations, which differ in respect to the time of onset of action, activity, and duration of action. Insulin preparations are classified as fastacting, intermediate-acting, and long-acting; the effects of fast-acting insulin last for thirty minutes to twenty-four hours, while those of long-acting preparations last from four to thirty-six hours. Some of the factors that affect the rate of insulin absorption include the site of injection, the patient’s age and health status, and the patient’s level of physical activity. For a person with diabetes, however, insulin is a reprieve, not a cure. Because of the complications that arise from chronic exposure to glucose, it is recommended that glucose concentrations in the blood be maintained as close to physiologically normal levels as possible. For this reason, it is preferable to administer multiple doses of insulin during the day. By monitoring plasma glucose concentrations, the diabetic person can adjust the dosage of insulin administered and thus mimic normal concentrations of glucose relatively closely. Basal concentrations of plasma insulin can also be maintained throughout the day by means of electromechanical insulin delivery systems. Whether internal or external, such insulin pumps can be programmed to deliver a constant infusion of insulin at a rate designed to meet minimum requirements. The infusion can then be supplemented by a bolus injection prior to a meal. Increasingly sophisticated systems automatically monitor blood glucose concentrations and adjust the delivery rate of insulin accordingly. These alternative delivery systems are intended to prevent the development of long-term tissue complications. Complications of Diabetes A number of chronic complications account for the shorter life expectancy of diabetics, including atherosclerotic changes throughout the entire vascular system. The thickening of basement membranes that surround the capillaries can affect their ability to exchange nutrients. Cardiovascular lesions are the most common cause of premature death in diabetic persons. Kidney disease, which is commonly found in longtime diabetics, can ultimately lead to kidney failure. For these persons, expensive medical care, including dialysis and the possibility of a kidney transplant, overshadows their lives. Diabetes is the leading cause of new blindness in the United States. In addition, diabetes leads to a gradual decline in the ability of nerves to conduct sensory information to the brain. For example, the feet of some diabetics feel more like stumps of wood than living tissue. Consequently, weight is not distributed properly; in concert with the reduction in blood flow, this problem can lead to pressure ulcers. If not properly cared for, areas of the foot can develop gangrene, which may then lead to amputation of the foot. Finally, in male patients, there are problems with reproductive function that generally result in impotence. The mechanism responsible for the development of these long-term
272 ✧ Diabetes mellitus complications of diabetes is genetic in origin and dependent on the amount of time the tissues are exposed to the elevated plasma glucose concentrations. As an animal ages, most of its cells become less efficient in replacing damaged material, while its tissues lose their elasticity and gradually stiffen. For example, the lungs and heart muscle expand less successfully, blood vessels become increasingly rigid, and ligaments tighten. These apparently diverse age-related changes are accelerated in diabetes, and the causative agent is glucose. Glucose becomes chemically attached to proteins and deoxyribonucleic acid (DNA) in the body without the aid of enzymes to speed the reaction along. What is important is the duration of exposure to the elevated glucose concentrations. Once glucose is bound to tissue proteins, a series of chemical reactions is triggered that, over the passage of months and years, can result in the formation and eventual accumulation of cross-links between adjacent proteins. The higher glucose concentrations in diabetics accelerate this process, and the effects become evident in specific tissues throughout the body. Understanding the chemical basis of protein cross-linking in diabetes has permitted the development and study of compounds that can intervene in this process. Certain compounds, when added to the diet, can limit the glucose-induced cross-linking of proteins by preventing their formation. One of the best-studied compounds, aminoguanidine, can help prevent the cross-linking of collagen; this fact is shown in a decrease in the accumulation of trapped lipoproteins on artery walls. Aminoguanidine also prevents thickening of the capillary basement membrane in the kidney. Aminoguanidine acts by blocking glucose’s ability to react with neighboring proteins. Vitamins C and B6 are also effective in reducing cross-linking. Alternatively, transplantation of the entire pancreas is an effective means of achieving an insulin-independent state in persons with Type I diabetes mellitus. Both the technical problems of pancreas transplantation and the possible rejection of the foreign tissue, however, have limited this procedure as a treatment for diabetes. Diabetes is usually manageable; therefore, a pancreas transplant is not necessarily lifesaving. Some limited success in treating diabetes has been achieved by transplanting only the insulin-producing islet cells from the pancreas or grafts from fetal pancreas tissue. It may one day be possible to use genetic engineering to permit cells of the liver to self-regulate glucose concentrations by synthesizing and releasing their own insulin into the blood. Controlling Type II Diabetes Some of the less severe forms of Type II diabetes mellitus can be controlled by the use of oral hypoglycemic agents that bring about a reduction in blood glucose. These drugs can be taken orally to drive the beta cells to release even more insulin than usual. These drugs also increase the ability of insulin
Diabetes mellitus ✧ 273 to act on the target cells, which ultimately reduces the insulin requirement. The use of these agents remains controversial, because they overwork the already strained beta cells. If a diabetic person is reliant on these drugs for extended periods of time, the insulin cells could “burn out” and completely lose their ability to synthesize insulin. In this situation, the previously noninsulin-dependent person would have to be placed on insulin therapy for life. If obesity is a factor in the expression of Type II diabetes, the best therapy is a combination of a reduction of calorie intake and an increase in activity. More than any other disease, Type II diabetes is related to lifestyle. It is often the case that people prefer having an injection or taking a pill to improving their quality of life by changing their diet and level of activity. Attention to diet and exercise results in a dramatic decrease in the need for drug therapy in nine out of ten diabetics. In some cases, the loss of only a small percentage of body weight results in an increased sensitivity to insulin. Exercise is particularly helpful in the management of both types of diabetes, because working muscle does not require insulin to metabolize glucose. Thus, exercising muscles take up and use some of the excess glucose in the blood, which reduces the overall need for insulin. Permanent weight reduction and exercise also help to prevent long-term complications and permit a healthier and more active lifestyle. Research into a Cure Although insulin, when combined with an appropriate diet and exercise, alleviates the symptoms of diabetes to such an extent that a diabetic can lead an essentially normal life, insulin therapy is not a cure. The complications that arise in diabetics are typical of those found in the general population except that they happen much earlier in the diabetic. In the mid-1970’s, Anthony Cerami introduced the concept of the nonenzymatic attachment of glucose to protein and recognized its potential role in diabetic complications. A decade later, this development led to the discovery of aminoguanidine, the first compound to limit the cross-linking of tissue proteins and thus delay the development of certain diabetic complications. In 1974, Josiah Brown published the first report showing that diabetes could be reversed by transplanting fetal pancreatic tissue. By the mid-1980’s, procedures had been devised for the isolation of massive numbers of human islets that could then be transplanted into diabetics. For persons with diabetes, both procedures represent more than a treatment; they may offer a cure for the disease. —Hillar Klandorf See also Childbirth complications; Exercise; Exercise and children; Exercise and the elderly; Genetic diseases; Obesity; Obesity and aging; Obesity
274 ✧ Disabilities and children; Prenatal care; Screening; Sexual dysfunction; Transplantation; Yeast infections. For Further Information: Biermann, June, and Barbara Toohey. The Diabetic’s Book. 4th ed. New York: G. P. Putnam’s Sons, 1998. This extremely helpful book deals with both Type I and Type II diabetes. It is filled with useful information to help patients live a more healthful and satisfying life and contains answers to 130 frequently asked questions about the disease, including lifestyle, diet, and therapy. Cerami, Anthony, Helen Vlassara, and Michael Browlee. “Glucose and Aging.” Scientific American 256 (May, 1987): 90-96. A pioneering article written by experts in the field of diabetic complications. This important work clearly explains the development of cross-linking in the tissues and challenges the reader with new approaches to treating a very old problem. Contains excellent figures and diagrams of the processes involved. Jovanovic-Peterson, Lois, Charles M. Peterson, and Morton B. Stori. A Touch of Diabetes. Minneapolis: Chronimed, 1995. A straightforward guide for people with Type II diabetes. Provides useful information on the disease and suggestions of how to change eating habits and monitor one’s lifestyle. Krall, Leo P., and Richard S. Beaser. Joslin Diabetes Manual. 12th ed. Philadelphia: Lea & Febiger, 1989. First published in 1918, this book serves as a guide for people with diabetes. Its intent is to help diabetics understand the disease and permit them to take control of their lives. Powers, Margaret A., ed. Handbook of Diabetes Medical Nutrition Therapy. Rev. ed. Gaithersburg, Md.: Aspen, 1996. A comprehensive book written by dietitians for persons interested in the nutritional treatment of diabetes; blends new scientific knowledge and thought with recent advances in clinical practice.
✧ Disabilities Type of issue: Economic issues, mental health, occupational health, social trends Definition: Physical or mental impairments that substantially limit major life activities. Persons with physical disabilities have the ability and the legal right to participate fully in family and community life, but this requires that everyone make special accommodations for their unique needs In the United States, disability is legally defined as any physical or mental
Disabilities ✧ 275 impairment that substantially limits one or more of a person’s major life activities. Temporary impairment due to an illness or injury from which the person can completely recover are not considered to be disabilities. Employment, education, use of public facilities, parenting, and social contact are all major life activities that can be limited by physical disabilities unless disabled persons, families, and communities work together to remove barriers in the way of full participation. The challenges faced by persons with disabilities affect everyone not only by law, but also because of the large numbers of disabled persons. One in six Americans has a disability, and one in eight has a physical disability. Almost every nuclear or extended family in America has at least one member who is or will be affected by a disability at some point during the life span. Types of Physical Disabilities There are four types of physical disabilities. The first is impairment in the sensory system (vision and hearing). The most common type of all physical disabilities is hearing impairment, which affected 22 million Americans by the late twentieth century. Hearing impairment ranges in severity from complete lack of sound perception to loss of only a portion of normal hearing. Vision impairment is less common than hearing impairment. The majority of vision-impaired persons are totally blind—that is, they have no functional sight. Legally blind persons have some sight but are limited in some life activities because of their limited acuity of vision (clarity and sharpness) or field of vision (the amount of area the eye can see at one time). Many people with sensory impairments can achieve nearly normal perception with the help of hearing aids, glasses, or surgery. Even though a disability can be completely compensated for, persons are still regarded as having a disability if they need continuing medical assistance to be able to fully engage in major life activities. The second type of physical disability is impairment of a person’s ability to move or control the body. This can include loss of control over involuntary functions such as bowel, bladder, breathing, or sexual activity. Persons with motor impairments may have difficulty eating or speaking. Most people with motor impairments use some type of equipment to help them move around, including wheelchairs, canes, walkers, and orthotic devices that keep paralyzed or spastic body parts in correct alignment. The most severe motor impairments include paraplegia, or paralysis in the legs and lower body, and quadriplegia, or paralysis in the upper and lower body. The majority of motor impairments affect only some body parts and functions, leaving others completely healthy. For example, a person with paraplegia due to spinal cord damage may have no sensation or movement in the legs, but may have bowel and bladder control and normal sexual functioning. Most people with motor impairments have the same cognitive ability as
276 ✧ Disabilities others, although individuals with severe mental retardation often have both sensory and motor impairments. The third type of physical disability is disfigurement of one or more body parts. Even if disfigurements do not cause motor or sensory impairments, they can contribute to social isolation or loss of self-esteem, presenting a barrier to many major life activities. The fourth type of physical disability includes chronic, incurable illnesses that interfere with major life activities. Such illnesses may include epilepsy, diabetes, human immunodeficiency virus (HIV) infection, autoimmune diseases such as multiple sclerosis (which affects the nervous system) or lupus erythematosus (which can affect all body tissues), and severe respiratory problems such as asthma or emphysema. These are only considered to be disabilities if they are severe enough to interfere with daily activities. Causes of Physical Disabilities There are three causes of physical disabilities, each of which presents families with unique challenges. The first is congenital or developmental problems. Congenital problems are present at birth and have many sources. Some congenital problems are inherited, as is true of some types of cataracts that result in blindness and some forms of hearing impairments. Others may be the result of prenatal exposure to toxic substances, drugs, or a disease such as German measles. Congenital problems can also be the result of random genetic accidents that are not inherited and can affect anyone, such as Down syndrome. Problems during pregnancy and childbirth, including anoxia (lack of oxygen) and illnesses contracted by expectant mothers can also create problems that lead to disabilities. Some problems start before birth, but are not apparent at birth. These often result in disabilities later in life as children grow and are called developmental problems because they appear during childhood. Many conditions that affect motor control, speech, and eating are only discovered when children fail to develop these abilities at the same time as other children of the same age. The second cause of physical disabilities is accidental injury. Such disabilities affect adolescents and young adults more than any other group. The leading cause of motor disabilities is head injuries, which most often occur in bicycle or automobile accidents. Automobile accidents are also responsible for most cases of spinal cord injuries that result in paralysis. The third cause of physical disabilities is physical deterioration and illnesses that sometimes accompany aging. Persons who have been healthy and unimpaired all their lives can become disabled by strokes, arthritis, chronic illnesses, and chronic pain.
Disabilities ✧ 277 Family Issues No two individuals with a physical disability, even the same disability, are alike. No two families will face the same challenges and experiences in dealing with disabilities. How families cope and the types of support they need depend on the types of disabilities, the causes of the disabilities, and families’ strengths and vulnerabilities. Disabilities that require a great deal of physical assistance are the most time-consuming for family members, who may take time away from work and education to care for disabled persons. There are some sources of funding in the United States and Canada for in-home help, ranging from caregiving for an evening to live-in aides. Family members with the most severe motor disabilities still require a great deal of family time and planning, even with such assistance. The causes of disabilities present different challenges to every family. Parents of children with congenital or developmental problems may blame themselves for their children’s impairments. This natural tendency toward self-blame is aggravated by the difficulty, present in most cases, of identifying the problem and finding appropriate treatment and support, a process which can take many years. Parents also face the financial and emotional responsibility of providing for children who may need assistance well into adulthood. When adolescents or adults are suddenly disabled by illness or injury, the issues are different but no less difficult. Persons who have been disabled by head injuries or strokes or who take medication to control pain may undergo personality changes in addition to suffering from their physical disability. Many people who become disabled later in life feel depressed and angry for a time after being injured, which can put a strain on family relationships. Like developmental problems, it can take many years to diagnose and treat chronic illnesses, leaving families on a roller coaster of hope and disappointment. The strongest factor contributing to family member satisfaction and the disabled person’s sense of fulfillment is not the cause or type of disability, as challenging as this may be. Nor is it the family’s financial status, education, or the number of family members, all of which can affect the amount of effort each member must devote to the care of the disabled. The strongest factor is the emotional climate before onset of the disability. Families in which communication has been good, the emotional climate has been positive, and family members’ needs have been met before the onset of disability are best able to cope when a disability occurs. This does not mean that emotionally strong families do not experience the self-blame, depression, and anger that normally accompany adjusting to a disability. Nor does it mean that families who faced emotional problems before the onset of disability will be unable to cope. It does mean that all family members must learn to communicate and meet each others’ emotional needs in order to cope with the disability when it arises.
278 ✧ Disabilities How Families Cope with Disabilities Many families who are faced with the challenges of disability have a strong desire to help the disabled person. Sometimes one or more family members devote all their energy and attention to the disabled person. This is a pattern of coping that does not work well either for the disabled person or for the family. Disabled children who receive too much help, attention, and pity may find it difficult to become as independent as they can be. Adults who suddenly become disabled often do not want help or extra attention; most such adults want life and family relationships to return to normal. Family members who devote all their energies to disabled relatives may feel either depleted of energy and feeling or neglected and angry. There are ways of coping with disabilities that help disabled persons as well as their families. First, every member of the family should feel free to discuss their caregiving responsibilities, feelings, and needs openly. Second, responsibilities should be divided as equitably as possible, allowing all family members to pursue their own lives. Third, families should seek as much help as they can get—financial, practical, and emotional. Fourth, nondisabled family members can find ways to value and enjoy the company of their disabled relatives as they are, while encouraging them to pursue their own goals and achieve independence. Finally, and most important, disabled persons should be active parts of their families’ coping processes; they should be included in any decisions that affect them or the family. By recognizing disabled persons’ right to be contributing members of the family, families help the disabled to see themselves as fully capable, independent, and valuable persons. Full Inclusion For the first time in North American history, government programs and disability rights legislation have shown communities how to take responsibility for protecting and accommodating the needs of persons with disabilities. In the 1990’s, 26 percent of disabled adults were fully employed. Every public school classroom included children with disabilities, and every college campus enrolled students with disabilities. Persons with disabilities, once segregated and kept out of sight, were involved in every aspect of community, social, and family life. As medical care has improved and people live longer, a result of the fact that once-fatal injuries have become only disabling, the number of families affected by disability may increase. The sharing of responsibility between families and communities may help families to cope with disability. Furthermore, research has shown that the inclusion of disabled persons in family and community life has persuaded more persons to believe that they can lead meaningful, productive lives—with or without a disability. —Kathleen M. Zanolli
Domestic violence ✧ 279 See also AIDS; AIDS and children; AIDS and women; Alzheimer’s disease; Autism; Birth defects; Chronic fatigue syndrome; Cleft lip and palate; Down syndrome; Dyslexia; Fetal alcohol syndrome; Foot disorders; Genetic counseling; Genetic diseases; Learning disabilities; Macular degeneration; Mental retardation; Mobility problems in the elderly; Parkinson’s disease; Physical rehabilitation; Safety issues for children; Safety issues for the elderly; Speech disorders; Spina bifida; Strokes. For Further Information: Albrecht, Donna G. Raising a Child Who Has a Physical Disability. New York: John Wiley & Sons, 1995. Written by a parent of two children with physical disabilities, this book explains how to find funding, set up a support network, navigate the medical and educational system, and how to cope with guilt and stress. Kissane, Sharon. Career Success for People with Physical Disabilities. Lincolnwood, Ill.: VGM Career Horizons, 1997. Provides many strategies for persons with disabilities in selecting, training for, finding, and keeping employment. LaPlante, Mitchell P. Families with Disabilities in the United States. Washington, D.C.: U.S. Department of Education, 1996. Describes in detail the facts of disability and its effect on families, with national, regional, and state breakdowns as well as descriptions of model programs for persons with disabilities. Sullivan, Tom. Special Parent, Special Child. New York: Putnam, 1995. Written by a visually impaired person from a unique and interesting perspective, this book relates the stories of families dealing with children’s disabilities. Tracey, William R. Training Employees with Disabilities. New York: Amacom, 1995. Detailed description of the legal, ethical, and training issues involved in hiring and managing persons with disabilities, pointing out that by the year 2000 the majority of the workforce, including persons with disabilities, will be protected by civil rights legislation.
✧ Domestic violence Type of issue: Children’s health, elder health, ethics, mental health, social trends, women’s health Definition: Assaultive behavior intended to punish, dominate, or control another in an intimate family relationship; physicians are often best able to identify situations of domestic violence and assist victims to implement preventive interventions. Domestic or family violence is the intentional use of violence against an intimate partner. The purpose of the violence is to assert domination, to
280 ✧ Domestic violence control the victim’s actions, or to punish the victim for some actions. Family violence generally occurs as a pattern of behavior over time rather than as a single, isolated act. Common Traits of All Domestic Abuse Forms of family violence include child physical abuse, child sexual abuse, spousal or partner abuse, and elder abuse. These forms of violence are related, in that they occur within the context of the family unit. Therefore, the victims and perpetrators know one another, are related to one another, may live together, and may love one another. These various forms of violence also differ insofar as victims may be children, adults, or frail, elderly adults. The needs of victims differ with age and independence, but there are also many similarities between the different types of violence. One such similarity is the relationship between the offender and the victim. Specifically, victims of abuse are always less powerful than abusers. Power includes the ability to exert physical and psychological control over situations. For example, a child abuser has the ability to lock a child in a bathroom or to abandon him or her in a remote area in order to control access to authorities. A spouse abuser has the ability to physically injure a spouse, disconnect the phone, and keep the victim from leaving for help. An elder abuser can exert similar control. Such differences in power between victims and offenders are seen as a primary cause of abuse; that is, people batter others because they can. Families that are violent are often isolated. The members usually keep to themselves and have few or no friends or relatives with whom they are involved, even if they live in a city. This social isolation prevents victims from seeking help from others and allows the abuser to establish rules for the relationship without answering to anyone for these actions. Abuse continues and worsens because the violence occurs in private, with few consequences for the abuser. Victims of all forms of family violence share common experiences. In addition to physical violence, victims are also attacked psychologically, being told they are worthless and responsible for the abuse that they receive. Because they are socially isolated, victims do not have an opportunity to take social roles where they can experience success, recognition, or love. As a result, victims often have low self-esteem and truly believe that they cause the violence. Without the experience of being worthwhile, victims often become severely depressed and anxious, and they experience more stressrelated illnesses such as headaches, fatigue, or gastrointestinal problems. Inherited Abuse Child and partner abuse are linked in several ways. About half of the men who batter their wives also batter their children. Further, women who are
Domestic violence ✧ 281 battered are more likely to abuse their children than are nonbattered women. Even if a child of a spouse-abusing father is not battered, living in a violent home and observing the father’s violence has negative effects. Such children often experience low self-esteem, aggression toward other children, and school problems. Moreover, abused children are more likely to commit violent offenses as adults. Children, especially males, who have observed violence between parents are at increased risk of assaulting their partners as adults. Adult sexual offenders have an increased likelihood of having been sexually abused as children. Yet, while these and other problems are reported more frequently by adults who were abused as children than by adults who were not, many former victims do not become violent. The most common outcomes of childhood abuse in adults are emotional problems. Although much less is known about the relationship between child abuse and future elder abuse, many elder abusers did suffer abuse as children. While most people who have been abused do not themselves become abusers, this intergenerational effect remains a cause for concern. Patterns of Abuse and Cycles of Violence Family violence typically consists of a pattern of behavior occurring over time and involving both hands-on and hands-off violence. Hands-on violence consists of direct attacks against the victim’s body. Such acts range from pushing, shoving, and restraining to slapping, punching, kicking, clubbing, choking, burning, stabbing, or shooting. Hands-on violence also includes sexual assault, ranging from forced fondling of breasts, buttocks, and genitals; to forced touching of the abuser; to forced intercourse with the abuser or with other people. Hands-off violence includes physical violence that is not directed at the victim’s body but is intended to display destructive power and assert domination and control. Examples include breaking through windows or locked doors, punching holes through walls, smashing objects, destroying personal property, and harming or killing pet animals. The victim is often blamed for this destruction and forced to clean up the mess. Hands-off violence also includes psychological control, coercion, and terror. This includes name calling, threats of violence or abandonment, gestures suggesting the possibility of violence, monitoring of the victim’s whereabouts, controlling of resources (such as money, transportation, and property), forced viewing of pornography, sexual exposure, or threatening to contest child custody. These psychological tactics may occur simultaneously with physical assaults or may occur separately. Whatever the pattern of psychological and physical tactics, abusers exert extreme control over their partners. Neglect—the failure of one person to provide for the basic needs of another dependent person—is another form of hands-off abuse. Neglect
282 ✧ Domestic violence may involve failure to provide food, clothing, health care, and shelter. Children, older adults, and developmentally delayed or physically handicapped people are particularly vulnerable to neglect. Family violence differs in two respects from violence directed at strangers. First, the offender and victim are related and may love each other, live together, share property, have children, and share friends and relatives. Hence, unlike victims of stranger violence, victims of family violence cannot quickly or easily sever ties with or avoid seeing their assailants. Second, family violence often increases slowly in intensity, progressing until victims feel immobilized, unworthy, and responsible for the violence that is directed toward them. Victims may also feel substantial and well-grounded fear about leaving their abusers or seeking legal help, because they have been threatened or assaulted in the past and may encounter significant difficulty obtaining help to escape. In the case of children, the frail and elderly, or people with disabilities, dependency upon the caregiver and cognitive limitations make escape from an abuser difficult. Remaining in the relationship increases the risk of continued victimization. Understanding this unique context of the violent family can help physicians and other health care providers understand why battered victims often have difficulty admitting abuse or leaving the abuser. Family violence follows a characteristic cycle that begins with escalating tension and anger in the abuser. Victims describe a feeling of “walking on eggs.” Next comes an outburst of violence. Outbursts of violence sometimes coincide with episodes of alcohol and drug abuse. Following the outburst, the abuser may feel remorse and expect forgiveness. The abuser often demands reconciliation, including sexual interaction. After a period of calm, the abuser again becomes increasingly tense and angry. This cycle generally repeats, with violence becoming increasingly severe. In partner abuse, victims are at greatest risk when there is a transition in the relationship such as pregnancy, divorce, or separation. In the case of elder abuse, risk increases as the elder becomes increasingly dependent on the primary caregiver, who may be inexperienced or unwilling to provide needed assistance. Without active intervention, the abuser rarely stops spontaneously and often becomes more violent. Identifying Child Abuse Because children do not usually tell a physician directly if they are being abused physically or sexually, physicians use several strategies to identify child and adolescent victims. Physicians screen for abuse during regular checkups by asking children if anyone has hurt them, touched them in private places, or scared them. To accomplish this screening with five-yearold patients having a routine checkup, physicians may teach their young patients about private areas of the body; let them know that they can tell a
Domestic violence ✧ 283 parent, teacher, or doctor if anyone ever touches them in private places; and ask the patients if anyone has ever touched them in a way that they did not like. For fifteen-year-old patients, physicians may screen potential victims by providing information on sexual abuse and date rape, then ask the patients if they have ever experienced either. A second strategy that physicians use to identify children who are victims of family violence is to remain alert for general signs of distress that may indicate a child or youth lives in a violent situation. General signs of distress in children, which may be caused by family violence or by other stressors, include depression, anxiety, low self-esteem, hyperactivity, disruptive behaviors, aggressiveness toward other children, and lack of friends. In addition to general signs of distress, certain specific signs and symptoms of physical and sexual abuse in children indicate that the child has probably been exposed to violence. For example, bruises that look like a handprint, belt mark, or rope burn would indicate abuse. X rays can show a history of broken bones that are suspicious. Intentional burns from hot water, fire, or cigarettes often have a characteristic pattern. Sexually transmitted diseases in the genital, anal, or oral cavity of a child who is aged fourteen or under would suggest sexual abuse. A physician observing specific signs of abuse or violence in a child, or even suspecting physical or sexual abuse, has an ethical and legal obligation to provide this information to state child protective services. Every state has laws that require physicians to report suspected child abuse. Physicians do not need to find proof of abuse before filing a report. In fact, the physician should never attempt to prove abuse or interview the child in detail because this can interfere with interviews conducted by experts in law, psychology, and the medicine of child abuse. When children are in immediate danger, they may be hospitalized so that they may receive a thorough medical and psychological evaluation while also being removed from the dangerous situation. In addition to filing a report, the physician records all observations in the child’s medical chart. This record includes anything that the child or parents said, drawings or photographs of the injury, the physician’s professional opinion regarding exposure to violence, and a description of the child abuse report. Identifying Partner Abuse Physicians also play a key role in helping victims of partner violence. Like children and adolescents, adult victims will usually not disclose violence. Therefore physicians should screen for partner violence and ask about partner violence whenever they notice specific signs of abuse or general signs of distress. Physicians screen for current and past violence during routine patient visits, such as during initial appointments; school, athletic, and work physicals; premarital exams; obstetrical visits; and regular check-
284 ✧ Domestic violence ups. General signs of distress include depression, anxiety disorders, low self-esteem, suicidal ideation, drug and alcohol abuse, stress illnesses (headache, stomach problems, chronic pain), or patient comments about a partner being jealous, angry, controlling, or irritable. Specific signs of violence include physical injury consistent with assault, including those requiring emergency treatment. When a victim reports partner violence, there are five steps that a physician can take to help. Communicating belief and support is the first step. Sometimes abuse is extreme and patient reports may seem incredible. The physician validates the victim’s experience by expressing belief in the story and exonerating the patient of blame. The physician can begin this process by making eye contact and telling the victim, “You have a right to be safe and respected” and “No one should be treated this way.” The second step is helping the patient assess danger. This is done by asking about types and severity of violent acts, duration and frequency of violence, and injuries received. Specific factors that seem to increase the risk of death in violent relationships include the abuser’s use of drugs and alcohol, threats to kill the victim, and the victim’s suicidal ideation or attempts. Finally, the physician should ask if the victim feels safe returning home. With this information, the physician can help the patient assess lethal potential and begin to make appropriate safety plans. The third step is helping the patient identify resources and make a safety plan. The physician begins this process by simply expressing concern for the victim’s safety and providing information about local resources such as mandatory arrest laws, legal advocacy services, and shelters. For patients planning to return to an abusive relationship, the physician should encourage a detailed safety plan by helping the patient identify safe havens with family members, friends, or a shelter; assess escape routes from the residence; make specific plans for dangerous situations or when violence recurs; and gather copies of important papers, money, and extra clothing in a safe place in or out of the home in the event of a quick exit. Before the patient leaves, the physician should give the patient a follow-up appointment within two weeks. This provides the victim with a specific, known resource. Followup visits should continue until the victim has developed other supportive resources. The physician’s final step is documentation in the patient’s medical chart. This written note includes the victim’s report of violence, the physician’s own observations of injuries and behavior, assessment of danger, safety planning, and follow-up. This record can be helpful in the event of criminal or civil action taken by the victim against the offender. The medical chart and all communications with the patient are kept strictly confidential. Confronting the offender about the abuse can place the victim at risk of further, more severe violence. Improper disclosure can also result in loss of the patient’s trust, precluding further opportunities for help.
Domestic violence ✧ 285 The physician should not encourage a patient to leave a violent relationship as a first or primary choice. Leaving an abuser is the most dangerous time for victims and should be attempted only with adequate planning and resources. The physician should not recommend couples counseling. Couples counseling endangers victims by raising the victim’s expectation that issues can be discussed safely. The abuser often batters the victim after disclosure of sensitive information. Finally, the physician should not overlook violence if the violence appears to be “minor.” Seemingly minor acts of aggression can be highly injurious. Identifying Abuse of the Elderly and Disabled Physicians also play an important role in helping adults who are older, developmentally delayed, or physically disabled. People in all three groups experience a high rate of family violence. Each group presents unique challenges for the physician. One common element among all three groups is that the victims may be somewhat dependent upon other adults to meet their basic needs. Because of this dependence, abuse may sometimes take the form of failing to provide basic needs such as adequate food or medical care. In many states, adults who are developmentally delayed are covered by mandatory child abuse reporting laws. The signs and symptoms of the abuse of elders are similar to the other forms of family violence. These include physical injuries consistent with assault, signs of distress, and neglect, including self-neglect. Elder abuse victims are often reluctant to reveal abuse because of fear of retaliation, abandonment, or institutionalization. Therefore, a key to intervention is coordinating with appropriate social service and allied health agencies to support an elder adequately, either at home or in a care center. Such agencies include aging councils, visiting nurses, home health aids, and respite or adult day care centers. Counseling and assistance for caregivers is also an important part of intervention. Many states require physicians to report suspected elder abuse. Because many elder abuse victims are mentally competent, however, it is important that they be made part of the decision-making and reporting process. Such collaboration puts needed control in the elder’s hands and therefore facilitates healing. Many other aspects of intervention described for partner abuse apply to working with elders, including providing emotional support, assessing danger, safety planning, and documentation. A Public Health Epidemic In its various forms, family violence is a public health epidemic in the United States. Once thought to be rare, family violence occurs with high frequency in the general population. Although exact figures are lacking and domes-
286 ✧ Domestic violence tic violence tends to be underreported, it is estimated that each year 1.9 million children are physically abused; 250,000 children are sexually molested; 1.6 million women are assaulted by their male partners; and between 500,000 and 2.5 million elders are abused. Rates of violence directed toward unmarried heterosexual women, married heterosexual women, and members of homosexual male and female couples tend to be similar. Victims come from all social classes, races, and religions. Partner violence directed toward heterosexual men, however, is rare and usually occurs in relationships in which the male hits first. Because family violence is so pervasive, physicians encounter many victims. One out of every three to five women visiting emergency rooms is seeking medical care for injuries related to partner violence. In primary care clinics, including family medicine, internal medicine, and obstetrics and gynecology, one out of every four female patients reports violence in the past year, and two out of five report violence at some time in their lives. It is therefore reasonable to expect all physicians and other health care professionals working in primary care and emergency rooms to provide services for victims of family violence. —L. Kevin Hamberger and Bruce Ambuel See also Addiction; Alcoholism; Alcoholism among teenagers; Alcoholism among the elderly; Child abuse; Depression; Depression in children; Depression in the elderly; Drug abuse by teenagers; Elder abuse; Ethics; Recovery programs; Schizophrenia; Stress. For Further Information: Barnett, Ola W., Cindy-Lou Miller-Perrin, and Robert D. Perrin. Family Violence Across the Lifespan: An Introduction. Thousand Oaks, Calif.: Sage Publications, 1997. Provides information about the different ways that domestic violence, and the warning signs associated with it, may be recognized at various stages in the life spans of individuals and families. Dutton, Donald G. The Abusive Personality: Violence and Control in Intimate Relationships. New York: The Guilford Press, 1998. Dutton, a psychologist, began as a disciple of social learning theory and eventually came to understand that theory alone was inadequate to explain the multifaceted origins of spousal abuse. He takes the reader through a journey across the various explanations of the male batterer, eventually arriving at an in-depth discussion of the cyclical abuser. Raphael, Jody. Saving Bernice: Battered Women, Welfare, and Poverty. Boston: Northeastern University Press, 2000. Raphael uses the case study of one welfare mother and survivor of domestic violence to exemplify the broader issues connecting domestic violence and poverty. In interviews taped during 1995-1999, Bernice, a mother of two and on welfare for eight years, recounts the trauma of abuse, harassment, and stalking by her former partner.
Down syndrome ✧ 287 Wilson, K. J. When Violence Begins at Home: A Comprehensive Guide to Understanding and Ending Domestic Violence. Alameda, Calif.: Hunter House, 1997. Wilson seeks to share her wealth of knowledge stemming from experience as the current training director at the Austin Center for Battered Women, as an educator, and as a survivor of domestic abuse. She targets a range of audiences, from domestic violence opponents, victims, family, and friends of survivors to a myriad of helping professionals. Wolfe, David A., Christine Wekerle, and Katreena Scott. Alternatives to Violence: Empowering Youth to Develop Healthy Relationships. Thousand Oaks, Calif.: Sage Publications, 1997. Offers information about how to recognize problems related to the development of violence in relationships, as well as strategies to help adolescents develop healthy relationship habits.
✧ Down syndrome Type of issue: Children’s health, mental health Definition: A congenital abnormality characterized by moderate to severe mental retardation and a distinctive physical appearance caused by a chromosomal aberration, the result of either an error during embryonic cell division or the inheritance of defective chromosomal material. Down syndrome results from an incorrect transfer of genetic material in the formation of cells. This disease is also termed trisomy 21 because it most commonly results from the presence of a third, extra copy of the smallest human chromosome, chromosome 21. Actually, it is not the entire extra chromosome 21 that is responsible, but rather a small segment of the long arm of this chromosome. Most incidences of Down syndrome are a consequence of a nondisjunction during meiosis. In about 75 percent of these cases, the extra chromosome is present in the egg. About 1 percent of Down syndrome cases occur after the fertilization of normal gametes from a mitosis nondisjunction, producing a mosaic in which some of the embryo’s cells are normal and some exhibit trisomy. The degree of mosaicism and its location will determine the physiological consequences of the nondisjunction. Although mosaic individuals range from apparent normality to completely affected, typically the disorder is less severe. In about 4 percent of all Down syndrome cases, the individual possesses not an entire third copy of chromosome 21 but rather extra chromosome 21 material, which has been incorporated via a translocation into a nonhomologous chromosome. In translocation, pieces of arms are swapped between two nonrelated chromosomes, forming hybrids. The most common translocation associated with Down syndrome is that between the long arm (Down gene area) of chromosome 21 and an end of chromosome 14. The
288 ✧ Down syndrome individual in whom the translocation has occurred shows no evidence of the aberration, since the normal complement of genetic material is still present, only at different chromosomal locations. The difficulty arises when this individual forms gametes.
Many agencies offer social and emotional support for people with Down syndrome and their families. (National Library of Medicine)
A mother who possesses the 21/14 translocation, for example, has one normal 21, one normal 14, and the hybrid chromosomes. She is a genetic carrier for the disorder, because she can pass it on to her offspring even though she is clinically normal. This mother could produce three types of
Down syndrome ✧ 289 viable gametes: one containing the normal 14 and 21; one containing both translocations, which would result in clinical normality; and one containing the normal 21 and the translocated 14 having the long arm of 21. If each gamete were fertilized by normal sperm, two apparently normal embryos and one partial trisomy 21 Down syndrome embryo would result. Down syndrome that results from the passing on of translocations is termed familial Down syndrome and is an inherited disorder. The Effects of Down Syndrome The presence of an extra copy of the long arm of chromosome 21 causes defects in many tissues and organs. One major effect of Down syndrome is mental retardation. The intelligence quotients (IQs) of affected individuals are typically in the range of 40-50. The IQ varies with age, being higher in childhood than in adolescence or adult life. The disorder is often accompanied by physical traits such as short stature, stubby fingers and toes, protruding tongue, and an unusual pattern of hand creases. Perhaps the most recognized physical feature is the distinctive slanting of the eyes, caused by a vertical fold (epicanthal fold) of skin near the nasal bridge which pulls and tilts the eyes slightly toward the nostrils. For normal Caucasians, the eye runs parallel to the skin fold below the eyebrow; for Asians, this skin fold covers a major portion of the upper eyelid. In contrast, the epicanthal fold in trisomy 21 does not cover a major part of the upper eyelid. It should be noted that not all defects associated with Down syndrome are found in every affected individual. About 40 percent of Down syndrome patients have congenital heart defects, while about 10 percent have intestinal blockages. Affected individuals are prone to respiratory infections and contract leukemia at a rate twenty times that of the general population. Although Down syndrome children develop the same types of leukemia in the same proportions as other children, the survival rate of the two groups is markedly different. While the survival rate for non-Down syndrome patients after ten years is about 30 percent, survival beyond five years is negligible in Down syndrome patients. It appears that the extra copy of chromosome 21 not only increases the risk of contracting the cancer but also exerts a decisive influence on the disease’s outcome. Reproductively, males are sterile while some females are fertile. Although many Down syndrome infants die in the first year of life, the mean life expectancy is about thirty years. This reduced life expectancy results from defects in the immune system, causing a high susceptibility to infectious disease. Most older Down syndrome individuals develop an Alzheimer’s-like condition, and less than 3 percent live beyond fifty years of age.
290 ✧ Down syndrome Risk Factors Trisomy 21 is one of the most common human chromosomal aberrations, occurring in about 0.5 percent of all conceptions and in one out of every seven hundred to eight hundred live births. About 15 percent of the patients institutionalized for mental deficiency suffer from Down syndrome. Even before the chromosomal basis for the disorder was determined, the frequency of Down syndrome births was correlated with increased maternal age. For mothers at age twenty, the incidence of Down syndrome is about 0.05 percent, which increases to 0.9 percent by age thirty-five and 3 percent for age forty-five. Studies comparing the chromosomes of the affected offspring with both parents have shown that the nondisjunction event is maternal about 75 percent of the time. This maternal age effect is thought to result from the different manner in which the male and female gametes are produced. Gamete production in the male is a continual, lifelong process, while it is a one-time event in females early in embryonic life, somewhere between the eighth and twentieth weeks. It appears that the frequency of nondisjunction events increases with the length of the storage period. Studies have demonstrated that cells in a state of meiosis are particularly sensitive to environmental influences such as viruses, X rays, and cytotoxic chemicals. It is possible that environmental influences may play a role in nondisjunction events. Up to age thirty-two, males contribute an extra chromosome 21 as often as do females. Beyond this age, there is a rapid increase in nondisjunctional eggs, while the number of nondisjunctional sperm remains constant. Testing for Down Syndrome Techniques such as amniocentesis, chorionic villus sampling, and alphafetoprotein screening are available for prenatal diagnosis of Down syndrome in fetuses. Amniocentesis, the most widely used technique for prenatal diagnosis, is generally performed between the fourteenth and sixteenth weeks of pregnancy. In this technique, about one ounce of fluid is removed from the amniotic cavity surrounding the fetus by a needle inserted through the mother’s abdomen. Although some testing can be done directly on the fluid (such as the assay for spina bifida), more information is obtained from the cells shed from the fetus that accompany the fluid. The mixture obtained in the amniocentesis is spun in a centrifuge to separate the fluid from the fetal cells. Unfortunately, the chromosome analysis for Down syndrome cannot be conducted directly on the amount of cellular material obtained. Although the majority of the cells collected are nonviable, some will grow in culture. These cells are allowed to grow and multiply in culture for two to four weeks, and then the chromosomes undergo karyotyping, which will detect both trisomy 21 and translocational aberration.
Down syndrome ✧ 291 In karyotyping, the chromosomes are spread on a microscope slide, stained, and photographed. Each type of chromosome gives a unique, observable banding pattern when stained which allows it to be identified. The chromosomes are then cut out of the photograph and arranged in homologous pairs, in numerical order. Trisomy 21 is easily observed, since three copies of chromosome 21 are present, while the translocation shows up as an abnormal banding pattern. Termination of the pregnancy in the wake of an unfavorable amniocentesis diagnosis is complicated, because the fetus at this point is usually about eighteen to twenty weeks old, and elective abortions are normally performed between the sixth and twelfth weeks of pregnancy. Earlier sampling of the amniotic fluid is not possible because of the small amount of fluid present. An alternate testing procedure called chorionic villus sampling became available in the mid-1980’s. In this procedure, a chromosomal analysis is conducted on a piece of placental tissue that is obtained either vaginally or through the abdomen during the eighth to eleventh week of pregnancy. The advantages of this procedure are that it can be done much earlier in the pregnancy and that enough tissue can be collected to conduct the chromosome analysis immediately, without the cell culture step. Consequently, diagnosis can be completed during the first trimester of the pregnancy, making therapeutic abortion an option for the parents. Chorionic villus sampling does have some negative aspects. One disadvantage is the slightly higher incidence of test-induced miscarriage as compared to amniocentesis—around 1 percent (versus less than 0.5 percent). Also, because tissue of both the mother and the fetus are obtained in the sampling process, they must be carefully separated, complicating the analysis. Occasionally, chromosomal abnormalities are observed in the tested tissue that are not present in the fetus itself. Prenatal maternal alpha-fetoprotein testing has also been used to diagnose Down syndrome. Abnormal levels of a substance called maternal alpha-fetoprotein are often associated with chromosomal disorders. Several research studies have described a high correlation between low levels of maternal alpha-fetoprotein and the occurrence of trisomy 21 in the fetus. By correlating alpha-fetoprotein levels, the age of the mother, and specific female hormone levels, between 60 percent and 80 percent of fetuses with Down syndrome can be detected. Although techniques allow Down syndrome to be detected readily in a fetus, there is no effective intrauterine therapy available to correct the abnormality. Caring for Children with Down Syndrome The care of a Down syndrome child presents many challenges for the family unit. Until the 1970’s, most of these children spent their lives in institutions. With the increased support services available, however, it is now common for
292 ✧ Down syndrome such children to remain in the family environment. Although many Down syndrome children have happy dispositions, a significant number have behavioral problems that can consume the energies of the parents, to the detriment of the other children. Rearing a Down syndrome child often places a large financial burden on the family: Such children are, for example, susceptible to illness; they also have special educational needs. Since Down syndrome children are often conceived late in the parents’ reproductive period, the parents may not be able to continue to care for these children throughout their offspring’s adult years. This is problematic because many Down syndrome individuals do not possess sufficient mental skills to earn a living or to manage their affairs without supervision. For parents who have produced a Down syndrome child, genetic counseling can be beneficial in determining their risk factor for future pregnancies. The genetic counselor determines the specific chromosomal aberration that occurred utilizing chromosome studies of the parents and affected child, along with additional information provided by the family history. If the cause was nondisjunction and the mother is young, the recurrence risk is much less than 1 percent; for mothers over the age of thirty-four, it is about 5 percent. If the cause was translocational, the Down syndrome is hereditary and risk is much greater—statistically, a one-in-three chance. In addition, there is a one-in-three chance that clinically normal offspring will be carriers of the syndrome, producing it in the next generation. —Arlene R. Courtney See also Amniocentesis; Birth defects; Children’s health issues; Disabilities; Genetic counseling; Genetic diseases; Health problems and families; Learning disabilities; Mental retardation; Prenatal care; Screening. For Further Information: Holtzman, Neil A. Proceed with Caution: Predicting Genetic Risks in the Recombinant DNA Era. Baltimore: The Johns Hopkins University Press, 1989. Discusses genetic counseling, how genetic disorders are diagnosed, and social implications. Pueschel, Siegfried. A Parent’s Guide to Down Syndrome. 2d ed. Baltimore: Paul H. Brookes, 2000. An informative guide highlighting the important developmental stages in the life of a child with Down syndrome. Rondal, Jean A., et al., eds. Down’s Syndrome: Psychological, Psychobiological, and Socioeducational Perspectives. San Diego: Singular, 1996. An academic text on issues surrounding Down syndrome. Includes references and an index. Shaw, Michael, ed. Everything You Need to Know About Diseases. Springhouse, Pa.: Springhouse Press, 1996. This well-illustrated consumer reference, compiled by more than one hundred doctors and medical experts, describes five hundred illnesses and conditions, their causes, symptoms,
Drowning ✧ 293 diagnosis, treatment, and prevention. A valuable reference book for everyone interested in health and disease. Of particular interest is chapter 21, “Genetic Disorders.” Tingey, Carol, ed. Down Syndrome: A Resource Handbook. Boston: Little, Brown, 1988. A practical resource for rearing a Down syndrome child, including guidelines on daily life, developmental expectations, and health and medical needs.
✧ Drowning Type of issue: Children’s health, public health Definition: Submersion in water or other fluid, resulting in death. When a person is submerged in water, the first step toward drowning is spasm of the larynx, followed by decreased oxygen and often the aspiration of water or other fluid. This is followed by decreased blood circulation to the brain. Damage to brain cells begins after about six minutes of submersion and is considered irreversible after about nine minutes. Up to one-fifth of drowning victims have no water in their lungs. These incidents are termed dry drownings. The temperature of the water is an important factor in drowning or near-drowning. Being suddenly submerged in cold water may cause an involuntary gasp that draws water into the lungs. Cold water also causes loss of consciousness. As the body temperature cools, abnormal heart rhythms may occur. On the other hand, hypothermia does reduce the oxygen requirements of the brain and may be protective. In some cases of submersion, especially in icy water, the so-called mammalian diving reflex is triggered, causing the circulation to slow dramatically and the brain to require less oxygen to survive undamaged. For this reason, victims who appear to have drowned should receive resuscitation until they are thoroughly warm, even if this takes a prolonged period of time. Victims of near-drowning have the best chance of a good outcome if they do not require cardiopulmonary resuscitation (CPR), if they have no lungrelated symptoms following the near-drowning, and if they were submerged in cold, clean water. Serious neurological problems occur in about 10 percent of victims who are victims of near-drowning. Resuscitation Initial treatment of someone who has apparently drowned is mouth-tomouth resuscitation beginning in the water, if necessary. Once the victim is on dry land, full CPR measures may be started if a pulse is absent. If there is
294 ✧ Drowning any evidence of neck injury, the rescuers must take appropriate precautions against further damage. Also, it is important to take precautions against the victim vomiting and choking on the vomited material. Rewarming should begin at the scene: Rescuers should remove the victim’s wet clothing and cover the body with dry blankets. In the hospital setting, emergency care is governed by the ABC’s: management of the airway, breathing, and circulation. The victim should be rewarmed by means appropriate to the core body temperature. Sometimes, victims can be reheated with radiant warmers; other times, they require warmed intravenous solutions. Abnormal heart rhythms may also be a problem. The length of the emergency room stay and the need for hospital admission depends on the patient’s condition. Some victims do well initially but show significant respiratory problems after twelve or more hours. The victim of near-drowning may recover without any brain damage or may suffer from significant problems. Factors that are associated with a poorer outcome include submersion for more than ten minutes, the need for CPR, a delay in beginning CPR, arrival at the emergency room in a coma, and a core body temperature of less than 30 degrees Celsius (86 degrees Fahrenheit). The Risk to Children Among children between the ages of one and fourteen, drowning is the third most common cause of death, and among all children and adolescents, it is the second most common cause of accidental death. Drownings take place not only in lakes and streams but also in toilets and washing machines. Although all children are at risk for drowning, toddlers and adolescents (particularly males) are the groups most at risk. About 40 percent of childhood drownings occur with children less than four years old, most of whom drown in swimming pools. More than half of all adolescent drowning deaths are associated with alcohol use. Drowning deaths among teenagers are largely the result of boating accidents or diving and swimming in unsafe areas. Not surprisingly, most drowning deaths occur in the summer and are more common in warm-weather areas, such as California and Florida. In the case of drowning in a child who is not able to walk or crawl, child abuse or neglect should be considered. Childhood drownings are nearly all preventable. Babies and toddlers should never be left alone in a bathtub; indeed, most drownings in children under the age of one are bathtub drownings. Toddlers have been known to drown in as little as one inch of water and in buckets of paint, so constant supervision is essential. Children with epilepsy are at particular risk of drowning and should be monitored even when they get older. Laws regarding the fencing of swimming pools must be rigorously enforced. Alcohol consumption near water recreation areas should be strictly
Drug abuse by teenagers ✧ 295 limited. Other public health measures include the easy availability of rescue equipment and widespread training in CPR. All children should be taught to swim, but such a measure does not decrease the need for careful supervision. —Rebecca Lovell Scott See also Children’s health issues; Choking; First aid; Safety issues for children. For Further Information: Berkow, Robert, ed. The Merck Manual of Medical Information, Home Edition. Whitehouse Station, N.J.: Merck Research Laboratories, 1997. Fein, Joel A., Dennis R. Durbin, and Steven M. Selbst. “Injuries and Emergencies.” In Rudolph’s Fundamentals of Pediatrics, edited by Abraham M. Rudolph and Robert K. Kamei. 2d ed. Stamford, Conn.: Appleton and Lange, 1998. Fulcher, William. “Thermal and Environmental Injuries.” In Textbook of Family Practice, edited by Robert E. Rakel. 5th ed. Philadelphia: W. B. Saunders, 1995. Hay, William W., et al., eds. “Emergencies, Injuries, and Poisoning.” In Current Pediatric Diagnosis and Treatment. 15th ed. New York: McGraw-Hill, 2000. Schmitt, Barton D. Your Child’s Health: The Parents’ Guide to Symptoms, Emergencies, Common Illnesses, Behavior, and School Problems. Rev. ed. New York: Bantam Books, 1991.
✧ Drug abuse by teenagers Type of issue: Children’s health, mental health, social trends Definition: A behavioral disorder characterized by dependence on and/or abuse of psychoactive substances. Drug abuse is a broad term subsuming a range of abused substances, including nicotine, alcohol, marijuana, cocaine, opiates, hallucinogens, amphetamine, and many others, including many prescription medications. The term also includes several disorders, including physical addiction and psychological dependence as well as experimental and recreational drug abuse. The latter two are disproportionately found among juvenile drug abusers. The causes of each form of abuse vary, as do the medical, behavioral, and social consequences.
296 ✧ Drug abuse by teenagers The Bigger Picture Most experimental and recreational abuse declines with maturity (unlike addiction or dependence). Nevertheless, in the short term, the associated behaviors are highly dangerous, including binge drinking, multiple substance abuse, and risk taking associated with intoxication. Thus, drug abuse is strongly linked to other juvenile behavioral disorders and problems, including automobile and other accidents, pregnancy, sexually transmitted diseases, and delinquent behavior. Academic problems also may result from, as well as be causally linked to, substance abuse. Addiction and dependence in juveniles are commonly associated with dysfunctionality in the home life. A combination of home stress, lack of parental supervision, modeling of abusive behavior, and genetic predisposition are likely involved. In addition, low socioeconomic status is commonly associated with addiction, probably owing to high stress and the accessibility of the criminal and drug subculture in many low-income neighborhoods. Not all addicts, however, come from such backgrounds. One of the risks that concerns counselors is that many addicts began the process of dependence while engaged in recreational drug abuse. Recreational and experimental drug abuse are also linked to home life and socioeconomic factors, although in a more complex fashion. High socioeconomic status is linked to certain forms of abuse, such as cocaine, while in general low socioeconomic status is associated with a higher general rate of substance abuse. Home stress can contribute to drug abuse, but adolescents from stable homes may be influenced by parental attitudes condoning recreational abuse. Additional causes include cultural factors such as the mass media (which may be seen as condoning recreational abuse), role models among celebrities and athletes, peer culture and conformity, and the general developmental processes associated with adolescent identity formation and autonomy seeking. The latter concerns cause problems in interpreting whether a particular instance of drug abuse indicates a more general psychological disorder or whether it is a part of “normal” development. Parents may become concerned that recreational drug abuse indicates addiction or dependence; a danger of overdiagnosis of these disorders exists. Consequences of Drug Use The physical consequences of drug abuse depend on the drug and on the nature of the abusive behavior. In addition to the noted link with risk-taking behavior, most of the abused substances are intrinsically dangerous. Overuse can lead to death through overdose, especially in cases of multiple drug abuse. Binge drinking is commonly the source of overdoses in cases involving alcohol alone. Combining prescription medications (especially tranquilizers) with alcohol is especially dangerous, leading to accidental overdoses.
Drug abuse by teenagers ✧ 297 Some overdoses may be deliberate, or in other cases involve deliberate recklessness. Long-term addiction is associated in many cases with damage to internal systems, particularly the liver, although these effects are cumulative over a lifetime and are not typically seen in adolescents. Psychological problems can occur even with limited use. In addition to the poor judgment associated with intoxication, counselors worry about the impact on general motivation, especially with marijuana. Involvement with a drug subculture can interfere with peer relationships and foster antiauthority attitudes. Juvenile Drug Treatment Treatment programs need to separate addicts from other substance abusers. This separation is in the interests of both addicts, who need intensive treatment, and nonaddicts, who can be harmed by extended contact with those with more serious abuse problems. Juvenile addicts may require home removal because of poor home environments and the need for supervised treatment. Because of expense and other practical considerations, treatment is frequently conducted on an outpatient basis, although this is generally considered less effective. Inpatient addiction programs for juveniles must ensure that education is not disrupted as a consequence of treatment. Eclectic approaches, combining insight-oriented therapies (both individually and in groups) along with behavior modification and training in social skills, are essential in treating this multifaceted problem. Family therapy is also frequently recommended. The long-term concern is with the high relapse rate, common to adult as well as juvenile addicts but further complicated by the lack of control that teenage clients have in constructing their own social environments upon leaving the treatment program. Follow-up outpatient care is recommended but is not always available or heeded. Treatment for nonaddicted abusers may be either as an outpatient or as an inpatient. The biggest risk is association with addicts and the labeling of one’s behavior by the patient and others. Family therapy can be particularly important in this context. Some therapists emphasize abstinence from all drugs; others emphasize learning responsible use, especially in the case of alcohol. Disruptions in academic and social development occurring as a result of abuse also need attention, with particular concern for the incident that led to referral (possibly an arrest or an accident). Prevention of Drug Use Most experts agree that prevention is more effective than treatment. One approach to prevention is through the legal system, either regulating or prohibiting use of psychoactive substances. Substance abuse experts are
298 ✧ Drug abuse by teenagers often concerned about the unintended consequences of many such approaches, such as the lack of regulation of illegal drugs, the fear of abusers to seek treatment (including during pregnancy), and the creation of contact with the criminal world in order to obtain illegal drugs. In addition, variations in the legal status of abused substances may send unintended messages. For example, alcohol use is often associated with proof of maturity. In the United States, legal efforts aimed at stopping the illegal drug trade have led to mandatory sentencing of many drug offenders. An increasing proportion of the prison population consists of such people, who ironically often end up with longer sentences than violent offenders who are not covered by such policies and who may receive early release in order to relieve prison overcrowding. Many legal experts have expressed concern with the lack of judicial discretion, especially for the convicted who might benefit from rehabilitation efforts. Juvenile drug abusers are not typically directly affected by these laws, unless charged with a crime as an adult (in some states, automatically so as young as age seventeen). Critics are also concerned about the ultimate diversion of public resources toward punishment and away from rehabilitation programs and education and prevention efforts. Thus, most experts advocate an emphasis on drug education. Efforts have included “scare tactics,” including graphic visual images of withdrawal or accident victims; straightforward information about risks; and broader programs aimed at developing the social skills and attitudes associated with resisting pressures to abuse drugs. The consensus is that the broader programs (combining information and skills training) are more successful, and especially so when begun before the ages at which children have been found abusing drugs—that is, earlier than age nine. Important social skills include resisting peer pressure, developing appropriate stress management, finding alternative social outlets, and handling anger. These skills need to be practiced through role play and other exercises. Thus, these programs require more than a single presentation by an outside speaker, as has been characteristic of less successful drug education programs. Information must be presented honestly; loss of credibility is a serious concern with many of the scare tactic approaches, although scaring teenagers with accurate information can be highly successful. Most experts also agree that the temptations to abuse drugs are intrinsic to human life, with its stresses and the escape or relief that drugs provide. It is for this reason that many programs emphasize responsible use, rather than abstinence, at least with alcohol. These programs emphasize the issue of responsibility, the avoidance of intoxication, and such practical safety methods as the use of designated drivers. Nevertheless, despite treatment and prevention efforts, drug abuse is likely to remain as a social problem.
Drug abuse by teenagers ✧ 299 Social Issues Several trends in juvenile drug use raise legitimate concerns. Drug abuse is occurring at ever-younger ages. The impact of these behaviors on puberty is not fully understood; moreover, interference with academic and social development from ages as young as nine is extremely serious. Such considerations drive the younger ages at which drug education is occurring in the United States. Political and social considerations lead to multiple difficulties in interpreting the dangers associated with specific drugs. The legal status of nicotine and alcohol may lead to an underestimation of their dangers. Political debates are not resolved concerning the relative dangers of marijuana. Social considerations can lead either to an argument for more leniency to avoid criminalizing relatively harmless behavior or, conversely, to more efforts at prohibition by those who consider marijuana a “gateway drug” that leads to the abuse of more dangerous drugs. Cocaine abuse is associated with high socioeconomic status, whereas crack abuse is associated with lower status. The harsher legal penalties for crack use have led to accusations of both social class and racial bias. Finally, keeping track of fads with regard to LSD, PCP, inhalants, and other substances is a constant worry to counselors, law enforcement officers, health professionals, and parents. All these issues end up as concerns in the counseling and education processes. Moreover, legal policies, as noted with regard to mandatory sentencing, influence the consequences of drug abuse, as well as the location of many drug rehabilitation programs. Increasingly, these programs are directly associated with prisons and juvenile detention centers. Most patients in drug treatment programs are not there entirely of their own choice but are required to be in such programs by schools or parents. Voluntary compliance with rehabilitation is highly associated with successful outcomes; the involvement of legally mandated treatment can complicate this issue further. In some cases, a legal requirement may be the only way to begin treatment that ultimately may be successful. In other cases, it can produce resentment that may interfere with the trust essential in any counselor/client relationship. Preventing drug abuse among juveniles must occur with each new generation. Cigarette use declined sharply among teenagers during the 1980’s but increased again in the 1990’s. Many experts attribute this increase in part to complacency over the success of education about nicotine. This example contains important lessons for all drug education programs. —Nancy E. Macdonald See also Addiction; Alcoholism among teenagers; Children’s health issues; Depression in children; Recovery programs; Smoking; Suicide among children and teenagers; Tobacco use by teenagers.
300 ✧ Dyslexia For Further Information: Boyd, Gayle M., Jan Howard, and Robert A. Zucker, eds. Alcohol Problems Among Adolescents: Current Directions in Prevention Research. Hillsdale, N.J.: Lawrence Erlbaum Associates, 1995. This volume contains eleven articles addressing a variety of issues in alcohol abuse prevention, including family influence, decision making, high-risk adolescents, and alcohol price policies. Gonet, Marlene Miziker. Counseling the Adolescent Substance Abuser: SchoolBased Intervention and Prevention. Thousand Oaks, Calif.: Sage Publications, 1994. The author provides detailed information on the needs of school-based counseling programs, including individual, group, and family counseling. Case examples are provided. Males, Mike A. The Scapegoat Generation: America’s War on Adolescents. Monroe, Maine: Common Courage Press, 1996. The author argues that political interests lead to an exaggeration of a number of social problems involving adolescents, including delinquency and drug abuse. This book provides a useful perspective to consider in responding to real and potential behavioral problems, including drug abuse. Miller, William R., and Nick Heather, eds. Treating Addictive Behaviors: Processes of Change. 2d ed. New York: Plenum Press, 1998. This book, written by medical and psychological scientists, is an overview of treatment strategies for problems ranging from nicotine to opiate addiction. Psychological, behavioral, interpersonal, familial, and medical approaches are outlined and discussed. Yoslow, Mark. Drugs in the Body: Effects of Abuse. New York: Franklin Watts, 1992. This book provides highly readable, straightforward information on the effects of cocaine and crack, the opiates, cannabis drugs, hallucinogens, and amphetamines.
✧ Dyslexia Type of issue: Children’s health, mental health Definition: Severe reading disability in children with average to aboveaverage intelligence. Nearly 25 percent of the individuals in the United States and of many other industrialized societies who otherwise possess at least average intelligence cannot read well. Many such people are viewed as suffering from a neurological disorder called dyslexia. This term was first introduced by the German ophthalmologist Rudolf Berlin in the nineteenth century. He defined it as designating all those individuals who possessed average or aboveaverage intelligence quotients (IQs) but who could not read adequately because of their inability to process language symbols.
Dyslexia ✧ 301 The modern definition of the disorder is based on long-term, extensive studies of dyslexic children that have identified dyslexia as a complex syndrome composed of a large number of associated behavioral dysfunctions that are related to visual-motor brain immaturity and/or brain dysfunction. These problems include a poor memory for details, easy distractibility, poor motor skills, visual letter and word reversal, and the inability to distinguish between important elements of the spoken language. Explaining Dyslexia Understanding dyslexia in order to correct this reading disability is crucial and difficult. To learn to read well, an individual must acquire many basic cognitive and linguistic skills. First, it is necessary to pay close attention, to concentrate, to follow directions, and to understand the language spoken in daily life. Next, one must develop an auditory and visual memory, strong sequencing ability, solid word decoding skills, the ability to carry out structural-contextual language analysis, the capability to interpret the written language, a solid vocabulary which expands as quickly as is needed, and speed in scanning and interpreting written language. These skills are taught in good developmental reading programs, but some or all are found to be deficient in dyslexic individuals. Two basic explanations have evolved for dyslexia. Many physicians propose that it is caused by brain damage or brain dysfunction. Evolution of the problem is attributed to accident, disease, and/or hereditary faults in body biochemistry. Here, the diagnosis of dyslexia is made by the use of electroencephalograms (EEGs), computed tomography (CT) scans, and related neurological technology. After such evaluation is complete, medication is often used to diminish hyperactivity and nervousness, and a group of physical training procedures called patterning is used to counter the neurological defects in the dyslexic individual. In contrast, many special educators and other researchers believe that the problem of dyslexia is one of dormant, immature, or undeveloped learning centers in the brain. Many proponents of this concept strongly encourage the correction of dyslexic problems by the teaching of specific reading skills. While such experts agree that the use of medication can be of great value, they attempt to cure dyslexia mostly through a process called imprinting. This technique essentially trains dyslexic individuals and corrects their problems via the use of exaggerated, repeated language drills. Types of Dyslexia A number of experts propose three types of dyslexia. The most common type and the one most often identified as dyslexia is called visual dyslexia, the lack of ability to translate the observed written or printed language into
302 ✧ Dyslexia meaningful terms. The major difficulty is that afflicted people see certain words or letters backward or upside down. The resultant problem is that—to the visual dyslexic—any written sentence is a jumble of many letters whose accurate translation may require five or more times as much effort as is needed by an unafflicted person. The other two problems viewed as dyslexia are auditory dyslexia and dysgraphia. Auditory dyslexia is the inability to perceive individual sounds of spoken language. Despite having normal hearing, auditory dyslexics are deaf to the differences between certain vowel and/or consonant sounds, and what they cannot hear they cannot write. Dysgraphia is the inability to write legibly. The basis for this problem is a lack of the hand-eye coordination that is required to write clearly. Many children who suffer from visual dyslexia also exhibit elements of auditory dyslexia. This complicates the issue of teaching many dyslexic students because only one type of dyslexic symptom can be treated at a time. Also, dyslexia appears to be a sex-linked disorder, being much more common in boys than in girls. Estimates vary between three and seven times as many boys having dyslexia as girls. Diagnosing Dyslexia The early diagnosis and treatment of dyslexia is essential to its eventual correction. Many experts agree that if a treatment begins before the third grade, there is an 80 percent probability that the dyslexia can be corrected. If the disorder remains undetected until the fifth grade, however, success at treating dyslexia is cut in half. If treatment does not begin until the seventh grade, the probability of successful treatment drops below 5 percent. The preliminary identification of a dyslexic child can be made from symptoms that include poor written schoolwork, easy distractibility, clumsiness, poor coordination, poor spatial orientation, confused writing and/or spelling, and poor left-right orientation. Because numerous nondyslexic children also show many of these symptoms, a second step is required for such identification: the use of written tests designed to identify dyslexics. These tests include the Peabody Individual Achievement Test, the HalsteadReitan Neuropsychological Test Battery, and the SOYBAR Criterion Tests. Correcting the Disorder Once conclusive identification of a dyslexic child has been made, it becomes possible to begin corrective treatment. Such treatment is usually the preserve of special education programs. These programs are carried out by the special education teacher in school resource rooms. They also involve special classes limited to children with reading disabilities and schools that specialize in treating learning disabilities.
Dyslexia ✧ 303 An often-cited method used is that of Grace Fernald, which utilizes kinesthetic imprinting, based on combined language experience and tactile stimulation. In this popular method or adaptations of it, a dyslexic child learns to read in the following way. First, the child tells a spontaneous story to the teacher, who transcribes it. Next, each word that is unknown to the child is written down by the teacher, and the child traces its letters repeatedly until he or she can write the word without using the model. Each word learned becomes part of the child’s word file. A large number of stories are handled this way. Though the method is quite slow, many reports praise its results. Nevertheless, no formal studies of its effectiveness have been made. A second common teaching technique that is utilized by special educators is the Orton-Gillingham-Stillman method, which was developed in a collaboration between two teachers and a pediatric neurologist, Samuel T. Orton. The method evolved from Orton’s conceptualization of language as developing from a sequence of processes in the nervous system that ends in its unilateral control by the left cerebral hemisphere. He proposed that dyslexia arises from conflicts between this cerebral hemisphere and the right cerebral hemisphere, which is usually involved in the handling of nonverbal, pictorial, and spatial stimuli. Consequently, the corrective method that is used is a multisensory and kinesthetic approach, like that of Fernald. It begins, however, with the teaching of individual letters and phonemes. Then, it progresses to dealing with syllables, words, and sentences. Children taught by this method are drilled systematically, to imprint them with a mastery of phonics and the sounding out of unknown written words. They are encouraged to learn how the elements of written language look, how they sound, how it feels to pronounce them, and how it feels to write them down. Although the Orton-Gillingham-Stillman method is as laborious as that of Fernald, it is widely used and appears to be successful. Another treatment aspect is the use of therapeutic drugs in the handling of dyslexia. Most physicians and educators propose the use of these drugs as a useful adjunct to the special education training of those dyslexic children who are restless and easily distracted and who have low morale because of continued embarrassment in school in front of their peers. The drugs that are utilized most often are amphetamine, Dexedrine, and methylphenidate (Ritalin). These stimulants, given at appropriate dose levels, will lengthen the time period during which certain dyslexic children function well in the classroom and can also produce feelings of self-confidence. Side effects of their overuse, however, include loss of appetite, nausea, nervousness, and sleeplessness. Furthermore, there is also the potential problem of drug abuse. When they are administered carefully and under close medical supervision, however, the benefits of these drugs far outweigh any possible risks. A proponent of an entirely medical treatment of dyslexia is psychiatrist
304 ✧ Dyslexia Harold N. Levinson. He proposes that the root of dyslexia is in inner ear dysfunction and that it can be treated with the judicious application of proper medications. Levinson’s treatment includes amphetamines, antihistamines, drugs used against motion sickness, vitamins, health food components, and nutrients mixed in the proper combination for each patient. He asserts that he has cured more than ten thousand dyslexics and documents many cases. Critics of Levinson’s work pose several questions, including whether the studies reported were well controlled and whether the patients treated were actually dyslexics. A major basis for the latter criticism is Levinson’s statement that many of his cured patients were described to him as outstanding students. The contention is that dyslexic students are never outstanding students and cannot work at expected age levels. An important aspect of dyslexia treatment is parental support of these children. Such emotional support helps dyslexics to cope with their problems and with the judgment of their peers. Useful aspects of this support include a positive attitude toward an afflicted child, appropriate home help that complements efforts at school, encouragement and praise for achievements, lack of recrimination when repeated mistakes are made, and positive interaction with special education teachers. —Sanford S. Singer See also Attention deficit disorder (ADD); Children’s health issues; Learning disabilities; Speech disorders. For Further Information: Huston, Anne Marshall. Understanding Dyslexia: A Practical Approach for Parents and Teachers. Rev. ed. Lanham, Md.: Madison Books, 1992. Explains dyslexia, describes its three main types, identifies causes and treatments, and covers useful teaching techniques. A bibliography, a useful glossary, appendices, and teaching materials are valuable additions. Levinson, Harold N. Smart but Feeling Dumb. Rev. ed. New York: Warner Books, 1994. Based on “thousands of cases cured,” this book explains the basis and treatment of dyslexia as inner ear dysfunction that can be cured with judicious application of the correct medications. Included are an overview, case studies, a summary, useful appendices, and a bibliography. Routh, Donald K. “Disorders of Learning.” In The Practical Assessment and Management of Children with Disorders of Development and Learning, edited by Mark L. Wolraich. Chicago: Year Book Medical Publishers, 1987. This succinct article summarizes salient facts about learning disorders, including etiology, assessment, management, and outcome. Interested readers will also find many useful references. Snowling, Margaret. Dyslexia: A Cognitive Developmental Perspective. 2d ed. New York: Basil Blackwell, 2000. Covers aspects of dyslexia, including its identification, associated cognitive defects, the basis for language skill
Eating disorders ✧ 305 development, and the importance of phonetics. Also contains many references. Valett, Robert E. Dyslexia: A Neuropsychological Approach to Educating Children with Severe Reading Disorders. Belmont, Calif.: David S. Lake, 1980. This text, containing hundreds of references, is of interest to readers wishing detailed information on dyslexia and on educating dyslexics. Its two main sections are the neuropsychological foundations of reading (including neuropsychological factors, language acquisition, and diagnosis) and a wide variety of special education topics.
✧ Eating disorders Type of issue: Children’s health, mental health, social trends, women’s health Definition: A set of emotional disorders centering on body image that lead to misuse of food in a variety of ways—through overeating, overeating and purging, or undereating—that severely threaten the physical and mental well-being of the individual. The presence of an eating disorder in a patient is defined by an abnormal mental and physical relationship between body image and eating. While obesity is considered an eating disorder, the most prominent conditions are anorexia nervosa and bulimia nervosa. Anorexia nervosa (the word “anorexia” comes from the Greek for “loss of appetite”) is an illness characterized by the relentless pursuit of thinness and fear of gaining weight. Bulimia nervosa (the word “bulimia” comes from the Greek for “ox appetite”) refers to binge eating followed by self-induced vomiting. These conditions are related in intimate, yet ill-defined ways. Anorexia Nervosa Anorexia nervosa affects more women than men by the overwhelming ratio of nineteen to one. It most often begins in adolescence and is more common among the upper and middle classes of the Western world. According to most studies, its incidence increased severalfold from the 1970’s to the 1990’s. Prevalence figures vary from 0.5 to 0.8 cases per one hundred adolescent girls. A familiar pattern of anorexia nervosa is often present, and studies indicate that 16 percent of the mothers and 23 percent of the fathers of anorectic patients had a history of significantly low adolescent weight or weight phobia. The criteria for anorexia nervosa include intense fear of becoming obese, which does not diminish with the progression of weight loss; disturbance of
306 ✧ Eating disorders body image, or feeling “fat” even when emaciated; refusal to maintain body weight over a minimal weight for age and height; the loss of 25 percent of original body weight or being 25 percent below expected weight based on standard growth charts; and no known physical illness that would account for the weight loss. Anorexia nervosa is also classified into primary and secondary forms. The primary condition is the distinct constellation of behaviors described above. In secondary anorexia nervosa, the weight loss results from another emotional or organic disorder. The most prominent symptom of anorexia nervosa is a phobic avoidance of eating that goes beyond any reasonable level of dieting in the presence of striking thinness. Attending this symptom is the characteristic distorted body image and faulty perceptions of hunger and satiety, as well as a pervasive sense of inadequacy. The distortion of body image renders patients unable to evaluate their body weight accurately, so that they react to weight loss by intensifying their desire for thinness. Patients characteristically describe themselves as “fat” and “gross” even when totally emaciated. The degree of disturbance in body image is a useful prognostic index. Faulty perception of inner, visceral sensations, such as hunger and satiety, extends also to emotional states. The problem of nonrecognition of feelings is usually intensified with starvation. Other cognitive distortions are also common in anorectic patients. Dichotomous reasoning—the assessment of self or others—is either idealized or degraded. Personalization of situations and a tendency to overgeneralize are common. Anorectics display an extraordinary amount of energy, directed to exercise and schoolwork in the face of starvation, but may curtail or avoid social relationships. Crying spells and complaints of depression are common findings and may persist in some anorectic patients even after weight is gained. Sleep disturbances have also been reported in anorectics. Obsessive and/or compulsive behaviors, usually developing after the onset of the eating symptoms, abound with anorexia. Obsession with cleanliness and house cleaning, frequent handwashing, compulsive studying habits, and ritualistic behaviors are common. As expected, the most striking compulsions involve food and eating. Anorectics’ intense involvement with food belies their apparent lack of interest in it. The term “anorexia” is, in fact, a misnomer because lack of appetite is rare until late in the illness. Anorectics often carry large quantities of sweets in their purses and hide candies or cookies in various places. They frequently collect recipes and engage in elaborate meal preparation for others. Anorectics’ behavior also includes refusal to eat with their families and in public places. When unable to reduce food intake openly, they may resort to such subterfuge as hiding food or disposing of it in toilets. If the restriction of food intake does not suffice for losing weight, the patient may resort to vomiting, usually at night and in secret. Self-induced vomiting
Eating disorders ✧ 307 then becomes associated with bulimia. Some patients also abuse laxatives and diuretics. Commonly reported physical symptoms include constipation, abdominal pain, and cold intolerance. With severe weight loss, feelings of weakness and lethargy replace the drive to exercise. Amenorrhea (cessation of menstruation) occurs in virtually all cases, although it is not essential for a diagnosis of anorexia. Weight loss generally precedes the loss of the menstrual cycle. Other physical symptoms reveal the effects of starvation. Potassium depletion is the most frequent serious problem occurring with both anorexia and bulimia. Gastrointestinal disturbances are common, and death may occur from either infection or electrolyte imbalance. Treating Anorexia The management of anorectic patients, in either hospital or outpatient settings, may include individual psychotherapy, family therapy, behavior modification, and pharmacotherapy. Many anorectic patients are quite physically ill when they first consult a physician, and medical evaluation and management in a hospital may be necessary at this stage. A gastroenterologist or other medical specialist familiar with this condition may be required to evaluate electrolyte disturbance, emaciation, hypothermia, skin problems, hair loss, sensitivity to cold, fatigue, and cardiac arrhythmias. Starvation may cause cognitive and psychological disturbances that limit the patient’s cooperation with treatment. Indications for hospitalization are weight loss exceeding 30 percent of ideal body weight or the presence of serious medical complications. Most clinicians continue the hospitalization until 80 percent to 85 percent of the ideal body weight is reached. The hospitalization makes possible hyperalimentation (intravenous infusion of nutrients) when medically necessary. Furthermore, individual and family psychiatric evaluations can be performed and a therapeutic alliance established more rapidly with the patient hospitalized. Most programs utilize behavior modification during the course of hospitalization, making increased privileges such as physical and social activities and visiting contingent on weight gain. A medically safe rate of weight gain is approximately one-quarter of a pound a day. Patients are weighed daily, after the bladder is emptied, and daily fluid intake and output are recorded. Patients with bulimic characteristics may be required to stay in the room two hours after each meal without access to the bathroom to prevent vomiting. Some behavior modification programs emphasize formal contracting, negative contingencies, the practice of avoidance behavior, relaxation techniques, role-playing, and systematic desensitization. The goal of dynamic psychotherapy is to achieve patient autonomy and independence. The female anorectic patient often uses her body as a battleground for the separation or individuation struggle with her mother.
308 ✧ Eating disorders The cognitive therapeutic approach begins with helping the patient to articulate beliefs, change her view of herself as the center of the universe, and render her expectations of the consequences of food intake less catastrophic. The therapist acknowledges the patient’s beliefs as genuine, particularly the belief that her self-worth is dependent on achieving and maintaining a low weight. Through a gradual modification of self-assessment, the deficits in the patient’s self-esteem are remedied. The therapist also challenges the cultural values surrounding body shape and addresses behavioral and family issues such as setting weight goals and living conditions. Bulimia Bulimia usually occurs between the ages of twelve and forty, with greatest frequency between the ages of fifteen and thirty. Unlike anorectics, bulimics usually are of normal weight, although some have a history of anorexia or obesity. Like anorectics, however, they are not satisfied by normal food intake. The characteristic symptom of bulimia is episodic, uncontrollable binge eating followed by vomiting or purging. The binge eating, usually preceded by a period of dieting lasting a few months or more, occurs when patients are alone at home and lasts about one hour. In the early stages of the illness, patients may need to stimulate their throat with a finger or spoon to induce vomiting, but later they can vomit at will. At times, abrasions and bruises on the back of the hand are produced during vomiting. The bingepurge cycle is usually followed by sadness, self-deprecation, and regret. Bulimic patients have troubled interpersonal relationships, poor self-concept, a high level of anxiety and depression, and poor impulse control. Alcohol and drug abuse are not uncommon with bulimia, in contrast to their infrequency with anorexia. From the medical perspective, bulimia is nearly as damaging to its practitioners as anorexia. Dental problems, including discoloration and erosion of tooth enamel and irritation of gums by highly acidic gastric juice, are frequent. Electrolyte imbalance, such as metabolic alkalosis or hypokalemia (low potassium levels) caused by the self-induced vomiting, is a constant threat. Parotid gland enlargement, esophageal lacerations, and acute gastric dilatation may occur. Cardiac irregularities may also result. The chronic use of emetics such as ipecac to induce vomiting after eating may result in cardiomyopathy (disease of the middle layer of the walls of the heart, the myocardium), occasionally with a fatal outcome. While their menstrual periods are irregular, these patients are seldom amenorrheic. Treating Bulimia The behavioral management of bulimia includes an examination of the patient’s thinking and behavior toward eating and life challenges in general.
Eating disorders ✧ 309 The patient is made fully aware of the extent of her binging by being asked to keep a daily record of her eating and vomiting practices. A contract is then established with the patient to help her restrict her eating to three or four planned meals per day. The second stage of treatment emphasizes self-control in eating as well as in other areas of the patient’s life. In the final stage of treatment, the patient is assisted in maintaining her new, more constructive eating behaviors. Almost all clinicians work intensively with the family of anorectic patients, particularly in the initial stage of treatment. Family treatment begins with the current family structure and later addresses the early family functioning that can influence family dynamics dramatically. Multigenerational sources of conflict are also examined. Family therapy with bulimics explores the sources of family conflicts and helps the family to resolve them. Particular attention is directed toward gender roles in the family, as well as the anxiety of the parents in allowing their children autonomy and self-sufficiency. The roots of impulsive and depressive behaviors and the role of parental satisfaction with the patients’ lives and circumstances are often explored and addressed. Obesity Another eating disorder, obesity, is the most prevalent nutritional disorder of the Western world. Using the most commonly accepted definition of obesity—a body weight greater than 20 percent above an individual’s normal or desirable weight—approximately 35 percent of adults in the United States were considered obese in the early 1990’s. This figure represents twice the proportion of the population that was obese in 1900. Evidently, more sedentary lifestyles strongly contributed to this increase, since the average caloric intake of the population decreased by 5 percent since 1910. Although the problem affects both sexes, obesity is found in a larger portion of women than men. In the forty- to forty-nine-year-old age group, 40 percent of women, while only 30 percent of men, were found to meet the criterion for obesity. Prevalence of obesity increases with both age and lower socioeconomic status. While results of both animal and human studies suggest that obesity is genetically influenced to some degree, most human obesity is reflective of numerous influences and conditions. Evidence indicates that the relationship between caloric intake and adipose tissue is not as straightforward as had been assumed. In the light of this evidence, the failure to lose unwanted pounds and the failure to maintain hard-won weight loss experienced by many dieters seem much more understandable. In the past, obese individuals often were viewed pejoratively by others and by themselves. They were seen as having insufficient willpower and self-discipline. It was incorrectly assumed that it is no more difficult for most obese individuals to lose fat by
310 ✧ Eating disorders decreasing caloric intake than it is for individuals in a normal weight range and that it would be just as easy for the obese to maintain normal weight as it is for those who have never been obese. Treating Obesity In the treatment of obesity, the use of a reduced-calorie diet regimen alone does not appear to be an effective approach for many patients, and it is believed that clinicians may do more harm than good by prescribing it. In addition to the high number of therapeutic failures and possible exacerbation of the problem, negative emotional responses are common side effects. Depression, anxiety, irritability, and preoccupation with food appear to be associated with dieting. Such responses have been found to occur in as many as half of the general obese population while on weight-loss diets and are seen with even greater frequency in the severely obese. Some researchers conclude that some cases are better off with no treatment. Their reasoning is based not only on the ineffectiveness of past treatments and the evidence of biological bases for differences in body size but also on the fact that mild to moderate obesity does not appear to put women (or men) at significant health risk. Moreover, an increase in the incidence of serious eating disorders in women has accompanied the increasingly stringent cultural standards of thinness for women. Given the present level of knowledge, it may be that some individuals would benefit most by adjusting to a weight that is higher than the culturally determined ideal. When an individual of twenty-five to thirty-four years of age is more than 100 percent above normal weight level, however, there is a twelvefold increase in mortality, and the need for treatment is clear. Although much of the increased risk is related to the effects of extreme overweight on other diseases (such as diabetes, hypertension, and arthritis), these risks can decrease with weight loss. Conservative treatments have had very poor success rates with this group, both in achieving weight reduction and in maintaining any reductions accomplished. Inpatient starvation therapy has had some success in reducing weight in the severely obese but is a disruptive, expensive, and risky procedure requiring very careful medical monitoring to avoid fatality. Furthermore, for those patients who successfully reduce their weight by this method, only about half will maintain the reduction. Severe obesity seems to be treated most effectively by surgical measures, which include wiring the jaws to make oral intake nearly impossible, reducing the size of the stomach by suturing methods, or short-circuiting a portion of the intestine so as to reduce the area available for uptake of nutrients. None of these methods, however, is without risk. —Genevieve Slomski
Elder abuse ✧ 311 See also Addiction; Anorexia nervosa; Children’s health issues; Depression; Depression in children; Infertility in women; Malnutrition among children; Menstruation; Nutrition and aging; Nutrition and children; Nutrition and women; Obesity; Obesity and aging; Obesity and children; Recovery programs; Stress; Weight changes with aging; Weight loss medications; Women’s health issues. For Further Information: Brownell, Kelly D., and Christopher G. Fairburn, eds. Eating Disorders and Obesity: A Comprehensive Handbook. New York: Guilford Press, 1995. This text addresses all eating disorders, particularly obesity. Includes references and an index. Garner, David M., and Paul E. Garfinkel, eds. Handbook of Treatment for Eating Disorders. 2d ed. New York: Guilford Press, 1997. This is an updated source on the diagnosis, assessment, and treatment of eating disorders, as well as key issues associated with developing eating disorders. Hsu, L. K. George. Eating Disorders. New York: Guilford Press, 1990. The work provides a summary of the knowledge about the eating disorders of anorexia and bulimia, a historical development of the concepts, their clinical features, methods of diagnostic evaluation, and various treatment options. Moe, Barbara. Understanding the Causes of a Negative Body Image. New York: Rosen, 1999. Designed for students in grades seven and above, who are bombarded by misinformation and media images of the perfect young adult, this book looks at the causes behind a negative body image and stresses that self-esteem is more important than personal size. Monroe, Judy. Understanding Weight-Loss Programs. New York: Rosen, 1999. Designed for students in grades seven and above, who are bombarded by misinformation and media images of the perfect young adult, this book makes it clear that most weight-loss programs are shams and should be viewed with a critical eye.
✧ Elder abuse Type of issue: Elder health, ethics, mental health, social trends Definition: A form of domestic violence against the elderly, including neglect and verbal, psychological, physical, economic, and sexual abuse, often committed by their primary caregivers. Social gerontologists and other professionals who study and work with older persons report that the prevalence of elder abuse is much greater than was previously realized and that it takes multiple forms. Neglect and verbal,
312 ✧ Elder abuse psychological, physical, economic, and sexual abuse do not typically occur at the hands of strangers or in unfamiliar surroundings. More often, the perpetrators of elder abuse are the primary caretakers or neighbors of the victims, and the setting is the victims’ own homes, neighborhoods, or institutions charged with their care. Researchers, social workers, medical professionals, and law-enforcement officials have agreed that documented cases of elder abuse represent a small proportion of all such incidents, which are increasing in frequency. Abuse by Family Caretakers The phrase “graying of America” alludes to the fact that the fastest-growing American age group is the sixty-five-and-over population and that the category of Americans older than eighty-five has the fastest growth rate of all. As Americans become ever older, the probability of their experiencing a degree of physiological or cognitive dysfunction that makes them dependent on others for their care increases. Members of any age group who depend on others for survival are the most likely targets of domestic abuse. The infirm elderly are the most often abused; they typically become more submissive to protect themselves from abandonment by their family caretakers. Although the prevalence of elder abuse, as with other forms of domestic violence, is impossible to assess accurately, of greatest concern are cases involving perpetrators closely related to the victims. Not only is the specter of abuse by a family member, as opposed to a stranger, especially disturbing, but a majority of incidents occur in domestic settings. The number of documented cases of domestic elder abuse, a mere fraction of real existing instances of the problem, is increasing geometrically. Between 1986 and 1994, officially reported cases steadily increased from 117,000 to 241,000. Most cases go unreported, and 70 percent or more of documented cases are reported by someone other than the victim. Estimates of the actual number of such cases range between one and two million annually. Data from the 1990’s show that substantiated cases of reported domestic elder abuse took every form imaginable. Neglect accounted for 58.5 percent of these cases, physical abuse 15.7 percent, financial exploitation 12.3 percent, psychological and emotional abuse 8.1 percent, and sexual abuse 0.5 percent. These same data indicate that close relatives of the victims are responsible for two-thirds of the cases. Perpetrators were victims’ adult children in about 38 percent of the reports, spouses in about 14 percent, and other family members in about 15 percent. Sociologists assert that, given the strong cultural normative prescriptions for intergenerational support and affection, domestic elder abuse constitutes a violation of a social taboo—the most serious category of social infractions. This form of deviant behavior is difficult to analyze because of the complexity of its causes. Researchers who attempt to understand such
Elder abuse ✧ 313 dysfunctional behavior in family settings contend that like all forms of domestic violence, the causes involve a combination of psychological, social, economic, and health-related characteristics of the perpetrators and the victims. In some cases, the stress associated with caring for an infirm elderly family member may lead to abuse, especially if the caregiver perceives the demands on time, energy, and financial resources as excessive or if the caregiver is not well prepared for the task. Some studies have found that the incidence of abuse increases when the continued physical or mental decline of the older person heightens the caretaker’s responsibilities. Some domestic elder abuse is related to the perpetrator’s personal problems, such as chronic financial difficulties, pathological emotional or mental conditions, or addiction to alcohol or other drugs. In these cases, the abuser is often dependent on the victim for financial support and housing, and the frustration of failing to function as an independent adult manifests itself in abusive episodes. Furthermore, some researchers report that abusers who have experienced or witnessed domestic violence in their households as children may have learned to abuse in response to conflicts or stress, resulting in an intergenerational transfer of violence. Complex combinations of these and other possible factors underlie each individual case of domestic elder abuse. Abuse in Institutional Settings Although only about 5 percent of older Americans reside in nursing and convalescent homes, they represent half of the long-term-care patients. As the eighty-five-and-over population continues to increase, the population of institutionalized older Americans is projected to grow from 1.5 million in 1990 to 2.6 million by the year 2020. The risk of abuse is especially high for this group of elderly Americans. Physicians have often recommended institutionalization as a way to prevent or stop abuse, but a potential for serious abuse in these settings has been demonstrated. Assessing the prevalence of elder abuse in health care settings is difficult. Studies in which nursing home staff were assured of confidentiality and anonymity, however, have shown that a problem does exist. In one such study involving almost six hundred nursing home workers, 45 percent said that they had yelled at, cursed, or threatened residents; 10 percent admitted physically abusing patients by hitting, pinching, or violently grabbing them; another 3 percent stated that they had hit patients with objects or thrown objects at them; and 4 percent had denied patients food or privileges. Such research efforts have probably underestimated levels of abuse by paid caregivers, and none are likely to produce reliable results regarding sexual abuse and theft.
314 ✧ Elder abuse Adult Protective Services A number of public agencies include elder abuse among their concerns: police and sheriffs’ departments, district attorneys’ offices, acute-care licensing and certification agencies, and State Long-Term Care Ombudsman’s offices, which were created by the federal Older Americans Act of 1965 and organized under State Agencies on Aging to investigate elder abuse in nursing homes. However, the agencies most responsible for investigating, intervening in, and resolving cases of domestic elder abuse in most states are Adult Protective Services (APS), which are usually part of the county departments of social services. Although APS offices deal with abuse of anyone older than eighteen, 70 percent of their cases involve elder abuse. APS responses to elder abuse have varied according to the severity and nature of the abuse. The problem is often addressed by APS caseworkers with a plan to provide assistance to family caregivers by linking them to public service, volunteer, and church-related agencies that assist in caregiving functions and even counsel abusive family caretakers. Caseworkers monitor caregiving plans to determine their effectiveness and the need for adjustments. In the most severe cases, the APS offices take more drastic measures, such as institutionalizing elderly persons or calling in law enforcement agencies. In cases requiring institutionalization, the State Long-Term Care Ombudsman program is often called upon to monitor the safety of abuse victims. APS faces great challenges in its attempts to prevent future abuse and improve the quality of life of abuse victims. Investigators’ interactions with family members are usually tense at best, because elder abuse, like spousal and child abuse, is often a well-kept family secret. Furthermore, caseworkers are prohibited from revealing the identities of the persons who report abuse, which often frustrates the families, and the interventions sometimes confuse the victims because they seldom report the abuse themselves. Not all APS elder abuse cases are successfully resolved. Agency intervention in cases involving chronic domestic violence, regardless of the victims’ ages, is especially difficult. Moreover, elder abuse intervention is often thwarted because older persons, unlike children, are beyond the age of majority and can thus refuse assistance if they fear institutionalization, abandonment, or retribution. APS caseworkers must be able to investigate cases, assess victims’ physical and psychological health, know about available elder services, work within the criminal justice system, deal with crisis situations, and protect themselves from violence at the hands of abusers. There are only a few thousand APS investigators in the United States, and their large caseloads are growing constantly. Crime Although most forms of elder abuse, including willful neglect in many states, are illegal, crimes against elderly victims committed by noncaretakers are of
Elder abuse ✧ 315 growing concern to law enforcement officials and older persons. Conventional analyses of crime statistics have indicated that the elderly have been far less victimized than the general adult population. There is a growing consensus, however, that these statistics have grossly underestimated the magnitude of elderly victimization. Older Americans appear to be the targets of certain types of crime, and the incidents most often occur in the victims’ homes or neighborhoods. Most victims of con artists, for example, are older persons. Con games take many forms, including phony insurance schemes, hearing aid scams, medical quackery of all types, real estate swindles, and investment fraud. Moreover, elderly persons are the main victims of purse snatchers, pickpockets, and petty thieves, whereby the victims are often assaulted. The perpetrators of these attacks are most often young males who live in their victims’ neighborhoods. Another form of crime-related elder abuse stems from older persons’ fear of crime, which research has indicated is the greatest single concern among older Americans. Although crime statistics indicate that the elderly are less likely than younger adults to be victims of most violent crimes, the consequences of physical abuse can be especially devastating to the aged. Young or middle-aged persons might sustain minimal injuries during an assault that would cripple older victims. Even a purse snatching can result in an older person requiring hip replacement surgery or long-term medical care for internal injuries. In addition, larceny can significantly affect the economic independence of older persons with limited and fixed incomes. Fear of crime itself compromises the quality of life of many older Americans, causing them to live reclusively, afraid to leave their homes. Furthermore, some studies have concluded that few crimes against the elderly are reported, because the victims fear retribution by neighborhood criminals and pressure from family and friends to give up living independently because of their limited ability to protect themselves. —Jack Carter See also Aging; Alcoholism among the elderly; Alzheimer’s disease; Child abuse; Dementia; Depression in the elderly; Domestic violence; Nursing and convalescent homes. For Further Information: Baumhover, Lorin A., and S. Coleen Beall, eds. Abuse, Neglect, and Exploitation of Older Persons: Strategies for Assessment and Intervention. Baltimore: Health Professions Press, 1996. Essays focusing on the causes and nature of elder abuse, with an emphasis on responses to the problem by health-care professionals. Byers, Bryan, and James E. Hendricks, eds. Adult Protective Services: Research and Practice. Springfield, Ill.: Charles C Thomas, 1993. Papers by social scientists from several disciplines examining elder abuse, highlighting the challenges facing government agencies.
316 ✧ Electrical shock Filinson, Rachel, and Stanley R. Ingman, eds. Elder Abuse: Practice and Policy. New York: Human Sciences Press, 1989. Contributors discuss the problem, focusing on federal and state policy responses to it. Lustbader, Wendy, and Nancy R. Hooyman. Taking Care of Aging Family Members. New York: Free Press, 1994. Discusses neglect and abuse and the caregiving stress that can lead to it. O’Connell, James J., Jean Summerfield, and F. Russell Kellogg. “The Homeless Elderly.” In Under the Safety Net: The Health and Social Welfare of the Homeless in the United States, edited by Philip W. Brickner et al. New York: W. W. Norton, 1990. Essay examining the demographics of elderly homelessness, the problems that plague these people, and the programs designed to help them in several large American cities.
✧ Electrical shock Type of issue: Children’s health, public health Definition: The physical effect of an electrical current entering the body and the resulting damage. Electrical shock ranges from a harmless jolt of static electricity to a power line’s lethal discharge. The severity of the shock depends on the current flowing through the body, and the current is determined by the skin’s electrical resistance. Dry skin has a very high resistance; thus 110 volts produces a small, harmless current. The resistance for perspiring hands, however, is lower by a factor of 100, resulting in potentially fatal currents. Because of their proximity to the heart, currents traveling between bodily extremities are particularly dangerous. Electrical shock causes injury or death in one of three ways: paralysis of the breathing center in the brain, paralysis of the heart, or ventricular fibrillation (extremely rapid and uncontrolled twitching of the heart muscle). The threshold of feeling (the minimum current detectable) ranges from 0.5 to 1.0 milliamperes. Currents up to 5.0 milliamperes, the maximum harmless current, are not hazardous, unless they trigger an accident by involuntary reaction. Currents in this range create a tingling sensation. The minimum current that causes muscular paralysis occurs between 10 and 15 milliamperes. Currents of this magnitude cause a painful jolt. Above 18 milliamperes, the current contracts chest muscles and breathing ceases. Unconsciousness and death follow within minutes unless the current is interrupted and respiration resumed. A short exposure to currents of 50 milliamperes causes severe pain, possible fainting, and complete exhaustion, while currents in the 100 to 300 milliampere range produce ventricular fibrillation, which is fatal unless quickly corrected. During ventricular fibril-
Electrical shock ✧ 317 lation, the heart stops its rhythmic pumping and flutters uselessly. Since blood stops flowing, the victim dies from oxygen deprivation to the brain in a matter of minutes. This is the most common cause of death for victims of electrical shock. Relatively high currents (above 300 milliamperes) may produce ventricular paralysis, deep burns in the body’s tissue, or irreversible damage to the central nervous system. Victims are more likely to survive a large but brief current, even through smaller, sustained currents are usually lethal. Burning or charring of the skin at the point of contact may be a contributing factor to the delayed death that often follows severe electrical shock. Very high voltage discharges of short duration, such as a lightning strike, tend to disrupt the body’s nervous impulses, but victims may survive. On the other hand, any electric current large enough to raise body temperature significantly produces immediate death. Treating Electrical Shock Before medical treatment can be applied, the current must be stopped or the shock victim must be separated from the current source without being touched. Nonconducting materials such as dry, heavy blankets or pieces of wood can be used for this purpose. If the victim is not breathing, artificial respiration immediately applied provides adequate short-term life support, though the victim may become stiff or rigid in reaction to the shock. Victims of electrical shock may suffer from severe burns and permanent aftereffects, including eye cataracts, angina, or disorders of the nervous system. Electrical shock can usually be prevented, particularly in children, by strictly adhering to safety guidelines and using commonsense precautions. Careful inspection of appliances and tools, compliance with manufacturers’ safety standards, and the avoidance of unnecessary risks greatly reduce the chance of an electrical shock. Electrical appliances or tools should never be used when standing in water or on damp ground, and dry gloves, shoes, and floors provide considerable protection against dangerous shocks from 110volt circuits. Electrical safety is also provided by isolation, guarding, insulation, grounding, and ground fault interrupters. Isolation means that high-voltage wires strung overhead are not within reach, while guarding provides a barrier around high voltage devices, such as are found in television sets. Old wire insulation may become brittle with age and develop small cracks. Defective wires are hazardous and should be replaced immediately. Most modern power tools are double-insulated; the motor is insulated from the plastic insulating frame. These devices do not require grounding, as no exposed metal parts become electrically live if the wire insulation fails. In a home, grounding is accomplished by a third wire in outlets, connected through a grounding circuit to a water pipe. If an appliance plug has
318 ✧ Emphysema a third prong, it will ground the frame to the grounding circuit. In the event of a short circuit, the grounding circuit provides a low resistance path, resulting in a current surge which trips the circuit breaker. In some instances, however, the current may be inadequate to trip a circuit breaker (which usually requires 15 or 20 amperes), but current in excess of 10 milliamperes could still be lethal to humans. A ground-fault interrupter ensures nearly complete protection by detecting leakage currents as small as 5 milliamperes and breaking the circuit. This relatively inexpensive device operates very rapidly and provides an extremely high degree of safety against electrocution in the household. Many localities now have codes which require the installation of ground-fault interrupters in bathrooms, kitchens, and other areas where water is used. —George R. Plitnik See also Burns and scalds; Children’s health issues; First aid; Resuscitation; Safety issues for children. For Further Information: Atkinson, William. “Electric Injuries Can Be Worse than They Seem.” Electric World 214, no. 1 (January/February, 2000): 33-36. Whether an electrical shock initially seems serious or mild, it is always a cause for concern. Aspects of electrical shock injuries are explored. Bridges, J. E., et al., eds. International Symposium on Electrical Shock Safety Criteria. New York: Pergamon Press, 1985. The summary of a symposium covering the physiological effects of shock, bioelectrical conditions, and safety measures. Hewitt, Paul G. Conceptual Physics. 8th ed. Reading, Mass.: Addison-Wesley, 1998. Comprehensive coverage of physics for the layperson that includes detailed discussions of the laws of electricity and electrical devices. Liu, Lynda. “Pullout Emergency Guide: Electric Shock.” Parents 75, no. 1 (January, 2000): 65-66. A pull-out emergency guide for the prevention and treatment of electrical shock in children. Household hazards and electricity dos and don’ts are among the tips offered. U.S. Department of Labor. Occupational Safety and Health Administration. Controlling Electrical Hazards. Washington, D.C.: Government Printing Office, 1991. A report which identifies common electrical hazards and discusses their prevention.
✧ Emphysema Type of issue: Elder health, environmental health, occupational health, public health
Emphysema ✧ 319 Definition: A lung disease characterized by increased shortness of breath on exertion, often a natural accompaniment of aging but also initiated or aggravated by cigarette smoking or a heritable specific protein deficiency. Emphysema is one of the two major clinical conditions encompassed in the terms “chronic obstructive pulmonary disease” (COPD) and “chronic airflow obstruction” (CAO). Fourteen million individuals in the United States suffer from emphysema or the other, more frequent condition, chronic bronchitis. Emphysema involves the lung tissue associated with the exchange of oxygen and carbon dioxide between the blood and the air. There is destruction of the walls of the alveoli, the small sacs where blood and air are in closest contact, so that permanent enlargement of the alveolar volume occurs. Clinically, patients with chronic bronchitis tend to an extreme characterized by marked decrease of oxygen in the blood, a bluish discoloration of the skin (cyanosis), and swelling of the legs (peripheral edema) as a result of heart failure. Such patients are sometimes referred to as “blue bloaters.” In contrast, patients with emphysema tend to an extreme characterized by marked shortness of breath on exertion, a pinkish complexion, and little, if any, peripheral edema. Such patients are sometimes referred to as “pink puffers.” Chronic bronchitis and emphysema may coexist in a given individual to a greater or lesser degree. With the increases in life expectancy and actual longevity in the United States, the number of individuals significantly affected by emphysema can be expected to increase with time. Most older individuals show some evidence of emphysema at death. Even without emphysema, however, aging is associated with a decrease in lung or pulmonary functions such that physical activities become more limited. These normal declines in pulmonary function cannot yet be reversed or even arrested and are the result of tissue changes occurring over time. They can be markedly aggravated if emphysema, such as that caused by cigarette smoking, is superimposed on the normal processes. The life span of affected individuals may be shortened significantly. Risk Factors, Epidemiology, and Natural History The incidence of emphysema increases with age and is much more common in men than in women. The dominant cause is cigarette smoking. The one other major identified cause is a deficiency of alpha-1 antitrypsin, a protein that inhibits the destruction of alveolar walls by enzymes. Other factors that may play significant but less certain roles are environmental pollution (including oxidants), hazardous occupations, socioeconomic status, diet, low birth weight, and severe childhood respiratory illnesses. Although the diagnosis of emphysema is made in slightly less than 1
320 ✧ Emphysema percent of the population, the incidence is much higher in cigarette smokers. Thus, in one study, 2.9 percent of nonsmoking males showed moderate changes associated with emphysema at autopsy, 25 percent of individuals smoking less than twenty cigarettes per day showed moderate changes, and 32.7 percent of those smoking twenty or more cigarettes per day showed such changes. Of the latter group, nearly 20 percent showed marked changes. COPD was the fourth leading cause of death in the United States at the end of the twentieth century. Between 80 and 90 percent of the cases of COPD could be attributed to cigarette smoking. Cigarette smoking clearly limits longevity; cessation of smoking increases life expectancy and decreases the rate of decline of pulmonary functions. One measure of pulmonary function is the volume of air that can be expelled forcibly from the lungs in one second after a maximal inspiratory effort. This measure normally peaks at age twenty-five and decreases to 75 percent of the value at age twenty-five when age seventy-five is reached. In those individuals whose pulmonary functions are affected by cigarette smoking, the measure drops to about 75 percent at age forty-five. If smoking continues, the life expectancy falls to well below seventy-five years. If smokers stop at about age fifty, however, the deterioration is slowed and their life expectancy is increased, although In emphysema, the body releases enzymes in response to they may show significant inhaling irritants in the air, such as cigarette smoke; disability by age seventy-five these enzymes reduce the lung’s elasticity, compromising or eighty. Cessation of smokthe bronchioles’ ability to expand and contract normally. Air becomes trapped in the alveoli upon inhalation (top) ing beyond the age of fifty, and cannot escape upon exhalation (bottom). Over time, for example at sixty-five, is breathing becomes extremely difficult. (Hans & Cassidy, associated with lesser benefits because much damage Inc.)
Emphysema ✧ 321 has already been done and there is superposition of the damage caused by cigarette smoking on the changes occurring with age. Of major importance to the cigarette smoker is the number of cigarettes smoked, calculated as pack years (number of packs of cigarettes smoked per day times the number of years the individual has smoked). For smokers with twenty-one to forty pack years, pulmonary function declines to about 90 percent of the predicted value for that age. For smokers with sixty-one or more pack years, it declines to less than 80 percent of the predicted value. Not all smokers are so affected. Indeed, 10 to 15 percent of smokers escape the effects mentioned, for reasons unknown. That some smokers are affected so much more than others might stem from intrinsic sensitivity of the airways, effects in childhood of environmental pollution or passive smoking, genetic factors, or manner of smoking (for example, whether they inhale deeply). Functional and Tissue Changes The patient with emphysema is generally thin, may purse the lips during expiration, is older (fifty to seventy-five years of age), and experiences increased limitation of exercise tolerance because of shortness of breath (dyspnea on exertion). This portrait is in contrast with the patient with chronic bronchitis, who has a chronic cough, excessive sputum production, and cyanosis at forty to fifty-five years of age. Chest radiographs (X rays) and computed tomography (CT) and magnetic resonance imaging (MRI) scans typically show that the patient with emphysema has a small heart, an increased lung and chest volume, lowering and flattening of the diaphragm, and areas of radiolucency (indicating decreased lung tissue density) and large bubbles or bullae (indicating the absence of any lung tissue in those areas). The patient with chronic bronchitis, in contrast, may show increased markings indicating changes in the walls of the bronchial airways and of vascular engorgement. Pulmonary function tests (PFTs) in patients with emphysema typically show marked increases in lung volumes, particularly the total lung capacity (essentially the maximal air content) and the residual air volume (RV), the volume remaining after full expiration. The RV is an indicator of air trapped because of airway closure. The rate of flow in expiration is decreased. The elastic recoil, the driving pressure of the lungs during expiration, is decreased because of tissue changes. The action of the diaphragm is also decreased because these muscles are flattened instead of being domed and cannot move as freely as in normal individuals. In addition, because of the destruction of lung tissue there is a reduction in the pulmonary diffusing capacity, which indicates that the rate of exchanges of oxygen between the air and the blood in the pulmonary vessels is reduced. The lungs must work at a mechanical disadvantage so that with the decrease of alveolar ventila-
322 ✧ Emphysema tion, the work of breathing and oxygen consumption are increased. With the destruction of lung tissue, the surface of the lungs available for gas exchanges is decreased. So while the demand for oxygen is increased, the delivery is decreased, particularly during exertion. The tissue changes in cigarette smokers differ somewhat from those observed in patients with alpha-l antitrypsin deficiency. In the former, the respiratory bronchioles are mainly affected, with relatively normal alveolar ducts and alveoli. The bronchioles widen and may fuse. In the latter, the alveolar walls are destroyed more uniformly throughout the lungs, so that mainly vascular, bronchial, and supporting structures are left. In both types of emphysema, proteases, enzymes that degrade structural proteins such as collagen and particularly elastin, overwhelm their inhibitors such as the antitrypsins. In cigarette smokers, the inflammatory response to the irritants in smoke is associated with macrophages (scavenger cells) and neutrophils, cells that respond to inflammation and produce proteases which not only attack tissues but also destroy antiproteases. Individuals with antiprotease deficiency have impaired defense mechanisms and are at greater risk of serious damage. Emphysema can be considered to occur as the result of imbalance between proteases and antiproteases. The resultant irreversible tissue changes in the peripheral parts of the lungs lead to overinflation of the alveolar air sacs and in turn may lead to compression of some of the remaining unaffected lung tissue. Prevention and Treatment In cigarette smokers, the single most effective treatment is cessation of smoking. In most cases, cessation will slow the decline in respiratory functions and in exercise tolerance. The best prevention is discouraging young individuals from ever starting to smoke. Only 10 to 15 percent of cigarette smokers develop emphysema, and relatively few of them have alpha-1 antitrypsin deficiency. Nevertheless, abolition of cigarette smoking could have not only major health benefits but also major economic benefits in reducing the costs of care for an aging population already faced with declining respiratory function and exercise tolerance. Other recognized measures for the treatment of emphysema include long-term supplemental oxygen administration as needed, bronchodilators, corticosteroids when airway inflammatory changes are present, antibiotics for infections, and diuretics and vasodilators for heart failure. Physical training programs and mechanically assisted ventilation can be extremely helpful. In patients with homozygous alpha-l antitrypsin deficiency, replacement therapy with the purified protein should be considered. Controlled clinical trials employing the surgical reduction of lung volume began in 1997 under the joint auspices of the National Institutes of Health (NIH) and the Health Care Financing Administration. This approach is
Endometriosis ✧ 323 based on the fact that the overinflation of the lungs is not uniform throughout the organs. It had been suggested in the 1950’s that surgical removal of the overinflated areas could improve pulmonary functions by permitting more normal positioning of the diaphragm and increasing elastic recoil. Early attempts in this direction were associated with marked subjective improvement in some patients, but the overall postoperative morbidity and mortality were very high. More recently, improved surgical techniques and intensive care procedures have resulted in better clinical results. However, the criteria for application of the procedure, the short-term benefits, and the long-term outcomes, together with cost-benefit considerations, have not yet been evaluated fully. The prospects for the controlled program, undertaken at nineteen centers in the United States, are encouraging. Emphysema will remain a major issue in an aging population for many years. Probably the most effective means of limiting the problem will be cessation of smoking for those who do smoke and efforts to discourage younger generations from ever smoking at all. —Francis P. Chinard See also Cancer; Illnesses among the elderly; Lung cancer; Smoking. For Further Information: Cherniack, N. S. Chronic Obstructive Pulmonary Disease. Philadelphia: W. B. Saunders, 1991. Fishman, Alfred P., ed. Fishman’s Pulmonary Diseases and Disorders. 3d ed. 2 vols. New York: McGraw-Hill, 1998. Haas, François, and Sheila Sperber Haas. The Chronic Bronchitis and Emphysema Handbook. Rev. and expanded ed. New York: John Wiley & Sons, 2000. Jenkins, Mark. Chronic Obstructive Pulmonary Disease: Practical, Medical, and Spiritual Guidelines for Daily Living with Emphysema, Chronic Bronchitis, and Combination Diagnosis. Center City, Minn.: Hazelden Information Education, 1999. Staton, G. W., and R. H. Ingram. “Chronic Obstructive Diseases of the Lungs.” In Scientific American Medicine, edited by D. C. Dale and D. D. Federman. New York: Scientific American, 1998.
✧ Endometriosis Type of issue: Women’s health Definition: A condition in which the endometrial tissue that lines the uterus grows in other parts of the body; it affects many women during their reproductive years, seriously impairing all aspects of their quality of life and sometimes resulting in infertility.
324 ✧ Endometriosis Endometriosis is a condition in which the endometrial tissue of the uterus grows into other parts of the body, usually into the ovaries, pelvic cavity, intestines, or bladder but occasionally in more distant locations such as the lungs. Like the uterine lining, this endometrial tissue also responds to the hormonal changes of the menstrual cycle. The blood and cells that are sloughed off by this tissue cannot leave the body during menstruation, and the results can be internal bleeding, the formation of cysts, and the creation of scar tissue. The primary symptom of endometriosis is intense pain connected with the menstrual cycle, particularly during ovulation and menstruation, but other symptoms include intestinal problems and infertility. The cause of endometriosis is not fully known. One theory associates it with a backward reflux of the menstrual flow, which permits endometrial tissue to attach and grow on other organs in the abdomen. Other theories connect endometriosis with hormonal problems or with an abnormal response by the immune system. Another suggestion is the dispersal of endometrial cells through the blood or lymph systems. Most likely, a combination of these and other elements causes this condition. Endometriosis is difficult to diagnose because only exploratory abdominal surgery can offer a definitive diagnosis. Such surgery is usually done by laparoscopy, in which a fiber-optic tube inserted into the abdomen allows the physician to view the pelvic organs directly. The successful treatment of endometriosis is even more difficult since the underlying causes of this condition are poorly understood. The two primary approaches are hormonal therapy and surgery. Because the growth of endometrial tissue responds to sex hormones, various kinds of hormonal treatment may improve the condition. Surgery can also be used to remove the tissue. New techniques such as laser laparoscopy are less invasive. In extreme cases, however, a hysterectomy (the removal of the uterus), often with the removal of the Fallopian tubes and the ovaries as well, may be indicated. Statistical information about endometriosis is hard to obtain because of the difficulty of diagnosis and the fairly recent acceptance within the medical community of the seriousness of this condition. It is estimated that at least five million women suffer from endometriosis during their reproductive years. The condition has been associated in the medical literature and the popular mind with white, educated, career-oriented women in their twenties and thirties. In fact, endometriosis occurs in women of all races, economic levels, and ages from puberty to the menopause. Many women are severely disabled because of endometriosis. The disease often restricts their ability to bear children, and it may substantially limit their productive capacity in a working environment. Increasingly, especially through the educational and lobbying efforts of the Endometriosis Association in the United States and similar organizations in other countries, the myths about endometriosis are being dispelled. Ongoing research into the causes and treatment of endometriosis will improve the outlook and relieve the physical
Environmental diseases ✧ 325 pain and psychological stigma associated with this major problem in women’s health. —Karen Gould See also Cervical, ovarian, and uterine cancers; Hysterectomy; Menstruation; Women’s health issues. For Further Information: Ballweg, Mary Lou, with Endometriosis Association. The Endometriosis Sourcebook. NTC/Contemporary, 1995. Provides information about research; surgical and medical treatments; alternative treatments; common myths about the disease; pregnancy, labor, and postpartum experiences of women with endometriosis; and advice for coping physically and emotionally. Phillips, Robert H., and Glenda J. Motta. Coping with Endometriosis: A Practical Guide to Understanding, Treating, and Living with Chronic Endometriosis. Los Angeles: Jeremy P. Tarcher, 2000. In addition to the latest research on treatment of endometriosis, this book addresses the psychological and emotional concerns brought on by its diagnosis. Venturini, Pier Luigi, and Johannes L. H. Evers, eds. Endometriosis: Basic Research and Clinical Practice. New York: Parthenon, 1999. Contains important information for clinicians treating endometriosis patients with pain or infertility problems. Covers the basic aspects of epidemiology, pathogenesis, and immunology, then clinical appearance, infertility and pelvic pain, medical treatment by endocrine modulation, and new methods of surgical treatment. Weinstein, Kate. Living with Endometriosis. Reading, Mass.: Addison-Wesley, 1987. The main divisions of this handy book are medical aspects, treatments and outcomes, emotional problems, and pain and psychiatric problems.
✧ Environmental diseases Type of issue: Environmental health, public health Definition: A wide variety of conditions and diseases resulting from largely human-mediated hazards in both the natural and humanmade (for example, home and workplace) environments; an area of special concern given rapid environmental degradation during the twentieth century. Almost any condition except those of purely genetic origin could be considered as environmentally caused or having an environmental component, but the term “environmental disease” is usually applied to the effects of
326 ✧ Environmental diseases human alterations in the physical environment and excludes transmissible disease caused by pathogenic organisms, except in cases where human alteration of the environment is an important factor in epidemiology. Health hazards generally classed as environmental include air and water (including groundwater) pollution, toxic wastes, lead, asbestos, pesticides and herbicides, ionizing and nonionizing radiation, noise, and light. Air and Water Pollution In the United States, the Clean Air Act of 1970 established maximum levels for sulfur and nitrogen dioxide, particulates, hydrocarbons, ozone, and carbon monoxide—the most common air pollutants of concern in urban environments. Even with increasingly stringent controls on emissions from automobiles and industry, air quality in urban areas frequently does not meet minimum standards. Carbon monoxide lowers the oxygen-carrying capacity of the blood, nitrogen and sulfur dioxide react with water to form acids which damage lung tissue, ozone damages tissue directly, and particulates may accumulate in the lungs. The result is decreased lung capacity and function. Indoor air quality poses additional concerns. Emphasis on energy efficiency in building design decreases air exchange. Carpets and furniture release organic compounds, and cleaning solvents leave a volatile residue. Formaldehyde from foam stuffing and insulation inhibits liver function and is a suspected carcinogen. Breathing in an enclosed space decreases atmospheric oxygen and increases carbon dioxide. In some areas, radioactive radon gas released by the soil becomes concentrated in buildings. A ventilation system which draws its air from a polluted outdoor environment, such as a loading dock, will fail to perform its function. Secondhand cigarette smoke poses the same hazards of emphysema and lung cancer to people chronically exposed to it in an enclosed environment as to the smokers themselves. The phenomenon known as sick building syndrome, in which large numbers of people in one building complain of respiratory illness, headaches, and impaired concentration, results from a combination of these factors. Inhalation of asbestos fibers carries a high risk of developing lung cancer after an interval of twenty or thirty years, a connection first established among shipyard workers. Between 1940 and 1970, asbestos was used extensively in public buildings as insulation. It is estimated that three to five million workers in the United States were exposed to unacceptably high levels of airborne fibers during this period, and millions of people continue to be exposed when building materials deteriorate. Asbestos abatement adds considerably to the cost of renovating old public buildings. A category of severe lung disease affects workers in environments with a high concentration of particulate matter in the air: black lung disease, from
Environmental diseases ✧ 327 coal dust in coal mines; silicosis, from fine rock powder in mines; and byssinosis, from textile fibers in spinning and weaving mills. The result of long-term breathing of particulates is obstruction and emphysema, which may be fatal. Lead additives in gasoline were once a significant source of atmospheric lead, but they are being phased out; unfortunately, they leave a permanent residue in soils of high-traffic areas. Levels of 20 micrograms per deciliter of lead in the blood inhibit hemoglobin production, slow the transmission of nerve impulses, and are suspected of causing cognitive impairment in children; higher levels cause anemia, weakness, stomach pains, and nervous system impairment. Even levels below 5 micrograms may be hazardous to children. Because of lead in the paint and plumbing in old houses and soil contamination, blood lead levels high enough to cause developmental impairment in children occur frequently in older parts of cities; low-income residents are most likely to be at risk. Mercury, another metallic neurotoxin, is introduced into water in small amounts through industrial effluent but becomes concentrated in the food chain, where it poses a hazard to people who eat large quantities of fish. Any waterborne pollutant that is not rapidly degraded has the potential for being concentrated in the food chain. Shellfish, which filter nutrients from seawater, can concentrate toxins. The most notorious cause of shellfish poisoning is a naturally occurring neurotoxic alga, but polychlorinated biphenyls (PCBs) and pesticides have also been implicated. Some metals, including lead, arsenic, and mercury, remain toxic indefinitely and are exceedingly difficult to remove from an environment into which they have been introduced. Urban drinking water in industrialized countries is monitored for hazardous contaminants; there is some question as to whether chlorine and fluoride, added for legitimate health reasons, are completely without negative effects. Well water in irrigated agricultural areas may have high levels of nitrates, which decrease blood oxygen and have been implicated in miscarriages and birth defects. Toxic Wastes, Radiation, and Other Hazards Organic chemical compounds make up 60 percent of the hazardous wastes generated by industry. This category includes PCBs (including dioxin), chlorofluorocarbons (CFCs), phthalate esters, chlorinated benzenes, chloromethanes, solvents (such as benzene and carbon tetrachloride), plasticizers, fire retardants, pesticides, and herbicides. Many are acutely toxic— dioxin is one of the most potent toxins known—and require elaborate precautions to prevent worker exposure or accidental contamination of foodstuffs. PCBs, which are used in a wide variety of manufacturing processes, have been shown to cause cancer and reproductive disorders in
328 ✧ Environmental diseases laboratory animals and have been linked to these conditions in humans. The herbicide 2,4,5-T, the defoliant Agent Orange used during the Vietnam War, is the subject of continuing claims against the manufacturer and the Veterans Administration by soldiers who later developed neurological symptoms, immune disorders, or cancer or who had children with birth defects. The burial of toxic by-products of manufacturing processes in landfills has created an ongoing environmental health crisis as containers rupture and chemicals leach into the surrounding soil. Underground fuel storage tanks pose a similar problem. Toxins leached from a waste dump eventually enter streams and become disseminated or, if volatile, enter the atmosphere. Residents of the infamous Love Canal site in New York State were made ill by fumes from contaminated soil and groundwater. Exposure to industrial solvents has been a significant source of workplace illness. Among the most dangerous solvents are benzene, used in a variety of processes and produced as a by-product in the coking industry; vinyl chloride, used in plastics manufacture; and formaldehyde. All these chemicals are carcinogenic. High energy from X-ray sources and radioactive materials is termed “ionizing” because such radiation can cause chemical changes in molecules, including genetic material. Chronic exposure to ionizing radiation poses a high risk of cancer, inheritable mutations, and fetal malformation. Exposure may be occupational, as with workers in the nuclear power industry or hospital radiology laboratories. Some radioactive by-products of nuclear weapons testing and reactor accidents (such as strontium 90 or carbon 14) are exceptionally hazardous because they are structurally incorporated into living tissue and become concentrated in the food chain. The by-products of the nuclear reactor accident in Chernobyl, Ukraine, in 1987 were disseminated across international boundaries and will continue to endanger the health of millions of people in Belarus, Ukraine, and Eastern Europe. Whether widespread atmospheric testing of nuclear weapons in the 1950’s caused radiation damage in the population at large is unknown; military personnel involved in the testing and inhabitants of the regions near test sites report increased rates of suspected radiation-induced illness. Hazards of nonionizing radiation (visible, ultraviolet, infrared, or microwave) are less well established. Intense visible light can damage vision. Artificial lighting is known to disrupt reproductive cycles in plants and invertebrates and could have subtle effects on human biology. That the level of microwave radiation to which the public at large is inadvertently exposed is well below levels known to produce adverse effects is not completely reassuring. Ultraviolet light, principally from sunlight, is a factor in skin cancer, which is increasing both because of the popularity of sunbathing and because ozone depletion increases ultraviolet exposure. Electromagnetic fields produced by power lines and electrical devices are an area of increasing controversy as electricity becomes more ubiquitous.
Environmental diseases ✧ 329 One study found a higher-than-average rate of childhood leukemia near high-tension power lines; other studies have failed to confirm this finding. Women who work constantly at video display terminals have somewhat higher miscarriage rates than other office workers. Societal Intervention It is notoriously difficult to prove that an illness has an environmental cause. Suspicion arises when epidemiological statistics on reportable illnesses show that some condition known to be influenced by environmental factors— such as cancer, endocrine disorders, reproductive disorders, or immunodeficiency—occurs at an unusually high frequency in some subset of the population, occurs in a restricted geographical area, or is increasing throughout the general population. The time interval between exposure and illness can be as long as twenty or thirty years, during which the exposed population may have dispersed and may no longer be readily identifiable. Subtle effects such as mild immunosuppression or cognitive impairment may escape detection or be dismissed as psychosomatic. Multiple environmental, behavioral, and even genetic factors are often involved, confounding efforts to pinpoint a cause. In the United States and Western Europe, high rates of exposure to pollutants are correlated with poverty and thus with higher-than-normal rates of malnutrition, alcohol and drug abuse, and inadequate access to health care. Tobacco smoking is a common confounding behavioral factor in environmental diagnosis. Where liability is involved, there are powerful financial incentives on the side of disproving the environmental or occupational linkage. When a new technology or chemical is introduced, regulations in most countries require an assessment of health impact, which includes experimentation with animal models and risk assessment to determine the probable impact on the human population. Animal experimentation is most effective at demonstrating short-term and acute effects of toxic materials, but it is poor at demonstrating effects of long-term, low-level exposure. Risk assessment must take into consideration unusually susceptible individuals (pregnant women, for example), deliberate or accidental overexposure, and synergistic effects. In the realm of environmental legislation, risk assessment is also influenced by psychology; people are more willing to accept familiar risks over which they have personal control. The increase in the proportion of morbidity and mortality attributable to environmental factors in the late twentieth century was the result not only of the exponential increase in energy use and the output of complex synthetic chemicals but also of changing demographics. Effects of low-level exposure to toxins may take decades to produce disease and may never become apparent in populations with a low life expectancy. In developing
330 ✧ Environmental diseases countries, where environmental protection is rudimentary and life expectancies are increasing rapidly, the adverse health effects of environmental degradation are particularly visible. In the United States, specific legislation addresses compensation for miners, asbestos workers, and other specific victims of exposure to hazardous materials. On a worldwide basis, monitoring of hazardous substances is a prime concern of the World Health Organization. —Martha Sherwood-Pike See also Allergies; Asbestos; Asthma; Birth defects; Cancer; Chlorination; Chronic fatigue syndrome; Fluoridation of water sources; Food irradiation; Food poisoning; Frostbite; Genetically engineered foods; Hazardous waste; Heat exhaustion and heat stroke; Holistic medicine; Lead poisoning; Lice, mites, and ticks; Lung cancer; Lyme disease; Mad cow disease; Mercury poisoning; Multiple chemical sensitivity syndrome; Noise pollution; Occupational health; Parasites; Pesticides; Plague; Poisoning; Poisonous plants; Radiation; Radon; Seasonal affective disorder (SAD); Secondhand smoke; Sick building syndrome; Skin cancer; Skin disorders with aging; Smog; Smoking; Snakebites; Sunburns; Water quality; Worms; Zoonoses. For Further Information: Cooper, M. G., ed. Risk: Man-Made Hazards to Man. Oxford, England: Clarendon Press, 1985. A book about how people perceive and assess risks, factors that affect environmental legislation. In addition to a discussion of statistics and the effects of publicity, this British publication adopts a conservative view that hazards are often overstated. Greenberg, Michael R., ed. Public Health and the Environment: The United States Experience. New York: Guilford Press, 1987. This text explores modern environmental problems from the point of view of public health. Part 1, a survey of the contribution of the environment to disease, includes sections on worker health and lifestyle as a factor in chronic disease. National Research Council. Committee on Environmental Epidemiology. Public Health and Hazardous Wastes. Vol. 1 in Environmental Epidemiology. Washington, D.C.: National Academy Press, 1991. The report of a committee assigned to investigate the question of whether the federal hazardous waste programs in the United States actually protect human health. Reviews agencies and the methodologies of exposure assessment, the extent of the problem in the United States, and specific examples of hazardous wastes in air, groundwater, soil, and food. Includes charts and maps summarizing data and extensive bibliographies. A lengthy glossary is provided. A good factual reference on many aspects of environmental health. Rom, William N., ed. Environmental and Occupational Medicine. 2d ed. Boston: Little, Brown, 1992. The emphasis in this textbook is on industrial
Epidemics ✧ 331 occupational safety, with approximately a third of the work devoted to the diagnosis and pathology of occupational lung diseases, including byssinosis and black lung disease. The effects of acute and chronic exposure to heavy metals, solvents, and other toxic substances are organized by agent. Intended as a guide for medical practitioners treating patients with environmental illnesses and as a guide to the prevention of exposure for professionals concerned with workplace safety. Steenland, Kyle, and David A. Savits. Topics in Environmental Epidemiology. New York: Oxford University Press, 1997. A comprehensive survey of the epidemiology of common environmental exposures, this volume covers diet, water, particulates in outdoor air, nitrogen dioxide, ozone, environmental tobacco smoke, radon in homes, electromagnetic fields, and lead.
✧ Epidemics Type of issue: Environmental health, epidemics Definition: Incidences of contagious, often widespread disease in human populations. An epidemic is characterized by a large increase in the frequency of a disease within a population. Until relatively recently, the term was used primarily for outbreaks of contagious diseases caused by infectious agents, but current epidemiology also concerns itself with environmentally caused diseases, such as radiation-induced cancers, and with mental and behavioral problems, such as drug use. Outbreaks of diseases in plants and animals are also loosely termed epidemics but are more properly termed epiphytotics and epizootics, respectively. The defining characteristic of an epidemic is not the absolute frequency of the disease or its severity, but the abrupt increase in its frequency. In contrast, an endemic disease is one whose frequency within a population does not vary markedly with time. An epidemic may be local in scope and limited in its effects; an endemic disease may be widespread and an important source of mortality within a population. The extreme case is a pandemic, an epidemic which transcends national boundaries and affects huge numbers of individuals on a worldwide basis. The most notorious pandemics in recorded history were the bubonic plague that swept Eurasia in the fourteenth century, killing an estimated one-third of the population of Europe, and the influenza epidemic of 1918-1919, which killed approximately 20 million people worldwide. The acquired immunodeficiency syndrome (AIDS) epidemic, not recognized in the United States and Europe as a major public health threat until the early 1980’s, has reached pandemic status; because of its predominantly sexual
332 ✧ Epidemics mode of transmission and relatively low infectivity, however, the number of infected individuals is far lower than would be the case for a disease transmitted by casual contact. Pathogens and Populations The nature and severity of an epidemic of infectious disease are influenced by the nature of the pathogen and by the physical and social makeup of the affected population. Characteristics of the pathogen include transmissibility (the ease with which a pathogen is passed from one host to another), infectivity (its ability to grow and multiply in that host), pathogenicity (its ability to produce clinical disease), and virulence (the severity of the disease produced). The worst epidemic diseases, such as smallpox, are highly transmissible, infective, pathogenic, and virulent. Chickenpox is highly transmissible and infective but not very virulent. Diseases that are not highly transmissible, such as leprosy, or are selectively pathogenic, such as tuberculosis, are more likely to be endemic than epidemic. Each infectious disease has characteristic modes of transmission that must be understood for the purpose of disease prevention. Respiratory diseases transmitted as airborne particles—smallpox, influenza, measles, pneumonic plague—spread rapidly and are difficult to control through sanitation and quarantine. Diseases spread through fecal contamination of water and food—cholera, hepatitis, typhoid, poliomyelitis—are more easily avoided and, in industrialized countries, tend to occur in localized outbreaks with identifiable sources. Blood-borne diseases transmitted by biting arthropods—malaria, yellow fever, typhus, bubonic plague—can erupt in devastating epidemics when both host and vector populations are high. Localized outbreaks of arthropod-transmitted diseases that have natural animal reservoirs (including yellow fever, St. Louis encephalitis, bubonic plague, murine typhus, and Lyme disease) occur throughout the world, but human-to-human chains of transmission are most likely to occur in Third World countries beset by social upheaval. The spread of sexually transmitted diseases is also aided by war and social dislocation. The transmission of blood-borne viral diseases through contaminated hypodermic needles became significant in the latter part of the twentieth century. Human resistance to disease is a function of genetic makeup, age, and general health. The impact of a measles epidemic illustrates these relationships. Europeans, through many generations of epidemics that killed the most susceptible individuals, inherit an immune system which is effective at fighting this virus. Disease resistance decreases with increasing age. Although no specific treatment for measles existed until a vaccine was developed in the 1960’s, mortality rates in the United States declined dramatically between 1850 and 1950 as a result of improved nutrition and housing and better nursing care. The mortality rate of untreated measles among Ameri-
Epidemics ✧ 333 can children in the 1950’s was one in two hundred or three hundred, among poor European slum dwellers in the nineteenth century was one in twenty or thirty, and among Amerindians and Polynesians, who were both impoverished and lacking genetic resistance, was one in two or three. Behavior, Environment, and Disease Diseases caused by behavioral and environmental factors can also be viewed as occurring in epidemics. A major explanation for the increased prominence of noninfectious diseases as causes of mortality and morbidity has been an increasing life span; the cumulative effects of environmental toxins and unhealthy behavior exhibit themselves only as an individual ages. The age-specific frequency of Alzheimer’s disease in the United States remained relatively constant in the twentieth century, but because of increasing longevity, the frequency increased dramatically. Both longevity and changes in behavior contributed to the increase in mortality from lung cancer in industrialized countries in the twentieth century. The various lines of investigation linking this epidemic to tobacco smoking are a good example of epidemiological research. Recent increases in the incidence of skin cancer seem to be linked partly to the popularity of sunbathing and partly to increases in ultraviolet radiation caused by pollution. Localized clusters of disease and mortality often point to a single environmental hazard. The long-term adverse effects of lead, asbestos, and herbicides have been identified and characterized based on observations of groups of peoples with high levels of exposure to these substances. Prevention, Diagnosis, and Treatment The discoveries by Robert Koch, Louis Pasteur, and others linking specific microorganisms to human disease ushered in an era when the most effective method for improving human health was the prevention of infection, principally through epidemiological public health measures. Sewage treatment, water purification, and the inspection of food preparation facilities reduced the incidence of cholera, typhoid, and hepatitis; draining and channeling stagnant water to control mosquitoes made malaria and yellow fever rare diseases in the United States and southern Europe. The pesticide DDT (although subsequently condemned because of the serious environmental problems that it caused) performed a laudable service to human health in the aftermath of World War II, killing the vectors of louse-borne typhus and other diseases. Statistics are the raw material of epidemiological investigation. Death certificates record both the primary and contributing causes of death, the age and sex of the deceased, and the place of death. Census figures give a
334 ✧ Epidemics picture of the community in which epidemiological events occur, such as its racial and socioeconomic composition, age structure, and population density. Physicians and hospitals are required to notify the public health authorities of the occurrence of certain “reportable” diseases, such as AIDS, syphilis, and tuberculosis. Hospital admission records will reflect increases in conditions requiring hospitalization, while school and workplace attendance figures reflect outbreaks of milder communicable diseases. Some outbreaks are routine and predictable, and the measures for controlling them are well established. When influenza cases increase, public health authorities identify the strain responsible and take steps to immunize those individuals who are most at risk for severe disease. Identifying the source of contaminated food or water is critical to controlling outbreaks of hepatitis A and typhoid in industrialized countries. When war or natural disaster disrupts the normal infrastructure of modern life, it is considered prudent to inoculate the affected population against a variety of infectious diseases. The history of the discovery of Lyme disease illustrates how epidemiology works. Physician and hospital records indicated a clustering of cases diagnosed as juvenile arthritis near Lyme, Connecticut. By comparing the cases and observing their common characteristics, epidemiologists deduced that an arthropod-transmitted organism normally found on wild animals was probably responsible. Armed with this information, they surveyed microorganisms found in biting arthropods and were able to establish that the same spirochete was found in wild deer, deer ticks, and patients exhibiting symptoms of juvenile arthritis. This organism, and the chronic disease that it causes, proved to be widespread, although not particularly common among humans. Knowing the etiology of the disease enabled physicians to diagnose the condition correctly and to treat it. Environmentally and behaviorally caused diseases are less amenable to control by health professionals alone, and consequently can prove much more intractable. This is particularly true when there are powerful economic factors working at cross purposes to disease control measures. The epidemiologist can demonstrate that the increase in lung cancer in the twentieth century paralleled an increase in tobacco consumption and that smokers account for most cases of lung cancer. The biomedical investigator studying etiology can show that tobacco derivatives cause cancer in laboratory animals and may ultimately be able to explain how this is brought about at the molecular level. Physicians can advise patients not to smoke, and psychologists can devise therapies to help people quit smoking. None of these efforts, however, will achieve definitive success as long as there are powerful forces encouraging people to smoke and undermining the efforts of the health professionals. The difficulty is compounded, as with any addictive drug, by the active participation of the very people who are the victims of the epidemic in perpetuating the conditions that favor it.
Epidemics ✧ 335 Progress in Controlling Epidemics Tremendous progress was made in controlling epidemic disease over the course of the twentieth century, so much so that there was a period when epidemics of life-threatening contagious diseases were viewed as past history in industrialized countries and there was optimism that the same result could be achieved in the Third World as well. The gradual elimination of smallpox was viewed as a model. Yet the worldwide epidemic of AIDS and the resurgence of malaria, tuberculosis, and cholera as epidemic diseases in the late twentieth century are ample evidence that the epidemiological battle against disease is far from won, and that medical science’s current arsenal of weapons against infectious disease has serious inadequacies. The factors favoring an increase in epidemics of transmissible disease in the last decades of the twentieth century included an increase in the speed and frequency of international travel, the emergence of drug-resistant strains of a wide variety of pathogens, and a high level of political and social instability in developing nations. AIDS is only one notable example of dozens of tropical diseases that have the potential for causing lethal worldwide epidemics. Another is Ebola virus, a virulent pathogen responsible for a 1976 epidemic in Zaire in which 90 percent of the victims died. A related virus, lethal to monkeys and infective but nonvirulent in humans, swept a primate quarantine facility in Maryland, and another member of this virus group caused a localized lethal epidemic among monkeys and laboratory workers in Marburg, Germany. Many other lethal transmissible viruses have been identified. AIDS, the widespread use of immunosuppressant drugs, and the aging of the population have created significant numbers of individuals who have weakened immune systems and are susceptible to infection by animal pathogens. It is worth noting that the worst pandemic in recorded human history, the fourteenth century bubonic plague epidemic, occurred when an animal pathogen became established in a human population and then mutated from a moderately transmissible, arthropod-borne disease to a highly transmissible, airborne infection. The likelihood that animal pathogens will spread to humans and that they will be disseminated internationally is increasing, and the chances of a mutation toward increased transmissibility or virulence increases with the number of infected individuals. The potential for a worldwide pandemic capable of overwhelming the efforts of modern medical science certainly exists, although its probability cannot be estimated. —Martha Sherwood-Pike See also AIDS; AIDS and children; AIDS and women; Childhood infectious diseases; Food poisoning; Herpes; Illnesses among the elderly; Influenza; Lice, mites, and ticks; Lyme disease; Mad cow disease; Meningitis; Necrotizing fasciitis; Occupational health; Parasites; Plague; Poisoning; Sexually transmitted diseases (STDs); Tuberculosis; Water quality; Worms; Zoonoses.
336 ✧ Ethics For Further Information: Clegg, E. J., and J. P. Garlick, eds. Disease and Urbanization. London: Taylor & Francis, 1980. A series of papers discussing the impact of the growth of cities on the frequency of disease. One paper compares the relative impacts of improved living standards and urban services versus specific medical intervention in reducing disease mortality, concluding that the former is far more important. Goldsmid, John. The Deadly Legacy: Australian History and Transmissible Disease. Kensington, New South Wales, Australia: New South Wales University Press, 1988. Because of its isolation before the eighteenth century, the epidemiological history of Australia is more completely documented than that of any other continent. This book discusses the disease history of Aborigines and settlers, as well as the history of government efforts to control epidemics from the early nineteenth century to the late twentieth century, with good coverage of the control measures in effect in 1988. Preston, Richard. “A Reporter at Large: Crisis in the Hot Zone.” The New Yorker 68 (October 26, 1992): 58. Focusing on how U.S. government epidemiologists controlled an outbreak of deadly Ebola virus in a primate quarantine facility in Maryland, this article gives a good overview of the various “new” human diseases that have surfaced, including AIDS, and the worldwide threat that they pose. Ranger, Terence, and Paul Slack, eds. Epidemics and Ideas: Essays on the Historical Perception of Pestilence. Cambridge, England: Cambridge University Press, 1992. A collection of papers describing the interplay among perceptions of the etiology of disease, social and religious attitudes, and politics in epidemics from classical antiquity to the present. For example, in sixteenth century Italy, the transmission of plague from the poor to the upper classes was viewed as punishment from God visited on the rich for their lack of charity, whereas in nineteenth century England, the high incidence of disease among the lower classes was viewed as resulting from poor constitution and moral character. Timmreck, Thomas C. An Introduction to Epidemiology. 2d ed. Boston: Jones and Bartlett, 1998. A book in the Jones and Bartlett series in health sciences. Discusses epidemiological methods. Includes a bibliography and an index.
✧ Ethics Type of issue: Ethics Definition: A philosophical discipline that attempts to analyze systematically the way in which moral decisions are made; in medicine, this involves defining appropriate patient care, humane biological research, an equi-
Ethics ✧ 337 table distribution of scarce medical resources, and a just health care delivery system. In the course of their work, health care professionals are faced with many situations that have moral significance. These situations are characterized by such questions as whether or when to proceed with treatment, which therapy to administer, which patient to see first, how to conduct research using human subjects, where to assign resources that are in short supply, or how to set up an equitable health care system. The discipline of medical ethics seeks to engage in a systematic examination of these questions which is as objective as possible. Ethical questions in general fall into two categories. A quandary is a moral question about which detailed ethical analysis yields a single, undisputed answer. A dilemma, on the other hand, is a moral question to which there are at least two ethically defensible responses, with neither one taking clear precedence over the other. Ethical analysis consists of the application of primary principles to concrete, clinical situations. It also employs comparative reasoning, in which a particular problem is compared to other situations about which a moral consensus exists. Principled reasoning rests on four fundamental principles of biomedical ethics: respect for autonomy, nonmaleficence, beneficence, and justice. Principles of Reasoning The principle of respect for autonomy requires that every person be free to take whatever autonomous action or make whatever autonomous decision he or she wishes without constraint by other individuals. An example of respect for autonomy is the doctrine of informed consent, which requires that patients or research subjects be provided with adequate information that they clearly understand before voluntarily submitting to therapy or participating in a research trial. The principle of nonmaleficence states that one should not inflict evil or harm upon a patient. Although straightforward in its enunciation, it is clear that this principle may come into conflict with the principle of respect for autonomy in cases where a request for withdrawal of therapy is made. Similarly, this principle may come into conflict with obligations to promote the good of the patient, as many medical decisions involve the use of therapies or diagnostic procedures that have undesirable side effects. The principle of double effect in the Roman Catholic moral tradition has attempted to resolve this latter conflict by stating that if the intent of an action is to effect an overriding good, the action is defensible even if unintended but foreseen harmful consequences ensue. Some commentators suggest, however, that intent is an artificial distinction because all the consequences, both good and bad, are foreseen. As a result, the potential for harm should
338 ✧ Ethics be weighed against the potential for benefit in deciding the best course of action. A formal evaluation of this kind is commonly referred to as a risk-benefit analysis. Individual interpretation of the principle of nonmaleficence lies at the heart of debates over abortion, euthanasia, and treatment withdrawal. The principle of beneficence expresses an obligation to promote the patient’s good. This can be construed as any action that prevents harm, supplants harm, or does active good to a person. As such, this principle provides the basis for all medical practice, be it preventive, epidemiologic, acute, or chronic care. Not all actions can be considered uniformly beneficial. Certain kinds of therapy that may prove to be lifesaving can leave a patient with what he or she finds to be an unacceptable quality of life. An examination of the positive and negative consequences of successful medical treatment is commonly called a benefit-burden analysis. In this context, the principle of beneficence most frequently comes into conflict with the principle of respect for autonomy. In situations such as these, the physician’s appeal to beneficence is often considered paternalistic. The principle of justice applies primarily to the distribution of health care resources in what can be considered to be a just and fair fashion. As there are many competing theories of justice, there is no one clear statement of this principle that can be succinctly applied to all situations. Nevertheless, the principle does require careful consideration of the means by which health care is allocated under conditions of scarcity. In the United States, scarce resources may comprise such entities as transplantable organs, intensive care beds, expensive medical technologies in general, and, in some circumstances, basic medical care itself. Under conditions of scarcity, one’s understanding of justice can easily come into conflict with obligations to each of the three preceding principles. In general, the more scarce the resource, the more concerns about distributive justice will influence the deployment of that resource. Ethical Disputes in Medical Practice Ethical issues in medicine can be divided into macrocosmic (large-scale) and microcosmic (small-scale) concerns. Macrocosmic issues are those which apply to a broad social constituency and therefore often intersect with both statutory and common law. Microcosmic concerns, on the other hand, are those which arise in the day-to-day practice of medicine, the discussion and resolution of which generally have less of a far-reaching impact on the society as a whole. Primary among the macrocosmic ethical debates is the question of health care allocation. This centers largely on the development of health care delivery systems in particular and health care financing in general. Other issues being argued at the macrocosmic level are broad social policies regarding such concerns as euthanasia, physician-assisted suicide, voluntary
Ethics ✧ 339 abortion, and regulations governing the withholding and withdrawal of life-sustaining therapy. Biomedical research using fetal tissue from induced abortions and research aimed at precisely mapping the human genetic code have raised serious ethical questions regarding both the morality of these endeavors and the nature of life itself. The question of whether—and if so, how—to screen patients for the human immunodeficiency virus (HIV) that causes acquired immunodeficiency syndrome (AIDS) has been argued in both state and federal courts. Mechanisms for Resolving Ethical Quandries U.S. research involving human subjects is subjected to ethical review at both macrocosmic and microcosmic levels. Nationally, it is regulated by agencies such as the Food and Drug Administration (FDA). At the microcosmic level, the FDA mandates and supervises the administration of institutional review boards (IRBs), which are charged with the responsibility of assuring that human subjects are involved in creditable research, are treated in a humane manner, are not subjected to undue risks, and are fully cognizant both of the nature of the project in which they are participating and of any potential risks and benefits associated with it. Resource allocation is a problem at the microcosmic as well as the macrocosmic level; however, the issues in small-scale settings revolve around who constitutes an appropriate candidate for a limited number of intensive care beds or what are the appropriate eligibility criteria for organ transplantation at a particular institution. Perhaps the most common microcosmic problems for hospitals and nursing homes are individual decisions regarding when to terminate life-sustaining therapy. Other common microcosmic dilemmas involve maternal-fetal conflict where the autonomous requests or medical best interests of the mother do not coincide with the presumed best interests of her unborn child. Institutional Ethics Committees In situations such as these, both acute and chronic health care facilities often solicit the assistance of institutional ethics committees. Such committees are characteristically composed of individuals representing a broad spectrum of professional disciplines as well as community members not directly employed by the facility. A typical committee might consist of representatives from physician and nursing staffs, social service, psychiatry, pastoral care, special care services (such as intensive care, AIDS management, and neonatal intensive care) that often have a greater number of patients with ethical concerns than others, and hospital administration. Many committees also employ the services of philosophers, attorneys, designated community representatives, or representatives of special interest groups.
340 ✧ Ethics In situations that require an institutional response, these committees will often assist in policy development. Examples include institutional policies specifying admission and discharge criteria for intensive care, or policies governing the procedures for withholding or withdrawing therapy. Ethics committees also serve as primary educational resources for both institutional staff and members of the surrounding community. When the care of individual patients raises ethical questions, many committees have established mechanisms for case consultation or case review. Consultations of this type involve an in-depth review of the patient’s clinical condition, as well as of various other social, religious, psychological, or family matters that may be pertinent. After a complete assessment of the facts of the case, consultants then investigate the various ethical arguments that support alternative courses of action before issuing a final recommendation. Case consultation is usually performed by a subcommittee of the institutional ethics committee and is sometimes offered by individual consultants who are not members of the committee. In most cases, the recommendations of the consultants are not binding. Certain models, however, require that some limited kinds of consultative recommendations determine the outcome in specific settings. Although intervention by an ethics committee often allows for the resolution of ethical disputes within the walls of an institution, sometimes irreconcilable differences require judicial review by a court of law. Under these circumstances, the court’s decision regarding a particular case becomes a matter of public record, providing precedent for future similar cases. In this way, certain ethical dilemmas that arise as microcosmic problems end up generating a body of common law which can have profound effects at the macrocosmic level. —John Arthur McClung, M.D. See also Abortion; Abortion among teenagers; Aging; Child abuse; Circumcision of boys; Circumcision of girls; Death and dying; Domestic violence; Elder abuse; Euthanasia; Fetal tissue transplantation; Genetic engineering; Genetically engineered foods; Health equity for women; Hippocratic oath; Hospice; Hysterectomy; In vitro fertilization; Law and medicine; Living wills; Malpractice; Mastectomy; Morning-after pill; Münchausen syndrome by proxy; Reproductive technologies; Resuscitation; Screening; Sterilization; Terminal illnesses; Transplantation. For Further Information: Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 5th ed. New York: Oxford University Press, 2001. A lucidly written, basic textbook of bioethics. Although some commentators are critical of a primarily principle-based approach to bioethics, this book remains the most widely recognized introductory resource in the field.
Euthanasia ✧ 341 Beauchamp, Tom L., and LeRoy Walters, eds. Contemporary Issues in Bioethics. 5th ed. Belmont, Calif.: Wadsworth, 1999. A composite of readings culled from legal decisions, seminal legislation, ethical codes of conduct, and the writings of well-known ethicists. The readings are organized by topic and are preceded by a short summary of ethical theory. This work serves as a good companion volume to a basic text. Jonsen, Albert R., Mark Siegler, and William J. Winslade. Clinical Ethics. 4th ed. New York: McGraw-Hill, 1998. A handbook of medical ethics aimed primarily at the physician in training. The authors present a method for evaluating the ethical dimensions of clinical cases, after which the book is organized lexically so that commonly encountered problems can be located easily. A very concise reference which concentrates on practical rather than theoretical priorities. Jonsen, Albert R., and Stephen Toulmin. The Abuse of Casuistry: A History of Moral Reasoning. Berkeley: University of California Press, 1988. A well-constructed history of the technique of case-based analysis which concludes with a practical description of how this approach can be used as an alternative to principle-based analysis in clinical situations. Reich, Warren T., ed. Encyclopedia of Bioethics. 2d ed. New York: Free Press, 1992. A broad look at the entire field of bioethics. Probably the most comprehensive collection of readings currently available under one title.
✧ Euthanasia Type of issue: Ethics Definition: The intentional termination of a life, which may be active (resulting from specific actions causing death) or passive (resulting from the refusal or withdrawal of life-sustaining treatment), voluntary (with the patient’s consent) or involuntary (on behalf of infants or others who are incapable of making this decision, such as comatose patients). Euthanasia, sometimes called mercy killing, comes from a Greek word that can be translated as “good death.” Most patients who express a wish to die more quickly are terminally ill; however, euthanasia is sometimes considered as a solution for nonterminal patients as well. An example of the latter would be seriously deformed or retarded infants whose futures are judged to have a poor “quality of life” and who would be a serious burden on their families and society. Types of Euthanasia When discussing the ethical implications of euthanasia, the types of cases have been divided into various classes. A distinction is made between volun-
342 ✧ Euthanasia tary and nonvoluntary euthanasia. In voluntary euthanasia, the patient consents to a specific course of medical action in which death is hastened. Nonvoluntary euthanasia would occur in cases in which the patient is not able to make decisions about his or her death because of an inability to communicate or a lack of mental facility. Each of these classes has advocates and antagonists. Some believe that voluntary euthanasia should always be allowed, but others would limit voluntary euthanasia to only those patients who have a terminal illness. Some, although agreeing in principle that voluntary euthanasia in terminal situations is ethically permissible, nevertheless oppose euthanasia of any type because of the possibility of abuses. With nonvoluntary euthanasia, the main ethical issues deal with when such an action should be performed and who should make the decision. If a person is in an irreversible coma, most agree that that person’s physical life could be ended; however, arguments based on “quality of life” can easily become widened to include persons with physical or mental disabilities. Infants with severe deformities can sometimes be saved but not fully cured with medical technology, and some individuals would advocate nonvoluntary euthanasia in these cases because of the suffering of the infants’ caregivers. Some believe that family members or those who stand to gain from the decision should not be allowed to make the decision. Others point out that the family is the most likely to know what the wishes of the patient would have been. Most believe that the medical care personnel, although knowledgeable, should not have the power to decide, and many are reluctant to institute rigid laws. The possibility of misappropriated self-interest from each of these parties magnifies the difficulty of arriving at well-defined criteria. The second type of classification is between passive and active euthanasia. Passive euthanasia occurs when sustaining medical treatment is refused or withdrawn and death is allowed to take its course. Active euthanasia involves the administration of a drug or some other means that directly causes death. Once again, there are many opinions surrounding these two types. One position is that there is no difference between active and passive euthanasia because in each the end is premeditated death with the motive of prevention of suffering. In fact, some argue that active euthanasia is more compassionate than letting death occur naturally, which may involve suffering. In opposition, others believe that there is a fundamental difference between active and passive euthanasia. A person may have the right to die, but not the right to be killed. Passive euthanasia, they argue, is merely allowing a death which is inevitable to occur. Active euthanasia, if voluntary, is equated with suicide because a human being seizes control of death; if nonvoluntary, it is considered murder. Passive euthanasia, although generally more publicly acceptable than active euthanasia, has become a topic of controversy as the types of medical treatment that can be withdrawn are debated. A distinction is sometimes
Euthanasia ✧ 343 made between ordinary and extraordinary means. Defining these terms is difficult, since what may be extraordinary for one patient is not for another, depending on other medical conditions that the patient may have. In addition, what is considered an extraordinary technique today may be judged ordinary in the future. Another way to assess whether passive euthanasia should be allowed in a particular situation is to weigh the benefits against the burdens for the patient. Although most agree that there are cases in which high-tech equipment such as respirators can be withdrawn, there is a question about whether administration of food and water should ever be discontinued. Here the line between passive and active euthanasia is blurred. The Physician’s Dilemma C. Everett Koop, former surgeon general of the United States, differentiated between the positive role of a physician in providing a patient “all the life to which he or she is entitled” and the negative role of “prolonging the act of dying.” Koop, opposed to euthanasia in any form, cautioned against the possibility of sliding down a slippery slope toward making choices about death that reflect the caregivers’ “quality of life” more than the patient’s. Dr. Jack Kevorkian, a Michigan physician, became the most well known advocate of assisted suicide in the United States. From 1990 to 1997, Kevorkian assisted at least sixty-six people in terminating their lives. According to his lawyer, many other assisted suicides were not publicized. Kevorkian stated that physician-assisted suicide is a matter of individual choice and that it should be seen as a rational way to end tremendous pain and suffering. Most of the patients assisted by him spent many years suffering from extremely painful and debilitating diseases, such as multiple sclerosis, bone cancer, and brain cancer. The American Medical Association (AMA) criticized this view, calling it a violation of professional ethics. When faced with pain and suffering, the AMA asserts that it is a doctor’s responsibility to provide adequate “comfort” care, not death. In the AMA’s view, Kevorkian is “a reckless instrument of death.” Three trials in Michigan for assisting in suicide resulted in acquittals for Kevorkian before another trial delivered a guilty verdict on the charge of second-degree murder in March, 1999. Legal Rights and Ramifications During the course of reevaluating the issues involved in terminating a life, the law has been in a state of flux. The decisions that are made by the courts act on the legal precedents of an individual’s right to determine what is done to his or her own body and society’s position against suicide. The balancing of these two premises has been handled legally by allowing refusal of
344 ✧ Euthanasia treatment (passive euthanasia) but disallowing the use of poison or some other method that would cause death (active euthanasia). The latter is labeled suicide, and anyone who assists in such an act can be found guilty of assisting a suicide, or of murder. Following the Karen Ann Quinlan case in 1976, in which the family of a comatose woman secured permission to withdraw life-sustaining treatment, the courts routinely allowed family members to make decisions regarding life-sustaining treatment if the patient could not do so. The area of greatest legal controversy involves the withdrawal of food and water. Some courts have charged doctors with murder for the withdrawal of basic life support measures such as food and water. Others have ruled that invasive procedures to provide food and water (intravenously, for example) are similar to other medical procedures and may be discontinued if the benefit to the patient’s quality of life is negligible. In 1994, 51 percent of the voters in Oregon passed the world’s first “death with dignity” law. It allowed physician-assisted suicide. Doctors could begin prescribing fatal overdoses of drugs to terminally ill patients. The vote was reaffirmed in 1997 by 60 percent of the state’s voters, despite opposition from the Roman Catholic Church, the AMA, and various anti-abortion and right-to-life groups. The 9th United States Circuit Court of Appeals in San Francisco then lifted a lower court order blocking implementation of the law. Doctors in Oregon became free to prescribe fatal doses of barbiturates to patients with less than six months to live. Physicians were required to file forms with the Oregon Health Division before prescribing the overdose. Then, there would be a fifteen-day waiting period between the request for suicide assistance and the approval of the prescription. Opponents of the Oregon law charged that it perverted the practice of medicine and forced many suffering people to “choose” an early death to save themselves from expensive medical care or pain that could be manageable if physicians were aware of new methods of pain control. The National Right to Life Committee indicated that it would continue to fight implementation of the law in federal courts. Although the laws vary from state to state, most states allow residents to make their wishes known regarding terminal health care either by writing a living will or by choosing a durable power of attorney. A living will is a document in which one can state that some medical treatments should not be used in the event that one becomes incapacitated to the point where one cannot choose. Living wills allow the patient to decide in advance and protect health care providers from lawsuits. Which treatment options can be terminated and when this action can be put into effect may be limited in some states. Most states have a specific format that should be followed when drawing up a living will and require that the document be signed in the presence of two witnesses. Often, qualifying additions can be made by the
Euthanasia ✧ 345 individual that specify whether food and water may be withdrawn and whether the living will should go into effect only when death is imminent or also when a person has an incurable illness but death is not imminent. A copy of the living will should be given to the patient’s physician and become a part of the patient’s medical records. The preparation or execution of a living will cannot affect a person’s life insurance coverage or the payment of benefits. Since the medical circumstances of one’s life may change and a person’s ethical stance may also change, a patient may change the living will at any time by signing a written statement. A second way in which a person can control what kind of decisions will be made regarding his or her death is to choose a decision maker in advance. This person assumes a durable power of attorney and is legally allowed to act on the patient’s behalf, making medical treatment decisions. One advantage of a durable power of attorney over a living will is that the patient can choose someone who shares similar ethical and religious values. Since it is difficult to foresee every medical situation that could arise, there is more security with a durable power of attorney in knowing that the person will have similar values and will therefore probably make the same judgments as the patient. Usually a primary agent and a secondary agent are designated in the event that the primary agent is unavailable. This is especially important if the primary agent is a spouse or a close relative who could, for example, be involved in an accident at the same time as the patient. An Age-Old Quandary The famous Hippocratic oath for physicians acted in opposition to the prevailing cultural bias in favor of euthanasia. Contained in this oath is the statement, “I will never give a deadly drug to anybody if asked for it . . . or make a suggestion to this effect.” The AMA reaffirmed this position in a policy statement: “the intentional termination of the life of one human being by another—‘mercy killing’—is contrary to that for which the medical profession stands and is contrary to the policy of the American Medical Association.” Although these issues have been debated by physicians and philosophers for centuries, there is a heightened need for thoughtful discussion and resolution today. Clearly, the decisions surrounding the issue of euthanasia are very complicated. The choice is not simply between commitments to “sanctity of life” or “quality of life” viewpoints. No consensus has yet been reached across the spectrum of society, and instead a variety of alternatives are supported by groups of individuals. A clear understanding of all positions in the debate is the best preparation for making personal decisions at the time of death. —Katherine B. Frederich; updated by Leslie V. Tischauser
346 ✧ Exercise See also Aging; Death and dying; Depression; Depression in the elderly; Ethics; Health insurance; Hippocratic oath; HMOs; Hospice; Hospitalization of the elderly; Law and medicine; Living wills; Pain management; Suicide; Suicide among the elderly; Terminal illnesses. For Further Information: Gorovitz, Samuel. Drawing the Line. Reprint. New York: Oxford University Press, 1993. This book reflects on the author’s seven-week sabbatical in residence at Beth Israel Hospital. Gorovitz presents numerous insights drawn from conversations with patients and medical personnel. Leone, Daniel A. The Ethics of Euthanasia. San Diego, Calif.: Greenhaven Press, 1999. Part of a new anthology series that focuses a wide range of viewpoints onto a single controversial issue. This volume includes ten essays on the ethics and morality of euthanasia, potential abuse, distinctions between active and passive euthanasia, and whether euthanasia is consistent with Christian belief. Spring, Beth, and Ed Larson. Euthanasia. Portland: Multnomah Press, 1988. This book considers the spiritual, medical, and legal issues in terminal health care, citing numerous perspectives from the religious community. Contains two chapters detailing practical guidelines for writing living wills and durable powers of attorney. Torr, James D. Euthanasia. San Diego, Calif.: Greenhaven Press, 1999. Designed for high school students, this volume brings together essays by authorities in diverse vocations. The four chapters explore whether euthanasia is ethical, if it should be legalized, if legalization would lead to involuntary killing, and under what circumstances, if any, doctors should assist in suicide. Wennberg, Robert N. Terminal Choices. Grand Rapids, Mich.: Wm. B. Eerdmans, 1989. The author presents a helpful history of the euthanasia debate and also discusses possible moral distinctions between treatment refusal and treatment withdrawal.
✧ Exercise Type of issue: Prevention, public health, social trends Definition: Various intensities and types of physical activity. Low or moderate exercise intensity relies on oxygen to release energy for work. This process is often referred to as aerobic exercise. In the muscles, carbohydrates and fats are broken down to produce adenosine triphosphate (ATP), the basic molecule used for energy. Aerobic exercise can be sustained for several minutes to several hours.
Exercise ✧ 347 Higher-intensity exercise is predominantly fueled anaerobically (in the absence of oxygen) and can be sustained for up to two minutes only. Muscle glycogen is broken down without oxygen to produce ATP. Anaerobic metabolism is much less efficient at producing ATP than is aerobic metabolism. During anaerobic metabolism, a by-product called lactic acid begins to accumulate in the blood as blood lactate. The point at which this accumulation begins is called the anaerobic threshold, or the onset of blood lactate accumulation. Blood lactate can cause muscle soreness and stiffness, but it also can be used as fuel during aerobic metabolism. A third and less often used energy system is the creatine phosphate (ATP-CP) system. Utilizing the very limited supply of ATP that is stored in the muscles, phosphate molecules are exchanged between ATP and CP to provide energy. This system provides only enough fuel for a few seconds of maximum effort. The type of muscle fiber recruited to perform a specific type of exercise is also dependent on exercise intensity. Skeletal muscle is composed of “slow-twitch” and two types of “fast-twitch” muscle fibers. Slow-twitch fibers are more suited to using oxygen than are fast-twitch fibers, and they are recruited primarily for aerobic exercise. One type of fast-twitch fiber also functions during aerobic activity. The second type of fast-twitch fiber serves to facilitate anaerobic, or high-intensity, exercise. Exercise mode is also a factor in the physiological responses to exercise. Dynamic exercise (alternating muscular contraction and relaxation through a range of motion) using many large muscles requires more oxygen than does activity utilizing smaller and fewer muscles. The greater the oxygen requirement of the physical activity, the greater the cardiorespiratory benefits. Measures of Increasing Fitness Many bodily adaptations occur over a training period of six to eight weeks, and other benefits are gradually manifested over several months. The positive adaptations include reduced resting and working heart rates. As the heart becomes stronger, there is a subsequent increase in stroke volume (the volume of blood the heart pumps with each beat), which allows the heart to beat less frequently while maintaining the same cardiac output (the volume of the blood pumped from the heart each minute). Another beneficial adaptation is increased metabolic efficiency. This is partially facilitated by an increase in the number of mitochondria (the organelles responsible for ATP production) in the muscle cells. One of the most recognized representations of aerobic fitness is the maximum volume of oxygen (VO2max) an individual can use during exercise. VO2max is improved through habitual, relatively high-intensity aerobic activity. After three to six months of regular training, levels of high-density lipoproteins (HDLs) in the blood increase. HDL molecules remove choles-
348 ✧ Exercise terol (a fatty substance) from the tissues to aid in protecting the heart from atherosclerosis. Two major types of flexibility have been identified. One type consists of the flexibility through the range of motion of a muscle group or joint. This is called static flexibility. It can be measured using a metric stick or a protractor-type instrument called a goniometer. Dynamic flexibility is the other major identified type of flexibility. It is the torque of or resistance to movement. Methods to measure dynamic flexibility have not been developed. Various internal and external factors influence the metabolic processes that take place during and after exercise. Internally, nutrition, degree of hydration, body composition, flexibility, sex, and age are some of the variables that play a role in the physiological responses. Other internal variables include medical conditions such as heart disease, diabetes, and hypertension (high blood pressure). Externally, environmental conditions such as temperature, humidity, and altitude alter how the exercising body functions. Various modes of exercise testing and data collection are used to study the physiological responses of the body to exercise. Treadmills and cycle ergometers (instruments used to measure work and power output) are among the most common methods of evaluating maximum oxygen consumption. During these tests, special equipment and computers analyze expired air, heart rate is monitored with an electrocardiograph (ECG), and blood pressure is taken using a sphygmomanometer. Blood samples and muscle fiber samples can also be extracted to aid in identifying the fuel system and type of muscle fibers being used. Other data sometimes collected, such as skin temperatures and body core temperatures, can provide pertinent information. Exercise and Body Composition Another factor greatly affecting the physical response to exercise is body composition. The three major structural components of the body are muscle, bone, and fat. Body composition can be evaluated using a combination of anthropometric measurements. These measurements include body weight, standard height, measurements of circumferences at various locations using a tape measure, measurements of skeletal diameters using a sliding metric stick, and measurements of skinfold thicknesses using calipers. Body fat can be estimated using several methods, the most accurate of which is based on a calculation of body density. This method is called hydrostatic weighing, which involves weighing the subject under water while taking into account the residual volume of air in the lungs. The principle underlying this measurement of body density is based on the fact that fat is less dense than water and will float, whereas bone and muscle, which are denser than water, will sink. One biochemical technique often used to
Exercise ✧ 349 determine levels of body fat is based on the relatively constant level of potassium 40 naturally existing in lean body mass. Another method utilizes ultrasound waves to measure the thickness of fat layers. X rays and computed tomography (CT) scanning can be used to provide images from which fat and bone can be measured. Bioelectrical impedance (BIA) is a method of estimating body composition based on the resistance imposed on a low voltage electrical current sent through the body. The most widely used and easily assessable method, however, involves measurement of skinfolds at various sites on the body using calipers. In all cases, mathematical formulas have been devised to interpret the collected data and provide the best estimate of an individual’s body composition. Other tests have been developed to determine muscular strength, muscular endurance, and flexibility. Muscular strength is often measured by performance of one maximal effort produced by a selected muscle group. Muscular endurance of a muscle or muscle group is often demonstrated by the length of time or number of repetitions a particular, submaximal workload or skill can be performed. The Goals of Exercise For the healthy adult participant, the American College of Sports Medicine, a widely recognized authoritative body on exercise prescription, recommends three to five sessions of aerobic exercise weekly. Each session should include a five- to ten-minute warm-up period, twenty to sixty minutes of aerobic exercise at a predetermined exercise intensity, and a five- to ten-minute cooldown period. Determining an individual’s maximum heart rate is important in choosing an appropriate aerobic exercise intensity. The best way to obtain this maximum heart rate is to take a maximal exercise test. Such a test can be supervised by an exercise physiologist or an exercise test technician; it is advisable, especially for the older participant, that a cardiologist also be in attendance. An ECG is monitored for irregularities as the subject walks, runs, cycles, or performs some dynamic exercise to exhaustion or until the onset of irregular symptoms or discomfort. Adequate physical fitness can be defined as the ability to perform daily tasks with enough reserve for emergency situations. All aspects of health-related fitness direct attention toward this goal. Aerobic exercise often provides some conditioning for muscular endurance, but muscular strength and flexibility need to be addressed separately. The ACSM recommends resistance training using the “overload principle,” which involves placing habitual stress on a system, causing it to adapt and respond. For this training, it is suggested that eight to twelve repetitions of eight to ten strengthening exercises of the major muscle groups be performed a minimum of two days per week.
350 ✧ Exercise Flexibility of connective tissue and muscle tissue is essential to maximize physical performance and to limit musculoskeletal injuries. At least one stretching exercise for each major muscle group should be executed three to four times per week while the muscles are warm. Exercise in Cardiac Rehabilitation Cardiac rehabilitation takes exercise prescription a step further. Participation of the heart patient is more individualized than in wellness programs. The condition of the circulatory system, pulmonary system, and joints are only a few of the special concerns. Secondary conditions such as obesity, diabetes, and hypertension must also be considered. The responsibilities of cardiac rehabilitation specialists include monitoring blood sugar in diabetic patients and blood pressure in all patients, especially those with hypertension. Many drugs affect heart rate or blood pressure, and most of these participants are taking more than one type of medication. Patients with heart damage caused by a heart attack may display atypical heart rhythms, which can be seen on an ECG monitor. Furthermore, the stage of recovery of the postsurgical patient is a major factor in recommending the type, frequency, intensity, and duration of exercise. Patient education is also important. Lifestyle is usually the main factor in the development of heart disease. Cardiac patients often have never participated in a regular exercise program. Frequently, they are smokers, are overweight, and have poor eating habits. Helping them to identify and correct destructive health-related behaviors is the focus of education for the heart patient. Sports Medicine Another application of the study of exercise physiology involves dealing with the competitive athlete. In this case, findings from the most recent research are constantly applied to yield the best athletic performance possible. A delicate balance of aerobic training, anaerobic training, strength training, endurance training, and flexibility exercises are combined with the optimum percentage of body fat, proper nutrition, and adequate sleep. The program that is designed must enhance the athletic qualities that are most beneficial to the sport in which the athlete participates. The competitive athlete usually pushes beyond the boundaries of general exercise prescription in terms of intensity, duration, and frequency of exercise performance. As a result, the athlete risks suffering more injuries than the individual who exercises for health benefits. If the athlete sustains an injury, the exercise physiologist may work in conjunction with an athletic trainer or sports physician to return the athlete to competition as soon as possible. —Kathleen O’Boyle
Exercise and children ✧ 351 See also Biofeedback; Canes and walkers; Cardiac rehabilitation; Exercise and children; Exercise and the elderly; Hypertension; Mobility problems in the elderly; Muscle loss with aging; Obesity; Obesity and aging; Obesity and children; Physical fitness tests for children; Physical rehabilitation; Preventive medicine; Steroid abuse; Wheelchair use among the elderly; Yoga. For Further Information: American College of Sports Medicine. Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2000. This manual provides guidelines for the professional working in preventive exercise programs or in cardiac rehabilitation. The recommendations are based on the most-up-to-date research available at the time of publication. Requirements for certification through the ACSM are also explained in detail. ________. Resource Manual for Guidelines for Exercise Testing and Prescription. 3d ed. Baltimore: Williams & Wilkins, 1998. Based on the objective of providing safe and effective exercise programs for all individuals, this publication provides an excellent overview of many of the topics of concern to the exercise physiologist. Specific recommendations regarding stress testing and exercise prescription are included in the text. McArdle, William D., Frank I. Katch, and Victor L. Katch. Exercise Physiology: Energy, Nutrition, and Human Performance. 4th ed. Baltimore: Williams & Wilkins, 1996. This textbook is designed for the serious student of exercise physiology. Provides relatively detailed explanations of various energy systems in the body. Powers, Scott K., and Edward T. Howley. Exercise Physiology: Theory and Application to Fitness and Performance. Dubuque, Iowa: Wm. C. Brown, 1990. The upper-level undergraduate or beginning graduate student will find detailed information concerning exercise physiology in this useful textbook. Designed for students who are serious about the study of exercise science. Sharkey, Brian J. Physiology of Fitness. 3d ed. Champaign, Ill.: Human Kinetics Books, 1990. Provides an excellent learning opportunity for the junior college student. Offers a guide to the prescription of exercise for health, fitness, and performance, but takes things a step further by explaining the scientific basis for these guidelines.
✧ Exercise and children Type of issue: Children’s health, prevention, public health Definition: Exertion of the body to develop or maintain physical fitness.
352 ✧ Exercise and children In 1996 the U.S. surgeon general issued a report on physical activity and health. The report documented the benefits of regular physical activity to the health and well-being of both adults and children. The Centers for Disease Control and Prevention followed in 1997 with guidelines for promoting lifelong physical activity. This document identifies the benefits of physical activity for children and adolescents as improving strength and endurance, building healthy bones and muscles, controlling weight, reducing anxiety and stress, increasing self-esteem, and potentially improving blood pressure and cholesterol levels. Types of Exercise Healthy individuals of all ages can benefit from regular exercise. General exercise regimens can be developed and may include training to improve flexibility, endurance, and strength. Specific exercise programs can also be prescribed to meet an individual’s special needs. Flexibility training primarily includes stretching to increase the range of motion in joints and to enhance freedom of movement. Healthy children can safely participate in stretching activities. To avoid injury and obtain the benefits of stretching, one must use good body mechanics and slow, controlled stretches. Fast, bouncing movements should be avoided. Moderation in stretching exercises is also recommended. Stretching for ballet, gymnastics, or other sports is necessary for competition purposes but goes beyond the level needed for normal healthy development. Regular stretching can contribute to an improved quality of life, as in the control of back pain, and has long-term health benefits. Cardiovascular exercise, one component of endurance exercise, is believed to offer the greatest long-term health benefits. This form of exercise is commonly called aerobic. Aerobic exercise relies on oxygen. It demands sufficient oxygen from the cardiovascular system to maintain the activity for fifteen minutes or longer. Aerobic activity is vigorous, continuous, and rhythmical and uses the major muscle groups. The purest forms of aerobic exercise include repetitive activities such as walking, running, bicycling, cross-country skiing, and rowing. Many exercise machines are also good aerobic options, such as climbers and ski machines. Young children do not need to participate in these types of activities on a regular basis. They benefit most from games that have a high aerobic component and strengthen the cardiovascular system like soccer, basketball, and other games involving a lot of running. Games are beneficial because they develop the muscles, heart, and lungs and also help children learn motor skills. Older children and adolescents can participate in most aerobic activities because their bodies are developed enough to obtain the cardiovascular benefits. Another component of endurance exercise is muscular endurance. This involves activities that focus on the muscles rather than the heart. While
Exercise and children ✧ 353 cardiovascular endurance activities generally improve muscular endurance, not all muscular endurance activities improve cardiovascular endurance. Muscular endurance activities involve contracting the same muscle group repeatedly. Examples include sit-ups, pull-ups, or push-ups. Although they are not aerobic, these exercises should be a component of any good exercise program. Adolescents can benefit from these activities as well and after reaching puberty can begin to include strength-training activities in their exercise routine. Strength training (or resistance training) is activity designed to increase the force of muscle contraction. Muscular endurance activities will increase strength as well, but not to the same extent as strength training. It is generally recommended that strength training be avoided until a child reaches adolescence and the hormone levels required to elicit increases in strength and muscle size are present. Prior to maturity, children will not obtain major increases in strength and size, and the risks to the growing body are much greater. If children do participate in strength-training programs, close, qualified adult supervision is absolutely required. Goals and Guidelines The goal of exercise programs for young people should be to promote lifelong physical activity. Children who mature into adults who exercise regularly are likely to have fewer cardiovascular risk factors. The major controllable risk factors include smoking, high blood pressure, high blood cholesterol, physical inactivity, and obesity. Physical activity may decrease blood pressure, improve blood cholesterol levels, and decrease obesity. From one to six years of age, the focus of exercise should be on gross motor skill development. This includes activities such as walking, running, jumping, and skipping. These fundamental motor skills are necessary for the development of the more advanced skills that will be part of adult physical activity. From seven years of age to maturity, the focus of physical activity should be on sport skill development. The type of sport is not important as long as the child continues to learn. Ball control, balance, eye-hand coordination, and body control are some of the useful skills. By developing these types of skills, children will be able to perform at a higher level in sports and, more important, to develop a good appreciation for lifelong exercise. After children reach maturity, they can safely begin training programs that include strength training and serious cardiovascular endurance training. Prior to maturity, the bones are still growing and have not fused. Increased risk of growth plate fractures (which can severely damage the growth of the injured bone) and ruptured intervertebral disks is involved in lifting heavy weights. Furthermore, hormone levels, especially testosterone levels, are much lower prior to maturity and this affects the tissue-building capabilities of the body. The body is also better prepared to handle cardio-
354 ✧ Exercise and children vascular endurance exercise after reaching maturity. Although the risks of beginning cardiovascular training before maturity are less than those associated with strength training, it is best to keep the focus on skill development in young children. The generally accepted guidelines for exercise in children recommend aerobic types of activities. However, these activities do not need to be continuous, as recommended for adults. Aerobic exercise can include various endurance games and activities. They should be done for thirty to sixty minutes duration at a time on a daily basis. The intensity of aerobic exercise is determined by a complicated set of equations and is based on the exercise heart rate for adults. The general recommendation for children is simply moderate intensity. The child’s physician should be consulted about concerns regarding exercise. It is recommended that adolescents get similar amounts of exercise as young children with the addition of twenty minutes of continuous, vigorous activity three times per week as part of their regular routine. Creating a Lasting Exercise Plan Additional considerations for exercise among children must be noted. First, competitive running and other competitive activities are not necessary for attaining health benefits. Second, children have a greater chance of fatigue than do adults in high intensity activities. Third, children have a lower tolerance for high heat. Children should be monitored closely, drink plenty of fluids, and decrease the intensity of exercise under these conditions. Organized youth sports are a popular type of physical activity for many children. However, with the goal of lifelong physical activity, poorly organized youth sports can have a negative effect. Children who do not get to play or who fail to develop new skills can quickly become discouraged with exercise in general. In a 1990 study called American Youth and Sports Participation, ten thousand students in grades seven to twelve were asked why they play their best sport. The top three reasons were to have fun, to improve skills, and to stay in shape. When asked what needed to change in order to get them involved again in a sport after quitting, the top answers were to make practices more fun, to play more, and for coaches to understand players more. These reasons provide valuable insight into the development of programs that have the goal of promoting long-term interest in exercise. Safe exercise for children and adults begins with a good warm-up and ends with a good cooldown. The warm-up prepares the body for intense exercise by performing light activity for several minutes, such as a slow run. It slowly raises the heart rate and increases body temperature. This helps the body function more efficiently and loosens the muscles. The cooldown prepares the body for rest. Light activity for several minutes helps the heart slow down gradually and maintains good circulation. The cooldown helps
Exercise and children ✧ 355 the body readjust gradually to the decrease in many body functions that follows exercise. Complications from exercise are a concern; however, healthy children are at much less risk than are adults. The aforementioned exercise guidelines have been developed to minimize problems during periods of physical activity. While the opportunity for injury increases during exercise, especially during competitive or contact sports, practicing these guidelines can ensure safe and effective exercise for children. Physical activity is characteristic of all animals, including humans. Young animals begin with play; older animals use their physical skills to survive. Animals that are the most fit have the best chance for survival. Historically, this was true for humans. As technology has advanced and there has been less reliance on physical activity to survive, humans have become more sedentary. Children have become less active with the advent of television, videotapes, computers, and electronic games. These technological advances have led to an increasing concern about the fitness levels of children. Researchers have been studying the effects of lack of exercise and in the process have established important guidelines to help people better understand the relationship between inactivity and health. In addition, new exercise regimens and equipment, books, and magazines have created a better awareness of the role of exercise in a healthy lifestyle. The future challenge is to develop more strategies to get people moving. These strategies must include children. Good exercise habits, developed at an early age, will promote continuing interest in physical activity throughout life. —Bradley R. A. Wilson See also Children’s health issues; Exercise; Exercise and the elderly; Obesity; Obesity and children; Physical fitness tests for children; Preventive medicine; Sports injuries among children; Steroid abuse. For Further Information: Foster, Emily R., Karyn Hartinger, and Katherine A. Smith. Fitness Fun. Champaign, Ill.: Human Kinetics, 1992. This book is full of activities that can be used to promote physical fitness in children. Eighty-five games and activities develop at least one of the components of fitness. Greene, Leon, and Matthew Adeyanju. “Exercise and Fitness Guidelines for Elementary and Middle School Children.” The Elementary School Journal 91, no. 5 (May, 1991): 437-444. This paper clearly lists the factors important for exercise and fitness in young people. Kalish, Susan. Your Child’s Fitness. Champaign, Ill.: Human Kinetics, 1996. This easy-to-read book covers most of the major areas of children’s physical fitness and exercise. Clear activities and assessments are presented. Pangrazi, Robert P., Charles B. Corbin, and Gregory J. Welk. “Physical
356 ✧ Exercise and the elderly Activity for Children and Youth.” Journal of Physical Education, Recreation, and Dance 67, no. 4 (April, 1996): 38-43. This brief review of children and physical activity gets straight to the point. The most commonly asked questions are addressed in very understandable terms. Rowland, Thomas W. Exercise and Children’s Health. Champaign, Ill.: Human Kinetics, 1990. This book contains a thorough review of the relationship between exercise and the health of children. It is slightly technical but easy to read. Waitz, Grete, with Gloria Averbuch. On the Run: Exercise and Fitness for Busy People. Emmaus, Pa.: Rodale Press, 1997. Geared to the family, this book has an excellent section on children’s fitness and a section on children and running. It also includes information on how to begin a training program.
✧ Exercise and the elderly Type of issue: Elder health, prevention, public health, social trends Definition: Regular physical activity undertaken for the purpose of maintaining or increasing physical and mental health. The physiological deterioration commonly associated with aging is not entirely caused by the aging process; it is also caused by the physical inactivity that often accompanies aging. In the United States, it has been reported that adults over age fifty are the most sedentary members of the population. By the year 2030, it has been predicted that 22 percent of the population will be over age sixty-five. Increased physical activity is a frequently suggested mechanism for reducing the rising health care costs that accompany cardiovascular disease and deterioration of the musculoskeletal system. Even so, 50 percent of men and 70 percent of women over age sixty-five are not participating in enough regular exercise to have a sufficient impact on their health. Four general components collectively represent physical fitness: cardiorespiratory endurance (aerobic capacity), anaerobic power, muscular strength and endurance, and body composition. All these components are susceptible to decline with aging; however, the magnitude of this decline is dependent upon the extent of physical inactivity and other health factors. Aerobic Capacity Aerobic capacity refers to the body’s ability to maximally transport and utilize oxygen to the cells (maximal volume of oxygen consumed, or VO2max). The body requires a higher volume of oxygen (O2) to sustain increased
Exercise and the elderly ✧ 357 magnitudes of exercise. Aerobic capacity declines with aging because of a cumulative effect of age-related functional changes in the heart as well as muscle mass loss caused by disuse or disease. The higher the O2max value (measured in milliliters of oxygen used per kilogram of body weight per minute), the greater the person’s aerobic capacity, or aerobic fitness. A higher aerobic capacity will allow an individual to exercise more comfortably and will also permit the older individual to complete activities of daily living without fatigue. Thus, functional ability is improved when aerobic fitness is improved. Up to age thirty, VO2max declines about 1 percent per year. Once adults reach middle age, the loss of VO2max is accelerated unless regular aerobic exercise is undertaken. Between forty-five and fifty-five years of age, O2max will be lost at a rate of 9 to 15 percent. Other accelerated losses occur between the ages of sixty-five to seventy-five and from seventy-five to eightyfive years of age. However, regular participation in aerobic exercise can slow or even reverse this decline. When middle-aged or older individuals participate regularly in aerobic exercise, they can expect a 10 to 25 percent improvement in VO2max. This can mean the difference between being functionally impaired, on one hand, and gaining back independent-living skills and sports participation, on the other. Individuals can have their aerobic capacities determined with an exercise stress test administered by a team of medical professionals, including a cardiologist, a nurse, and an exercise physiologist. An aerobic exercise training program that elicits 50 to 70 percent of one’s O2max would be sufficient to improve an older individual’s aerobic capacity. Examples of aerobic exercise are walking, swimming, cycling, skiing, and dancing. Exercise of moderate intensity—enough to cause an increase in breathing and heart rate but not so much that it prevents one from being able to carry on a conversation—is sufficient for most people to gain health benefits. The experience of pain is a cue to stop exercise and reevaluate the exercise intensity level. The Cardiovascular and Respiratory Systems The primary purpose of the cardiovascular and respiratory or pulmonary systems (also referred to collectively as the cardiopulmonary or cardiorespiratory system) is to deliver oxygen and nutrients to the tissues while removing carbon dioxide and waste products from the tissues. With aging, lung tissue loses elasticity, the chest wall becomes more rigid, and respiratory muscle strength is lost. This causes a loss of ventilatory (breathing) efficiency, making the mechanics of breathing harder for the aged. With exercise, the demand for more oxygen requires more frequent and deeper breaths. Since the aged pulmonary system is compromised, pulmonary ventilation is decreased during maximal exercise as well as
358 ✧ Exercise and the elderly during recovery after exercise. Even with aging limitations, in the absence of pulmonary disease, the resting tissues still have an adequate oxygen supply to carry out daily functional and recreational activities. The oxygen deficit and higher respiratory work is not noticed until vigorous exercise puts a demand on the system for more oxygen, challenging the ventilatory capacity of the lungs. Although the total amount of blood flow increases as aerobic capacity increases, this does not result in an improvement in gaseous diffusion in the aged. In fact, gas exchange of oxygen and carbon dioxide in the tissues decreases with aging, and exercise training appears to have little impact on this function. On the other hand, forced vital capacity (FVC), the maximum amount of air that can be expelled after a maximal inhalation, is one of the few pulmonary volumes influenced by both aging and exercise training. With aging, FVC declines approximately 4 to 5 percent per decade in the average individual. However, research studies that tracked aerobically trained individuals over twenty or more years found that their FVCs at age forty-five were the same as their FVCs at age twenty. This maintenance may be because of the mechanical stressing of the respiratory muscles afforded by regular aerobic exercise.
Elderly individuals may find low-impact exercise, such as swimming, to be a safer and easier way to stay fit. (PhotoDisc)
As with the pulmonary system, resting cardiovascular function experiences only moderate changes, whereas the cardiovascular response during exercise declines substantially with aging. The major reason that maximal aerobic capacity declines with aging is because of the decrease in maximal heart rate. Maximal heart rate (the highest heart rate attainable) declines
Exercise and the elderly ✧ 359 approximately 6 percent per decade. Using the mathematical formula to estimate maximal heart rate (220 minus age equals heart rate in beats per minute), it can be seen that the estimated maximal heart rate of a seventyyear-old (150 beats per minute) is significantly less than that of a twenty-yearold (200 beats per minute). Heart rate is under the control of both the parasympathetic and sympathetic nervous systems. The parasympathetic nervous system is responsible for keeping the heart rate lower at rest. The sympathetic nervous system takes over during exercise so that heart rate can be increased in order to meet the increased oxygen demand. The decline in maximal heart rate is caused by the aging heart becoming less sensitive to sympathetic nervous system stimulation, thereby decreasing the heart’s maximal contractile capabilities. This results in the inability of the heart to attain the higher maximal values that were possible during youth. No amount of exercise training can alter this. Submaximal exercise is also more strenuous for an older adult. Exercise sessions that were once easy during youth cause higher heart rates and longer recovery times when one is older. This reflects the heightened need of the aging heart to work harder in order to meet the increased oxygen demands of the exercising tissues. Regular exercise participation lowers resting heart rate (the number of times the heart beats per minute) and improves stroke volume (the volume of blood ejected with each beat of the heart) in both the young and the old. Even though cardiac contractility and total blood volume in older individuals are less and the ventricular walls are less compliant, regular aerobic exercise training increases total blood volume and tone of the peripheral vessels, thereby reducing vascular resistance and increasing the volume of blood flow back to the heart. This enables the heart to eject more blood with each beat. In aerobically trained individuals, stroke volume is improved not only during exercise but also at rest. The lower resting heart rates commonly seen in trained individuals is partially caused by the improved stroke volume. Since the heart is able to deliver more blood with each beat of the heart, the heart does not need to work as hard to deliver oxygen. In addition, regular aerobic exercise enhances the heart’s parasympathetic activity. Therefore, the combined effect of improved parasympathetic activity and improved stroke volume explains the bradycardia (a heart rate below 60 beats per minute) commonly observed in healthy, aerobically trained individuals. Even though the cardiovascular parameters that determine aerobic fitness all decline with the aging process, participation in regular aerobic exercise has been shown to improve maximal stroke volume and cardiac output (the volume of blood pumped by the heart each minute, equal to heart rate minus stroke volume) by as much as 25 percent. Maximal cardiac output is increased because of the increase in stroke volume, since maximal heart rate does not increase. The types of exercise training employed, as well as the person’s initial level of fitness, influence the magnitudes of these increases. Aerobic exercise, not strength training, is the type of exercise
360 ✧ Exercise and the elderly required to improve cardiovascular function. Those who are more severely deconditioned will be able to accomplish greater gains simply because they have more room for improvement. Anaerobic Power Converse to aerobic capacity, anaerobic power is not dependent upon the replenishment of oxygen to the cells. The fuel source used to power anaerobic movement is retrieved from energy stores located within the cell. Quick, explosive movements characterize anaerobic activities. In most athletic events, the ability to generate anaerobic power will have a direct effect upon athletic success. It is also important in daily living when one encounters an emergency situation demanding a quick, powerful response. A few examples of anaerobic activities include sprinting, throwing the discus, and lifting heavy objects. The sports-related “anaerobic response” includes a sharp rise in lactic acid accumulation in the muscles and blood, a sharp increase in pulmonary ventilation, and a drop in the blood pH, giving rise to a more acidic state. Lactic acid accumulates with high-intensity or maximal exercise because of a combination of an increased production rate and a reduced rate of removal. The recruitment of fast-twitch muscle fibers (those fibers responsible for performing quick, explosive movements) also triggers the production of lactic acid. In addition, the need for more oxygen at maximal exercise stimulates the metabolic pathways to speed up. This results in an increase in glycolysis. Glycolysis is the energy pathway responsible for the initial breakdown of blood glucose (blood sugar) so that energy (adenosine triphosphate, or ATP) can be created to perform work. At the end of glycolysis, if enough oxygen is not available, excess lactic acid will be formed. An abundance of lactic acid quickly causes muscle fatigue, and exercise soon stops. Data on aging suggest that anaerobic power, mechanical power, and mechanical capacity peak by age forty, then decline thereafter. Several factors may explain this decline. First, older adults have reduced blood glucose stores (glycogen) in the muscle tissue, which results in a decrease in glycolysis. A decrease in glycolysis will decrease energy production. Second, with aging, fewer fast-twitch muscle fibers are available because of atrophy (shrinkage from disuse). Third, the enzyme lactate dehydrogenase (LDH), which is responsible for lactic acid production when fast-twitch muscle fibers are activated, decreases with aging. Even though the anaerobic processes decline with aging, participation in anaerobic-type activities is still possible as long as the health and fitness status of the older adult is carefully considered.
Exercise and the elderly ✧ 361 The Nervous and Musculoskeletal Systems With aging, the nervous system is unable to receive, process, and transmit messages as quickly as it did in youth. The clinical outcome is slower reaction and movement times. This is an important issue, as many aspects of functional independence require an individual to be able to react quickly in certain situations to prevent potential injury, such as when driving a car or regaining one’s balance to prevent a fall. Older individuals who exercise regularly have demonstrated better reaction times, balance, and coordination in comparison to their sedentary peers. Research investigating older adults who play tennis regularly has demonstrated that active older adults can maintain and perhaps improve their motor skills with continued use. Blood flow to the brain also increases during exercise. Short-term, immediate improvements in performance of memory tasks have been demonstrated immediately following aerobic exercise. Whether there is a longterm increase in cerebral blood flow because of regular exercise participation is a question subject to continued research. Beginning in middle age, muscular strength declines because of a combination of factors, such as muscle mass loss, decreased motor unit activation, and a decreased ability of the muscles to contract forcefully. This decline is selective as well, with some muscle groups losing substantially more strength than others. For instance, leg and trunk muscle strength appears to decline at a faster rate than arm strength. The decline in muscle mass occurs in phases. From twenty-five to fifty years of age, only about 10 percent of muscle mass is lost. However, by age eighty, almost 40 percent of muscle mass is lost because of atrophy. This “wasting away” of muscle tissue commonly seen in the elderly is known as sarcopenia. Weakened respiratory muscles will result in limited aerobic capabilities. Weakened lower-extremity muscles give rise to balance problems and increased risk for falls. Insufficient strength to carry out activities of daily living or functional tasks results in a loss of independent living. Although the age-related loss of muscle mass and strength cannot be totally eliminated, it can be reduced. Aging does not impair the ability of skeletal muscles to respond to exercise training. Progressive strength training programs have demonstrated that older adults can achieve gains in muscle mass (hypertrophy) and muscle strength similar to what has been observed in young individuals. Exercise has been shown to be beneficial in reducing bone mass loss (osteoporosis). Both weight-bearing aerobic training and strength training have been found to be beneficial in improving bone mass. However, the modest improvements shown to occur with bone mass because of exercise conditioning is not great enough to prevent a fracture caused by a fall. Rather, exercise training will help to reduce the risk of falls by strengthening the ambulatory musculature. Research studies indicate that aerobic training and strength training improve neuromuscular functioning, gait, and balance, all of which are important variables in the risk profile for falls.
362 ✧ Exercise and the elderly Psychosocial Benefits of Exercise Psychological well-being includes components such as self-esteem, self-efficacy, depression, and anxiety. The majority of research studies investigating these factors in older individuals agree that participation in regular exercise is associated with improved psychological well-being. The benefits are greater and more consistent if the individual participates in an exercise program for at least ten weeks. Either aerobic training or strength training will work well, but very light or very vigorous exercise is not as effective as moderate-intensity exercise. It is often cited that older individuals benefit from group activities— group interactions alleviate feelings of loneliness often encountered with aging. While this may be true for some, home-based exercise may be preferable to the class setting for certain groups of older adults. Many older adults remain very active and are unable to fit a regularly scheduled exercise class into their own tight schedule. Others are unable to get to the exercise site because of transportation problems or physical disabilities but are still capable of performing some type of exercise or physical activity at home. A safe, moderately paced home program would better meet their needs. Health Benefits It has been demonstrated that participation in regular exercise can assist with weight management and body-fat reduction, lower blood pressure for those with mild hypertension (elevated blood pressure), reduce blood triglyceride and low-density lipoproteins (LDL, or “bad cholesterol”), and improve highdensity lipoprotein levels (HDL, or “good cholesterol”). Both aerobic and strength training programs can promote a loss of calories and therefore reduce fat deposits and encourage muscle maintenance or growth throughout the life span. However, only aerobic training has been proven to be effective in improving the lipoprotein profiles and lowering blood pressure in older individuals. The risk of glucose intolerance increases as one ages because of insulin resistance. “Glucose intolerance” is a term used to describe the body’s inability to regulate its glucose (blood sugar) level. This causes the blood glucose level to be chronically elevated, which can lead to diabetes. Insulin is a hormone that helps to regulate blood glucose levels. It is released when the blood glucose levels are elevated, such as after eating a meal or during high-intensity exercise. Therefore, the role of insulin is to reduce the blood glucose level. However, sometimes the body cannot utilize its insulin properly. This creates a condition known as insulin resistance. The result is an overload of blood glucose in the system, which again predisposes the individual to diabetes. Physical inactivity and obesity compound the problem. Regular participation in either aerobic exercise or strength training has been shown to be equally effective for improving glucose balance and the body’s ability to use insulin in older adults.
Exercise and the elderly ✧ 363 Risks and Guidelines There are many exercise options available for the older adult, depending on specific goals and health status. Even though exercise is associated with a variety of health benefits, it is also associated with such health risks as worsening existing medical problems, muscle and joint injuries, and, in some cases, heart attack. Therefore, exercise programs should be designed to maximize the benefits and minimize the potential risks. Regardless of age, the Report of the Surgeon General recommends that everyone should participate in moderate exercise for at least thirty minutes on all or most days of the week for optimal health and fitness. This should be accomplished gradually. If one’s goal is to improve aerobic fitness, blood pressure, cholesterol level, mood, or glucose tolerance or to reduce body fat, moderate aerobic exercise should be done at least three times per week. This requires activities that are rhythmic in nature, involve the use of larger muscle groups, and can be sustained for at least fifteen to twenty continuous minutes. If the goal is to increase muscle mass, muscular endurance, or strength, then a well-rounded strength-training program should be done twice per week, with each session followed by at least one day of rest. If the goal is to maintain or improve bone mass, either weight-bearing aerobic exercise or resistance training could be used. The ideal exercise program includes both aerobic training and strength training. A healthy older individual can begin a light to moderate exercise program without the need for a medical examination or clinical exercise test. However, if the individual has risk factors for heart disease, is taking medications, or has any medical concerns, he or she should consult with a physician to determine a safe level of exercise participation. —Bonita L. Marks See also Aging; Broken bones in the elderly; Cholesterol; Diabetes mellitus; Exercise; Exercise and children; Hypertension; Medications and the elderly; Mobility problems in the elderly; Muscle loss with aging; Osteoporosis; Reaction time and aging; Safety issues for the elderly; Sports injuries among children; Temperature regulation and aging. For Further Information: American College of Sports Medicine. ACSM Fitness Book. Edited by Susan M. Puhl, Madeline Paternostro-Bayles, and Barry Franklin. 2d ed. Champaign, Ill.: Human Kinetics, 1998. A basic book written by academic and clinical professionals intended to guide adults who wish to begin a low-intensity exercise program. Ettinger, Walter H., Brenda S. Mitchell, and Steven N. Blair. Fitness After Fifty. St. Louis: Beverly Cracom, 1996. A “how-to” book written by experts in the field of aging and epidemiology for middle-aged and older individuals desiring to become physically active.
364 ✧ Factitious disorders Hurley, Ben F., and James M. Hagberg. “Optimizing Health in Older Persons: Aerobic or Strength Training?” In Exercise and Sport Science Reviews, edited by John O. Hollszy. American College of Sports Medicine Series 26. Baltimore: Williams & Wilkins, 1998. This chapter in a collection of exercise-related papers reviews the facts known about the effects of aerobic exercise and strength training on the physiological processes in the older adult. Rowe, John W., and Robert L. Kahn. Successful Aging. New York: Pantheon Books, 1998. A summary of research results dedicated to determining the effects of aging on the body and maximizing health in older individuals; written for the layperson by renowned gerontologists. Westcott, Wayne L., and Thomas R. Baechle. Strength Training Past Fifty. Champaign, Ill.: Human Kinetics, 1998. An excellent layperson’s guide for safe and effective strength training written by leaders in the field of strength and conditioning.
✧ Factitious disorders Type of issue: Mental health Definition: Psychophysiological disorders in which individuals intentionally produce symptoms in order to play the role of patient. Although factitious disorders cover a wide array of physical symptoms and are believed to be closely related to a subset of psychophysiological disorders (somatoform disorders), they are unique in all of medicine for two reasons. The first distinguishing factor is that whatever the physical disease for which treatment is sought and regardless of how serious, the patients who seek its treatment have deliberately and intentionally produced the condition. They may have done so in one of three ways, or in any combination of these three ways. First, patients fabricate, invent, lie about, and make up symptoms that they do not have; for example, they claim to have fever and night sweats or severe back pain that they actually do not have. Second, patients have the actual symptoms that they describe, but they intentionally caused them; for example, they might inject human saliva into their own skin to produce an abscess or ingest a known allergic food to cause the predictable reaction. Third, someone with a known condition such as pancreatitis has a pain episode but exaggerates its severity, or someone else with a history of migraines claims his or her headache to be yet another migraine when it is not. The second element that makes these disorders unique (and at the same time both fascinating to study and frustrating to treat) is that the sole motivation for causing or claiming the symptoms is for these patients to
Factitious disorders ✧ 365 become and remain patients, to assume the sick role wherein little can be expected from them. These patients are not malingerers, individuals who consciously use actual or feigned symptoms for some other gain (such as claiming a fever so one does not have to go to work or school, or insisting that one’s post-traumatic stress is worse than it is to enhance the judgment in a lawsuit). In fact, it is the absence of any discernible external benefit that makes these disorders so intriguing. Types of Factitious Disorder Factitious disorders have three subtypes. In the first, patients claim to have predominantly psychological symptoms such as memory loss, depression, contemplation of suicide, the hearing of voices, or false memory of childhood molestation. Characteristically, the symptoms worsen whenever the patients know themselves to be under observation. In the second, patients have predominantly physical symptoms that at least superficially suggest some general medical condition. In a more extreme form called Münchausen syndrome, individuals will have spent much of their lives getting admitted to medical facilities and, once there, remaining as long as possible. While common complaints include vomiting, dizziness, blacking out, generalized rashes, and bleeding, the symptoms can involve any organ and seem limited only to the individuals’ medical knowledge and experience with the medical system. The third subtype combines both psychological and physical complaints in such a way that neither predominates. Factitious disorders are difficult to diagnose. Usually, the diagnosis is considered when the course of treating either a medical or a mental illness becomes atypical and protracted. Often, the person with a factitious disorder will present in a way which seems odd to the experienced clinician. The person may have an unusually extensive history of traveling, much familiarity with medical procedures and terminology, a complex medical and surgical history, few visitors during the hospitalization, behavioral disruptions and disturbances while hospitalized, exacerbation of symptoms while under observation, and/or fluctuating illness with new symptoms and complications arising as the workup proceeds. When present, these traits along with others make suspicion of factitious disorders reasonable. No one knows how many people suffer with factitious disorders, but the condition is generally regarded as uncommon. It is certainly rarely reported, but this in part may be attributable to the difficulties in determining the diagnosis. While brief episodes of the condition occur, most people who claim a factitious disorder have it chronically, and they usually move on to another physician or facility when they are confronted with the true nature of their illness. It is therefore likely that some individuals are reported more than once by different hospitals and providers.
366 ✧ Factitious disorders The Question of Cause There is little certainty about what causes factitious disorders. This is true in large measure because those who know the most about the subject—patients with the disorder—are notoriously unreliable in providing information about their psychological state and often seem only dimly aware of what they are doing to themselves. It may be that they are generally incapable of putting their feelings into words. They are unaware of having inner feelings and may not know, for example, that they are sad or angry. It is possible that they experience emotions more physically, behaviorally, and concretely than do most others. Another view suggests that people learn to distinguish their primitive emotional states through the responsivity of their primary caretaker. A normal, healthy parent responds appropriately to an infant’s differing affective states, thereby helping the infant, as he or she develops, to distinguish, define, and eventually name what he or she is feeling. When a primary caretaker is, for any of several reasons, incapable of responding in consistently appropriate ways, the infant’s emotional awareness remains undifferentiated and the child experiences confusion and emotional chaos. Treating Factitious Disorders Internists, family practitioners, and surgeons are the specialists most likely to encounter patients with factitious disorder, although psychiatrists and psychologists are often consulted in the management of these patients. These patients pose a special challenge because in a real sense they do not wish to become well even as they present themselves for treatment. They are not ill in the usual sense, and their indirect communication and manipulation often make them frustrating to treat using standard goals and expectations. Sometimes mental and medical specialists’ joint, supportive confrontation of these patients results in a disappearance of the troubling and troublesome behavior. During these confrontations, the health professionals are acknowledging that such extreme behavior evidences extreme distress in these patients, and as such is its own reason for psychotherapeutic intervention. These patients are not psychologically minded, however; they also have trouble forming relationships that foster genuine self-disclosure, and they rarely accept the recommendation for psychotherapeutic treatment. Because they believe that their problems are physical, not psychological, they often become irate at the suggestion that their problems are not what they believe them to be. —Paul Moglia See also Münchausen syndrome by proxy.
Failure to thrive ✧ 367 For Further Information: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Rev. 4th ed. Washington, D.C.: Author, 2000. Feldman, Marc D., and Charles V. Ford. Patient or Pretender? Inside the Strange World of Factitious Disorders. New York: John Wiley & Sons, 1994. Ford, Charles V. The Somatizing Disorders: Illness as a Way of Life. New York: Elsevier Biomedical, 1983. Viederman, M. “Somatoform and Factitious Disorders.” In The Personality Disorders and Neuroses, edited by Arnold M. Cooper, Allen J. Frances, and Michael H. Sacks. New York: Basic Books, 1986.
✧ Failure to thrive Type of issue: Children’s health Definition: A disorder of early childhood growth that includes disturbances in psychosocial skills and development. Failure to thrive may be organic or nonorganic; in many children, the etiology is multifactorial. The onset of growth problems may be prenatal as a result of maternal substance abuse, most notably alcohol use, or of maternal infection, particularly with rubella, cytomegalovirus (CMV), or toxoplasmosis. Small size in infants secondary to prematurity resolves by two to three years of age unless there are complications. Many children with failure to thrive are both stunted (linear growthaffected) and wasted (weight-affected). Assessing which of the two conditions predominates can be done using the body mass index (BMI), which is calculated by dividing weight in kilograms by height in meters squared. A low BMI is a sign of malnutrition. Children with environmental failure to thrive fall into this category. A child who is small but has an appropriate BMI has short stature rather than failure to thrive. The two leading causes of short stature are familial short stature and constitutional delay. Learning to Thrive The main focus of the medical intervention with failure to thrive is to ensure a nurturing environment and adequate nutrition. Nutritional intervention can be achieved in many ways, such as by securing adequate access to food for the family and offering concentrated formulas, nutritional supplementation, and calorie dense food, depending on the age of the child. Developmental intervention should also be provided if delay is detected. Likewise, family counseling, especially focusing on parenting skills, may be indicated.
368 ✧ Falls among children The term “failure to thrive” originated in 1933; it replaced the term “cease to thrive,” which appeared in 1899. Initially, the condition was reported in institutionalized children, including those in orphanages. In the 1940’s, it was recognized as a condition that could also affect children living at home with their biological or adoptive parents. Although the list of conditions that can cause growth impairment in children is quite extensive, a systematic approach using history and both physical and psychosocial assessment will provide clues to the diagnosis. Intervention ensures an adequate outcome, with improved prospects for physical growth and brain development. —Carol D. Berkowitz, M.D. See also Children’s health issues; Fetal alcohol syndrome; Malnutrition among children; Nutrition and children; Well-baby examinations. For Further Information: Garrow, J. S., and W. P. T. James, eds. Human Nutrition and Dietetics. Rev. 9th ed. New York: Churchill Livingstone, 1993. Kreutler, Patricia A., and Dorice M. Czajka-Narins. Nutrition in Perspective. 2d ed. Englewood Cliffs, N.J.: Prentice Hall, 1987. Whitney, Eleanor Noss, and Sharon Rady Rolfes. Understanding Nutrition. 6th ed. St. Paul, Minn.: West, 1993. Winick, Myron, Brian L. G. Morgan, Jaime Rozovski, and Robin Marks-Kaufman, eds. The Columbia Encyclopedia of Nutrition. New York: G. P. Putnam’s Sons, 1988.
✧ Falls among children Type of issue: Children’s health, prevention Definition: Episodes of sudden, usually unintentional movement from an erect to a prone position. Falls may occur at any age in the pediatric population. In the younger age groups, they may be caused by toys, rugs, stairs, unguarded windows, and climbing. In older groups, falls may be related to bicycle riding, climbing, and various risk-taking behaviors. After Tumbling The treatment of falls ranges from nothing at all to immediate intervention, depending on the severity of the resulting injuries. Toddlers often tumble down without adverse consequences. Sprains, fractures, significant bruising,
Falls among children ✧ 369 lacerations, or head injury, however, can occur. Any child who falls and is unresponsive needs to be transported to an emergency room for evaluation. Appropriate precautions must always be taken in case of neck injury. Falls from a moderate height in children under the age of twelve rarely cause fractures. A child who sustains a significant injury from a minor fall should be evaluated for potential child abuse, as should the toddler with a head injury. Preventing Falls Especially in the early years, parents need to monitor the child’s environment for risk of falls. Stairways should be well lit, and carpet should be tacked down firmly. Throw rugs and scattered toys may lead to falls. If the floors in a home are slippery, parents should provide the child with skidproof socks or footwear. Stairwells should be closed off with a door or gate. For those living above ground level, windows should have guards to prevent falls. Infant walkers on wheels are associated with falls resulting in serious injuries. The use of these walkers must be monitored closely or avoided if possible. Children and adolescents should be warned about climbing in hazardous areas. Falls in adolescents may be associated with alcohol or other drug use. Mind-altering substances not only affect balance but also may impede judgment, leading teenagers to take risks that they would not take when sober. —Rebecca Lovell Scott See also Child abuse; Children’s health issues; Drug abuse by teenagers; Falls among the elderly; First aid; Safety issues for children; Sports injuries among children. For Further Information: American Academy of Pediatrics. Playground Safety. Elk Grove Village, Ill.: Author, 1994. This brochure reviews the safety hazards of playgrounds and offers prevention measures. Free samples of this brochure are available upon request with a self-addressed, stamped envelope to AAP, Dept C-“Playground Safety,” 141 Northwest Point Blvd., P.O. Box 927, Elk Grove Village, IL 60009. The phone number of the AAP is (800) 4339016. Shelov, Steven P., et al., eds. Caring for Your Baby and Young Child: Birth to Age Five. Rev. ed. New York: Bantam Books, 1998. Offers a comprehensive discussion of the accidents that commonly occur with young children, accident-prevention techniques for the home and outdoors, and emergency measures to enact if an accident does take place.
370 ✧ Falls among the elderly
✧ Falls among the elderly Type of issue: Elder health, prevention Definition: Falling as a result of imbalance, dizziness, or weakness, which is common among the elderly and which may cause serious injury, particularly hip fractures. Falls are the most frequent cause of injury among the elderly. Those people over eighty years of age have a mortality rate from falls eight times greater than people sixty years of age. Falls are the major risk factor for hip fractures; approximately 200,000 hip fractures occur each year in the United States, 12 to 20 percent of which lead to death. Only one-fourth of older adults who sustain a hip fracture fully recover. Elderly people who suffer from osteoporosis have a greater chance of sustaining fractures of the hips, wrist, pelvis, and lumbar vertebrae. The loss of skin elasticity and subcutaneous tissue that generally accompanies aging can also lead to bruising and skin tears. Although most falls occur when a person is descending a stairway, they may be caused by numerous factors in the home, including unstable furniture, loose floor coverings, poor lighting in hallways and bathrooms, clutter, pets, and slick substances on the floor, such as polish, ice, water, or grease. The use of certain medications may also cause the elderly to fall. Some diuretics, sedatives, antibiotics, antidepressants, and antipsychotics can induce drowsiness, confusion, or dizziness. Physical changes that accompany the aging process can also make people more susceptible to sustaining injuries from falls. Vision and hearing may become impaired, leading to changes in perception. Reflexes may become slower. Vertigo and syncope episodes may cause falls. Mental changes, such as depression and inattention, can also cause falls in the elderly. Prevention and Precautions Medical experts advise elderly people to take precautions against falls. People who do not have good balance are often advised to wear shoes with a soft sole and a low, broad heel. High heels, loose-fitting slippers, or socks without shoes on stairs or waxed floors should be avoided. In addition, tennis shoes that have good traction can cause people to trip. Elderly people with poor night vision can use bedside lamps or night-lights in case they have to get up in the middle of the night. Those prone to dizziness are advised to stand up slowly to avoid vertigo. Keeping the thermostat at 65 degrees Fahrenheit or above at night can help people avoid the drowsiness that tends to accompany prolonged exposure to cold temperatures. Another way to prevent falls is to keep walkways free of clutter and to keep electrical and phone cords out of the way. Low furniture can be positioned
Falls among the elderly ✧ 371 so it is not an obstacle to people when walking. White paint or white strips on the edges of steps can help elderly people see them better. The risk of falls in the kitchen can be minimized by placing frequently used items in accessible cupboards to avoid reaching, bending, or stooping, and by covering tile or linoleum floors with nonskid wax. In the bathroom, grab bars can be installed on the wall by the tub, shower, and toilet, while nonskid mats or adhesive strips can be placed on all surfaces that can get wet and slippery. Exercise can also help minimize the risk of injury from falls. Such activities as walking, gardening, and housework can improve gait, posture, and balance. Weight-bearing exercise, such as walking, helps prevent loss of bone mass, as well as stiffness and loss of muscle tone. Lifting small weights can prevent loss of muscle tone and help strengthen hand grip, both of which are important for holding on to railings and properly executing such tasks as getting up from chairs. Elderly people who fear falling may decrease their activity level, which causes their muscles to deteriorate even more. The fear of falling can also make them clinically depressed, which often shortens their attention span and makes them more likely to fall. This is especially true if they have fallen before and have sustained an injury or fracture. —Mitzie L. Bryant See also Aging; Broken bones in the elderly; Canes and walkers; Disabilities; Exercise and the elderly; Falls among children; Foot disorders; Hospitalization of the elderly; Medications and the elderly; Mobility problems in the elderly; Osteoporosis; Reaction time and aging; Safety issues for the elderly; Temperature regulation and aging; Vision problems with aging; Wheelchair use among the elderly. For Further Information: DeWit, Susan C. Essentials of Medical-Surgical Nursing. 4th ed. Philadelphia: W. B. Saunders, 1998. DeWit provides information on fractures, accidents, and burns in the elderly and how to prevent them. Murray, Ruth Beckmann, and Judith Proctor Zentner. Health Assessment and Promotion Strategies Through the Life Span. 7th ed. Englewood Cliffs, N.J.: Prentice Hall, 2000. Provides insight on contributing factors and prevention of injuries in the elderly. Rosdahl, Caroline Bunker, ed. Textbook of Basic Nursing. 7th ed. Philadelphia: Lippincott Williams & Wilkins, 1999. Discusses the normal physical signs of aging that can be associated with and contribute to injuries. Solomon, Jacqueline. “Osteoporosis: When Supports Weaken.” RN 61 (May, 1998). Solomon provides useful information on a condition of the bone common among the aged that causes fractures and weak muscles. Walker, Bonnie L. “Preventing Falls.” RN 61 (May, 1998). Walker discusses the likelihood of falls in the elderly and how to minimize the risk.
372 ✧ Fetal alcohol syndrome
✧ Fetal alcohol syndrome Type of issue: Children’s health, women’s health Definition: Growth retardation and mental or physical abnormalities in a child resulting from alcohol consumption by the mother during pregnancy. Fetal alcohol syndrome was first identified in the early 1970’s. Whether consumed as beer, wine, or hard liquor, alcohol is a teratogen, a toxic substance that can cause abnormalities in unborn children. The damage ranges from subtle to severe, depending on the quantity consumed and the stage of pregnancy when the exposure occurs. A critical period is in early pregnancy, when a woman may not know that she is pregnant. Even one or two drinks a day by the mother may have an effect on her child. Effects and Causes of Fetal Alcohol Syndrome There are three diagnostic criteria for fetal alcohol syndrome: growth retardation, certain facial anomalies, and central nervous system impairment. Growth retardation begins in utero, causing low birth weight. Babies with low birth weight are at risk for delayed growth and development and even death. Growth impairment affects not only the skeleton but also the brain and face. The resulting head and facial abnormalities are characterized by thin lips; small, wide-set eyes; a short, upturned nose; a receding chin; and low-set ears. Fetal alcohol syndrome children have intelligence quotients (IQs) well below the mean of the population because of impaired brain growth that results in irreversible mental retardation. Fetal alcohol syndrome is a leading cause of mental retardation. Abnormalities often originate during the first trimester, when bones and organs are forming. Major organ systems such as the heart, kidney, liver, and skeleton can be impaired. Less specific problems that result from alcohol damage are clumsiness, behavioral problems, a brief attention span, poor judgment, impaired memory, and a diminished capacity to learn from experience. These symptoms are often labeled “fetal alcohol effects.” Alcohol enters the fetal bloodstream as soon as the mother has a drink. It not only can damage the brain but also may impair the function of the placenta, which is the organ interface between maternal and fetal circulation. The exact mechanism for this damage is not completely understood. The most probable cause is that alcohol creates a glucose or oxygen deficit for the fetus. Because it is not known what dose of alcohol is safe, the best preventive measure is to abstain from alcohol during pregnancy and even when planning a pregnancy. —Wendy L. Stuhldreher, R.D.
Fetal tissue transplantation ✧ 373 See also Addiction; Alcoholism; Alcoholism among teenagers; Birth defects; Child abuse; Childbirth complications; Drug abuse by teenagers; Genetic diseases; Pregnancy among teenagers; Premature birth; Prenatal care; Screening; Smoking; Tobacco use by teenagers. For Further Information: Abel, Ernest L., ed. Fetal Alcohol Syndrome: From Mechanism to Prevention. Boca Raton, Fla.: CRC Press, 1996. Huebert, Kathryn M., and Cindy Raftis. Fetal Alcohol Syndrome and Other Alcohol-Related Birth Defects. Edmonton: Alberta Alcohol and Drug Abuse Commission, 1996. Spohr, Hans-Ludwig, and Hans-Christoph Steinhausen., eds. Alcohol, Pregnancy, and the Developing Child. New York: Cambridge University Press, 1996. Stratton, Kathleen, Cynthia Howe, and Frederick Battaglia, eds. Fetal Alcohol Syndrome: Diagnosis, Epidemiology, Prevention, and Treatment. Washington, D.C.: National Academy Press, 1996. Streissguth, Ann Pytkowicz. Fetal Alcohol Syndrome: A Guide for Families and Communities. Baltimore: Paul H. Brookes, 1997.
✧ Fetal tissue transplantation Type of issue: Ethics, medical procedures, treatment Definition: The controversial use of tissue from aborted human fetuses to replace damaged tissue in patients with diseases in which the patient’s own tissue has been destroyed. Tissues from aborted fetuses have been shown in experimental trials to be an excellent source of replacement tissue for patients whose diseases have destroyed their own vital tissues. Parkinson’s, Huntington’s, and Alzheimer’s diseases (in which regions of the brain deteriorate) or type I diabetes mellitus (in which insulin-secreting cells of the pancreas degenerate) theoretically could be cured with suitable tissue replacement. Fetal tissues do not induce a full-scale immune response when transplanted. Fetal cells are said to be immunologically naïve since they have not yet acquired the cell surface molecular markers that are recognized by the immune system. When transplanted into a patient, they seem to be invisible to the patient’s immune system and are tolerated without the use of immunosuppression. Other properties add to the suitability of fetal tissue for transplantation. Because it is not yet fully differentiated, fetal tissue is said to be very plastic in its abilities to adapt to new locations. Moreover, once placed in a patient,
374 ✧ Fetal tissue transplantation it secretes factors that promote its own growth and those of the new blood vessels at the site. Tissue from an adult source does not have these properties, and consequently is slow-growing and poorly vascularized. Though growth factors can be added along with the graft, adult tissue is less responsive to these hormones than is fetal tissue. Controversy over Sources of Fetal Tissue It is the source of fetal tissue that has fired such debate over its use for transplantation. Though there has been general acceptance of tissue from spontaneous abortions (miscarriages) or ectopic pregnancies which, because of their location outside of the womb, endanger the life of the mother and must be terminated, these sources are not well suited to transplantation. Spontaneous abortions rarely produce viable tissue, since in most cases the fetus has died two to three weeks before it is expelled. In addition, there are usually major genetic defects in the aborted fetus. In ectopic pregnancies as well, more than 50 percent of the fetuses are genetically abnormal, and most resolve themselves in spontaneous abortion outside a clinic setting. These types of abortions are almost always accompanied by a sense of tragic loss felt by the parents. Many researchers find it unacceptable to request permission from these parents to transplant tissue from the lost fetus. The alternative source of fetal tissue is elected abortions. One-and-a-half million of these abortions occur in the United States every year. The debate over the ethical correctness of elected abortions has left a cloud of confusion over the issue of using this tissue for transplantation. When an abortion is performed in a clinic, the tissue is removed by suction through a narrow tube. Normally, the tissue would be thrown away. If it is to be used for transplantation, written permission must be obtained from the woman after the abortion is completed. No discussion of transplantation is to take place prior to the abortion, and no alteration in the abortion procedure, except to keep the tissue sterile during collection, is to be made. The donor may not be paid for the tissue, and both the donor and the recipient of the tissue must remain anonymous to each other. Uses of Fetal Tissue Transplants The major focus for fetal tissue transplantation has been the treatment of patients with Parkinson’s disease, and results have been encouraging. The drugs used to treat the disorder, dopamine precursors such as L-dopa, produce side effects that cause unrelenting and uncontrolled movement of the limbs, periods in which the patient is completely frozen, and hallucinations. Patients with parkinsonism who have received fetal tissue transplants have shown remarkable improvement and diminished requirements for drug treatment. Even better results have been obtained in patients with
Fetal tissue transplantation ✧ 375 induced Parkinson-like symptoms. Because no patient with parkinsonism or Parkinson-like symptoms has yet been cured by a fetal tissue transplant, however, some have considered the results of such experiments to be disappointing. Yet many parkinsonism patients themselves are encouraged, and many have resumed driving and the other tasks of normal daily life. That transplanted fetal brain tissue can replace damaged brain tissue to any extent has opened the doors of hope for many diseases. For example, Huntington’s disease, a genetic disorder that destroys a different set of neurons but in the same region as that affected by parkinsonism, brings a slow death to those carrying the dominant trait. Its severe dementia and uncontrollable jerking and writhing that steadily progress have had no treatment and no cure. In animal studies in which fetal brain tissue was transplanted into rats with symptoms mimicking Huntington’s disease, results have been encouraging enough to warrant human trials, and one human trial in Mexico has shown limited success. Researchers are hopeful, though less optimistic, that Alzheimer’s disease also may be treatable with fetal tissue transplants. Because the destruction is so widespread, however, it is difficult to determine where the transplants should be placed. Type I or insulin-dependent diabetes also has been treated with fetal tissue transplants. After animal tests showed a complete reversal of the disease when fetal pancreatic tissue was transplanted into diabetic rats, human trials were initiated with great expectations. Though complete success has not been achieved, the sixteen diabetic patients who were given fetal pancreatic tissue transplants by Dr. Kevin Lafferty between 1987 and 1992 all showed significant drops in the amount of insulin needed to manage their disease. The transplanted tissue continued to pump out insulin. An unusual variation of such procedures has been to transplant fetal tissue into fetuses diagnosed with severe metabolic diseases. It is more effective to treat the condition while the fetus is still in the womb than to wait until after birth, when damage from the disease may already be extensive. Fetuses with Hurler’s syndrome and similar “storage” diseases have been treated in this way. Hurler’s syndrome is a lethal condition in which tissues become clogged with stored mucupolysaccharides, long-chain sugars that the body is unable to break down because it lacks the appropriate enzyme. One of the fetuses to receive this treatment was the child of a couple who had lost two children to the disease. With the transplanted tissue, the child lived and by one year of age was producing therapeutic levels of the enzyme. It has been estimated that at least 155 other genetic disorders could be similarly treated by fetal tissue transplants in utero. Other ailments that fetal tissue transplants may alleviate include sicklecell disease, thalassemias, metabolic disorders, immune deficiencies, myelin disorders, and spinal cord injuries. —Mary S. Tyler
376 ✧ First aid See also Abortion; Alzheimer’s disease; Diabetes mellitus; Ethics; Genetic diseases; Genetic engineering; Law and medicine; Parkinson’s disease; Transplantation. For Further Information: Beardsley, Tim. “Aborting Research.” Scientific American 267, no. 2 (August, 1992): 17-18. An excellent encapsulation of the debate over fetal tissue transplantation and the instances in which it has been used. Begley, Sharon. “From Human Embryos, Hope for ‘Spare Parts.’” Newsweek, November 16, 1998, 73. Researchers have teased out clumps of cells from human embryos and induced them to burst into a veritable cellular symphony, forming most of the 210 kinds of cells that constitute the human body. These colonies could revolutionize transplantation medicine. “Fetal Cell Study Shows Promise for Parkinson’s.” The Los Angeles Times, April 22, 1999, p. 29. The first federally funded trial to study the effectiveness of fetal cell transplants for Parkinson’s disease has proved that it works for some patients, mainly those under the age of sixty. Singer, Peter, H. Kuhse, S. Buckle, K. Dawson, and P. Kasimba, eds. Embryo Experimentation. Cambridge, England: Cambridge University Press, 1990. This text provides an excellent discussion of the moral questions raised by the use of fetal tissue for transplantation. Wade, Nicholas. “Primordial Cells Fuel Debate on Ethics.” The New York Times, November 10, 1998, p. 1. Two groups of scientists report success in the attempt to grow primordial human cells outside the body, increasing the ethical debate over the use of these cells.
✧ First aid Type of issue: Medical procedures, public health, treatment Definition: The immediate evaluation, care, stabilization, and transport of victims suffering sudden and/or acute trauma or illness. First aid begins when someone recognizes and responds to an emergency. Unusual sounds can mean emergency: moans, cries for help, shattering glass, squealing brakes, or the thud of falling objects. Out-of-the-ordinary sights often indicate emergency: fallen electric wires, overturned vehicles, smoke, spilled medicines, or bleeding. Strong or unrecognizable odors sometimes require quick action: burning smells or the odor of spilled caustic liquids or volatile gases. Children or adults may need help if they are exhibiting unusual behavior: gasping, clutching at the chest, sweating profusely, staggering, turning red or blue, or abruptly losing color or consciousness.
First aid ✧ 377 How to Evaluate an Emergency The ABCD survey helps first responders evaluate a situation quickly. A stands for airway, the path from the mouth or nose to the lungs. Blood, food, mucus, foreign objects, or broken teeth can obstruct a child’s flow of air. Removing the obstruction with a finger sweep or an abdominal thrust (the Heimlich maneuver) usually clears the airway and often allows spontaneous breathing. B stands for breathing. Allergic reactions, electrical shock, drowning, or severe asthma can cause breathing to stop. Tilting the patient’s head and performing rescue breathing can cause the victim to begin breathing spontaneously or can provide sufficient oxygen for the patient to survive while awaiting advanced emergency care. Unless the victim has an open airway and can breathe, no other emergency care can succeed. C stands for circulation. If the victim has no perceptible pulse, then the child has no blood circulating. Body parts, especially the vulnerable brain, can begin to die in four minutes without oxygen. Where no heartbeat exists, first responders can perform rhythmic chest thrusts. “Squeezing” the heart between the center chest and the backbone causes the heart to push blood through the body and can lead to spontaneous resumption of a heartbeat or keep a victim alive until advanced life support becomes available. Circulation refers to the amount of blood in the victim’s venous system as well as to the heartbeat. If bleeding is profuse, the heart can shut down. Bright red, spurting blood means a damaged artery and requires prompt treatment. First responders can apply pressure directly to the wound or fasten a constriction band between the wound and the heart to slow bleeding. Because tourniquets cut off the blood supply to an injured area completely, they pose dangers of their own, including gangrene and/or loss of the wounded limb; tourniquets are usually considered a last resort, when the only alternative is death from blood loss. Darker red, nonspurting blood means that a vein has been damaged. Applying direct pressure, a constricting band, or a snug and thick bandage or elevating the injured area usually slows the bleeding. D stands for disability. It includes the victim’s level of consciousness and the likelihood of a neck or spinal cord injury. First responders can keep the victim quiet and warm. Pillows, rocks, or branches can immobilize the patient and prevent further damage to the neck or spine. Tending to Lesser Injuries The ABCD pattern applies only to the rudiments of immediate care, without which the victim might die. Tending to less-threatening injuries and illnesses makes up the rest of first responder care. Pediatric emergencies can include burns, bites, sprains, broken bones, the ingestion of toxic substances, dislocations, snakebites, sunburn, frostbite, splinters, and many other illnesses
378 ✧ Fluoridation of water sources and injuries. Because children’s heads are proportionally smaller and their bones are less dense than those of adults, they can incur greater injuries than adults in similar situations. In addition, children usually lack adult awareness of hygiene, environmental dangers, and their own limitations, so they may require first aid more frequently than do adults. Any first aid or emergency care involves the complication of later infection or undetected injuries. Both rescuers and victims may suffer emotional trauma or physical problems. Checking with a health care professional benefits everyone involved in first aid. World wars and assorted disasters have challenged health care professionals to develop better means of triage, treatment, transport, and follow-up. Emergency medical services (EMS) systems in the United States now include air transport, first responder training, trauma centers, burn units, 911 dialing, and an array of lifesaving implements to improve the survival chances for victims. —Sonya H. Cashdan See also Allergies; Asthma; Burns and scalds; Children’s health issues; Choking; Drowning; Electrical shock; Falls among children; Falls among the elderly; Food poisoning; Broken bones in the elderly; Frostbite; Heat exhaustion and heat stroke; Injuries among the elderly; Meningitis; Poisoning; Poisonous plants; Snakebites; Sports injuries; Suicide; Suicide among children and teenagers; Suicide among the elderly; Sunburns. For Further Information: American Red Cross. First Aid: Responding to Emergencies. 3d ed. St. Louis: Mosby-Year Book, 1996. National Safety Council. Infant and Child CPR. Sudbury, Mass.: Jones & Bartlett, 1997. Watson, Sheila, and Elena Bosque. Safe and Sound: How to Prevent and Treat the Most Common Childhood Emergencies. Rev. ed. New York: St. Martin’s Press, 1997.
✧ Fluoridation of water sources Type of issue: Environmental health, prevention, public health Definition: The treatment of water with chemicals that release fluoride into a community’s water-supply system. Fluoridation is an example of preventive medicine and was first introduced into the United States in the 1940’s in an attempt to reduce tooth decay. Since then, many cities have added fluoride to their public water-supply systems.
Fluoridation of water sources ✧ 379 Proponents of fluoridation have claimed that it has dramatically reduced tooth decay, which was a serious and widespread problem in the early twentieth century. Opponents of fluoridation have not been entirely convinced of its effectiveness and have been concerned about possible health risks that many be associated with fluoridation. The decision to fluoridate drinking water has generally rested with local governments and communities and has always been a controversial issue. Fluoride and Tooth Decay Fluoride is the water-soluble, ionic form of the element fluorine. It is present naturally in most water supplies at low levels, generally less than 0.2 part per million (ppm), and nearly all food contains traces of fluoride. Tea contains more fluoride than most foods, while fish and vegetables also have relatively high levels. Most scientific studies have suggested that water containing a concentration of about 1 ppm fluoride dramatically reduces the incidence of tooth decay. Tooth decay occurs when food acids dissolve the protective enamel surrounding teeth and create holes, or cavities, in the teeth. These acids are present in food and can also be formed by acid-produced bacteria that convert sugars into acids. Americans have always consumed large quantities of sugar, which is a significant factor in the high incidence of tooth decay. By contrast, studies of people in primitive cultures reveal tooth decay to be less common, which has been attributed to their more natural diets. Early fluoridation studies between 1930 and 1950 demonstrated that fluoridation of public water systems produced a 50 to 60 percent reduction in tooth decay and that there were no immediate health risks associated with increased fluoride consumption. Consequently, many communities quickly moved to fluoridate their water, and fluoridation was endorsed by most major health organizations in the United States. Growth of Opposition to Fluoridation Strong opposition to fluoridation began to emerge in the 1950’s as opponents claimed that the possible side effects of fluoride had not been adequately investigated. This concern was not unreasonable, since high levels of ingested fluoride can be lethal. However, it is not unusual for a substance that is lethal at high concentration to be safe at low levels, as is the case with most vitamins and trace elements. Opponents of fluoridation were also concerned on moral grounds because fluoridation represented compulsory mass medication. Since the 1960’s, controversy and heated debate have surrounded the issue of fluoridation across the country. Critics have pointed to the harmful effects of large doses of fluoride, including bone damage and special risks
380 ✧ Fluoridation of water sources for some people with kidney disease or those who are particularly sensitive to toxic substances. Between the 1950’s and 1980’s, some scientists suggested that fluoride may have a mutagenic effect—that is, it may be associated with human birth defects, including Down syndrome. Controversial claims that fluoride can cause cancer were also raised in the 1970’s, most notably by biochemist John Yiamouyiannis, who claimed that U.S. cities with fluoridated water had greater cancer death rates than cities with unfluoridated water. Fluoridation proponents were quick to discredit his work by pointing out that he had failed to take other factors into consideration, such as the levels of known environmental carcinogens. Most scientific opinion suggests that the link between cancer and fluoride is a tenuous one. Nevertheless, it is a link that cannot be completely ignored, and a number of respected scientists continue to argue that the benefits of fluoridation are not without potential health risks. A 1988 article in the American Chemical Society publication Chemical and Engineering News created considerable attention by suggesting that scientists opposing fluoridation were more credible than had been previously acknowledged. By the 1990’s even some fluoridation proponents began suggesting that observed tooth decay reduction as a result of water fluoridation may have been at levels of only around 25 percent. Other factors—such as education, better dental hygiene, and the addition of fluoride to some foods, salt, toothpastes, and mouthwashes—may also contribute to the overall reduction in tooth decay levels. Fluoridation in the International Arena The development of the fluoridation issue in the United States was closely observed by other countries. Dental and medical authorities in Australia, Canada, New Zealand, and Ireland endorsed fluoridation, although not without considerable opposition from various groups. Fluoridation in Western Europe was greeted less enthusiastically, and scientific opinion in some countries, such as France, Germany, and Denmark, concluded that it was unsafe. As a result, few Europeans drink fluoridated water. While there is little doubt that fluoride does reduce tooth decay, the exact degree to which fluoridated water contributes to the reduction remains unanswered. It also remains unclear what, if any, side effects are involved in ingesting 1 ppm levels of fluoride in water over many years. Although it has been argued that any risks associated with fluoridation are small, these risks may not necessarily be acceptable to everyone. Since the 1960’s and 1970’s, concerns over environmental and health issues have been growing, and it has often been difficult, if not impossible, for science to resolve completely the potential hazard of small amounts of chemical substances in the environment. The fact that only about 50 percent of U.S. communities have elected to adopt fluoridation is indicative of people’s cautious approach to the issue. In 1993 the National Research
Fluoride treatments in dentistry ✧ 381 Council published a report on the health effects of ingested fluoride and attempted to determine if the Environmental Protection Agency’s maximum recommended level of 4 ppm for fluoride in drinking water should be modified. The report concluded that this level was appropriate but that further research may indicate a need for revision. The report also found inconsistencies in the scientific studies of fluoride toxicity and recommended further research in this area. —Nicholas C. Thomas See also Birth defects; Chlorination; Dental problems in children; Dental problems in the elderly; Environmental diseases; Fluoride treatments in dentistry; Preventive medicine; Water quality. For Further Information: De Zuane, John. Handbook of Drinking Water Quality. 2d ed. New York: Van Nostrand Reinhold, 1997. A good summary of fluoridation. Hileman, Bette. “Fluoridation of Water.” Chemistry and Engineering News 66 (August 1, 1988). An easy-to-read article in a readily accessible journal. Martin, Brian. Scientific Knowledge in Controversy: The Social Dynamic of the Fluoridation Debate. Albany: State University of New York Press, 1991. A detailed look at the fluoride debate. National Research Council. Health Effects of Ingested Fluoride. Washington, D.C.: National Academy Press, 1993. Report on fluoridation. Stewart, John Cary. Drinking Water Hazards. Hiram, Ohio: Envirographics, 1989. Another good summary of fluoridation.
✧ Fluoride treatments in dentistry Type of issue: Children’s health, medical procedures, prevention, treatment Definition: Treatment of the teeth with a fluoride-releasing substance to help the enamel resist tooth decay. Tooth decay involves the solubility of food during eating. Consumed carbohydrates are oxidized to organic acids, such as lactic acid, by the action of specific bacteria that adhere to the teeth. These acids dissolve tooth enamel, which mainly consists of a mineral called hydroxyapatite and is considered to be the hardest substance in the body. The protection of the enamel, and thus the inner part of the tooth, from decomposition can be achieved through fluoride treatments. Fluoride treatment involves the ingestion of fluoride ions in drinking water, toothpaste, and other sources to change the nature and composition of hydroxyapatite by producing a new compound called fluorapatite. Be-
382 ✧ Food irradiation cause it is less basic than hydroxyapatite, fluorapatite forms a more resistant enamel. Because of its effectiveness in preventing cavities, fluoride is added in the form of sodium fluoride or sodium hexafluorosilicate to the public water supply of many municipalities in the United States in concentrations of about 1 milligram per milliliter, or 1 part per million. The Benefits of Fluoride As a result of this so-called fluoridation process, a drastic reduction in dental decay has been observed. In addition, more than 80 percent of all toothpastes and gels now sold in the United States contain fluoride, in the form of stannous fluoride, sodium monofluorophosphate, and/or sodium fluoride in concentrations of about 0.1 percent fluoride by weight. The recommended annual or semiannual dental cleaning by a dentist or oral hygienist removes accumulated plaque and may include further application with a fluoride substance. Generally, only children and teenagers receive such a fluoride treatment, although some adults may also have it. It must be noted that fluoride ions are toxic in large quantities. As a result, when the fluoride concentration in water is about 2 to 3 parts per million, discoloration (mottling) or damage of the teeth may occur. —Soraya Ghayourmanesh See also Children’s health issues; Dental problems in children; Fluoridation of water sources; Preventive medicine. For Further Information: Foster, Malcolm S. Protecting Our Children’s Teeth: A Guide to Quality Dental Care from Infancy Through Age Twelve. New York: Insight Books, 1992. Smith, Rebecca W. The Columbia University School of Dental and Oral Surgery’s Guide to Family Dental Care. New York: W. W. Norton, 1997. Woodall, Irene R., ed. Comprehensive Dental Hygiene Care. 4th ed. St. Louis: C. V. Mosby, 1993.
✧ Food irradiation Type of issue: Environmental health, industrial practices, public health Definition: A process that uses nuclear radiation to sterilize foods in order to reduce spoilage and decrease the incidence of illness from contaminated food. The U.S. Food and Drug Administration (FDA) has certified that irradiation is safe for many foods, including spices, fresh fruit, fish, poultry, and
Food irradiation ✧ 383 hamburger meat. Opponents of food irradiation focus on the inherent hazards of nuclear technology—especially the production, transportation, and disposal of radioactive materials—and criticize the possible creation of harmful radiation products in foods. The Process of Irradiation The most common radioactive source used for food processing is cobalt 60, which is produced by irradiating ordinary cobalt metal in a nuclear reactor. The shape of the source is typically a bundle of many thin tubes mounted in a rack. The source is kept in a building with thick walls and under 4.6 meters (15 feet) of water for shielding. The food to be irradiated is packaged and put on a conveyor belt. The operator raises the cobalt-60 source out of the water by remote control, while the food packages slowly travel past the source on the moving belt. The typical exposure time is three to thirty minutes, depending on the type of food, the required dose, and the source intensity. Radiation dose is measured in a unit called the kilogray, where 1 kilogray equals 1,000 Grays, and 1 Gray equals 100 radiation absorbed doses (rads). The Gray is named for a British radiation biologist. The rad is an older unit still commonly used in the medical profession. When radiation passes through the food, it interacts with atomic electrons and breaks chemical bonds. Microorganisms that cause food spoilage or illnesses are inactivated so they cannot reproduce. Fresh strawberries, sweet cherries, and tomatoes have a normal shelf life of only seven to ten days. Research has shown that a radiation dose of 2 kilograys can double their shelf life without affecting the flavor. Trichinosis parasites in fresh pork can be controlled with a dose of 1 kilogray. Doses up to 3 kilograys are used to destroy 99.9 percent of salmonella in chicken meat and Escherichia coli in ground hamburger. A dose of less than 0.1 kilogray is sufficient to interrupt cell growth in onions and potatoes to prevent undesirable sprouting in the spring. Larger doses, up to 30 kilograys, are used to eliminate insects, mites, and other pests in spices, herbs, and tea. The American Dietetic Association supports food irradiation as an effective technique to reduce outbreaks of food-borne illnesses, which cause several million cases of sickness and more than nine thousand fatalities annually in the United States. Irradiated food does not become radioactive. It does not “glow in the dark” as some opponents have claimed. Hundreds of animal feeding studies with irradiated foods have been done since the late 1950’s. Irradiated chicken, wheat, oranges, and other foods were fed to four generations of mice, three generations of beagles, and thousands of rats and monkeys. No increase in cancer or other inherited diseases was detected in comparison to a control group eating nonirradiated food. In one experiment, several thousand mice were fed nothing but irradiated food. After sixty genera-
384 ✧ Food irradiation tions—about ten years—the cancer rate for the experimental group was no greater than for the control group. Chemical analyses of irradiated foods have looked for potentially harmful by-products from radiation. Small quantities of benzene and formaldehyde were found. However, canning, cooking, and baking have been shown to create these same by-products even more abundantly. Based on the accumulated evidence, food irradiation has been endorsed by an impressive list of organizations: the American Medical Association, the U.S. Department of Agriculture, the American Diabetic Association, the World Health Organization, the United Nations Food and Agriculture Organization, and the FDA. Astronauts on space missions have eaten irradiated foods since 1972, and many hospitals use irradiated foods for patients with an impaired immune system. Fears Concerning Irradiation A consumer activist organization called Food and Water, based in Walden, Vermont, connects fear of the atomic bomb with food irradiation by showing a picture of a mushroom cloud hovering over a plate filled with food. The caption says, “The Department of Energy has a solution to the problem of radioactive waste. You’re going to eat it.” The most serious safety issues relating to food irradiation are in the production of radioactive cobalt; the safety of workers while transporting, installing, and using the source; and the eventual disposal of radioactive waste. Such issues, however, do not have the same impact on consumers as the implied claim that foods may become tainted by irradiation. Commercial food processors have been deterred from installing irradiation facilities by fear of negative publicity and a potential consumer backlash. The FDA requires that irradiated foods be labeled with a special radura symbol and the statement “treated with radiation.” It will be up to consumers to decide if the benefits of a safer food supply outweigh the potential hazards of an expanded nuclear industry. —Hans G. Graetzer See also Environmental diseases; Food poisoning; Radiation. For Further Information: Gibbs, Gary. The Food That Would Last Forever: Understanding the Dangers of Food Irradiation. Garden City Park, N.Y.: Avery Publishing Group, 1993. A critical assessment of irradiation technology. Massachusetts Institute of Technology. Technology Review (November-December, 1997). Contains an informative article quoting both supporters and opponents of food irradiation. Satin, Morton. Food Irradiation: A Guidebook. 2d ed. Lancaster, Pa.: Tech-
Food poisoning ✧ 385 nomic, 1996. Description of the application of radiation to food preservation. Wagner, Henry, and Linda Ketchum. Living with Radiation: The Risk, the Promise. Baltimore: The Johns Hopkins University Press, 1989. A good introduction to the uses and hazards of radioactivity.
✧ Food poisoning Type of issue: Environmental health, epidemics, public health Definition: Food-borne illness caused by bacteria, viruses, or parasites consumed in food and resulting in acute gastrointestinal disturbance that may include diarrhea, nausea, vomiting, and abdominal discomfort. A person feeling the symptoms of nausea, vomiting, diarrhea, and abdominal discomfort may assume that influenza is to blame, but the presence of a true influenza virus is uncommon. More likely, these symptoms are caused by eating food that contains undesirable bacteria, viruses, or parasites. This is called food-borne illness, or food poisoning. Most food-borne pathogens are colorless, odorless, and tasteless. Common Sources of Food Poisoning Certain foods, particularly foods with a high protein and moisture content, provide an ideal environment for the multiplication of pathogens. The foods with high risk in the United States are raw shellfish (especially mollusks), underdone poultry, raw eggs, rare meats, raw milk, and cooked food that another person handled before it was packaged and chilled. In addition, some developing countries could add raw vegetables, raw fruits that cannot be peeled, foods from sidewalk vendors, and tap water or water from unknown sources. Most of the documented cases of food-borne illness are caused by only a few bacteria, viruses, and parasites. Bacteria known as Salmonella are ingested by humans in contaminated foods such as beef, poultry, and eggs; they may also be transmitted by kitchen utensils and the hands of people who have handled infected food or utensils. Once the bacteria are inside the body, the incubation time is from eight to twenty-four hours. Since the bacteria multiply inside the body and attack the gastrointestinal tract, this disease is known as a true food infection. The main symptoms are diarrhea, abdominal cramps, and vomiting. The bacteria are killed by cooking foods to the well-done stage. The major food-borne intoxication in the United States is caused by eating food contaminated with the toxin of Staphylococcus bacteria. Because the toxin or poison has already been produced in the food item that is
386 ✧ Food poisoning ingested, the onset of symptoms is usually very rapid (between one-half hour and six hours). Improperly stored or cooked foods (particularly meats, tuna, and potato salad) are the main carriers of these bacteria. Since this toxin cannot be killed by reheating the food items to a high temperature, it is important that foods are properly stored. Botulism is a rare food poisoning caused by the toxin of Clostridium botulinum. It is anaerobic, meaning that it multiplies in environments without oxygen, and is mainly found in improperly home-canned food items. Originally one of the sources of the disease was from eating sausages (the Latin word for which is botulus)—hence, the name “botulism.” A very small amount of toxin, the size of a grain of salt, could kill hundreds of people within an hour. Danger signs include double vision and difficulty swallowing and breathing. Groups at High Risk Though everyone is at risk for food-borne illness, certain groups of people develop more severe symptoms and are at a greater risk for serious illness and death. Higher-risk groups include pregnant women, very young children, the elderly, and immunocompromised individuals, such as patients with acquired immunodeficiency syndrome (AIDS) and cancer. Bacteria known as Listeria were first documented in 1981 as being transmitted by food. Most people are at low risk of becoming ill after ingesting these bacteria; however, pregnant women are at high risk. Listeria infection is rare in the United States, but it does cause serious illness. It is associated with consumption of raw (unpasteurized) milk, nonreheated hot dogs, undercooked chicken, various soft cheeses (Mexican style, feta, Brie, Camembert, and blue-veined cheese), and food purchased from delicatessen counters. Listeria cause a short-term illness in pregnant women; however, this bacteria can cause stillbirths and spontaneous abortions. A parasite called Toxoplasma gondii is also of particular risk for pregnant women. For this reason, raw or very rare meat should not be eaten. In addition, since cats may shed these parasites in their feces, it is recommended that pregnant women avoid cleaning cat litter boxes. As the protective antibodies from the mother are lost, infants become more susceptible to food poisoning. Botulism generally occurs by ingesting the toxin or poison; however, in infant botulism it is the spores that germinate and produce the toxin within the intestinal tract of the infant. Since honey and corn syrup have been found to contain spores, it is recommended that they not be fed to infants under one year of age, especially those under six months.
Food poisoning ✧ 387 The Treatment of Food Poisoning In cases of severe food poisoning marked by vomiting, diarrhea, or collapse—especially in cases of botulism and ingestion of poisonous plant material such as suspicious mushrooms—emergency medical attention should be sought immediately, and, if possible, specimens of the suspected food should be submitted for analysis. Identifying the source of the food is especially important if that source is a public venue such as a restaurant, because stemming a widespread outbreak of food poisoning may thereby be possible. In less severe cases of food poisoning, the victim should rest, eat nothing, but drink fluids that contain some salt and sugar; the person should begin to recover after several hours or one or two days and should see a doctor if not well after two or three days. Thorough Cooking Cooking foods well means cooking them to a high enough temperature in the slowest-to-heat part and for a long enough time to destroy pathogens that have already gained access to foods. Cooking foods well is only a concern when they have become previously contaminated from other sources or are naturally contaminated. Recommendations for cooking temperatures are based not only on the temperature required to kill food-borne pathogens but also on aesthetics and palatability. Generally, a margin of safety is built into the cooking temperature because of the possibility of nonuniform heating. Based on generally accepted temperature requirements, cooking red meat until 71 degrees Celsius (160 degrees Fahrenheit) will reach the thermal death point. Hamburger should be well cooked so that it is medium-brown inside. If pressed, it should feel firm and the juices that run out should be clear. Cooking poultry to the well-done stage is done for palatability. Tenderness is indicated when there is a flexible hip joint, and juices should run clear and not pink when the meat is pierced with a fork. Fish should be cooked until it loses its translucent appearance and flakes when pierced with a fork. Eggs should be thoroughly cooked until the yolk is thickened and the white is firm, not runny. Cooked or chilled foods that are served hot (that is, leftovers) should be reheated so that they come to a rolling boil. Sources of Contamination There are a number of possible sources of contamination of food products. Coastal water may contaminate seafood. Filter-feeding marine animals (such as clams, scallops, oysters, cockles, and mussels) and some fish (such as anchovies, sardines, and herring) live by pumping in seawater and sifting out organisms that they need for food. Therefore, they have the ability to
388 ✧ Food poisoning concentrate suspended material by many orders of magnitude. Shellfish grown in contaminated coastal waters are the most frequent carriers of a virus called hepatitis A. Contaminated eggs can be another vehicle of food-borne illness. Contamination of eggs can occur from external as well as internal sources. If moist conditions are present and there is a crack in the shell, the fecal material of hens carrying the microorganism can penetrate the shell and membrane of the egg and can multiply. In the early 1990’s, Salmonella enteritidis began to appear in the intact egg, particularly in the northeastern part of the United States. It is hypothesized that contamination occurs in the oviduct of the hen before the egg is laid. Food vehicles in which Salmonella enteritidis has been reported include sandwiches dipped in eggs and cooked, hollandaise sauce, eggs Benedict, commercial frozen pasta with raw egg and cheese stuffing, Caesar salad dressing, and blended food in which cross-contamination had occurred. Foods such as cookie or cake dough or homemade ice cream made with raw eggs are other possible vehicles of foodborne illness. Milk, especially raw milk, can be contaminated. Sources could be an unhealthy cow (such as from mastitis, a major infection of the mammary gland of the dairy cow) or unclean methods of milking, such as not cleaning the teats well before attaching them to the milker or using unclean utensils (milking tanks). If milk is not cooled fast enough, contaminants can multiply. Modern mechanized milking procedures have reduced but not eliminated food-borne pathogens. Postpasteurization contamination may occur, however, especially if bulk tanks or equipment have not been properly cleaned and sanitized. Avoiding Cross-Contamination Cross-contamination occurs when microorganisms are transmitted from humans, cutting boards, and utensils to food. Contamination between foods, especially from raw meat and poultry to fresh vegetables or other ready-to-eat foods, is a major problem. One of the best ways to prevent cross-contamination is simply washing one’s hands with soap and water. Twenty seconds is the minimum time span that should be spent washing one’s hands. In order to prevent the spread of disease, it is also recommended that the hands be dried with a paper towel, which is then thrown away. Thoroughly washed hands can still be a source of bacteria, however, so one should use tongs and spoons when cooking to prevent contamination. It is especially important to wash one’s hands after blowing the nose or sneezing, using the lavatory, diapering a baby, smoking, or petting animals and before cooking or handling food. Other sources of cross-contamination include utensils and cutting surfaces. If people use the same knife and cutting board to cut up raw chicken
Food poisoning ✧ 389 for a stir-fry and peaches for a fruit salad, they are putting themselves at great risk for food-borne illness. The bacteria on the cutting board and the knife could cross-contaminate the peaches. While the chicken will be cooked until it is well done, the peaches in the salad will not be. In this situation, one could cut the fruit first and then the chicken, and then wash and sanitize the knife and cutting board. Cleaning and sanitizing is actually a two-step process. Cleaning involves using soap and water and a scrubber or dishcloth to remove the major debris from the surface. The second step, sanitizing, involves using a diluted chloride solution to kill bacteria and viruses. Wooden cutting boards are the worst offenders in terms of causing cross-contamination. Since bacteria and viruses are small, they can adhere to and grow in the grooves of a wooden cutting board and spread to other foods when the cutting board is used again. Use of a plastic or acrylic cutting board prevents this problem. Preventing Bacterial Growth The danger zone in which bacteria can multiply is a range of 4.4 degrees Celsius (40 degrees Fahrenheit) to 60 degrees Celsius (140 degrees Fahrenheit). Room temperature is generally right in the middle of this danger zone. The danger zone is critical because, even though they cannot be seen, bacteria are increasing in number. They can double and even quadruple in fifteen to thirty minutes. Consequently, perishable foods such as meats, poultry, fish, milk, cooked rice, leftover pizza, hard-cooked eggs, leftover refried beans, and potato salad should not be left in the danger zone for more than two hours. Keeping hot foods hot means keeping them at a temperature higher than 60 degrees Celsius. Keeping cold foods cold means keeping them at a temperature lower than 4.4 degrees Celsius. Other rules are helpful for preventing contamination. When shopping, the grocery store should be the last stop so that foods are not stored in a hot car. When meal time is over, leftovers should be placed in the refrigerator or freezer as soon as possible. When packing for a picnic, food items should be kept in an ice chest to keep them cold or brought slightly frozen. Much serious illness and death could be prevented if such food safety rules were followed. Overseeing Food Safety in the United States An important role of government and industry is to ensure a safe food supply. In the United States, setting and monitoring of food safety standards are the responsibility of the Food and Drug Administration (FDA) under the auspices of the U.S. Department of Health and Human Services and the Food Safety and Inspection Service (FSIS) under the auspices of the U.S. Department of Agriculture (USDA). The FDA is responsible for the wholesomeness of all food sold in interstate commerce, except meat and poultry,
390 ✧ Foot disorders while the USDA is responsible for the inspection of meat and poultry sold in interstate commerce and internationally. Food poisoning is a worldwide problem. In developing countries, diarrhea is a factor in child malnutrition and is estimated to cause 3.5 million deaths per year. Despite advances in modern technology, food-borne illness is a major problem in developed countries as well. In the United States, an estimated 24 million cases of food-borne diarrheal disease occur each year, which means that about one out of ten people experience a food-associated illness in a given year. —Martha M. Henze, R.D.; updated by Maria Pacheco See also Antibiotic resistance; Epidemics; Food irradiation; Genetically engineered foods; Lead poisoning; Mad cow disease; Parasites; Pesticides; Poisoning; Poisonous plants; Ulcers; Zoonoses. For Further Information: Gaman, P. M. The Science of Food: An Introduction to Food Science, Nutrition, and Microbiology. 4th ed. New York: Pergamon Press, 1996. An easy-to-read book dealing with food composition and microbiology. Includes good bibliographical references and an index. Hobbs, Betty C. Food Poisoning and Food Hygiene. London: Edward Arnold, 1993. A nontechnical handbook of the causes of food poisoning and other food-borne diseases for those in the fields of food microbiology and food hygiene. Emphasis is given to the main aspects of hygiene necessary for the production, preparation, sale, and service of safe and palatable food. Jay, James Monroe. Modern Food Microbiology. 6th ed. New York: Van Nostrand Reinhold, 2000. This excellent textbook summarizes the current state of knowledge of the biology and epidemiology of the microorganisms that cause food-borne illness. Longree, Karla, and Gertrude Armbruster. Quantity Food Sanitation. 5th ed. New York: John Wiley & Sons, 1996. An excellent reference guide on food safety for quantity cooking in institutions such as hospitals and restaurants. Ray, Bibek. Fundamental Food Microbiology. Boca Raton, Fla.: CRC Press, 1996. A comprehensive text on the basic principles of food microbiology. Includes bibliographical references and an index.
✧ Foot disorders Type of issue: Elder health, women’s health Definition: Problems associated with the feet such as flat feet, neuromas, Achilles tendinitis, plantar fascitis, and heel spurs.
Foot disorders ✧ 391 Each foot contains twenty-six bones, including fourteen phalanges (toe bones), five metatarsals (instep bones), and seven tarsals (ankle bones). The thirty-three joints in each foot are stabilized by more than a hundred ligaments, with their movements governed by nineteen muscles and their tendons. All these structures must work together in precise harmony during gait. When the delicate biomechanical action of one or both feet is upset and compensatory movements are made, abnormal compensations and pain often occur. It is estimated that the average American takes approximately nine thousand steps per day and walks the equivalent of three and a half times around the equator in a lifetime. Recreational and competitive sports enthusiasts who previously had well-functioning feet often develop foot health problems at around age fifty, by which time the average foot has ambulated more than seventy-five thousand miles. Even less-active people in midlife and later are prone to foot disorders that can have serious consequences for mobility, even loss of the ability for independent living. Flatfeet and Neuromas Chronic foot problems are often caused by excessive pronation (rotation of the midtarsal medial bones inward when walking, so that the foot comes down on its inner margin) of the rearfoot at the subtalor joint between the heel bone (calcaneus) and the wedge-shaped talus bone directly above it. Also called overpronation or fallen arches, flatfeet involve a flattening of the medial longitudinal arch, resulting in the middle of the ankle joint rolling in toward the midline of the body and a calcaneus that often appears to turn out laterally when viewed from the back. The big toe may also point up more than it should during weightbearing, causing the medial part of the foot to be more unstable. Calluses may build up under the second or third toes, indicating a lack of propulsion during the toe-off phase of running. A neuroma, essentially a benign tumor of the nerves, involves the classic signs of aching, burning, numbness, and shooting sensations in the forefoot, often occurring during the latter half of prolonged activities. Excessive foot pronation is often the culprit, as rotation of the metatarsal heads tends to pinch the nerve running between the third and fourth toes. Chronic pinching inflames and enlarges the nerve sheath, causing increasing pain as the enlarged sheath becomes squeezed even more. Chronic Heel Problems The most common disorder of the heel is plantar fascitis, evidenced by pain and fatigue on the sole, arch swelling, and inflammation of dense fibrous connective tissue called fascia on the plantar (bottom) surface of the foot. When the foot flattens and becomes unstable during stance, the plantar
392 ✧ Foot disorders fascia stretches excessively, possibly even pulling away from its attachment onto the calcaneus. The discomfort is particularly evident while pushing off with the toes, as this motion further stretches the inflamed fascia. When fascia begins to tear away from the bone, the bone often attempts to compensate by laying down more calcium and creating more bone, thus forming a heel spur that can been seen on an X ray. Plantar fascitis and heel spurs that go untreated often cause an alteration in stride mechanics, with these additional compensatory actions causing even more damage. Muscle and Tendon Injuries The Achilles tendon connects the calcaneus to both the lateral and medial heads of the gastrocnemius muscle (which crosses the knee, ankle, and subtalor joints) and the soleus (an important balance muscle underneath the gastrocnemius that does not cross the knee). Nagging inflammation of the Achilles tendon often takes months to heal, with the biggest contributor to chronic tendinitis being ignoring the pain and continuing heavy activity during its early stages. The Achilles tendon is not protected by a true tendon sheath as are many other tendons, and it does not possess a rich blood supply to enhance healing. It is highly recommended that, if the Achilles tendon is feeling sore, one should reduce activities that aggravate it immediately. Sudden increases in exercise level and movement up and down hills greatly aggravate Achilles tendon problems. Some runners attempt to combat chronic Achilles tendinitis by wearing excessive heel cushioning such as huge air-filled soles, but this action may actually increase the ongoing damage. Wearing shoes that provide inappropriately large shock absorption causes the heel to sink lower as the shoe attenuates the shock, thus rapidly stretching the already-tender tendon more than necessary with every step. Prolonged, gentle stretches to both the calves and the hamstrings are important prior to any lower extremity workout; repeated, short, and bouncy stretches, however, are the primary cause of tendinitis. Shoe Selection Distance walking and running for people of all ages is best done in shoes designed predominantly for forward running, whereas court sport shoes (such as tennis shoes) are designed more to provide stability during lateral movements in addition to forward movement. Court sport shoes generally do not have enough heel elevation to make them effective running shoes. Running shoes have a slightly elevated heel to reduce stress to the Achilles tendon, although this design does reduce lateral stability and can contribute to ankle sprains. The feet of distance runners generally come into contact with the ground heel first for a majority of the race, until the sprint to the
Foot disorders ✧ 393 finish, and are thus designed appropriately. Shoes for sprinting are constructed for more forefoot contact upon footstrike. The useful life of athletic shoes is approximately 350 to 550 miles, depending greatly on the ground surface. Shoes should be purchased at the end of the average day because the feet will be somewhat larger. The heel counter should be vertical, and pressing down vertically with the end of a pencil in the middle of the heel can determine shoe stability. The area of highest flexibility of a running shoe should occur approximately 40 percent of the way from the toe of the shoe to the heel. Orthotic Inserts and Heel Lifts Orthotic inserts placed within the shoe can be made of soft, semiflexible, or rigid material. They can be customized via computer-aided construction or with casts made of each foot. Orthotic inserts improve function and efficiency of foot motion by keeping the subtalar joint in neutral at midstance and balancing the rear part of the foot to both the forefoot and the ground. Orthotics are often specifically designed to prevent the foot from excessive pronation during midstance and to maintain stability so the foot can function as a rigid lever during push-off. An orthotic device only exerts its influence when the foot comes into contact with the ground, and often, but not always, creates an arch within the foot. Orthotic inserts can be designed to support or restrict range of motion in specific foot joints, dissipate body weight over a larger contact area and thus decrease shearing force on the bottom of the foot, redistribute weightbearing to stronger parts of the foot, and eliminate contact on weaker areas. Semiflexible orthotics, constructed from rubber, plastic, or leather, are generally first used to determine if the expense of individualized computer-constructed orthotics is necessary. Heel lifts essentially bring the ground up to the foot and save the individual from having to compensate continually by slapping the foot to the ground. They are effective in alleviating a variety of orthopedic problems, including leg length discrepancies and loss of the fat pad beneath the heel. Leg length discrepancies should be corrected gradually by increasing the heel lift height over several months. Instantly overcorrecting foot problems will quickly redistribute the weight of the body over a relatively smaller and weaker area of the foot and possibly cause more problems than before. Diagnosis and Treatment Foot abnormalities can only be diagnosed specifically during a clinical evaluation by a physician, physical therapist, or podiatrist. Most active older adults do not make the effort to see a physician or physical therapist for foot problems until knee pain develops. Examination of the feet and also shoes worn for at least 300 miles can help identify many foot disorders. The skin
394 ✧ Foot disorders of the foot should be thick in areas where an increase in weightbearing normally occurs, such as the heel, the lateral border, and just medial to the base of the first and fifth toes at the metatarsal heads. Bunion deformities are common in older women who wear dress shoes with high heels and pointed toes. Shoes worn by flatfooted individuals will generally have broken medial A bunion, a bony overgrowth of the big toe, can be counters, whereas persons with removed surgically by cutting off the excess segment toe-in gait will cause excessive of bone, thus reshaping the foot. (Hans & Cassidy, wear on the shoe’s lateral sole. Inc.) The absence of a significant crease across the forefoot area indicates a reduction in toe-off at the end of stance phase. Rehabilitation after even a relatively minor foot injury caused by either overuse or trauma can become a long and frustrating process if not conducted properly. Balance, coordination, strength, and overall posture during various types of movements are the major focus of clinical treatment. Foot pain can often be alleviated at home by superficial heat and cold application, stretching the muscles and fascia, and stimulating the feet using various types of massage. —Daniel G. Graetzer See also Broken bones in the elderly; Canes and walkers; Exercise and the elderly; Mobility problems in the elderly; Wheelchair use among the elderly; Women’s health issues. For Further Information: Hertling, Darlene, and Randolph M. Kessler. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. Philadelphia: Lippincott, 1996. An often-referenced physical therapist text on the evaluation and treatment of orthopedic disorders. Lorimer, Donald L., Gwen French, and Steve West, eds. Neal’s Common Foot Disorders: Diagnosis and Management. 5th ed. New York: Churchill Livingstone, 1997. A general clinical guide to foot disorders and diseases and their treatment. Includes a bibliography and an index. Magee, David J. Orthopaedic Physical Therapy Assessment. Philadelphia: W. B. Saunders, 1997. Discusses physical therapy assessment and treatment of various orthopedic conditions affecting the middle aged and elderly.
Frostbite ✧ 395
✧ Frostbite Type of issue: Environmental health, public health Definition: An injury or destruction of skin and underlying tissues as a result of the freezing of extremities. Frostbite generally occurs in people who exercise at high altitudes (such as athletes or mountain climbers), those who are at risk for diabetes, and those who are required to take particular care of their fingers and toes in cold situations. Frostbite can occur in anyone, however, upon exposure to extreme cold (below 0 degrees Celsius or 32 degrees Fahrenheit) and wind. The first symptom of frostbite is a pins-and-needles sensation, followed by complete numbness. The skin turns white, cold, and hard before becoming red and swollen. Frostnip, a mild form of frostbite, affects the cheeks or nose, turning them white and numb. Blisters can develop in more serious cases, and the skin then hardens gradually or turns black, or gangrenous, indicating that the tissue has died as a result of ischemia (insufficient blood supply). This is followed by swelling and aching of the underlying tissue. If the injury is superficial, the dead tissue peels off in a few months. In severe cases, muscles, bone, and tendon can be frozen and the affected parts become swollen, mottled, blue or grey, although without any blisters or immediate pain. Iatrogenic frostbite is caused by the excessive use of ethyl chloride sprays as local anesthesia for relief of muscle and tendon strains. Prevention and Treatment To guard against frostbite, it is essential that children and adults wear proper clothing and never venture out in extremely cold weather. Frostnip should be treated immediately by warming the affected part with a warm hand or glove until blood circulation returns to normal and the color of the skin is restored. In more severe cases, hospital treatment is necessary. The affected part is thawed through repeated applications of warm air or water for twentyminute periods. Movement or massage of the affected areas is not helpful, and exposure to open fire is dangerous. Generalized warming of the whole body may be required by way of hot drinks or the use of a sleeping bag. If gangrene has set in, amputation of an affected part is necessary. —Keith Garebian See also Environmental diseases; First aid; Injuries among the elderly; Safety issues for children; Safety issues for the elderly.
396 ✧ Gene therapy For Further Information: Calvert, John H., Jr. “Frostbite.” Flying Safety 54, no. 10 (October, 1998): 24-25. Phillips, David. “How Frostbite Performs Its Misery.” Canadian Geographic 115, no. 1 (January/February, 1995): 20-21. Tilton, Buck. “The Chill That Bites.” Backpacker 28, no. 7 (September, 2000): 27. Wilkerson, James A., ed. Medicine for Mountaineering. 4th ed. Seattle: The Mountaineers, 1992.
✧ Gene therapy Type of issue: Medical procedures, treatment Definition: A procedure that attempts to cure a condition by adding specific genes to cells; the expression of these genes results in the production of specific proteins. Gene therapy is a technology that holds great promise for treating a variety of illnesses. Its major goal is to transfer genes into cells that will be of therapeutic use. Where defective genes are responsible for causing inherited diseases such as cystic fibrosis, it is hoped that the defective gene can be replaced by a corrected copy of the gene. Where a disease state, such as cancer or acquired immunodeficiency syndrome (AIDS), could be improved by delivering therapeutic substances to specific sites, it is hoped that genes coding for therapeutic products could be transferred to specific cells at specific sites. The cells that are being targeted for gene therapy are somatic cells, body cells other than those that give rise to eggs or sperm. This ensures that the therapy does not affect future generations. The Mechanics of Gene Therapy Inserting copies of genes into cells can be done in a variety of ways, typically using cloning vectors. A vector is anything that will deliver a copy of the gene to the cells. Viruses are often used as vectors because of their ability to bring genetic material into a cell with great efficiency, infecting as many as 100 percent of the cells to which they are exposed. Since viruses are normally pathogens, however, they must first be engineered so that they can no longer multiply or cause disease. This is done by removing certain viral genes before inserting the gene of choice into the virus. Retroviruses and adenoviruses are two types that are often used. A retrovirus inserts its genetic material directly into the host cell’s genome, making the inserted genes stable. A retrovirus will infect only dividing cells and, by inserting its genes
Gene therapy ✧ 397 into the cell’s genome, may interfere with normal cell function. An adenovirus infects both dividing and nondividing cells but does not insert its genetic material into the host cell’s genome. The advantage of using adenoviruses is that they do not carry the risk of interfering with normal gene function. The genetic material brought into the cell, however, is less stable and can easily be lost. Nonviral vectors can also be used to deliver genes to their target cells. One of the more successful methods is to use lipids to envelop the gene. Nonviral vectors are less efficient than viral vectors, infecting as few as one in every ten thousand cells; however, they do not carry some of the risks involved in using viruses. A more direct method, in which naked DNA is injected directly into a tissue, has yielded results as well, although how the cells take up the DNA is not known. When gene therapy is being delivered, treatment can be either in vivo, in which the viral or nonviral vector is introduced directly into the patient’s body, or ex vivo, in which the target cells are removed from the patient, treated, and then returned to the patient’s body. Ex vivo methods allow the selection of cells that have incorporated the therapeutic gene and their growth in culture to increase cell number greatly before returning them to the patient. Potential Uses Gene therapy is being investigated as a tool for treating a number of disorders. By the end of the twentieth century, however, no patient had been cured of a disease using gene therapy, despite more than one hundred clinical trials involving more than two thousand patients. Nevertheless, there was a report of success in using gene therapy to cause the growth of new blood vessels around blocked blood vessels. This use of gene therapy—in which genes are added to cells not to replace a faulty gene product but to cause the production of a substance such as a growth factor in a selected location—greatly increases the possible applications beyond the correction of inherited genetic disorders. Initially, it was thought that gene therapy would first be used to cure a number of disorders caused by defects in a single gene. By 1990, candidates for the earliest gene therapies included beta-thalassemias, severe combined immunodeficiency syndrome (SCID), hemophilia types A and B, familial hypercholesterolemia, inherited emphysema, cystic fibrosis, Duchenne muscular dystrophy, and lysosomal storage disease. By 1995, gene therapies for most of these diseases were in clinical trials, but without any clear successes. By then, however, added to this list of disorders in clinical trials were a number in which treatment was aimed not at correcting a single gene but at delivering a gene product to a specific site. Among these were gene therapies for rheumatoid arthritis, AIDS, and cancer. By 1997, about 50 percent of all gene therapy research was focused on cancer, with the next
398 ✧ Gene therapy largest group of studies, about 10 percent, focused on AIDS. The first authorized human gene therapy was performed on a four-yearold girl, Ashanti DeSilva, who had adenosine deaminase (ADA) deficiency. Without treatment, this genetic deficiency leads to a fatal malfunctioning of the immune system. In 1990, a correct version of the ADA gene packaged in a retroviral vector was delivered by injection to the young girl. Several other young patients were treated afterward, but DeSilva was the only patient to show marked improvement in her condition. In all cases, however, the more traditional treatment, in which a synthetic version of ADA is administered in the form of PEG-ADA, was continued, indicating that the gene therapy did not cure the condition completely. Cystic fibrosis is another disease that has been thought to be potentially curable through gene therapy. Several characteristics make it a promising candidate. Since correcting the gene CFTR in as few as 6 percent of the cells of an affected organ can produce normal function, not all cells would need to incorporate a functional gene. Also, the cells in most critical need of correction are those lining the airways of the lungs, cells that are easily accessible for in vivo treatment. Most trials have involved using an adenovirus as a vector to carry the CFTR gene, since these viruses normally infect human airways—they are the viruses that produce the common cold. The engineered viruses carrying the CFTR gene are delivered through an aerosol spray. Although patients show partially corrected chloride ion transport, the effect is short lived because most of the cells incorporating the corrected gene are short lived. Consequently, the gene therapy must be repeated every few months, but this method soon becomes ineffectual. Because the adenovirus stimulates an immune response, with repeated treatment the patient’s immune system soon destroys the viral vector. Therefore, nonviral vectors are being tried in order to avoid an immune response. A number of gene therapies that have entered clinical trials have been aimed at cancer. Among these are therapies designed to make tumor cells incorporate genes for substances such as interleukin-2 that will stimulate or augment an immune system attack against the cancer. In other approaches, genes dubbed “suicide” genes, which cause cell death, are being incorporated into tumor cells. Other trials have been aimed at trying to correct the genes that have caused the cells to become cancerous. An alternative approach has been to introduce the multidrug resistance (MDR) gene into normal bone marrow cells in order to increase their resistance to the toxic effects of the chemotherapy used to kill cancer cells. Quite a different use of gene therapy has been to insert genes into highly accessible cells, such as muscle or skin fibroblasts, to turn them into protein factories for particular components that normally would be produced elsewhere—for example, to produce clotting factors, normally produced in the liver, that are missing in hemophiliacs. —Mary S. Tyler
Genetic counseling ✧ 399 See also AIDS; AIDS and children; AIDS and women; Arthritis; Cancer; Genetic diseases; Genetic engineering. For Further Information: Bank, Arthur. “Human Somatic Cell Gene Therapy.” BioEssays 18 (December, 1996): 999-1007. A sophisticated discussion of clinical trials in gene therapy, focusing primarily on cancer. Clark, William R. The New Healers: The Promise and Problems of Molecular Medicine in the Twenty-first Century. New York: Oxford University Press, 1999. Clark’s background as a teacher of immunology helps him initiate readers into the realm of molecular biology and gene therapy, the likely linchpin in eradicating most of the four thousand genetic disorders within the next fifty years. Felgner, Philip L. “Nonviral Strategies for Gene Therapy.” Scientific American 276 (June, 1997): 102-106. Explains how lipoplexes (DNA surrounded by lipids) rather than viruses could be used as a method of delivering genes. Friedmann, Theodore. “Overcoming the Obstacles to Gene Therapy.” Scientific American 276 (June, 1997): 96-101. Discusses in vivo and ex vivo methods of gene therapy and the advantages and disadvantages of different gene delivery systems. Ho, Dora Y., and Robert M. Sapolsky. “Gene Therapy for the Nervous System.” Scientific American 276 (June, 1997): 116-120. Predicts ways in which gene therapy might be used to combat neurological disorders such as Parkinson’s disease and stroke.
✧ Genetic counseling Type of issue: Children’s health, ethics, mental health, prevention Definition: The use of biochemical and imaging techniques, as well as family histories, to provide information about genetic conditions or diseases in order to help individuals make medical and reproductive decisions. Genetic counseling is a process of communicating to a couple the medical problems associated with the occurrence of an inherited disorder or birth defect in a family. Included in this process is a discussion of the prognosis and treatment of the problem. Specific reproductive options include abortion of an ongoing pregnancy, birth control or sterilization to prevent additional pregnancies, artificial insemination, the use of surrogate mothers, embryo transplantation, and adoption.
400 ✧ Genetic counseling Genetic Disorders The two major categories of medical problems covered in genetic counseling are birth defects and genetic diseases. The first group includes Down syndrome and spina bifida, while the latter includes hemophilia, sickle-cell disease, and Tay-Sachs disease. Although the distinction between these two categories can sometimes blur, the key difference involves the clear pattern of inheritance shown by the genetic diseases. A genetic disease can occur when deoxyribonucleic acid (DNA) changes in structure, which is also known as a mutation. A mutation can lead to the production of a defective protein that cannot carry out its normal function, thus causing a physiological defect. As with all genetic diseases, such mutations are relatively rare. Certain diseases may, however, be more prevalent within certain ethnic groups; for example, African Americans have a high incidence of sickle-cell disease, and Ashkenazic Jews have a high incidence of Tay-Sachs disease. Humans have two of each kind of chromosomes; one set of twenty-three is inherited from the mother and another set inherited from the father. Thus, each person has two copies of each gene. Many types of defects, such as sickle-cell disease, require that both genes have mutations in order to have an effect. Individuals who have one normal gene and one mutated gene are normal but carry the disease; they can pass the mutation to the next generation in their eggs and sperm. This type of disease is called a recessive genetic disease. Since it is equally likely for each parent to pass on the normal gene in eggs or sperm as to pass on the mutation, the laws of probability predict that, on the average, one-fourth of such a couple’s offspring should have the disease. One of the major tasks of genetic counseling is to advise couples of these probabilities if the diagnoses and family histories suggest that they are carriers. Since the laws of genetics involve random occurrences, however, it is possible that in a family with three or four children, all the children will be normal, or that in another family, all the children will have the disease. Other diseases, such as Huntington’s disease or chorea, are dominant, which means that an individual needs to inherit only one mutated gene in order to have the disease. Unlike recessive diseases that can disappear from a family for generations, a dominant mutation can be inherited only from a person who has the disease. In most cases, such a person has one normal gene and one with the mutation, which means that there is a 50 percent chance that the gene will be passed on. Huntington’s chorea is a particularly insidious genetic disease, because the symptoms usually begin to show only in middle age, often after childbearing decisions have been made. Thus, the children of an afflicted parent must decide whether they will marry and have children before they know whether they have inherited the mutation from their parents.
Genetic counseling ✧ 401 The Screening Controversy One of the more controversial aspects of genetic counseling is the procedure of screening, in which at-risk individuals are tested for a mutation. Screening can let people know whether they have a disease or whether they are carriers. Screening can be extended to all individuals, regardless of family or ethnic history. For example, in the United States, most states require that all newborn infants undergo a test for phenylketonuria (PKU). Although the costs of this screening are not insignificant, the benefit is that those infants found to have the disease can be treated immediately by being placed on a special diet. Other screening procedures are targeted at specific groups. In the United States, a screening program for Tay-Sachs disease focuses on ethnic Jewish populations. This successful, voluntary program has reduced the incidence of the disease significantly. The key to success was the money spent to educate the targeted group. Because of the much-larger potential group at risk, similar efforts to screen African American populations for sickle-cell disease have been much less successful. Ethical concerns about the motivations behind government-sponsored or government-encouraged screening of minority populations make these programs difficult to implement. In addition, in mandatory programs, concerns about confidentiality and information release become major obstacles. Collecting and Interpreting the Data Genetic counseling usually begins when a couple or an individual seeks the advice of a family physician or obstetrician regarding the medical risks associated with having a child. Motivating this request may be a previous birth of a child with a defect, a general uneasiness on the part of a couple worried about environmental exposure to potentially harmful agents, a family history of genetic disease, or advanced maternal age. If pregnant already, the woman may undergo a prenatal diagnostic procedure that could include ultrasound, blood tests, amniocentesis, and chorionic villus sampling. The counselor’s task is to take the diagnostic results and interpret them in the context of the medical history and particular family situation. The counselor must point out the options available, both for further diagnosis to confirm or rebut less-sensitive preliminary tests and to discuss potential medical interventions such as the special diets available for children born with PKU. In cases in which no medical intervention is possible, the severity of the problem should be discussed honestly so that the parents can choose either to continue or to abort the pregnancy. Other options, including adoption, artificial insemination, and embryo transplants, can also be evaluated. Finally, the risk of recurrence of the problem in future pregnancies should be discussed. Compounding the tasks of the counselor is the fact that, in many cases, exact diagnoses are not yet possible. Sometimes, only the relative risks
402 ✧ Genetic counseling associated with another pregnancy can be determined. Different couples will perceive risks very differently depending on their own religious and moral backgrounds, as well as on the expected severity of the defect. In the case of a genetic disease such as Tay-Sachs, which is 100 percent fatal and requires extensive hospitalization of the child, a modest risk may be considered unacceptable. In the case of a birth defect such as Down syndrome, whose severity cannot be predicted, a modest risk may be considered quite differently. The Future of Genetic Counseling The need for centers specializing in genetic counseling arose when it became clear that certain diseases and birth defects had a hereditary component. Many families request the services of counselors from these centers, and the centers are also involved in both voluntary and mandatory screening programs. In the United States, about 4 percent of all newborns suffer from a defect that is recognized either at birth or shortly thereafter. This group includes 0.5 percent who have a chromosomal abnormality that results in an obvious medical problem, 0.5 to 1 percent who have classical genetic diseases, and 2 percent who suffer from a birth defect that may have a heritable component. Estimates vary, but more than one-third of all children in pediatric hospitals are there because of some association with a genetic disease. Genetic counseling clinics usually employ a range of specialists, including clinicians, geneticists, laboratory personnel for performing diagnostic testing, and public health and social workers. Today, most large counseling programs at medical centers use specially trained personnel. In rural areas, however, family physicians are still a primary source of counseling; thus, genetic training is an important component of basic medical education. As DNA tools become more widely available, counseling will become a more integral part of preventive medicine. A DNA diagnostic procedure for a heritable form of breast cancer is available that allows women who have the mutation to monitor their health closely in order to receive prompt, lifesaving medical intervention. An important ethical issue here is that some women who have been diagnosed as having the mutation are undergoing preventive mastectomies without having developed any growths in order to ensure that they will not develop cancer. This radical therapy carries with it considerable emotional stress and should be undertaken only after consultation with a physician. As DNA-based diagnostic procedures, perhaps coupled with mandatory screening, become more commonplace, concerns about the release of this information to potential employers or health insurers will become more critical. —Joseph G. Pelliccia
Genetic diseases ✧ 403 See also Abortion; Amniocentesis; Birth defects; Breast cancer; Disabilities; Down syndrome; Ethics; Gene therapy; Genetic diseases; Genetic engineering; Mastectomy; Phenylketonuria (PKU); Prenatal care; Preventive medicine; Screening; Spina bifida. For Further Information: Filkins, Karen, and Joseph F. Russo, eds. Human Prenatal Diagnosis. 2d rev. ed. New York: Marcel Dekker, 1990. An advanced sourcebook that describes the procedures of prenatal diagnosis in great detail. Contains information on risk, reliability, cost, and so forth. Harper, Peter S. Practical Genetic Counselling. 5th ed. London: Wright, 1998. A good overview of all aspects of genetic counseling, including a discussion of the types of diagnoses, treatments, risks, and emotional strains associated with counseling. Also gives a history of counseling as a discipline. Mange, Arthur P., and Elaine J. Mange. Genetics: Human Aspects. 2d ed. Sunderland, Mass.: Sinauer Associates, 1990. An excellent advanced high school or college text that introduces most of the concepts relevant to genetic counseling, from basic theory to practical applications. Pierce, Benjamin A. The Family Genetic Sourcebook. New York: John Wiley & Sons, 1990. Good background reading on genetics and genetic diseases. The book gives short, clear descriptions of a number of genetic diseases, along with their diagnosis and treatment. U.S. Congress. Office of Technology Assessment. Genetic Counseling and Cystic Fibrosis Carrier Screening: Results of a Survey-Background Paper. OTA-BP-BA97. Washington, D.C.: Government Printing Office, 1992. Genetic screening is a controversial subject. This source discusses the problems and successes associated with one such effort.
✧ Genetic diseases Type of issue: Children’s health, public health Definition: A variety of disorders transmitted from parent to child through chromosomal material. Genetic diseases are inherited as a result of the presence of abnormal genes in the reproductive cells of one or both parents of an affected individual. There are two broad classifications of genetic disease: those caused by defects in chromosome number or structure and those resulting from a much smaller flaw within a gene. Within the latter category, four predominant mechanisms exist by which the disorders can be transmitted from generation to generation: autosomal dominant inheritance, autosomal recessive inheritance, X-linked chromosomal inheritance, and multifactorial inheritance.
404 ✧ Genetic diseases Types of Genetic Diseases Errors in chromosome number include extra and missing chromosomes. The most common chromosomal defect observed in humans is Down syndrome, which is caused by the presence of three copies of chromosome 21, instead of the usual two. Gross defects in chromosome structure include duplicated and deleted portions of chromosomes and broken and rearranged chromosome fragments. Prader-Willi syndrome results from a deletion of a small portion of chromosome 15. Children affected with this disorder are mentally retarded, obese, and diabetic. Cri du chat (literally, cat cry) syndrome is associated with a large deletion in chromosome 5. Affected infants exhibit facial abnormalities, are severely retarded, and produce a high-pitched, kittenlike wail. Manifestation of an autosomal dominant disorder requires the inheritance of only one defective gene from one parent who is afflicted with the disease. Inheritance of two dominant defective genes, one from each parent, is possible but generally creates such severe consequences that the child dies while still in the womb or shortly after birth. An individual who bears one copy of the gene has a 50 percent chance of transmitting that gene and the disease to his or her offspring. Among the most common autosomal dominant diseases are hyperlipidemia, hypercholesterolemia, and Huntington’s disease. The onset of the symptoms is usually in adulthood, frequently after the affected individual has had children and potentially transmitted the faulty gene to them. Autosomal recessive genetic diseases require that an affected individual bear two copies of a defective gene, inheriting one from each parent. Usually the parents are simply carriers of the defective gene; their one normal copy masks the effect of the one flawed copy. If two carriers have offspring, 25 percent will receive two copies of the flawed gene and inherit the disease, and 50 percent will be asymptomatic carriers. Autosomal recessive disorders in the United States include cystic fibrosis, which occurs at a rate of about one in two thousand live births among Caucasians, and sickle-cell disease, the most common genetic disease among African Americans. X-linked genetic diseases are transmitted by faulty genes located on the X chromosome. Females need two copies of the defective gene to acquire such a disease, and in general women carry only one flawed copy, making them asymptomatic carriers of the disorder. Males, having only a single X chromosome, need only one copy of the defective gene to express an X-linked disease. Half of the male offspring of a female carrier will inherit the defective gene and develop the disease. In the rare case of a female with two defective X-linked genes, 100 percent of her male offspring will inherit the disease gene, and, assuming that the father does not carry the defective gene, 50 percent of her female offspring will be carriers. More than 250 X-linked disorders exist; some of the more common are Duchenne muscular dystrophy, hemophilia, and red-green color blindness.
Genetic diseases ✧ 405 Multifactorial inheritance is caused by the complex interaction of one or more genes with each other and with environmental factors. This group of diseases includes many disorders which, anecdotally, run in families. Representative disorders include cleft palate, spina bifida, anencephaly, and some inherited heart abnormalities. Other diseases appear to have a genetic component predisposing an individual to be susceptible to environmental stimuli that trigger the disease, such as cancer, hypertension, diabetes, schizophrenia, alcoholism, depression, and obesity. Diagnosis and Detection Most, but not all, genetic diseases manifest their symptoms immediately or soon after the birth of an affected child. Rapid recognition of such a medical condition and its accurate diagnosis are essential for the proper treatment and management of the disease by parents and medical personnel. In many cases, testing of the fetus occurs prior to birth. In addition, tests are available that determine the carrier status of an individual for many autosomal recessive and X-linked diseases. These test results are used in conjunction with genetic counseling of individuals and couples who are at risk of transmitting a genetic disease to their offspring. Thus, such individuals can make informed decisions when planning their reproductive futures. Defects in chromosome number and structure can be identified in a fetus using amniocentesis and chorionic villus sampling. Errors in chromosome number and structure can be detected in an individual by analyzing his or her chromosomes. A small piece of skin or a blood sample is taken, the cells in the sample are grown to a sufficient number, and the chromosomes within each cell are stained with special dyes so that they may be viewed with a microscope. A picture of the chromosomes, called a karyotype, is taken, and the patient’s chromosome array is compared with that of a normal individual. Extra or missing chromosomes or alterations in chromosome structure are determined, thus identifying the genetic disease. Karyotyping is the method used to determine the presence of Down, Prader-Willi, and cri du chat syndromes, among others. Identifying Genetic Errors The majority of hereditary disorders, however, are caused by gene flaws that are too small to see microscopically. For many of these diseases, diagnosis is available through either biochemical testing or deoxyribonucleic acid (DNA) analysis. Many genetic disorders cause a lack of a specific biochemical which is necessary for normal metabolism. These types of disorders are frequently referred to as inborn errors of metabolism. Many of these errors can be detected by the chemical analysis of fetal tissue. For example, galactosemia is a disease which results from the lack of
406 ✧ Genetic diseases galactose-1-phosphate uridyl transferase. Infants with this disorder cannot break down galactose, one of the major sugars in milk. If left untreated, galactosemia can lead to mental retardation, cataracts, kidney and liver failure, and death. By analyzing fetal cells obtained from amniocentesis or chorionic villus sampling, the level of this important chemical can be assessed, and if necessary, the infant can be placed on a galactose-free diet immediately after birth. DNA analysis can be used to determine whether a genetic disease has been inherited when the chromosomal location of the gene is known, when the chemical sequence of the DNA is known, and/or when particular DNA sequences commonly associated with the gene in question, called markers, are known. Direct analysis of the DNA of the individual suspected of carrying a certain genetic disorder is possible in many cases. For example, in sickle-cell disease, it is known that a change in a single DNA chemical element leads to the disorder. To test for this disease, a tissue sample is obtained from prenatal sources. The DNA is isolated from the cells and analyzed with highly specific probes that can detect the presence of the defective gene which will lead to sickle-cell disease. Informed action may be taken regarding the future of the fetus or the care of an affected child. Evaluating Risk Factors Individuals who come from families in which genetic diseases tend to occur can be tested as carriers. In this way, they will know the risk of passing a certain disease to offspring. DNA samples from the potential parents can be analyzed for the presence of a defective gene. Many of the gene flaws of multifactorial diseases, those that interact with environmental factors to produce disease, have been identified and are testable. Individuals armed with the knowledge of having a gene which puts them at risk for certain disorders can incorporate preventive measures into their lifestyle, thus minimizing the chances of developing the disease. The Future of Genetic Disease Research Recombinant DNA revolution spawned the development of the DNA tests for genetic diseases and carrier status. Knowledge of what a normal gene product is and does is exceptionally helpful in the treatment of genetic diseases. For example, Duchenne muscular dystrophy is known to be caused by the lack of a protein called dystrophin. This suggests that a possible treatment of the disease is to provide functional dystrophin to the affected individual. Ultimately, medical science seeks to treat genetic diseases by providing a functional copy of the flawed gene to the affected individual. While such gene therapy would not affect the reproductive cells—the introduced gene
Genetic diseases ✧ 407 copy would not be passed down to future generations—the normal gene product would alleviate the genetic disorder. —Karen E. Kalumuck See also Alzheimer’s disease; Amniocentesis; Attention-deficit disorder (ADD); Autism; Birth defects; Breast cancer; Cancer; Colon cancer; Diabetes mellitus; Down syndrome; Dyslexia; Environmental diseases; Gene therapy; Genetic counseling; Genetic engineering; Lactose intolerance; Learning disabilities; Mental retardation; Phenylketonuria (PKU); Schizophrenia; Screening. For Further Information: Bellenir, Karen, ed. Genetic Disorders Sourcebook: Basic Information About Heritable Diseases and Disorders Such as Down Syndrome, PKU, Hemophilia, and Von Willebrandt Diseases. New York: Omnigraphics, 1996. This nontechnical sourcebook offers basic information about lifestyle expectations, disease management techniques, and current research initiatives for the most common types of genetic disorders, including a resource list of three hundred genetic disorders and related topics. Gormley, Myra Vanderpool. Family Diseases: Are You at Risk? Reprint. Baltimore: Genealogical Publishing, 1999. The author, a certified genealogist and syndicated columnist, explores the relationship between family trees and genetic diseases. Written in popular language, this book gives instruction on how to assess a family’s genetic risk, information on the latest scientific breakthroughs, and direction for obtaining further information. Maxon, Linda, and Charles Daugherty. Genetics: A Human Perspective. Dubuque, Iowa: Wm. C. Brown, 1992. This textbook, designed for persons with no science background, thoroughly covers the background information on cells and genetics needed for an informed understanding of human genetic disease. The discussion of scientific advances in the understanding,treatment, and diagnosis of genetic disease is a strong point of the text. Millunsky, Aubrey, ed. Genetic Disorders of the Fetus: Diagnosis, Prevention, and Treatment. Baltimore, Md.: Johns Hopkins University Press, 1998. This source treats a number of issues, from fetal cells in the maternal circulation to ethical issues surrounding a misdiagnosis, in chapters written by experts in the field. Recommended for clinicians in training and scientists working on the laboratory side of prenatal genetic testing. Tropp, Burton E. Biochemistry: Concepts and Applications. Belmont, Calif.: West/Wadsworth, 1997. This book presents the basic concepts of biochemistry, including proteins and their functions, genetic information, and recombinant DNA technology. A good source for basic biochemical information.
408 ✧ Genetic engineering
✧ Genetic engineering Type of issue: Ethics, medical procedures Definition: The use of recombinant deoxyribonucleic acid (DNA) technology to create DNA carrying specific genes or parts of genes that can be transferred from one organism to another to alter an organism’s genetic makeup. Genetic engineering relies foremost on the ability of the scientist to cut and rejoin DNA molecules and to increase the ability of bacteria to take up DNA from a culture solution. One type of enzyme that cuts a linear DNA molecule into fragments is called a restriction endonuclease or restriction enzyme. Restriction enzymes cut DNA into predictable, reproducible-sized fragments by cutting at specific nucleotide sequences. Recombinant DNA molecules made by combining fragments of DNA from different sources such as bacteria and humans rely on the fact that restriction enzymes leave the same type of ends on every fragment they generate. Therefore, fragments can be rejoined in almost any desirable combination. The types of DNA fragments that are commonly joined by genetic engineers include a DNA fragment containing a gene of interest, such as the human insulin gene, and a special DNA fragment which will allow that gene to propagate and be expressed in bacteria. Once the appropriate fragments are combined, the recombinant DNA molecule must be inserted into the bacteria. Because inserting new genetic information into a bacterium will change or transform its genetic makeup, this procedure is called transformation. Benefits for Diabetics and Dialysis Patients One of the greatest potential uses of genetic engineering technology is in the diagnosis and treatment of human disease. The first genetically engineered product, approved by the Food and Drug Administration in 1982, was marketed by the Eli Lilly company under the product name of Humulin—a human form of insulin for the treatment of diabetes mellitus. Patients suffering from diabetes must take injections of insulin daily. The traditional source of insulin has been beef and pork pancreas, but there are associated problems. The methods of extraction can be tedious and costly and provide a relatively small amount of insulin from a large amount of animal tissue. Also, a common problem among diabetics is allergic reactions to impurities in the insulin preparation and resistance to the insulin itself. Genetic engineering has provided a way to obtain pure, human insulin in large quantities. In normal human cells, an insulin precursor is synthesized as a single
Genetic engineering ✧ 409 protein chain and then split into two pieces, which remain held together by strong chemical bonds. Scientists can engineer separate genes into bacteria to produce each of the two pieces that compose insulin. Each segment is purified from the bacteria and then combined chemically to form active insulin. Although the insulin is produced by bacteria, the genetic instructions used are human in origin, and the insulin protein is indistinguishable from insulin actually produced in human cells. Another useful protein that can be genetically engineered is erythropoietin, which stimulates the production of red blood cells, or erythrocytes, the oxygen-carrying cells in the blood. The kidneys normally help remove toxic substances from the body. Sufferers of kidney disease can undergo a treatment known as dialysis that substitutes for this cleansing function. Dialysis is a much safer alternative for most patients than kidney transplantation. Because the kidneys also normally produce erythropoietin, however, patients with diseased kidneys often have a low number of red blood cells and suffer from severe anemia. This anemia can be alleviated with blood transfusions, but transfusions carry the risk of blood-borne diseases. Fortunately, genetically engineered erythropoietin is available to stimulate red blood cell production in dialysis patients. Vaccines and Gene Therapy Another medical use of genetic engineering involves the creation of safe and effective vaccines for viral diseases. Vaccines work by presenting a harmless protein from the virus or a noninfectious or nonpathogenic strain of the virus to the immune system. One way to produce a vaccine for human immunodeficiency virus (HIV) might be to engineer bacteria genetically to synthesize a viral protein. The protein could then be purified and injected into a human. The person’s immune system would make antibodies to the HIV protein, and, if he or she were ever exposed to the virus, the immune system would be able to combat the virus before an infection could be established. Unfortunately, purified proteins cannot always serve as effective vaccines. Another approach might be to engineer the HIV viral protein genetically into a relatively harmless virus and intentionally infect people with that virus. The harmless virus would present the HIV protein to the immune system so that antibodies could be created for protection against HIV infection. Genetic engineering is also being applied to human cells in attempts to treat cancer and genetic diseases. Medical treatments using genetic engineering are called human gene therapies. In gene therapy, genes may be added, deleted, or altered to change the properties of certain cells within the body. Human gene therapy may succeed in providing cures for some of the more than three thousand known genetic diseases. One particularly severe disease is readily amenable to gene therapy.
410 ✧ Genetic engineering Adenosine deaminase (ADA) deficiency results when an individual’s own cells are unable to produce the enzyme ADA. The most harmful effect of this deficiency is the lack of an effective immune system to fight disease. Consequently, the individual must live in an almost entirely sterile environment to avoid potentially harmful bacteria, fungi, and viruses. Bone marrow cells could be extracted from an ADA-deficient person, however, and a new ADA gene could be inserted into the cells. When the bone marrow cells are replaced, they should function normally. The Ethical Questions Human gene therapy brings up several important ethical questions. First, do humans have the moral and ethical right to alter the genetic makeup of themselves or others? A more critical question is whether one has the right to alter the genetic makeup of future generations. Gene therapy of normal body cells that will die when the individual dies is called somatic cell gene therapy. Most people see little ethical problem with such techniques. Yet the potential also exists to alter genetically sperm and egg cells, the germ cells, so that future progeny will all carry the alterations. Many individuals argue against the development of such germ cell gene therapy. Scientists involved in the early development of recombinant DNA methodology saw the danger of reckless experimentation. In fact, in 1974, those scientists called for a worldwide moratorium on genetic engineering until they could discuss the safety concerns. In 1975, the scientists met at Asilomar, California, and developed a set of guidelines under which they would conduct their research. In 1976, the National Institutes of Health (NIH) stepped in and issued formal guidelines based on those recommended at the Asilomar conference. Since the initial NIH guidelines, concern about the potential risks of genetic engineering has subsided. Most experiments are now performed in an open laboratory environment with little containment other than that used for handling normal bacteria or viruses. In addition to those concerned about the issues of safety, opponents of genetic engineering include those who question the ethics and morality of altering the genetic makeup of organisms, especially humans. Genetic recombination takes place every day in the natural world, but this recombination is usually limited to members of the same species. When organisms reproduce, groups of genes from each parent are recombined to form progeny. Yet scientists have taken the process one step further, developing the ability to recombine genes from different organisms. Many people, including some scientists, believe that genetic engineering goes against the laws of nature or is playing God; they call for a halt to genetic engineering. Many others, scientists and laypersons alike, believe that genetic engineering mimics natural events such as viral infections and evolution and that the
Genetically engineered foods ✧ 411 potential benefits—scientific, social, and medical—are too great to stop genetic engineering. —Gary J. Lindquester See also Cancer; Chemotherapy; Diabetes mellitus; Ethics; Fetal tissue transplantation; Gene therapy; Genetically engineered foods; Hormone replacement therapy. For Further Information: Frank-Kamenetskii, Maxim D. Unraveling DNA—The Most Important Molecule of Life. Rev. ed. Reading, Mass.: Addison-Wesley, 1997. This very readable book provides an excellent history of the discovery of DNA. Also describes the nature of DNA and discusses genetic engineering and the ethical questions that surround its use. McHughen, Alan. Pandora’s Picnic Basket: The Potential and Hazards of Genetically Modified Foods. New York: Oxford University Press, 2000. McHughen offers a balanced, informed look at the new technology of genetically modified foods. He easily imparts a basic understanding of the molecular genetics required to understand genetic modification and the controversy it sparks. Nicholl, Desmond. Introduction to Genetic Engineering. Cambridge, England: Cambridge University Press, 1994. A valuable textbook for the nonspecialist and anyone interested in genetic engineering. It provides an excellent foundation in molecular biology and builds on that foundation to show how organisms can be genetically engineered. Particularly useful is the glossary of terms. Wilmut, Ian, Keith Campbell, and Colin Tudge. The Second Creation: Dolly and the Age of Biological Control. New York: Farrar, Straus and Giroux, 2000. Science writer Tudge helps the scientists responsible for cloning the sheep Dolly tell their story. Discusses the groundwork laid by others and the scientific methodology they employed in cloning the first mammal from the cell of an adult of its species.
✧ Genetically engineered foods Type of issue: Environmental health, industrial practices, public health Definition: Foods that are derived from living organisms that have been modified by gene-transfer technology. Humans rely on plants and animals as food sources and have long used microbes to produce foods such as cheese, bread, and fermented beverages. Conventional techniques such as cross-hybridization, production of mu-
412 ✧ Genetically engineered foods tants, and selective breeding have resulted in new varieties of crop plants or improved livestock with altered genetics. However, these methods are relatively slow and labor intensive, are generally limited to intraspecies crosses, and involve a great deal of trial and error. Recombinant deoxyribonucleic acid (DNA) techniques developed in the 1970’s enable researchers to rapidly make specific, predetermined genetic changes. Since the technology also allows for the transfer of genes across species and kingdom barriers, an infinite number of novel genetic combinations are possible. The first animals and plants containing genetic material from other organisms (transgenics) were developed in the early 1980’s. By 1985 the first field trials of plants engineered to be pest resistant were conducted. In 1990 the U.S. Food and Drug Administration (FDA) approved chymosin as the first substance produced by engineered organisms to be used in the food industry for dairy products such as cheese. That same year the first transgenic cow was developed to produce human milk proteins for infant formula. The well-publicized Flavr Savr tomato obtained FDA approval in 1994. The Goals of Genetic Engineering By the mid-1990’s, more than one thousand genetically engineered crop plants were approved for field trials. The goals for altering food crop plants by genetic engineering fall into three main categories: to create plants that can adapt to specific environmental conditions to make better use of agricultural land, increase yields, or reduce losses; to increase quality, nutritional value, and flavor; and to alter transport, storage, and processing properties for the food industry. Many genetically engineered crops are also sources of ingredients for processed foods and animal feed. Herbicide-resistant plants such as the Roundup Ready soybean can be grown in the presence of glyphosphate, a herbicide that normally destroys all plants with which it comes in contact. Beans from these plants have been approved for food-industry use in several countries, but there has been widespread protest by activists such as Jeremy Rifkin Jeremy and organizations such as Greenpeace. Frost-resistant fruit containing a fish antifreeze gene, insect-resistant plants with a bacterial gene that encodes for a pesticidal protein (Bacillus thuringiensis), and a viral disease-resistant squash are examples of other genetically engineered food crops that have undergone field trials. Scientists have also created plants that produce healthier unsaturated fats and oils rather than saturated ones, coffee plants whose beans are caffeine-free without processing, and tomatoes with altered pulp content for improved canned products. Animals can also be genetically engineered food sources. Transgenic research in animals is technically more difficult than with plants, although the technology used to clone Dolly the sheep in 1997 was a significant
Genetically engineered foods ✧ 413 advancement. Animal rights issues, vegetarian and religious objections to animal-based components in food, and concerns over infectious agents that could be transferred to humans have all hindered developments in this field. The most notorious application of genetic engineering in animals involves the bovine growth hormone (BGH; also known as BST) synthesized by bacteria containing the bovine BGH gene. When BGH is given to cows as a supplement, milk production can increase up to 20 percent, but concerns over the health of treated cows and the safety of the milk have made this practice controversial. Genetically engineered microbes are used for the production of food additives such as amino acid supplements, sweeteners, flavors, vitamins, and thickening agents. In some cases, these substances previously had to be obtained from slaughtered animals. Altered organisms are also used for improving fermentation processes in the food industry. Areas of Controversy Applications of genetic engineering in agriculture and the food industry could increase world food supplies, reduce environmental problems associated with food production, and enhance the nutritional value of certain foods. However, these benefits are countered by food-safety concerns, the potential for ecosystem disruption, and fears of unforeseen consequences resulting from altering natural selection. Food safety and quality are at the center of the genetically engineered food controversy. Concerns include the possible introduction of new toxins or allergens into the diet and changes in the nutrient composition of foods. Proponents argue that food sources could be designed to have enhanced nutritional value. A large percentage of crops worldwide are lost each year to drought, temperature extremes, and pests. Plants have already been engineered to exhibit frost, insect, disease, and drought resistance. Such alterations would increase yields, allow food to be grown in areas that are currently too dry or infertile, and positively impact the world food supply. Environmental problems such as deforestation, erosion, pollution, and loss of biodiversity have all resulted, in part, from conventional agricultural practices. Use of genetically engineered crops could allow better use of existing farmland and lead to a decreased reliance on pesticides and fertilizers. Critics fear the creation of “superweeds”—either the engineered plants or new plant varieties formed by the transfer of recombinant genes conferring various types of resistance to wild species. These weeds, in turn, would compete with valuable plants and have the potential to destroy ecosystems and farmland unless stronger poisons were used for eradication. The transfer of genetic material to wild relatives (outcrossing, or “genetic pollution”) might also lead to the development of new plant diseases. As
414 ✧ Hair loss and baldness with any new technology, there may be other unpredictable environmental consequences. Despite the risks, genetic engineering may be required to develop food sources that can survive rapidly changing environmental conditions. Pollution, global climate change, and increased ultraviolet irradiation result in stress conditions for living organisms, and all impact agriculture. The processes of natural selection and adaptation may be too slow to maintain required food supplies. —Diane White Husic See also Food irradiation; Genetic engineering. For Further Information: Engel, Karl-Heinz, Gary R. Takeoka, and Roy Teranishi, eds. Genetically Modified Foods: Safety Issues. Washington, D.C.: American Chemical Society, 1995. A thorough overview of the technology, applications, and risks associated with genetically engineered foods. Rissler, Jane, and Margaret Mellon. The Ecological Risks of Engineered Crops. Cambridge, Mass.: MIT Press, 1996. Discusses the potential environmental impact of this technology.
✧ Hair loss and baldness Type of issue: Elder health, men’s health, social trends Definition: The loss of hair as a result of aging or illness. In 1999, more than thirty million men in the United States were bald or going bald, mostly from the condition known as androgenetic alopecia, or male pattern baldness. This condition usually starts with a receding hairline at the forehead and temples and often is accompanied by a hairless spot at the crown of the head—the “monk’s tonsure.” Finally, the hairless areas join over the skull until the individual is left only with a fringe over the ears and collar. The Nature of Hair and Types of Loss Hair is an accessory organ of the skin and consists primarily of two parts: the hair shaft, which protrudes above the skin surface, and the root, which lies below the skin. The hair follicle surrounds the root and it is here, in the follicle, where blood vessels provide nourishment for the growing hair. The hair shaft—which is combed, brushed, pomaded, shampooed, dyed, and “nourished” by a variety of nostrums—is a thread of keratinized cells, dead material similar to fingernails and toenails.
Hair loss and baldness ✧ 415 The average number of human scalp hairs is between 100,000 and 150,000. Individual scalp hairs may persist for three to five years and then are shed in a cycle that includes growth, a resting stage, shedding, and another growth period. Balding occurs when the number of hairs shed in the cycle exceeds the number that grow. Dermatologists, medical specialists in the study and treatment of diseases of the skin, recognize three main forms of alopecia, or baldness. Alopecia areata refers to the loss of hair in patches that vary in size; although it usually affects the scalp, hair loss may involve the beard or other body hair. If the follicles are not compromised, regrowth of the hair usually occurs. Alopecia totalis occurs when all the scalp hair is lost and the scalp remains totally bare, smooth, and shiny. Other body hair such as the eyebrows, pubic hair, and beard usually is not involved. Alopecia universalis is the most extreme form of hair loss. Not only is the scalp hair lost, but the pubic hair, underarm hair, eyebrows, and leg and arm hair is lost as well. The affected individuals undergo both the psychological trauma of the hair loss and the physical trauma of the loss of the protective qualities of the hair. Perspiration that usually is trapped by the eyebrows may now trickle directly into the eyes. Dust, pollen, and other airborne particles freely enter the nasal passages in the absence of nose hair. Genetics and Baldness About 95 percent of male pattern baldness is hereditary and is passed on by both the male as well as the female line. As the name suggests, it affects mostly men, although some older women undergo a general thinning of scalp hair with actual bald spots. Male pattern baldness usually begins at puberty or the early twenties, although it may not make an appearance until the forties. By middle age, the degree of baldness is usually known. Male pattern baldness appears to run in families on either the mother’s or the father’s side. As has long been suspected, the tendency toward this condition is influenced by the male sex hormone, testosterone. Testosterone is produced by the primary male sex glands, the testes. The hormone is responsible for the secondary sexual characteristics in males, including facial hair, a deepened voice, and a more robust body build. Testosterone begins to exert its influence at puberty, the time of sexual maturation. It is not the testosterone itself that is the culprit in androgenetic alopecia; it is its derivative, dihydrotestosterone (DHT). As testosterone circulates through the blood, it is converted by an enzyme to DHT, which attaches to hair follicle cells. If there is a large amount of DHT, the follicles begin sprouting hair that is progressively thinner in diameter. Finally, the follicles no longer produce hair and in turn waste away. It is the production of more or less amounts of the enzyme, and thus DHT, not the production of testosterone, that determines the retention or loss of an individual’s head of hair.
416 ✧ Hair loss and baldness Baldness Cover-Ups and Surgical Restoration Some steps can be taken by the balding individual. One alternative is to do nothing about the hair loss and to accept the inevitable as a natural part of the aging process. Some men allow one side of the hair that remains in the fringe to grow long and fashion it in a variety of loops and swirls over the balding center of the scalp. A variation of accepting the inevitable is to remove the remaining hair by shaving the entire scalp. Another option is to buy and wear a hairpiece (toupee) or a wig. A good one is expensive, however, and regardless of how much is paid for it, a hairpiece is detectable in bright light or when the wearer is in close proximity to others. A number of surgical techniques have been developed to put hair on the balding scalp. One technique is hair weaving, in which anchoring stitches are sewn into the bald scalp and new hair is woven and knotted into the anchors. In the hands of a skilled technician, hair weaving can be a satisfactory prosthesis. The wearer can swim, shower, shampoo, blow dry, and style, as well as be windblown, almost as though the hair was his own natural growth. Periodic tightening of the knots is required, however, and there is always the danger of irritation or infection from the anchoring stitches. Hair transplantation has worked well for some men. In this technique, skin plugs containing dense hair from the back or sides of the individual’s head are transplanted into prepared holes in the bald areas. The success of the procedure depends greatly on the skill of the physician. A skillful surgeon can achieve a natural-looking hairline and a fair-to-good coverage of hair if the donor sites are good. The procedure may take many weeks to months, depending on the area of scalp to be covered. Not all hair transplants “take,” and there is also the danger of infection. Women usually are not good candidates for hair transplantation because their hair loss is diffuse, involving almost the entire scalp. Thus, good donor sites generally are not available. A more radical approach to covering the balding scalp with the individual’s own hair is scalp reduction surgery. This involves removing a large section of the hairless scalp and stitching the edges together. The looseness and stretch of the human scalp makes this technique possible. Another radical surgical procedure is one in which a flap of hair-bearing scalp is moved from the sides or back of the head to replace a section of hairless scalp. Unfortunately, the flap technique involves bleeding, infection, and scarring. Regrowing Hair The search for a magic bullet to cure male pattern baldness and restore a healthy head of hair to the afflicted individual seemed to have ended with the development and availability of minoxidil (Rogaine). This prescription drug had been developed and prescribed for high blood pressure (hyper-
Hair loss and baldness ✧ 417 tension). Researchers discovered that a lotion form of the drug applied to the scalp grew some hair in some men. Clinical trials of a 2 percent solution of minoxidil among a group of men nineteen to forty-nine years of age with varying degrees of male pattern baldness produced varying results. Approximately 26 percent of the men reported moderate-to-dense regrowth of hair. This is compared to 11 percent of the men of the control group who applied only the liquid part of the solution minus the active ingredient. About 33 percent of the men achieved what was considered minimal regrowth of hair, while 31 percent of the control group also achieved minimal regrowth of hair. In each group, the experimental and the control, a sizable portion of men experienced no regrowth of hair, either with the drug or with the placebo. The lotion is available in a 2 percent solution form without a prescription. It must be applied twice daily for at least four months before any new hair growth can be expected. If no new hair develops after one year, the user is advised to stop applying the product and consult a physician. The product works best on men under fifty years of age with bald spots no larger than 3 to 5 inches in diameter. Once favorable results are obtained, the user must continue to apply the lotion or the new hair will be lost. Some cautions are associated with the use of minoxidil. It should not be used if there is no family history of hair loss, if the individual is less than eighteen years old, or if scalp irritation is present. Users should consult their physicians if they experience chest pain, rapid heartbeat, dizziness or fainting, or swelling of the feet or hands. Clearly, the magic bullet has not yet been found. —Albert C. Jensen See also Aging; Cosmetic surgery and aging. For Further Information: Hanover, Larry. “Hair Replacement: What Works, What Doesn’t.” FDA Consumer 31 (April, 1997). Discusses the use of minoxidil, surgical techniques such as transplants, and cover-ups, including wigs and toupees. Mayhew, John. Hair Techniques and Alternatives to Baldness. New York: Oweni Trado-Medic Books, 1963. A review of hair dressing, care and hygiene of the hair, and alternatives to baldness, including transplantation. Sadick, Neil S., and Donald C. Richardson. Your Hair and Helping to Keep It. Yonkers, N.Y.: Consumer Reports Books, 1991. An authoritative review of baldness, its causes, and what to do about it. Includes a discussion of human hair growth and hair care. SerVaas, Cory. “Early Male Pattern Baldness.” Saturday Evening Post 266 (March/April, 1996). In a question-and-answer format, SerVaas offers four suggestions for coping with this condition, including wait and see, application of minoxidil, surgery (including transplantation), and, if necessary, a hairpiece.
418 ✧ Hazardous waste Thompson, Wendy, and Jerry Shapiro. Alopecia Areata: Understanding and Coping with Hair Loss. Baltimore: The Johns Hopkins University Press, 1996. Provides a guide to the diagnosis and treatment of hair loss with reliable information from two medical professionals.
✧ Hazardous waste Type of issue: Environmental health, industrial practices, public health Definition: Products of industrial society that pose dangers to human health and the environment; in the United States they are legally defined as materials that have ignitable, corrosive, reactive, or toxic properties. In the early 1990’s approximately 97 percent of all hazardous waste in the United States was produced by 2 percent of the waste generators. Remediation and cleanup of these wastes involve substantial economic cost. Since the 1970’s the United States and other Western democracies have tried to regulate hazardous waste disposal. Hazardous wastes are also a serious problem in the former Soviet Union and other Eastern European nations. Improper disposal of hazardous waste can lead to the release of chemicals into the air, surface water, groundwater, and soil. High-risk wastes are those known to contain significant concentrations of constituents that are highly toxic, persistent, highly mobile, or bioaccumulative. Examples include dioxin-based wastes, polychlorinated biphenyls (PCBs), and cyanide wastes. Intermediate-risk wastes may include metal hydroxide sludges, while lowrisk wastes are generally high-volume, low-hazard materials. Radioactive waste is a special category of hazardous waste, often presenting extremely high risks, as do biomedical and mining wastes. Degrees of Risk Hazardous waste presents varying degrees of health and environmental hazards. When combined, two relatively low-risk materials may pose a high risk. Factors that affect the health risk of hazardous waste include dosage received; age, gender, and body weight of those exposed; and weather conditions. The health effects posed by hazardous waste include cancer, genetic defects, reproductive abnormalities, and central nervous system disorders. Environmental degradation resulting from hazardous waste can render various natural resources, such as cropland or forests, useless and can harm animal life. For example, chemicals can leach out of improperly stored waste and into groundwater. Hazardous wastes may generate long-lasting air and water pollution or soil contamination. Because the amount of waste pro-
Hazardous waste ✧ 419 duced in any period is based on the amount of natural resources used, the generation of both hazardous and nonhazardous waste poses a threat to the sustainability of the economy. Because there were no standards for what constituted a hazardous waste in the past, such materials were often buried or stored in unattended drums or other containers. This situation created a threat to the environment and human health when the original containers began to leak or the material leached into the water supply. The technology for dealing with hazardous solid and liquid waste continues to evolve. Several solutions have had positive impacts on the environment and consumption of natural resources. One solution is to reduce the volume of the waste material by generating less of it. The second approach is to recycle hazardous material as much as possible. A third means of dealing with hazardous waste is to treat it to render it less harmful and often reduce its volume. The least-preferred solution is to store the waste in landfills. The Environmental Protection Agency (EPA) has established standards for responsibility and tracking of hazardous wastes, based on the principle that waste generators are responsible for their waste “from cradle to grave.” This principle has involved extensive record-keeping by waste generators and disposal sites. The U.S. Congress’s 1984 Resource Conservation and Recovery Act (RCRA) revisions involved a thorough overhaul of hazardous waste legislation. Previously exempt sources that generated between 100 and 1,000
Controversy has surrounded how to store hazardous waste safely to avoid human contamination and illness. (PhotoDisc)
420 ✧ Hazardous waste kilograms of hazardous waste per month were brought under the RCRA provisions. Congress further tried to force the EPA to adopt a bias against the landfilling of hazardous waste with a “no land disposal unless proven safe” provision. Congress also added underground storage tanks for gasoline, petroleum, pesticides, and solvents to the list of sources to be regulated and remediated. In addition to the RCRA, Superfund (from the Comprehensive Environmental Response, Compensation, and Liability Act of 1980) provides for the cleanup of all categories of abandoned hazardous waste sites except for radioactive waste. Several other statutes (and ensuing EPA regulations) deal with these aspects of the hazardous waste problem. The costs for the cleanup and remediation of hazardous waste are substantial and are likely to continue to grow. This situation is particularly true in Eastern Europe and the former Soviet Union, where the magnitude of past dumping of hazardous materials is slowly becoming apparent. Meanwhile, less industrialized nations are ignoring the hazardous waste issue and are therefore setting themselves up for future difficulties. The waste minimization philosophy expressed in the RCRA is a sound long-range strategy for dealing with hazardous waste. However, some materials will continue to be deposited in landfills. Incineration offers some solutions to the problem of volume of material but poses issues of air quality and highly toxic ash. As some firms have found, minimizing their waste stream affords them economic benefits while conserving natural resources. Household waste, which is not regulated by the RCRA, often includes small quantities of hazardous materials such as pesticides. Most of this waste was still being landfilled in the late 1990’s. The cleanup of existing sites will continue to be a troubling problem, while the cleanup and disposal of radioactive waste will be a major issue for the future. —John M. Theilmann See also Environmental diseases; Mercury poisoning; Occupational health; Pesticides; Poisoning; Radiation; Water quality. For Further Information: Gerrard, Michael B. Whose Backyard, Whose Risk. Cambridge, Mass.: MIT Press, 1994. A helpful work. Grisham, Joe, ed. Health Aspects of the Disposal of Waste Chemicals. New York: Pergamon Press, 1986. Another helpful work. LaGrega, Michael D., Philip L. Buckingham, and Jeffrey C. Evans. Hazardous Waste Management. New York: McGraw-Hill, 1994. Useful discussions of various aspects of hazardous waste. Wildavsky, Aaron. But Is It True? Cambridge, Mass.: Harvard University Press, 1995. More discussions of various aspects of hazardous waste.
Headaches ✧ 421
✧ Headaches Type of issue: Mental health, public health Definition: A general term referring to pain localized in the head and/or neck, which may signal mere tension or a serious disorder. In 1988, an ad hoc committee of the International Headache Society developed the current classification system for headaches. This system includes fourteen exhaustive categories of headache with the purpose of developing comparability in the management and study of headaches. Headaches most commonly seen by health care providers can be classified into four main types: migraine, tension-type, cluster, and “other” acute headaches. Migraines Migraine headaches have been estimated to affect approximately 12 percent of the population. The headaches are more common in women and tend to run in families; they are usually first noticed in the teen years or young adulthood. For the diagnosis of migraine without aura (“aura” refers to visual disturbances or hallucinations, numbness and tingling on one side of the face, dizziness, or impairment of speech or hearing—symptoms that occur twenty to thirty minutes prior to the onset of the headache), the person must experience at least ten headache attacks, each lasting between four and seventy-two hours with at least two of the following characteristics: The headache is unilateral (occurs on one side), has a pulsating quality, is moderate to severe in intensity, or is aggravated by routine physical activity. Additionally, one of the following symptoms must accompany the headache: nausea and/or vomiting, or sensitivity to light or sounds. The person’s medical history, a physical examination, and (where appropriate) diagnostic tests must exclude other organic causes of the headache, such as brain tumor or infection. Migraine with aura is far less common. Migraines may be triggered or aggravated by physical activity, by menstruation, by relaxation after emotional stress, by ingestion of alcohol (red wine in particular) or certain foods or food additives (chocolate, hard cheeses, nuts, fatty foods, monosodium glutamate, or nitrates used in processed meats), by prescription medications (including birth control pills and hypertension medications), and by changes in the weather. Yet the precise pathophysiology of migraines is unknown. It had been posited that spasms in the blood vessels of the brain, followed by the dilation of these same blood vessels, cause the aura and head pain; however, studies using sophisticated brain and cerebral bloodflow scanning techniques indicate that this is likely not the case and that some type of inflammatory process may be involved related to the permeability of cerebral blood vessels and the resultant release of certain neurochemicals.
422 ✧ Headaches Tension Headaches Tension-type headaches are the most common type; the prevalence is approximately 79 percent. Tension-type headaches are not hereditary, are found more frequently in females, and are first noticed in the teen years of young adulthood, although they can appear at any time of life. For the diagnosis of tension-type headaches, the person must experience at least ten headache attacks lasting from thirty minutes to seven days each, with at least two of the following characteristics: The headache has a pressing or tightening (nonpulsating) quality, is mild or moderate in intensity (may inhibit but does not prohibit activities), is bilateral or variable in location, and is not aggravated by physical activity. Additionally, nausea, vomiting, and light or sound sensitivity are absent or mild. Furthermore, the patient’s medical history and physical or neurological examination exclude other organic causes for the headache apart from the following: oral or jaw dysfunction, muscular stress, or drug overuse. Tension-type headache sufferers describe these headaches as a bandlike or caplike tightness around the head, and/or muscle tension in the back of the head, neck, or shoulders. The pain is described as slow in onset with a dull or steady aching. Tension-type headaches are believed to be precipitated primarily by emotional factors but can also be stimulated by muscular and spinal disorders, jaw dysfunction, paranasal sinus disease, and traumatic head injuries. The pathophysiology of tension-type headaches is controversial. Historically, tension-type headaches were attributed to sustained muscle contractions of the pericranial muscles. Studies indicate, however, that most patients do not manifest increased pericranial muscle activity and that pericranial muscle blood flow and/or central pain mechanisms might be involved in the pathophysiology of tensiontype headaches. It is also believed that muscle contraction and scalp muscle ischemia play some role in tension-type headache pain. Cluster Headaches Cluster headaches are the least frequent of the headache types and are thought to be the most severe and painful. Cluster headaches are more common in males, with estimates of 0.4 to 1.0 percent of males being affected. Traditionally, these headaches first appear at about thirty years of age, although they can start later in life. There is no genetic predisposition to these headaches. For the diagnosis of cluster headaches, the person must experience at least ten severely painful headache attacks, typically on one side of the face and lasting from fifteen minutes to three hours. One of the following symptoms must accompany the headache on the painful side of the face: a bloodshot eye, tearing, nasal congestion, nasal discharge, forehead and facial sweating, contraction of the pupils, or drooping eyelids. Physical and neurological examination and imaging must exclude organic causes for the headaches, such as tumor or infection. Cluster headaches
Headaches ✧ 423 often occur once or twice daily, or every other day, but can be as frequent as ten attacks in one day, recurring on the same side of the head during the cluster period. The temporal “clusters” of these headaches give them their descriptive name. A cluster headache is described as a severe, excruciating, sharp, and burning pain through the eye. The pain is occasionally throbbing but always unilateral. Radiation of the pain to the teeth has been reported. Duration can range from ten minutes to three hours, with the next headache in the cluster occurring sometime the same day. Cluster headache sufferers are often unable to sit or lie still and are in such pain that they have been known, in desperation, to hit their heads with their fists or to smash their heads against walls or floors. Cluster headaches can be triggered in susceptible patients by alcohol consumption, subcutaneous injections of histamine, and sublingual use of nitroglycerine. Because these agents all cause the dilation of blood vessels, these attacks are believed to be associated with dilation of the temporal and ophthalmic arteries and other extracranial vessels. There is no evidence that intracranial blood flow is involved. Cluster headaches have been shown to occur more frequently during the weeks before and after the longest and shortest days of the year, lending support for the hypothesis of a link to seasonal changes. Additionally, cluster headaches often occur at about the same time of day in a given sufferer, suggesting a relationship to the circadian rhythms of the body. Vascular changes, hormonal changes, neurochemical excesses or deficits, histamine levels, and autonomic nervous system changes are all being studied for their possible role in the pathophysiology of cluster headaches. Acute Headaches Acute headaches, using the International Headache Society’s classification scheme, constitute many of the headaches not mentioned above. Distinct from the other headache types, which are often considered to be chronic in nature, acute headaches often signify underlying disease or a life-threatening medical condition. These headaches can display pain distribution and quality similar to those seen in chronic headaches. The temporal nature of acute headaches, however, often points to their seriousness. Acute headaches of concern are usually the first or worst headache the patient has had or are headaches with recent onset that are persistent or recurrent. Other signs that cause a high index of suspicion include an unremitting headache that steadily increases without relief, accompanying weakness or numbness in the hands or feet, an atypical change in the quality or intensity of the headache, headache upon exertion, recent head trauma, or a family history of cardiovascular problems. Such headaches can point to hemorrhage, meningitis, stroke, tumor, brain abscess, hematoma, and infec-
424 ✧ Headaches tion, which are all potentially life-threatening conditions. A thorough evaluation is necessary for all patients exhibiting the danger signs of acute headache. Treatment Options for Headaches A number of pharmacological treatments are available for stopping migraine headaches. Ergotamine tartrate is effective in terminating migraine symptoms by either reducing the dilation of extracranial arteries or in some way stimulating certain parts of the brain. Isomethaptine is a combination of chemicals that stimulates the sympathetic nervous system, provides analgesia, and is mildly tranquilizing. Another class of medications for migraines are nonsteroidal anti-inflammatory drugs (NSAIDs); these drugs work on the principle that inflammation is involved in migraine. Both narcotic and nonnarcotic pain medications are often used for migraines, primarily for their analgesic properties. Antiemetic medications, which prevent or arrest vomiting, have been used in the treatment of migraines. Sumatriptan, a vasoactive agent that increases the amount of the neurochemical serotonin in the brain, shows promise in treating migraines that do not respond to other treatments. Preventive treatments for migraines include beta-blockers, methysergide, and calcium channel blockers, which are believed to interfere with the dilation or contraction of extracranial arteries by acting on the sympathetic nervous system or on the central nervous system itself. Antidepressants have also been found to prevent migraine attacks; there appears to be an analgesic effect from certain antidepressants that is effective for chronic migraines. Antiseizure medications have been found to be useful for some migraine patients, although the mechanism of action is unknown. NSAIDs have also been used as a preventive measure for migraines. Several nonpharmacological treatments for migraines are also available, including stress management, relaxation training, biofeedback, psychotherapy, and the modification of headache-precipitating factors, such as avoiding certain dietary triggers. The treatment options for tension-type headaches include narcotic and nonnarcotic analgesics. More often with tension-type headaches, the milder over-the-counter pain medications (such as aspirin or acetaminophen) are used. NSAIDs, simple muscle relaxants, or antianxiety drugs can also be helpful. Muscle relaxants and antianxiety drugs are believed to relax smooth muscles, reducing scalp muscle ischemia and therefore head pain. Preventive treatments for tension-type headaches include antidepressants, narcotic and nonnarcotic analgesics, muscle relaxants, and antianxiety drugs. Occasionally, “trigger-point injections” are used to relieve tension-type headaches. Trigger points are areas within muscles, primarily in the upper back and neck, that are hypersensitive; when stimulated, they
Headaches ✧ 425 can cause headaches. These trigger points can be injected with a local anesthetic or steroid to decrease their sensitivity or to eliminate possible inflammation in the area. Nonpharmacological treatment of tension-type headaches is similar to that for migraines and includes stress management, relaxation training, biofeedback, and psychotherapy. Other self-management techniques include taking a hot shower or bath, placing a hot water bottle or ice pack on the head or back of the neck, exercising, and sleeping. For cluster headaches, the most common treatment is administering pure oxygen to the patient for ten minutes. The exact mechanism of action is unknown, but it might be related to the constriction of dilated cerebral arteries. Ergotamine tartrate or similar alkaloids given orally, intramuscularly, or intravenously can also abort the attack in some patients. Nasal drops of a local anesthetic (lidocaine hydrochloride) or cocaine have been used to interrupt the activity of the trigeminal nerve that is believed to be involved in cluster attacks. The efficacy of these treatments is inconclusive. Preventive treatment of this headache type is crucial. Ergotamine, methysergide, calcium channel blockers, antiseizure medications, and steroidal anti-inflammatory medications have been used with some success in the prevention of cluster attacks. The mechanism of action for these medications is unknown. Lithium carbonate, a drug commonly prescribed for bipolar disorder, has been found to be effective for some cluster patients. This medication is believed to affect certain regions of the brain, possibly the hypothalamus. While no nonpharmacological treatment strategies are routinely offered to cluster headache patients, surgery is an option in severe cases, particularly if the headaches are resistant to all other available treatments. One such surgical procedure destroys the trigeminal nerve pathway, the chief nerve pathway to the face. Modest successes have been found with this extreme treatment option. The total economic costs of headaches are staggering. Headaches constitute approximately 1.7 percent of all visits to physician offices. Of visits to hospital emergency rooms, 2.5 percent are for headaches. The expenses associated with advances in assessment techniques and routine health care have risen rapidly. The cost in lost workdays adds to this economic picture. Thirty-six percent of headache sufferers in one study reported missing one or more days of work in the previous year because of headaches. The scientific study of headaches is necessary to understand this prevalent illness. —Oliver Oyama See also Pain management; Stress. For Further Information: Blanchard, Edward B., and Frank Andrasik. Management of Chronic Headaches: A Psychological Approach. New York: Pergamon Press, 1985. The authors
426 ✧ Health insurance review the evaluation and treatment of headaches from a psychological perspective. Alternative, nonpharmacological treatments for headaches are described in detail. The chapters are practical and offer a guide for managing headaches derived from the authors’ experiences at a headache clinic. Diamond, Seymour. “Migraine Headaches.” The Medical Clinics of North America 75, no. 3 (May 1, 1991): 545-566. Diamond is one of the world’s authorities on headaches. His article is well organized and comprehensively addresses the subject of migraines in a readable and interesting format. A practical guide to treating the headache patient. Rapoport, Alan M., and Fred D. Sheftell. Headache Relief. New York: Simon & Schuster, 1991. The book takes the often-complicated theory, evaluation, and treatment of headaches and explains each area in very understandable terms for the layperson. The authors describe a “how-to” approach to treating headaches. Raskin, Neil H. Headache. 2d ed. New York: Churchill Livingstone, 1988. A review of headaches from a technical perspective. The reader looking for a thorough resource study of headaches will find this text useful. The review of common headache types is comprehensive and reflects the research on headaches in the mid-1980’s. Saper, Joel R., et al., eds. Handbook of Headache Management: A Practical Guide to Diagnosis and Treatment of Head, Neck, and Facial Pain. 2d ed. Baltimore: Williams & Wilkins, 1999. A manual for doctors with patients complaining of headache pain.
✧ Health insurance Type of issue: Economic issues, public health, social trends Definition: Insurance to cover medical care. Medical insurance in the United States began in the 1850’s when insurance companies began offering policies protecting railroad passengers against injury. Health maintenance organizations (HMOs) were first implemented in the 1930’s, with the 1970’s seeing increased HMO proliferation due to higher health care costs and increased competition between growing numbers of physicians. The Health Maintenance Organizations Act of 1973 provided federal grants and loans for HMOs and required many employers to offer HMO membership to employees as a health insurance alternative. The HMO concept served as a means to control costs by discouraging physicians from performing unnecessary and costly procedures, meet the increased demand for health insurance particularly in medically underserved areas, and foster preventive medicine. Financial incentives are, in
Health insurance ✧ 427 theory, the major force behind personal freedom of choice, containment of costs, and assurance of quality. Preferred provider organizations (PPOs) appeared in the 1980’s as a flexible alternative to standard HMOs, with many health insurers such as Blue Cross and Blue Shield exerting control over their daily operations. Medicare and its companion program Medicaid are federally administered programs begun in the 1960’s that guarantee medical insurance coverage for elderly and low-income American citizens. Other government medical insurance plans cover armed forces personnel, veterans, American Indians, and federal employees. Social Security pays disability benefits to covered persons and their dependents, whereas workers’ compensation pays medical expenses and covers income losses for workers injured on the job. Medical insurance plans can be generally divided into medical expense insurance, income loss insurance, and accidental death and dismemberment coverage. Private Medical Insurance Programs Private insurance companies provide a majority of the medical insurance plans in the United States. Some are for-profit stock companies or mutual companies owned by their policyholders. Nonprofit hospital associations such as Blue Cross and medical associations such as Blue Shield also provide insurance for hospitalization and surgical expenses, respectively. Hospitalization insurance generally covers the cost of hospital room and board and expenses such as X rays, blood tests, and medications required as an inpatient. A deductible often applies before the insurer begins to pay benefits, with coverage often also limited to a specified number of days per illness. Hospitalization insurance generally does not cover general physician or surgeon fees, with many policies dictating a specified amount per clinic visit or surgical procedure. Prescription drugs, rehabilitation costs, and items such as prostheses are also often covered as stated in the policy. Major medical insurance has a much higher maximum benefit limit, often over one million dollars and sometimes unlimited. A larger deductible generally applies, with the insurer often paying 80 percent of the expenses over the deductible. Comprehensive major medical policies often do not have an initial deductible and require the insurer to pay all expenses up to a stated amount, with the insurer paying 80 percent of all expenses over that amount. Disability insurance protects against loss of income resulting from accidental injury or illness, with benefits often structured to pay approximately 40 to 60 percent of earnings up to the maximum total amount. Accidental injury cases may receive payments beginning with the day of injury, whereas illness benefits may not be paid until the insured person has been unable to work for a specified period of time.
428 ✧ Health insurance Accidental death or dismemberment insurance, commonly advertised in vending machines at transportation centers such as airports, provides benefits in the event of death or loss of organs or limbs as a result of travel. Health Maintenance Organizations (HMOs) HMOs provide medical insurance to groups and individuals for an established, prepaid monthly premium. Generally, an HMO attempts to provide care at a lower cost than traditional fee-for-service insurance programs by transferring financial risk to physicians through capitation and other incentives. The result is that patients often have to accept fewer choices in treatment options and specialist providers. Preferred providers are physicians and other health care providers and hospitals who choose to provide health care on a reduced-cost basis to subscribers of an HMO. HMOs function in a dual role as both a health insurance company and a provider of health services, roles that were previously separated within American health care. HMOs are often organized by employers, physician groups, unions, consumer groups, insurance companies, or for-profit health care agencies. They were originally formed from one, or a mixture of, the following practice models: point of service, staff, group, and independent practice association. A point-of-service model HMO, also called an open-ended HMO, includes an option that allows subscribers to seek medical care outside the established network and receive partial reimbursement, with all remaining expenses paid out of pocket. A staff model HMO is directly controlled at its headquarters locations, with all physicians and other health care workers being direct, full-time salaried employees. A group model HMO is organized by physicians whereby a private professional corporation is established that then individually contracts with an HMO to provide services exclusively for its subscribers. An independent practice association model HMO provides a flexible arrangement created by office physicians and administrators designed to compete with the classic HMOs; several office physicians in a community form a networked professional corporation that seeks group contracts among local employers and provides all medical care for a capitated rate per client per month to subscribers who often choose a personal primary care physician. The term “managed care” describes the techniques by which an HMO, a health insurance carrier, or a self-insuring employer makes certain that the health care services it endorses are high quality and cost effective. An HMO will also furnish services from other health care providers, such as physical and occupational therapists, pharmacists, and mental health professionals. HMOs are attractive to employers because the annual medical bill for the average subscriber-patient has consistently proven to be approximately 30 percent less than that of conventional insurers. Advantages of HMO mem-
Health insurance ✧ 429 bership include that all medical expenses, from routine and emergency care to hospitalization, are covered within a single, fixed monthly premium and that presenting an HMO membership card at the time of services with a small copayment requires no forms to fill out, deductibles to pay, or bills to submit. Disadvantages include that subscribers often cannot keep a trusted physician that they have had for years, providers become extremely busy when they are assigned five hundred or more patients in exchange for a fixed fee, and subscribers often have to accept fewer choices in treatment options. Each client is assigned to a “primary care gatekeeper,” a physician who is expected to provide most care in his or her private office for limited fees. When a referral to a specialist, laboratory, or hospital is necessary, authorization is required from the headquarters of the managed care organization. Hospitals contract with these organizations to limit their charges and follow established rules about economical care and prompt discharge. The managed care organization reviews utilization by physicians and hospitals, attempts to correct wasteful practices, and subsequently drops health care providers with expensive and/or poor practice styles. Point-of-Service Plans In contrast to more traditional HMOs, point-of-service plans have emerged that enable clients to have freedom of choice with respect to providers and some treatment options but that require them personally to pay the balance for their chosen higher-priced services. If a patient goes to physicians, hospitals, and other providers within the network and follows rules about utilization and authorization, the out-of-pocket financial costs are minimal. The patient retains the option to go to an out-of-plan provider, pay the bill in full, and then be reimbursed for the limited amount established in the individual plan. The employer’s group contract with the managed care organization provides for limited and predictable premiums. The considerable costs of out-of-plan services thus are shifted from the group contract to the individual patient. Managed care plans will continue to monitor closely the treatment patterns of physicians and encourage them to prescribe cheaper medications, develop standards that physicians are expected to follow in the treatment of various diseases, and have utilization review panels that examine patient records and decide which treatments a patient’s health plan will cover and which it will not. Many states have passed comprehensive managed care laws as a result of numerous consumer complaints about the decisions of case managers who often have no medical training. Legislation has focused on issues such as adopting measures to ban physician gag clauses, establish consumer grievance procedures, require disclosure of financial incentives for physicians to withhold care, conduct external reviews of an HMO’s
430 ✧ Health insurance internal decision to deny care, and grant the ability to sue an HMO for malpractice. The largest looming question regarding the future of HMOs is whether physicians and other health care workers and client subscribers will continue to enroll in and thus support the system. Managed care necessarily adds substantial administrative overhead, with the ongoing question of whether the final result is greater efficiency for the entire system or just for the subscribing employers. An organization that will exert considerable influence on future HMO developments is the American Association of Retired Persons (AARP), a large nonprofit advocacy group for Americans over the age of fifty with more than thirty million members. AARP has begun giving endorsements to HMOs that meet its standards of quality and price. Medicare and Medicaid In 1965, amendments to the Social Security Act of 1935 that established Medicare and Medicaid were enacted. Medicare went into effect in 1966 and authorized compulsory health insurance for American citizens aged sixtyfive and older who were entitled to receive Social Security or railroad retirement benefits. Medicaid was established by the 1965 amendments as a means-tested entitlement program to provide medical assistance to low-income persons who were aged, blind, disabled, pregnant, or members of families with dependent children, as well as other groups of needy children. The establishment of Medicare and Medicaid followed considerable heated political debate over the feasibility of a national health care program, stimulated by a 1963 government survey that revealed only about 50 percent of elderly American citizens had health insurance. Many older Americans could not afford private coverage, and the elderly who attempted to pursue coverage were often denied on the basis of age or preexisting conditions. Passage of Medicare and Medicaid guaranteed insurance coverage for elderly and low-income Americans and initiated numerous major changes involving private financing relationships between physician and patient, physician training, insurance industry growth, and expansion of hospitalonly coverage to extended care. The late 1960’s saw these programs become substantially more expensive than originally anticipated, with amendments in 1972 being the first major attempts to limit expenditures. Medicare’s basic benefits package, which includes part A (hospital insurance) and part B (supplemental medical insurance), has changed little since its inception, with the only major variation being that many services are now delivered beyond traditional acute care settings. Part A is an earned benefit for most Americans and requires no premium upon eligibility, whereas part B is voluntary for a monthly premium. Nearly all older and disabled beneficiaries elect to participate in part B. Part A benefits include inpatient hospital care coverage for the first sixty days, less a deductible for each
Health insurance ✧ 431 period of acute illness; inpatient psychiatric care; skilled nursing care or rehabilitation associated with recuperation for up to one hundred days following hospitalization; home health care as prescribed by a physician; and hospice care for the terminally ill. Not covered are outpatient prescription drugs, routine physical examinations, nonsurgical dental services, hearing aids and eyeglasses, and most long-term care in nursing facilities, in the community, or at home. In 1972, Medicare coverage was extended to persons of any age with end-stage renal (kidney) disease, those receiving Social Security Disability Insurance for at least two years, and persons aged sixty-five and older who are otherwise not eligible but elect to enroll by paying a monthly premium. In the late 1990’s, Medicare accounted for 28 percent of all hospital payments in the U.S. health care system and 20 percent of all physician payments. Medicare covered 45 percent of overall health care spending for the elderly but a lower percentage for the very elderly, particularly those requiring full-time nursing home care. The Medicare Catastrophic Coverage Act of 1988 attempted to require Medicare beneficiaries to pay the full cost of expanded benefits through an income-related tax surcharge and a flat premium. Elderly citizens organized groups in intense opposition to premium funding, leading to the repeal of the act one year later. Beginning in 1984, Congress made amendments to Medicaid to require individual states to cover all infants and pregnant women below the poverty level, with their eligibility determined by an index based on income level and family size. The Catastrophic Coverage Act gave states the option of covering those below 185 percent of the poverty line and required the states to pay Medicare cost sharing for all poor elderly and disabled Medicare beneficiaries. These provisions were retained when the act was repealed. Other Government Medical Insurance Programs Numerous other programs exist at various levels of government to help Americans pay medical expenses and meet income losses. The federal government provides medical insurance for armed forces personnel and their dependents, veterans, American Indians, and federal employees. Social Security pays disability benefits to covered workers and their dependents until the individual recovers and returns to work, dies, or reaches age sixty-five, when retirement benefits are received. Workers’ compensation pays medical expenses and covers income losses for workers injured on the job. —Daniel G. Graetzer See also HMOs; Hospice; Hospitalization of the elderly; Nursing and convalescent homes.
432 ✧ Hearing aids For Further Information: Brink, Susan, and Nancy Shute. “Are HMOs the Right Prescription?” U.S. News and World Report 123, no. 4 (October 13, 1997): 60-65. Covered in this well-researched article is the growing dissatisfaction of subscribers with the quality of health care received, with a rating of the best HMOs in the United States. Gold, M. “Health Maintenance Organizations: Structure, Performance, and Current Issues for Employee Health Benefits Design.” Journal of Occupational Medicine 33, no. 3 (1991): 288-296. From an occupational medicine viewpoint, this manuscript reviews numerous health benefit plans designed for large and small company employees by examining consumer satisfaction, quality of health care, and analysis of the cost-benefit ratio. National Academy on Aging. Facts on Medicare: Hospital Insurance and Supplemental Medical Insurance. Washington, D.C.: Author, 1995. Contains current information and answers to frequently asked questions about Medicare. Current information can also be obtained from Medicare’s Web site: http://epn.org/aging/agmedi.html.
✧ Hearing aids Type of issue: Elder health, treatment Definition: Mechanical devices that counteract the effects of hearing loss by amplifying soundwaves as they enter the ear. In the United States, about 10 percent of the population have some degree of hearing loss. Hearing loss tends to worsen with aging, and, as the proportion of people living past sixty-five years of age increases, so will the percentage of those who develop hearing loss. The causes of hearing loss are many and must be pinpointed in individual cases before any treatment can be initiated. Types of Hearing Loss There are three general types of hearing loss, classified according to what structures of the ear may be involved. All types of hearing loss are not equally amenable to improvements with the use of hearing aids. In conductive hearing loss, changes have occurred in the outer and middle ear. Sensorineural hearing loss involves the inner ear. In the third type, damage involves both conductive and sensorineural aspects, resulting in a mixed loss. It is not unusual to find the mixed type of hearing loss among the elderly. The causes of the different types of hearing loss are varied. In some cases of conductive damage, the loss may be caused by an infection and may be effectively treated by medication. Surgery may be recommended in those
Hearing aids ✧ 433 cases where the hearing loss is a result of a problem in the middle ear. In the condition known as otosclerosis, a bony growth forms at the base of the stapes and prevents the proper movement of the small, bony ossicles in the middle ear so that normal transmission of the sound wave cannot occur. Otosclerosis is the most common cause of conductive deafness in adults. The condition can usually be corrected by surgically removing the stapes and replacing it with a plastic or metal device. Hearing aids may be of considerable benefit to most people who have sensorineural hearing loss. However, people with severe sensorineural hearing loss (commonly known as nerve deafness) who do not gain any benefit from hearing aids may use cochlear implants, which allow the auditory nerve to be directly stimulated. Presbycusis, or age-related deafness, is the most common cause of sensorineural hearing loss among those individuals sixty-five years of age and older. By the age of sixty-five, nearly 20 percent of the population suffers from presbycusis, which results from changes in the inner ear and in the auditory nerve. The inner ear contains hair cells that are, in fact, nerve cells that respond to stimuli, including sound vibrations. At birth, there are twenty thousand to thirty thousand hair cells in the ear; as they gradually wear out and die during the course of a lifetime, people experience a loss of their ability to hear high-pitched sounds. A person might have difficulty hearing all the words produced by some women and children. Since individuals suffering from presbycusis have trouble hearing only certain things from certain people, they may not be aware of the deterioration in hearing and may not realize that the situation might be improved through use of a hearing aid. The loss of hearing also may affect a person’s ears unequally. If the imbalance is severe enough, a person may experience difficulty in localizing sound, which may lead to disorientation. This condition tends to get progressively worse with age, and certain families are at higher risk than others. Factors that contribute to presbycusis are many, and it is difficult to determine how these factors interact with those “normal” changes that accompany aging. Without a doubt, occupational noise and other everyday noises are major contributors to presbycusis. There is wide variation in the rate of decline in hearing among individuals as they age. Types of Hearing Aids Hearing aids fall into four general types: those worn on the body, those that are part of an eyeglass frame, those worn behind the ear, and those worn in the ear. Some types are effective only for mild hearing loss, whereas other models may be required for more severe hearing impairments. Continued advances in technology have increased the ability of hearing aids to help improve even severe hearing loss. The different types of hearing aids are not used in equal numbers. Relatively few people use the body-worn type or the
434 ✧ Hearing aids eyeglass unit. Used somewhat more frequently is the behind-the-ear aid. However, the majority of hearing-impaired people use some form of the in-the-ear type. Like any product, the useful life of a hearing aid will vary, but they should last, on the average, four to five years. All hearing aids function in a similar manner. A battery furnishes the operational power source. The size of the battery depends on the size of the aid and the amount of power required to carry out its specific function. The life of a battery is related to the length of time the aid is used and the power needs of the hearing aid. Zinc-air batteries usually maintain performance until they go completely dead, whereas other types, such as mercury batteries, tend to weaken before they are entirely drained. Batteries may last three weeks or less, and it is prudent to always have a supply on hand. Hearing aids work by picking up sound waves with a microphone and converting them into electrical energy. An amplifier unit controls the volume by increasing the strength of the electrical energy. The receiver then converts the electrical signal back into sound waves. One final, but critical, component of the behind-the-ear hearing aid, the body aid, and the eyeglass aid is the earmold, which connects the hearing aid to the ear. Earmolds must be fitted or molded to individual ears. Since the earmold governs the amount and quality of the sound that passes from the aid into the ear, it not only must match the physical characteristics of each ear but also must be chosen on the basis of the type of hearing loss. Once a person begins to wear a hearing aid, it is essential that hearing and the hearing aid be checked regularly. The checkup usually includes an examination of the earmold, since the shape and size of the ear may change over time. A hearing aid is an extremely sensitive instrument that must be carefully adjusted for the individual who is using it. The Invisible Handicap Although the nature and cause of an individual’s hearing loss may have been determined and a proper hearing aid may have been decided upon, it does not necessarily mean that a person’s hearing problem has been solved. Hearing loss is often referred to as the “invisible handicap.” Many people are slow to recognize that their hearing is deteriorating, others are slow to do anything about it, and many go into a period of denial. Individuals may have problems adjusting to wearing hearing aids because they feel embarrassed or do not want to “stand out.” Learning to hear with hearing aids also requires a period of adjustment. However, once a hearing-impaired person has overcome these obstacles, a return to a near-normal life, with all its personal and social benefits, follows. —Donald J. Nash See also Aging; Disabilities; Hearing loss; Noise pollution.
Hearing loss ✧ 435 For Further Information: American Association of Retired Persons. A Report on Hearing Aids: User Perspectives and Concerns. Washington, D.C.: Author, 1993. Dugan, Marcia P. Keys to Living with Hearing Loss. New York: Barron’s Educational Service, 1997. Pope, Anne. Solutions, Skills, and Sources for Hard of Hearing People. New York: Dorling Kindersley, 1997. Wayner, Donna A. Hear What You’ve Been Missing. Minneapolis: Chronimed, 1998. _______. The Hearing Aid Handbook: User’s Guide for Adults. Washington, D.C.: Gallaudet University Press, 1990.
✧ Hearing loss Type of issue: Elder health, occupational health, public health Definition: Loss of sensitivity to sound pressure changes as a result of congenital factors, disease, traumatic injury, noise exposure, or aging. In the truest sense, hearing loss is any reduction in threshold sensitivity for any frequency, including those below or above the range for the normal hearing of speech. The real issue, however, is whether minor changes in sensitivity create significant problems in understanding speech and other information-bearing acoustic signals. For example, it is known that loss of threshold sensitivity below 300 hertz and above 4,000 hertz has a minimal affect on understanding speech information. It is when hearing loss exists within this critical frequency range that an individual may experience appreciable difficulty in understanding intended messages. The question becomes, then, what conditions cause a permanent or temporary loss of hearing and how such a loss is managed by medical, surgical, or rehabilitative intervention. Conductive Hearing Loss Any barrier or impedance that keeps sound from reaching the cochlea of the human auditory system at its intended loudness is termed conductive hearing loss. A very common cause of conduction loss is a buildup of earwax (cerumen) in the external ear canal. Normally, earwax will migrate out of the ear. It is when the earwax accumulates to an amount sufficient to block sound from entering the ear that something needs to be done. In most cases, earwax can be removed by irrigation. A physician washes out the earwax using a special liquid solution that does not damage the tissue of the ear canal or the eardrum itself.
436 ✧ Hearing loss Another cause of conductive hearing loss is a hole (perforation) in the eardrum, which can be created by a number of conditions, including injury. Depending on the size and location of the hole, surgery (tympanoplasty) is often successful in restoring normal hearing function. For some persons, otosclerosis, a disease causing hardening and fixing of the three small bones in the middle-ear space, results in significant conductive hearing impairment. Otosclerosis prevents these tiny bones from moving efficiently as the eardrum moves, and hearing sensitivity is reduced. Advances in surgical procedures have allowed the surgeon to replace the stapes bone with a suitable prosthesis, reinstating relatively normal activity of the ossicles and greatly improving hearing ability. A frequently occurring cause of conductive pathology is otitis media. Otitis media may refer to inflammation involving the middle-ear space or to a disorder in which the middle ear is filled with a watery fluid. In some cases, the fluid may harbor bacteria, creating significant medical problems if this condition is not treated early. Such middle-ear effusions are more common in children than in adults. If fluid is present in the middle ear, its mass will restrict the movement of the ossicles and create hearing impairment. Generally, patients with otitis media can be successfully treated through medical or surgical intervention. Conductive pathology does not affect the behavior of inner-ear structures. If the conductive pathology is eliminated by appropriate treatment, normal hearing will be restored. Severity of the condition may prevent the restoration of hearing, however, even if an aggressive treatment program is followed. Sensorineural Hearing Loss There are two types of hearing loss within this classification. One is a sensory loss which involves the destruction of nerve cells (hair cells) in the cochlea. The other is a neural loss which involves neural cells in the ascending auditory pathway from the cochlea to the brain. It is possible to experience one type of loss without the other. Some examples of sensory loss include loss of nerve cells resulting from traumatic injury to the cochlea (such as from whiplash, sharp blows to the head, or sudden, brief, and intense noises); loss of sensory cells from viral infections such as measles; loss of sensory cells caused by ototoxic drugs as those in the mycin group (such as streptomycin or kanamycin); congenital problems associated with a lack of embryonic development; and exposure to loud and continuous noise, a common cause of hearing loss in adults. This last type of impairment is different from traumatic injury resulting from sudden, intense noise because it may take months or years for hearing loss caused by long-term noise to manifest itself. Research has also established a clear correlation between the normal aging process and sensory hearing impairment.
Hearing loss ✧ 437 When sensory hearing impairment occurs, it is permanent. At the moment, there is no way of regenerating sensory tissue after the cell body has died. The only exception is found in those patients suffering from Ménière’s disease, which is characterized by vertigo, dizziness, vomiting, and hearing loss. In the initial stages, however, the loss of sensitivity to sound is the result of changes in cellular physiology rather than of death of the nerve cells. Examples of neural hearing loss are found among those hearing-impaired individuals with tumors, acoustic neuromas (benign tumors), cysts, and other anomalous conditions affecting the transmission of nerve impulses from the cochlea to the brain. Depending on the magnitude of the disorder, neural hearing loss has a much more devastating effect on speech understanding and signal processing than does sensory loss. As with sensory hearing impairment, neural hearing loss is a rather frequent occurrence associated with the aging process. For a sizable portion of those who experience hearing impairment, components of both sensory and neural loss are present. If the cause of the hearing deficit is entirely neural in nature, then the impairment is referred to as a retrocochlear loss. For some types of neural pathology, medical or surgical intervention can be undertaken successfully. Acoustic neuromas are often removed after they have been confirmed by audiologic, otologic, radiologic, and other diagnostic modalities. The size and location of the neuroma or tumorous growth will often dictate whether hearing can be preserved following surgery. The Prevalence and Treatment of Hearing Loss Hearing loss is quite common and affects some twenty million Americans, ranging from infants to the elderly. The primary reason for preserving hearing is to maintain social adequacy in communication skills. Hearing conservation programs have been instituted by public and private schools, industry, military installations, construction organizations, and more recently, the U.S. government. In 1970, the Occupational Safety and Health Act (OSHA) was passed, making it mandatory for employers to provide safe work areas for workers exposed to noise levels exceeding government standards. For those millions suffering from hearing impairment, it is the loss of speech discrimination ability that is of greatest concern. Thousands of studies have been undertaken to investigate the correlation between the magnitude, type, and length of hearing loss and the degree of speech recognition difficulty. One of the essential findings indicates that hearing loss is more pronounced for the high frequencies (above 1,000 hertz), whether the loss is caused by disease, drugs, noise, or the aging process. Another major finding is that one’s ability to identify vowel and consonant information is frequency-dependent. Vowel identification is dependent on frequencies from about 200 hertz to 1,000 hertz, while consonant identifica-
438 ✧ Hearing loss tion is dependent on frequencies above 1,000 hertz. A listener understands about 68 percent of speech sounds if nothing above 1,500 hertz is heard and about 68 percent of speech if nothing below 1,500 hertz is heard. For the hearing impaired, understanding of speech is related to the degree of loss and the type of impairment. Because medical or surgical care cannot always ameliorate the loss, rehabilitation programs may take the form of speech or lipreading to improve communication skills. These rehabilitative programs constituted the treatment of choice until the introduction of wearable electric hearing aids. Hearing aids have become the treatment of choice when medical or surgical intervention is not indicated in resolving hearing loss. It is possible not only to control the loudness of the hearing aid sound but also to shape the frequency response of the instrument to match the acoustic needs of the patient. Transistor technology makes it possible to reduce the size of the hearing aid device without sacrificing performance. Computer science has also been used in the design of hearing aids. With digital technology, it is now possible to program electroacoustic characteristics into the hearing aid, which extends its utility. —Robert Sandlin See also Aging; Disabilities; Hearing aids; Noise pollution; Speech disorders. For Further Information: Gerber, Sanford. Introductory Hearing Science. Philadelphia: W. B. Saunders, 1974. Somewhat more than a basic text, but one that clearly outlines the various aspects of hearing science, from the measurement of sound and hearing to the use and description of hearing aid devices for the acoustically impaired. Suitable for those readers who have some basic knowledge of how the ear works and the fundamentals of sound, but can be understood by those having little or no previous knowledge of acoustics or the auditory system. Pascoe, David. Hearing Aids: Who Needs Them? St. Louis: Big Bend Books, 1991. This easy-to-read text presents an abundance of data relative to hearing, hearing aid devices, and their use. Answers many questions that may arise concerning hearing aid use in direct and simple terms. One of the most significant aspects of this book is that it explains, in reasonable detail, how to use and evaluate hearing aids. Yost, William. Fundamentals of Hearing. 4th ed. San Diego: Academic Press, 2000. This text describes, in easy-to-understand terms, the organ of hearing and its contribution to an individual’s behavior. Simple auditory theory is examined, as is the nature of the ear’s response to acoustic energy.
Heart attacks ✧ 439
✧ Heart attacks Type of issue: Elder health, public health Definition: The sudden death of heart muscle characterized by intense chest pain, sweating, shortness of breath, or sometimes none of these symptoms. Although varied in origin and effect on the body, heart attacks (or myocardial infarctions) occur when there are interruptions in the delicately synchronized system either supplying blood to the heart or pumping blood from the heart to other vital organs. The heart is a highly specialized muscle with four chambers, two ventricles and two atria. The heart’s action involves the development of pressure to propel blood through arriving and departing channels—veins and arteries—that must maintain that pressure within their walls at critical levels. The efficiency of this process, as well as the origins of problems of fatigue in the heart that can lead to heart attacks and eventual heart failure, is tied to the maintenance of a reasonably constant level of blood pressure. If pulmonary problems (blockage caused by the effects of smoking or environmental pollution, for example) make it harder for the right ventricle to push blood through the lungs, the heart must expend more energy. Similarly, and often in addition to the added work for the heart because of pulmonary complications, the efficiency of the left ventricle in handling blood flow may be reduced by the presence of excessive fat in the body, causing this ventricle to expend more energy to propel oxygenated blood into vital tissues. Although factors such as these may be responsible for overworking the heart and thus contributing to eventual heart failure, other causes of heart attacks are to be found within the heart, particularly in the coronary arteries. The passageways inside these and other key arteries are vulnerable to the process known as atherosclerosis,, the accumulation of fatty deposits. If these deposits continue to collect, less blood can flow through the arteries. A narrowed artery also increases the possibility of a variant form of heart attack, in which a sudden and total blockage of blood flow follows the lodging of a blood clot. A symptomatic condition called angina pectoris, characterized by intermittent chest pains, may develop if atherosclerosis reduces blood (and therefore oxygen) supply to the heart. These danger signs can continue over a number of years. If diagnosis reveals a problem that might be resolved by preventive medication, exercise, or recommendations for heart surgery, then this condition, known as myocardial ischemia, may not necessarily end in a full heart attack.
440 ✧ Heart attacks Types of Heart Attack A full heart attack occurs when, for one of several possible reasons including a vascular spasm suddenly constricting an already clogged artery or a blockage caused by a clot, the heart suddenly ceases to receive the necessary supply of blood. This brings almost immediate deterioration in some of the heart’s tissue and causes the organ’s consequent inability to perform its vital functions effectively. Another form of attack and disruption of the heart’s ability to deliver blood can come either independently of or in conjunction with an arterially induced heart attack. This form of attack involves a sustained interruption in the rate of heartbeats. The necessary pace or rate of contractions is regulated in the sinoatrial node in the right atrium, which generates its own electrical impulses. There are, however, other so-called local pacemakers located in the atria and ventricles. If these sources of electrical charges begin giving commands to the heart that are not in rhythm with those coming from the sinoatrial node, then dysrhythmic or premature beats may confuse the heart muscle, causing it to beat wildly. In fact, the concentrated pattern of muscle contractions will not be coordinated and instead will be dispersed in different areas of the heart. The result is fibrillation, a series of uncoordinated contractions that cannot combine to propel blood out of the ventricles. This condition may occur either as the aftershock of an arterially induced heart attack or suddenly and on its own, caused by the deterioration of the electrical impulse system commanding the heart rate. In patients whose potential vulnerability to this form of heart attack has been diagnosed in advance, a heart physician may decide to surgically implant a mechanical pacemaker to ensure coordination of the necessary electrical commands to the heart. Preventing and Treating Heart Attacks Medical advances have helped reduce the high death rates formerly associated with heart attacks, many in the field of preventive medicine. The most widely recognized medical findings are related to diet, smoking, and exercise. Although controversy remains, there is general agreement that cholesterol absorbed by the body from the ingestion of animal fats plays a key role in the dangerous buildup of platelets inside arterial passageways. It has been accepted that regular, although not necessarily strenuous, exercise is an essential longterm preventive strategy that can reduce the risk of heart attacks. Exercise also plays a role in therapy after a heart attack. In both preventive and postattack contexts, it has been medically proven that the entire cardiovascular system profits from the natural muscle-strengthening process and general cleansing effects that result from controlled regular exercise. The domains of preventive surgery and specialized drug treatment to prevent dangerous blood clotting are vast. Statistically, the most important
Heart attacks ✧ 441 and widely practiced operations that were developed in the later decades of the twentieth century were replacement of the aortic valve, coronary bypass, and heart transplantation. Coronary bypass operations involve the attachment of healthy arteries to carry the blood that can no longer pass through the patient’s clogged arterial passageways; these healthy arteries are taken by the heart surgeon from other areas of the patient’s own body. Balloon angioplasty held out a major nonsurgical promise of preventing deterioration of the arteries leading to the heart. This sophisticated form of treatment involves the careful, temporary introduction of inflatable devices inside clogged arteries, which are then stretched to increase the The pain associated with heart attacks can take space within the arterial passeveral different forms. (Hans & Cassidy, Inc.) sageway for blood to flow. By the 1990’s, however, doctors recognized one disadvantage of balloon angioplasty. By stretching the essential blood vessels being treated, this procedure either stretches the plaque with the artery or breaks loose debris that remains behind, creating a danger of renewed clogging. Thus another technique, called atherectomy, was developed to clear certain coronary arteries, as well as arteries elsewhere in the body. Atherectomy involves a motorized catheter device resembling a miniature drill that is inserted into clogged arteries. As the drill turns, material that is literally shaved off the interior walls of arteries is retrieved through a tiny collection receptacle. Early experimentation, especially to treat the large anterior descending coronary artery on the left side of the heart, showed that atherectomy was 87 percent effective, whereas, on the average, angioplasty removed only 63 percent of the blockage. In addition, similar efforts to provide internal, nonsurgical treatment of clogged arteries using laser beams were being made by the 1990’s. —Byron D. Cannon
442 ✧ Heart disease See also Arteriosclerosis; Cardiac rehabilitation; Cholesterol; Exercise; First aid; Heart disease; Heart disease and women; Hypertension; Obesity; Obesity and aging; Preventive medicine; Resuscitation; Secondhand smoke; Smoking. For Further Information: Baum, Seth. The Total Guide to a Healthy Heart: Integrative Strategies for Preventing and Reversing Heart Disease. New York: Kensington, 2000. This book brings together the practices of both conventional and alternative approaches to reversing heart disease and maintaining heart health. Offers great insight into why the integrative approach to maintaining a healthy heart will be the medicine of the new millennium. Gillis, Jack. The Heart Attack Prevention and Recovery Handbook. Point Roberts, Wash.: Hartley & Marks, 1995. Using simple, brief explanations, Gillis’s text covers essential information that heart attack victims and families need immediately for reassurance and recovery. Presents excellent discussions of emotional effects on patients, medications, and treatments. McGoon, M. The Mayo Clinic’s Heart Book. New York: William Morrow, 1993. The most respected text for laypeople on heart disease. Covers all aspects of anatomy, physiology, diagnosis, treatment, and prevention. Yannios, Thomas A. The Heart Disease Breakthrough: What Even Your Doctor Doesn’t Know About Preventing a Heart Attack. New York: Wiley, 1999. Yannios, associate director of critical care and nutritional support at Ellis Hospital in Schenectady, New York, describes the smallest components of cholesterol, which can do more damage to the heart than the overall LDL levels that concern so many people. Zaret, Barry L., Marvin Moser, and Lawrence S. Cohen, eds. Yale University School of Medicine Heart Book. New York: Hearst Books, 1992. Discusses the prevention and control of heart disease. Illustrated, with a bibliography and an index.
✧ Heart disease Type of issue: Prevention, public health Definition: One of the leading causes of death in many industrialized nations; heart diseases include atherosclerotic disease, coronary artery disease, cardiac arrhythmias, and stenosis. The heart diseases collectively include all the disorders that can befall every part of the heart muscle: the pericardium, epicardium, myocardium, endocardium, atria, ventricles, valves, coronary arteries, and nodes. The most significant sites of heart diseases are the coronary arteries and the nodes; their malfunction can cause coronary artery disease and cardiac arrhyth-
Heart disease ✧ 443 mias, respectively. These two disorders are responsible for the majority of heart disease cases. Coronary Artery Disease Coronary artery disease occurs when matter such as cholesterol and fibrous material collects and stiffens on the inner walls of the coronary arteries. This plaque that forms may narrow the passage through which blood flows, reducing the amount of blood delivered to the heart, or may build up and clog the artery entirely, shutting off the flow of blood to the heart. In the former case, when the coronary artery is narrowed, the condition is called ischemic heart disease. Because the most common cause of ischemia is narrowing of the coronary arteries to the myocardium, another designation of the condition is myocardial ischemia, referring to the fact that blood flow to the myocardium is impeded. Accumulation of plaque within the coronary arteries is referred to as coronary atherosclerosis. As the coronary arteries become clogged and then narrow, they can fail to deliver the required oxygen to the heart muscle, particularly during stress or physical effort. The heart’s need for oxygen exceeds the arteries’ ability to supply it. The patient usually feels a sharp, choking pain, called angina pectoris. Not all people who have coronary ischemia, however, experience anginal pain; these people are said to have silent ischemia. The danger in coronary artery disease is that the accumulation of plaque will progress to the point where the coronary artery is clogged completely and no blood is delivered to the part of the heart serviced by that artery. The result is a myocardial infarction (commonly called a heart attack), in which some myocardial cells die when they fail to receive blood. The rough, uneven texture of the plaque instead may cause the formation of a blood clot, or thrombus, which closes the artery in a condition called coronary thrombosis. Although coronary ischemia is usually thought of as a disease of middle and old age, in fact it starts much earlier. Autopsies of accident victims in their teens and twenties, as well as young soldiers killed in battle, show that coronary atherosclerosis is often well advanced in young persons. Some reasons for these findings and for why the rates of coronary artery disease began to rise in the twentieth century have been proposed. Western societies underwent significant changes in lifestyle and eating habits: high-fat diets, obesity, and the stressful pace of life in a modern industrial society. Further, cigarette smoking, once almost a universal habit, has been shown to be highly pathogenic (disease-causing), contributing significantly to the development of heart disease. In the early and middle decades of the twentieth century, coronary heart disease was considered primarily an ailment of middle-aged and older men. As women began smoking, however, the incidence shifted so that coronary artery disease became almost equally prevalent, and equally lethal, among men and women.
444 ✧ Heart disease Other conditions such as hypertension or diabetes mellitus are considered precursors of coronary artery disease. Hypertension, or high blood pressure, is an extremely common condition that, if unchecked, can contribute to both the development and the progression of coronary artery disease. Over the years, high blood pressure subjects arterial walls to constant stress. In response, the walls thicken and stiffen. This “hardening” of the arteries encourages the accumulation of fatty and fibrous plaque on inner artery walls. In patients with diabetes mellitus, blood sugar (glucose) levels rise either because the patient is deficient in insulin or because the insulin that the patient produces is inefficient at removing glucose from the blood. High glucose levels favor high fat levels in the blood, which can cause atherosclerosis. Cardiac Arrhythmias Cardiac arrhythmias are the next major cause of morbidity and mortality among the heart diseases. Inside the heart, an electrochemical network regulates the contractions and relaxations that form the heartbeat. In the excitation or contraction phase, a chain of electrochemical impulses starts in the upper part of the right atrium in the heart’s pacemaker, the sinoatrial or sinus node. The impulses travel through internodal tracts (pathways from one node to another) to an area between the atrium and the right ventricle called the atrioventricular node. The impulses then enter the bundle of His, which carries them to the left atrium and left ventricle. After the series of contractions is complete, the heart relaxes for a brief moment before another cycle is begun. On the average, the process is repeated sixty to eighty times a minute. This is normal rhythm, the regular, healthy heartbeat. Dysfunction at any point along the electrochemical pathway, however, can cause an arrhythmia. Arrhythmias range greatly in their effects and their potential for bodily damage. They can be completely unnoticeable, merely annoying, debilitating, or frightening. They can cause blood clots to form in the heart, and they can cause sudden death. The arrhythmic heart can beat too quickly (tachycardia) or too slowly (bradycardia). The contractions of the various chambers can become unsynchronized, or out of step with one another. For example, in atrial flutter or atrial fibrillation, the upper chambers of the heart beat faster, out of synchronization with the ventricles. In ventricular tachycardia, ventricular contractions increase, out of synchronization with the atria. In ventricular tachycardia, ventricular contractions increase, out of synchronization with the upper chambers. In ventricular fibrillation, ventricular contractions lose all rhythmicity and become uncoordinated to the point at which the heart is no longer able to pump blood. Cardiac death can then occur unless the patient receives immediate treatment. An arrhythmic disorder called heart block occurs when the impulse from
Heart disease ✧ 445 the pacemaker is “blocked.” Its progress through the atrioventricular node and the bundle of His may be slow or irregular, or the impulse may fail to reach its target tissues. The disorder is rated in three degrees. First-degree heart block is detectable only on an electrocardiogram (ECG), in which the movement of the impulse from the atria to the ventricles is seen to be slowed. In second-degree heart block, only some of the impulses generated reach from the atria to the ventricles; the pulse becomes irregular. Thirddegree heart block is the most serious manifestation of this disorder: No impulses from the atria reach the ventricles. The heart rate may slow dramatically, and the blood flow to the brain can be reduced, causing dizziness or loss of consciousness. Heart Valve Disorders and Heart Failure Disorders that affect the heart valves usually involve stenosis (narrowing), which reduces the size of the valve opening; physical malfunction of the valve; or both. These disorders can be attributable to infection (such as rheumatic fever) or to tissue damage, or they can be congenital. If a valve has narrowed, the passage of blood from one heart chamber to another is impeded. In the case of mitral stenosis, the mitral valve between the left atrium and the left ventricle is narrowed. Blood flow to the left ventricle is reduced, and blood is retained in the left atrium, causing the atrium to enlarge as pressure builds in the chamber. This pressure forces blood back into the lungs, creating a condition called pulmonary edema in which fluid collects in the air sacs of the lungs. Similarly, malfunctions of the heart valves that cause them to open and close inefficiently can interfere with the flow of blood into the heart, through it, and out of it. This impairment may cause structural changes in the heart that can be life-threatening. Heart failure may be a consequence of many disease conditions. It occurs primarily in the elderly. In this condition, the heart becomes inefficient at pumping blood. If the failure is on the right side of the heart, blood is forced back into the body, causing edema in the lower legs. If the failure is on the left side of the heart, blood is forced back into the lungs, causing pulmonary edema. There are many manifestations of heart failure, including shortness of breath, fatigue, and weakness. Treating Heart Diseases The main goals of therapy in treating heart diseases are to cure the condition, if possible, and otherwise help the patient live a normal life and prevent the condition from becoming worse. In coronary artery disease, the physician seeks to maintain blood flow to the heart and to prevent heart attack. Hundreds of medications are available for this purpose, including vasodilators (agents that relax blood vessel walls and increase their capacity
446 ✧ Heart disease to carry blood). Chief among the coronary vasodilators are nitroglycerin and other drugs in the nitrate family. Also, calcium channel blockers are often used to dilate blood vessels. Beta-blocking agents are used because they reduce the heart’s need for oxygen and alleviate the symptoms of angina. In addition, various support measures are recommended by physicians to stop plaque buildup and halt the progress of the disease. These include losing weight, reducing fats in the diet, and stopping smoking. The physician also treats concomitant illnesses that can contribute to the progress of coronary artery disease, such as hypertension and diabetes. Sometimes medications and diet are not fully successful, and the ischemia continues. In a relatively new procedure, the cardiologist can unblock a clogged artery by a procedure called angioplasty. The physician threads a catheter containing a tiny balloon to the point of the blockage. The balloon is inflated to widen the inner diameter of the artery, and blood flow is increased. This procedure is often successful, although it may have to be repeated. When it is not successful, coronary bypass surgery may be indicated. In this procedure, clogged coronary arteries are replaced with healthy blood vessels from other parts of the body. When coronary artery disease progresses to a heart attack, the patient should be treated in the hospital or similar facility. The possibility of sudden death is high during the attack and remains high until the patient is stabilized. Emergency measures are undertaken to minimize the extent of heart damage, reduce heart work, keep oxygen flowing to all parts of the body, and regulate blood pressure and heartbeat. Cardiac arrhythmias can be managed by a variety of medications and procedures. Digitalis, guanidine, procainamide, tocanamide, and atropine are widely used to restore normal heart rhythm. In acute situations, the patient’s heart rhythm can be restored by electrical cardioversion, in which an electrical stimulus is applied from outside the body to regulate the heartbeat. When a slowed heartbeat cannot be controlled by medication, a pacemaker may be implanted to regulate heart rhythm. Treatment of heart valve disorders and disorders of the heart wall is directed at alleviating the individual condition. Antibiotics and/or valve replacement surgery may be required. In many cases, valve disorders can be completely corrected. Heart transplantation remains a possible treatment for some heart patients. This is an option for comparatively few patients because there are ten times as many candidates for heart transplants as there are available donor hearts. —C. Richard Falcon See also Arteriosclerosis; Cardiac rehabilitation; Cholesterol; Diabetes mellitus; Exercise; Heart attacks; Heart disease and women; Hypertension; Obesity; Obesity and aging; Obesity and children; Secondhand smoke; Smoking; Stress; Tobacco use by teenagers.
Heart disease and women ✧ 447 For Further Information: Baum, Seth. The Total Guide to a Healthy Heart: Integrative Strategies for Preventing and Reversing Heart Disease. New York: Kensington, 2000. Brings together the practices of both conventional and alternative approaches to reversing heart disease and maintaining heart health. Offers great insight into why the integrative approach to maintaining a healthy heart will be the medicine of the new millennium. Kowalski, Robert E. Eight Steps to a Healthy Heart. New York: Warner Books, 1992. In addition to outlining how to avoid heart disease, this book advises patients with heart disease about how to get the most benefit from their therapy. Larson, David G., ed. Mayo Clinic Family Health Book. 2d ed. New York: William Morrow, 1996. This large reference work was written for the layperson. The sections on the heart diseases are exemplary for clarity and thoroughness. McGoon, M. The Mayo Clinic’s Heart Book. New York: William Morrow, 1993. The most respected text for laypeople on heart disease. Covers all aspects of anatomy, physiology, diagnosis, treatment, and prevention. Yannios, Thomas A. The Heart Disease Breakthrough: What Even Your Doctor Doesn’t Know About Preventing a Heart Attack. New York: Wiley, 1999. Describes the smallest components of cholesterol, which can do more damage to the heart than the overall LDL levels that concern so many people.
✧ Heart disease and women Type of issue: Prevention, women’s health Definition: Various heart conditions that impair function in female patients. Coronary artery disease (CAD) is the major form of heart disease that afflicts women in the United States and Canada. CAD is the result of atherosclerosis, a disease that causes plaque to build up in the arterial walls, thereby reducing blood flow to the heart muscle. If complete blockage of the coronary arteries occurs, the result is a myocardial infarction, commonly known as a heart attack. Mitral valve prolapse, a form of heart disease that affects about one-third of all women, is a backflow of blood between the upper and lower chambers of the heart, causing a heart murmur. While this condition is potentially serious, it generally does not interfere with normal daily living. Arrhythmias (irregular heart rhythms) are abnormal electrical conduction patterns in the heart. These abnormal patterns can range from “skipped” beats (premature ventricular contractions, or PVCs) to an accelerated heart rate known as tachycardia.
448 ✧ Heart disease and women The mortality rate from heart disease for American women decreased from 305 deaths per 100,000 in 1970 to a rate of 280 deaths per 100,000 in the 1990’s. Nevertheless, every year more than 350,000 women die from heart disease in the United States, representing 34.4 percent of all female deaths. While heart disease is the leading cause of death for all women, it primarily affects women after the age of sixty-five (as contrasted to forty-five years and older in men). This twenty-year difference in mortality between men and women is often attributed to the protective effect of female hormones. There is also evidence to suggest that women experience a decreased risk for heart disease, in comparison to men, because of their tendency toward better social cohesion and support. Diagnosis The first symptom of heart disease in women is generally angina pectoris, a pain or pressure in the chest and upper body attributable to ischemia, a lack of blood flow to the heart. Angina usually occurs with moderate exertion, such as walking up a flight of stairs. All chest pain or pressure should be reported to a physician immediately and should never be ignored. The exercise stress test is the first diagnostic tool used to detect CAD. The patient exercises while the physician monitors her electrocardiogram (ECG or EKG) for indications of ischemia. This noninvasive test, however, fails to identify about 20 percent of women with heart disease. If symptoms persist, the next procedure is a thallium exercise test, which involves injecting a radionucleotide into the patient while an X-ray motion picture is taken of the exercising heart. This procedure allows the physician to observe any areas of the heart where blood is not flowing. The definitive diagnostic procedure is heart catheterization, or coronary angioplasty. A tube is inserted through a vein in the leg and threaded to the heart. During a continuous-motion X ray, radioactive isotopes are injected that identify the arteries affected and the extent of coronary artery blockage. The survival rates for heart disease are dependent on treatment. Women see their doctors more often than men do, but they are less likely to receive the correct diagnosis. This trend may be caused in part by the low rates of heart disease in women before the age of sixty. It may also be the result of physicians mistakenly attributing CAD symptoms to stress. Fortunately, myocardial infarctions that result in sudden cardiac death are less prevalent in women than in men. While women are not always treated for CAD adequately, they do seek medical care more often and are eventually treated, whereas men too often disregard initial symptoms, resulting in more severe outcomes.
Heart disease and women ✧ 449 Treatment and Survival Atherosclerotic obstructions in the coronary arteries can be treated by coronary artery bypass graft (CABG) surgery or by balloon angioplasty. CABG involves the removal of veins from the legs and their surgical attachment from the main artery of the body to a point that bypasses the blockage in the coronary arteries. In balloon angioplasty, a catheter with a balloon attachment is inserted into the obstructed artery, and the balloon is expanded, thus opening a channel by compressing the plaque against the arterial walls. Both techniques are effective in improving blood flow to the heart. Treatments for women after a myocardial infarction are not as effective as they are for men, with generally poorer outcomes such as increased mortality, poorer quality of life, depression, and emotional distress. This finding may be attributable to a higher average age among affected women, making them physically less able to withstand treatment. Another explanation may be that most treatments utilized today are primarily the result of research with male subjects. Research CAD afflicts women about twenty years later than men, with the incidence of myocardial infarctions four times higher in men than in women. The greater occurrence of CAD in middle-aged men has drawn most of the attention and research, resulting in a lack of studies that focus on the prevention and treatment of CAD in women. For example, women made up less than 20 percent of apparently healthy subjects and only 4 percent of subjects with preexisting CAD in several major studies that examined methods to lower serum cholesterol. Compounding the research issue is the perception among women that breast cancer kills more women than CAD when, in reality, more than ten times the number of women die from CAD every year. Fortunately, several major studies on women are underway, such as the Nurses Health Study (with more than 120,000 subjects), the Women’s Health Study, and the Women’s Health Initiative. These studies are examining the preventive role that physical activity, nutrition, and low-dose aspirin intake may have against CAD in women. Additionally, oral contraceptives, the menopause, and estrogen replacement therapy are being examined to see how each factor affects the rate of CAD in women. The result of these studies on women will provide preventive measures, medications, and treatments for CAD that are appropriate for female populations. —Chester J. Zelasko See also Aging; Arteriosclerosis; Cardiac rehabilitation; Exercise; Exercise and the elderly; Heart attacks; Heart disease; Hypertension; Nutrition and women; Preventive medicine; Stress; Women’s health issues.
450 ✧ Heat exhaustion and heat stroke For Further Information: Baum, Seth. The Total Guide to a Healthy Heart: Integrative Strategies for Preventing and Reversing Heart Disease. New York: Kensington, 2000. Diethrich, Edward, and Carol Cohan. Women and Heart Disease. New York: Ballantine Books, 1994. Helfant, Richard. The Women’s Guide to Fighting Heart Disease: A Leading Cardiologist’s Breakthrough Program. New York: Berkley Publishing Group, 1994. Rich-Edwards, Janet, JoAnn Manson, Charles Hennekens, and Julie Buring. “The Primary Prevention of Coronary Heart Disease in Women.” New England Journal of Medicine 332, no. 26 (June 29, 1995): 1758-1766. Yates, Beverly. Heart Health for Black Women: A Natural Approach to Healing and Preventing Heart Disease. New York: Marlowe, 2000.
✧ Heat exhaustion and heat stroke Type of issue: Environmental health, public health Definition: Heat-related illnesses in which the body temperature rises to dangerous levels and cannot be controlled through normal mechanisms, such as sweating. Body temperature in human beings rarely leaves a very narrow range of 36.1 to 37.8 degrees Celsius (97 to 100 degrees Fahrenheit) regardless of how much heat the body produces or what the environmental temperature may be. If internal temperatures rise, brain function becomes slower as important proteins and enzymes lose their ability to operate effectively. Most adults go into convulsions when their temperature reaches 41 degrees Celsius (106 degrees Fahrenheit), and 43 degrees Celsius (110 degrees Fahrenheit) is usually fatal. A special region of the brain known as the hypothalamus regulates body temperature. The hypothalamus detects blood temperature much like a thermostat detects room temperature. When the body becomes too warm, the hypothalamus activates heat-loss mechanisms. Most excess heat is lost through the skin by the radiation of heat and the evaporation of sweat. Blood vessels in the skin dilate to carry more blood. Heat from the warm blood is then lost to the cooler air. If the increase in blood flow to the skin is not enough, then sweat glands are stimulated to produce and secrete large amounts of sweat. The process, called perspiration, is an efficient means of ridding the body of excess heat as long as the humidity is not too high. At 60 percent humidity, however, evaporation of sweat from the skin stops. When the body cannot dissipate enough heat, heat exhaustion and heat stroke may occur.
Heat exhaustion and heat stroke ✧ 451 Heat Exhaustion and Heat Stroke Heat exhaustion is the most prevalent heat-related illness. It commonly occurs in individuals who have exercised or worked in high temperatures for long periods of time. These people have usually not ingested adequate amounts of fluid. Over time, the patient loses fluid through sweating and respiration, which decreases the amount of fluid in the blood. Because the body is trying to reduce its temperature, blood has been shunted to the skin and away from vital internal organs. This reaction, in combination with a reduced blood volume, causes the patient to go into a mild shock. Common signs and symptoms of heat exhaustion include cool, moist skin that may appear either red or pale; headache; nausea; dizziness; and exhaustion. If heat exhaustion is not recognized and treated, it can lead to life-threatening heat stroke. Heat stroke occurs when the body is unable to eradicate the excess heat as rapidly as it develops. Thus, body temperature begins to rise. Sweating stops because the water content of the blood decreases. The loss of evaporative cooling causes the body temperature to rise rapidly, soon reaching a level that can cause organ damage. In particular, the brain, heart, and kidneys may begin to fail until the patient experiences convulsions, coma, and even death. Therefore, heat stroke is a serious medical emergency which must be recognized and treated immediately. The signs and symptoms of heat stroke include high body temperature (41 degrees Celsius or 106 degrees Fahrenheit); loss of consciousness; hot, dry skin; rapid pulse; and quick, shallow breathing. Treatment Procedures As with most illnesses, prevention is the best medicine for heat exhaustion and heat stroke. When exercising in hot weather, people should wear loosefitting, lightweight clothing and drink plenty of fluids. When individuals are not prepared to avoid heat-related illness, however, rapid treatment may save their lives. When emergency medical personnel detect signs and symptoms of sudden heat-induced illness, they attempt to do three major things: cool the body, replace body fluids, and minimize shock. For heat exhaustion, the initial treatment should be to place the patient in a cool place, such as a bathtub filled with cool (not cold) water. The conscious patient is given water or fruit drinks, sometimes containing salt, to replace body fluids. Occasionally, intravenous fluids must be given to return blood volume to normal in a more direct way. Hospitalization of the patient may be necessary to be sure that the body is able to regulate body heat appropriately. Almost all patients treated quickly and effectively will not advance to heat stroke. The activity that placed the patient in danger should be discontinued until one is sure all symptoms have disappeared and steps have been taken to prevent a future episode of heat exhaustion. Heat stroke requires urgent medical attention, or the high body tempera-
452 ✧ Herpes ture will cause irreparable damage and often death. Reduction of body temperature must be done rapidly. With the patient in a cool environment, the clothing is removed and the skin sprinkled with water and cooled by fanning. Contrary to popular belief, rubbing alcohol should not be used, as it can cause closure of the skin’s pores. Ice packs are often placed behind the neck and under the armpits and groin. At these sites, large blood vessels come close to the skin and are capable of carrying cool blood to the internal organs. Body fluid must be replaced quickly by intravenous administration because the patient is usually unable to drink as a result of convulsions or confusion and may even be unconscious. Once the body temperature has been brought back to normal, the patient is usually hospitalized and watched for complications. With early diagnosis and treatment, 80 to 90 percent of previously healthy people will survive. —Matthew Berria See also Exercise; Exercise and children; Exercise and the elderly; First aid; Resuscitation; Sunburns; Temperature regulation and aging. For Further Information: American Red Cross First Aid: Responding to Emergencies. Rev. ed. St. Louis: Mosby Year Book, 1994. Clayman, Charles B., ed. The American Medical Association Encyclopedia of Medicine. New York: Random House, 1989. Hales, Dianne. An Invitation to Health. 9th ed. Belmont, Calif.: Wadsworth Thomson Learning, 2001. Marieb, Elaine N. Human Anatomy and Physiology. 5th ed. Redwood City, Calif.: Benjamin/Cummings, 2000.
✧ Herpes Type of issue: Epidemics, public health Definition: A family of viruses that cause several diseases, including infectious mononucleosis, cold sores, genital herpes, and chickenpox. Herpesviruses that affect humans include herpes simplex virus types 1 and 2, Epstein-Barr virus, varicella-zoster virus, and cytomegalovirus. Herpesviruses cause three types of infections: primary, latent, and recurrent. Most first-time, or primary, infections with herpesviruses cause few or no symptoms in the victim. Following the primary infection, herpesviruses have the unique ability to become latent, or hidden, in the body. Latent infections may persist for the life of the individual with no further symptoms, or the virus may reactivate and cause a recurrent infection.
Herpes ✧ 453 Although herpesvirus infections are often mild in healthy persons, they can cause potentially fatal infections in immunocompromised patients. Persons in this group include infants, whose immune systems are not fully developed; immunodeficient persons, whose immune systems are lacking some important component; and immunosuppressed patients, such as cancer or transplant patients, whose immune systems are being suppressed by drugs or radiation. Herpesviruses have also been implicated in the causes of certain types of cancer. Herpes Simplex and Varicella-Zoster Herpes simplex viruses exist in two forms: type 1 (HSV1) and type 2 (HSV2). HSV1 and HSV2 infections cause the formation of painful or itchy vesicular (blisterlike) lesions, which ulcerate, crust over, and heal within a few weeks. The virus is transmitted by direct contact with infected lesions, and the virus enters the recipient through broken skin or mucous membranes. HSV1 usually causes infections in the mouth, throat, eye, skin, and brain. Gingivostomatitis, the most common form of primary HSV1 infection, is seen mostly in small children and is characterized by ulcerative lesions inside the mouth. Cold sores, the most common recurrent disease caused by HSV1, are characterized by blisters on the outer portion of the lips. HSV1 can also cause infection in any area of the skin where trauma (burns, scrapes, eczema) gives the virus an opening to get in. HSV1 infection of the eye can lead to scarring and blindness, and HSV1 infection of the brain can lead to death. Genital herpes, a disease transmitted by sexual contact, is most often caused by HSV2. The virus infects the penis in males and the cervix, vulva, vagina, or perineum in females. Two to seven days after infection, painful blisters appear in the genital area that ulcerate, crust over, and disappear in a few weeks. Fever, stress, sunlight, or local trauma may trigger the virus to come out of hiding and cause a recurrent infection, and about 88 percent of persons with an HSV2 genital infection will have recurrences at a frequency of up to five to eight times per year. A severe form of HSV2 infection, neonatal herpes, occurs when a mother suffering from genital herpes passes the virus to her baby as it travels through the birth canal during delivery. This type of infection is usually disseminated, its death rate is high, and its survivors suffer from severe neurological damage. Varicella zoster virus (VZV) causes two diseases: Chickenpox (varicella) and shingles (zoster). Chickenpox is a highly contagious common childhood disease caused by a primary infection with VZV. The virus is transmitted during close personal contact with an infected patient via airborne droplets that enter the respiratory tract or direct contact with skin lesions. Once inside a person, the virus travels from the respiratory tract to the blood, and then to the skin. Ten to twenty-one days after infection, a typical
454 ✧ Herpes rash appears on the skin and mucous membranes. On skin, the rash begins as red spots that develop into clear, fluid-filled vesicles that become cloudy, ulcerate, scab over, and fall off in a few days. Mucous membrane lesions in the mouth, eyelid, rectum, and vagina rupture easily and appear as ulcers. Fever, headache, tiredness, and itching may accompany the rash. Recovery from chickenpox confers lifelong immunity to reinfection but not latency. Chickenpox infection in adults is often more severe than in children, and adults run the risk of developing a fatal lung or brain infection. Individuals with prior varicella infection may later develop shingles, which is caused by the reactivation of latent VZV. More than 65 percent of cases of shingles appear in adults older than forty-five years of age. The mechanism of reactivation is unknown, but recurrence is often associated with physical and emotional stress or a suppressed immune system. Shingles is usually localized to one area of the skin; it begins with pain in the nerves, and then a chickenpox-like rash appears on the skin over the nerves. The pain may be severe for one to four weeks, and recovery occurs in two to five weeks, with pain persisting longer in some elderly patients. Epstein-Barr Virus and Cytomegalovirus Epstein-Barr virus (EBV) causes infectious mononucleosis, an infection of the lymphatic system. In infected persons, the virus is present in saliva and blood, and thus it is transmitted by intimate oral contact (for example, kissing), sharing food or drinks, or by blood transfusions. Primary infection early in life usually causes no symptoms of disease, whereas primary infection later in life usually causes symptoms of infectious mononucleosis. In countries where sanitation is poor, most people have been infected by the age of five, without symptoms. In contrast, in countries where sanitation is good, primary infection is delayed until adolescence or young adulthood, and thus more than half the people in this age group develop symptoms. Once the infection begins, the virus grows in the throat and spreads to blood and lymph, invading white blood cells called B lymphocytes. The typical symptoms of infectious mononucleosis are extreme exhaustion, sore throat, fever, swollen lymph nodes, and sometimes an enlarged liver and spleen. The disease is self-limiting, and recovery takes place in four to eight weeks. The virus remains latent in the blood, lymphoid tissue, and throat and can continue to be transmitted to others even when no signs of active infection are present. EBV infection has also been associated with chronic fatigue syndrome and several types of cancer. The widespread cytomegalovirus (CMV) is responsible for a broad spectrum of diseases. Primary infection by CMV early in life usually results in no symptoms, while primary infection as an adult yields mononucleosis-like symptoms. CMV also causes congenital cytomegalic inclusion disease and is a significant danger to bone marrow transplant patients. The virus is found
Herpes ✧ 455 in body secretions such as saliva, urine, semen, cervical secretions, and breast milk. Babies may acquire the virus from infected mothers during birth or through breast milk. Children in day care may acquire CMV from other children who orally excrete the virus, and parents may get it from their children. CMV may be acquired through sexual transmission and blood transfusions. Patients undergoing transplants, especially bone marrow transplants, are at higher risk for CMV infection, since the virus may be present in the transplanted organs. The mononucleosis-like disease caused by CMV has the same symptoms as EBV-induced mononucleosis except the sore throat, swollen lymph nodes, and enlarged spleen. Congenital cytomegalic inclusion disease causes severe neurological damage, mental retardation, and death in infants; it is a result of primary CMV infection of the mother during pregnancy. Treating Herpes Simplex and Varicella-Zoster The major treatment procedure for most mild HSV infections is supportive care. These measures, such as bed rest and medication to relieve itching or pain, treat the symptoms but not the infection. For most infections, the symptoms eventually go away by themselves. For more severe HSV infections, several antiviral drugs have been used. Idoxuridine and trifluridine have been used to treat eye infections. Vidarabine and acyclovir are used to treat encephalitis and disseminated disease; both reduce the severity of the infection but do not reverse any neurological damage or prevent recurrent infections. Acyclovir has also been useful in reducing the duration of primary genital herpes, but not recurrent infection. The use of oral acyclovir to suppress recurrent infection may cause more severe and more frequent infections once the therapy has stopped. Chickenpox takes care of itself and disappears after a few weeks; therefore, the only treatment needed is supportive care for the patient during that time. Often, drying lotions such as calamine help relieve the itching. It is important to cut the fingernails of young children so that they cannot scratch hard enough to break through the skin and leave themselves susceptible to secondary bacterial infection. It is extremely important not to give a child aspirin for the fever, because of the association between the use of aspirin during chickenpox and the development of Reye’s syndrome. In this syndrome, the patient persistently vomits and exhibits signs of brain dysfunction a few days after the initial infection has receded. Coma and death can follow if the syndrome is not treated. A child with chickenpox may be given acetaminophen if necessary. Varicella is treated mostly with medication to control the pain. Steroids given early in the infection help reduce the severity of the infection, and acyclovir increases the rate of recovery. Antiviral drugs such as acyclovir, interferon, and vidarabine have been used in the treatment of immunocom-
456 ✧ Herpes promised patients with chickenpox to help reduce the potential severe complications of the disease. Since 1981, varicella-zoster immunoglobin (VZIG) has been available for the prevention and treatment of chickenpox in these patients. VZIG provides a short time of immunity, can lessen symptoms, and is recommended for immunocompromised children exposed to chickenpox, but it has no value once chickenpox has started. A VZV vaccine has been shown to provide protection from infection in children. Treating Epstein-Barr Virus and Cytomegalovirus Infectious mononucleosis is a self-limiting disease, which means that it will eventually run its course and go away. Therefore, treatment involves mostly supportive care, such as bed rest and aspirin or acetaminophen for the fever and sore throat. It is also recommended that mononucleosis patients avoid contact sports, to prevent possible rupture of an enlarged spleen. In some severe cases, steroids are administered, and antiviral drugs are in the process of being tested to determine whether they are of any therapeutic value. The best way to prevent an EBV infection is to avoid intimate contact with an infected individual. Unfortunately, many persons shed the virus in their saliva without exhibiting any symptoms. Mild cases of CMV need no treatment except supportive measures. Antiviral drugs such as interferon, vidarabine, idoxuridine, and cytosine arabinoside as well as CMV immune globin have all been tested for their benefit in severe cases of CMV infections, but none has been successful. The drug ganciclovir has been shown to have some therapeutic value. A CMV vaccine has been developed, but further work is needed. Until better measures are available, it is important to try to avoid infection in immunocompromised patients, especially transplant recipients. The screening of organ donors for the presence of CMV may be helpful in accomplishing this goal. All pregnant women should be tested for CMV antibodies to determine whether they have already been infected; if not, they should avoid contact with small children who might carry CMV. A Public Health Threat Between 20 and 40 percent of the people in the United States suffer from cold sores, and more than twenty million persons suffer from genital herpes. In addition, HSV1 infection of the eye is the most common cause of corneal blindness in the United States, and HSV2 infection is associated with an increased risk of cervical cancer, which strikes some fifteen thousand women each year. Two hundred babies in the United States die each year, and two hundred more suffer physical or mental impairment caused by HSV infection. Chickenpox is the second most reported disease in the United States,
Herpes ✧ 457 with more than two hundred thousand cases per year. This number is probably too low, since many cases go unreported. About 100 deaths per year are attributed to chickenpox. EBV infection is worldwide, and EBV antibodies can be found in more than 90 percent of most adult populations. EBV infection has been shown to be an important factor in the development of Burkitt’s lymphoma (a cancer of the jaw) in Africa and nasopharyngeal carcinoma (a fatal cancer of the nose) in China. EBV has also been linked to chronic fatigue syndrome, but the relationship is not conclusive. CMV infection is worldwide, with 40 to 100 percent of a population possessing antibodies to CMV. Almost all kidney transplant recipients and half of bone marrow recipients get CMV infection. Congenital CMV infection is the cause of severe neurological damage in more than five thousand children born each year in the United States. —Vicki J. Isola See also Cervical, ovarian, and uterine cancers; Children’s health issues; Chronic fatigue syndrome; Epidemics; Reye’s syndrome; Sexually transmitted diseases (STDs). For Further Information: Biddle, Wayne. Field Guide to Germs. New York: Henry Holt, 1995. This comprehensive book is easily accessible to the nonspecialist and includes a discussion of nearly every virus, bacterium, and fungus known to cause human and nonhuman animal disease. The history of the microbe and the treatment of diseases are included. Ebel, Charles. Managing Herpes: How to Live and Love with a Chronic STD. Research Triangle Park, N.C.: American Social Health, 1998. With 20 percent of the American population now carrying the virus that causes genital herpes, the revised edition of this book, first published in 1994 by a nonprofit organization dedicated to stopping sexually transmitted diseases, is timely and welcome. Regush, Nicholas. The Virus Within: A Coming Epidemic. New York: Dutton, 2000. A virus called HHV-6 (a form of the human herpes virus) is at the heart of a controversy brewing in the scientific community. Scientists are uncovering evidence that it may play a role in serious illnesses such as AIDS and multiple sclerosis. Regush makes a strong case for further research. Stoff, Jesse A., and Charles Pellegrino. Chronic Fatigue Syndrome. Rev. ed. New York: HarperPerennial, 1992. Discusses EBV and its relationship to chronic fatigue syndrome. Zinsser, Hans. Zinsser Microbiology. 20th ed. Edited by Wolfgang K. Joklik et al. Norwalk, Conn.: Appleton and Lange, 1992. The information presented in this textbook is thorough, logical, and supplemented by inter-
458 ✧ Hippocratic oath esting diagrams, photographs, and charts. Chapter 66, “Herpesviruses,” gives a complete description of infections with HSV, VZV, EBV, and CMV.
✧ Hippocratic oath Type of issue: Ethics Definition: A document, written in the fifth century b.c.e., to offer guidelines for the emerging medical profession, which continues to be the subject of debate in modern practice because of the ethical issues that it addresses. Western civilization has long held the writings of the fifth century b.c.e. Greek physician Hippocrates, and in particular the Hippocratic oath, as a model of ethical values to be followed in the medical profession. As the nature of Western civilization itself has changed over the centuries, interpretations of the ethical values behind the Hippocratic oath have also changed. The circumstances of modern medical practice and ethical values, however, have ironically made certain elements of the classical Hippocratic tradition even more relevant than they may have appeared in previous eras. The first part of the oath covers the physician’s lifelong commitment to his or her teachers. This commitment extends not only to the symbolic bonds of respect but also to obligation to share one’s medical practice and even to provide financial assistance to one’s teachers, if requested. Additionally, the physician is committed to train, free of charge, the families of his or her teachers in the art of medicine. The second part of the Hippocratic oath contains the more general pledges that would contribute to its value as an ethical guide for the medical profession. The physician is bound, in a very general way, to help the sick according to his or her ability and judgment in a manner that can never be interpreted as involving injury or wrongdoing. The physician is bound both to confidentiality concerning direct experiences in the patient-doctor relationship and to extreme discretion to avoid the circulation of professional knowledge that is not appropriate for publication abroad. In addition to these general precepts, all of which have an ethical timelessness that would survive the centuries, there were two points in the oath that refer to specific issues that cannot be separated from the modern debate over medical ethics. Addressing the questions of euthanasia (“mercy killing”) and abortion, Hippocrates stated: “I will give no deadly drug to any, though it be asked of me, nor will I counsel such, and especially I will not aid a woman to procure abortion.”
Hippocratic oath ✧ 459 Modern Applications of the Hippocratic Oath Although neither the original nor edited versions of the Hippocratic oath are applied today as a condition for becoming a doctor, the medical profession in the United States has definitely formalized publication of what it considers to be a necessary code of medical ethics. Evolving versions of this “Code of Medical Ethics” date from the original (1847) text of the American Medical Association (AMA) as revised by specific decisions in 1903, 1912, and 1947. When the AMA adopted a statement under the title “Guide to Responsible Professional Behavior” in 1980, it assigned to a formal body within its organization, the Council on Ethical and Judicial Affairs, the task of publishing, on a yearly basis, updated paragraphs that reflect ethical guidelines for the profession as a whole. These evolving guidelines are organized under such subheadings as “Social Policy Issues,” “Interprofessional Relations,” “Hospital Relations,” “Confidentiality,” and “Fees and Charges.” Thus, in the absence of a specific professional oath with detailed provisions, modern physicians are bound to respect the ethical guidelines provided to them by their professional association. Failure to respect these guidelines is tantamount to breaking one’s binding ethical obligations and can lead to expulsion from the medical profession. Several major changes, both in levels of medical technology and in social attitudes toward issues relating to medical practice, have played key roles in several spheres of an ongoing debate concerning medical ethics. In two cases, those of abortion and euthanasia, debate has focused on the ethics of deciding to end life; in the third, referred to generally as genetic engineering, the central question involves both the living and those yet to be born. In all these spheres, the legal and ethical debates have revolved around potential conflicts between physicians and patients but also in the context of wider social values. Movement from the historical domain of idealized codes or oaths to the more practical and contemporary realm of changing societal reactions to what constitutes injury or breach of professional ethics in several areas of modern medicine is facilitated by reference to landmark legal decisions that have given a modern and quite different meaning to Hippocratic concepts. Life-Sustaining Technology Two issues, one involving the ethics of sustaining life by means of advanced medical technology and the other involving the “engineering” of lives according to genetic predictions, fall under the provisions of the Hippocratic oath. As one approaches more contemporary statements of professional obligations of medical doctors, such as the “Principles of Medical Ethics” (1957) of the American Medical Association, one finds that, as certain areas of specificity in classical Hippocratic or Christian medical
460 ✧ Hippocratic oath ethics (the illegality of abortions or the administration of deadly potions) tend to decline in visibility, another area begins to come to the forefront; namely, striving continually to improve medical knowledge and skills to be made available to patients and colleagues. This more modern concern for the application of advancements in medical knowledge, especially in the technology of medical lifesaving therapy, has introduced a new focus for ethical debate: not “lifesaving” but “life-sustaining” techniques, particularly in cases judged to be otherwise terminal or hopeless. The question of a doctor’s responsibility to use every means within his or her reach to sustain life, even when there is no hope of a meaningful future for the patient, also reflects a dilemma regarding Hippocratic injunctions. This debate is more important now than in any earlier era because advanced medical technology has made it possible either to extend the lives of aged patients who would die without life-sustaining machines or—in the case of younger persons afflicted by brain damage, for example—to sustain life although the patient remains in a comatose state. A prototype in the latter case was a 1976 Supreme Court decision that allowed the parents of New Jersey car accident victim Karen Quinlan to instruct her physician to remove life support systems so that their comatose daughter would die. At issue in this complicated case, which also rested on legal discussions of the constitutional right of privacy, was the question of who should decide that inevitable natural death is preferable to prolongation of life by externally administered means. When the Court took this decision away from an appointed court guardian and gave it to those closest to the patient, the question became whose privacy was being protected. To whom does the physician’s oath to avoid doing injury actually apply? Genetic Engineering A final area of contemporary debate over medical ethics illustrates how far conceptions of ultimate responsibility for the protection of life have gone beyond frames of reference that might have been familiar not only in Hippocrates’ time but also as recently as the generation of doctors trained before the 1980’s. Impressive advances in the research field of human genetics by the mid-1980’s began to make it possible to predict, through analysis of deoxyribonucleic acid (DNA) structures, the likelihood that certain genetic traits (specifically debilitating chronic diseases) might be transmitted to the offspring of couples under study. Inherent in the rising debate over the ethics of such studies, which range from the prediction of reproductive combinations (genetic counseling) through actual attempts to detach and splice DNA chains (genetic engineering), was the delicate question of who, if anyone, should hold the responsibility of determining if individuals have ultimate control over their genes. In the most extreme hypothetical argument, a notion of scientific exclusion of
HMOs ✧ 461 certain gene combinations, or planning of desirable gene pools in future generations, began to appear in the 1980’s and 1990’s. These notions represent potential problems for medical ethics that, because of exponential changes in technological possibilities, surpass the entire realm of Hippocratic principles. —Byron D. Cannon See also Abortion; Death and dying; Ethics; Euthanasia; Genetic engineering; Law and medicine; Malpractice; Terminal illnesses. For Further Information: Casarett, David J., Frona Daskal, and John Lantos. “Experts in Ethics? The Authority of the Clinical Ethicist.” The Hastings Center Report 28, no. 6 (November/December, 1998): 6-11. This article examines the work of Jurgen Habermas, which provides a basis for a model of clinical ethics consultation in which consensus, grounded in moral theory, assumes a central theoretical role. Fletcher, John C., et al., eds. Introduction to Clinical Ethics. 2d ed. Frederick, Md.: University, 1997. This group of essays by contributing authors addresses the topic of ethics in contemporary medicine. Includes a bibliography. Gorovitz, Samuel. Doctors’ Dilemmas. New York: Macmillan, 1982. This book deals with the rising complexity of modern medical practice and moral decisions that increasingly affect doctors’ decisions concerning treatment. Also explores issues of public policy making with respect to patientdoctor relations. Harron, Frank, John Burnside, and Tom Beauchamp. Biomedical-Ethical Issues. New Haven, Conn.: Yale University Press, 1983. A collection of key contemporary documents, including court decisions, state and federal laws, and policy statements by a number of professional associations regarding the most-debated ethical issues in medicine. Jonsen, Albert R., Mark Siegler, and William J. Winslade. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 4th ed. New York: McGraw-Hill, 1998. Discusses the whole range of medical ethics, including legal issues, confidentiality, care of the dying patient, and euthanasia and assisted suicide.
✧ HMOs Type of issue: Economic issues, social trends Definition: A company that provides health insurance and services to group
462 ✧ HMOs and individual clients for an established, prepaid monthly premium and that generally attempts to provide care at a lower cost than traditional fee-for-service insurance programs by transferring financial risk to physicians through capitation and other incentives. A health maintenance organization (HMO) in a free market economy functions in a dual role as both a health insurance company and a provider of health services, roles that were previously separated within the U.S. health care system. HMOs—also known as competitive medical plans, managed care plans, or alternative delivery systems—are generally organized by an employer, physician group, union, consumer group, insurance company, or for-profit health care agency. They were originally formed from one, or a mixture, of the following models: point of service, staff, group, and independent practice association. The role of an HMO as an insurer is to seek group contracts with employers and individual clients and to negotiate premiums to be prepaid in exchange for covering preagreed benefits. Its role in service delivery is to affiliate with or hire directly physicians to provide the expected volume of care that is required for all subscribers under contract. An HMO owns or contracts with one or more health centers for ambulatory care and with hospitals for inpatient care. Within its private health center or in contracts with free-standing providers, an HMO will furnish services from other health care providers such as physical and occupational therapy, pharmacy, and mental health care, which are rapidly increasing in their level of responsibility. HMOs are attractive to employers because the annual medical bill for the average subscriber-patient consistently has proved to be approximately 30 percent less than that of conventional insurers. One advantage of HMO membership is that all medical expenses, from routine and emergency care to hospitalization, are covered within a single, fixed monthly premium. In addition, presenting an HMO membership card at time of services with a small copayment means no forms to fill out, no deductibles to pay, and no bills to submit. Disadvantages include that new subscribers often cannot keep a trusted physician they have had for years, providers become extremely busy when they are assigned hundreds of patients in exchange for a fixed fee, and subscribers often must accept fewer choices in treatment options. The Process of Managed Care The headquarters of an HMO competitively markets its services to employer groups and individuals and administers the revenue and payments. An HMO generally contracts or directly hires a limited number of physicians in addition to building, staffing, and equipping the necessary number of
HMOs ✧ 463 health centers and hospitals. Its marketing claim is to provide good quality care within the employer’s group premium, without seeking further supplements from the employer. Because an HMO and its providers are at personal financial risk, the organization directly imposes financial discipline upon its physicians, hospitals, and other health care providers. The HMO retains a percentage of the premiums paid from employers for its administrative and facility costs and pays a monthly “capitated rate” per client to the providers. Managed care procedures generally involve the HMO establishing a network of physicians with superior reputations in each region, with these physicians agreeing to bill the carriers according to limited reimbursement rules. Each client is assigned to a “primary care gatekeeper” who is expected to provide most care in his or her private office for limited fees. When a referral to a specialist, laboratory, or hospital is necessary, authorization is required from the headquarters of the managed care organization. Hospitals contract with these organizations to limit their charges and follow established rules about economical care and prompt discharge. The managed care organization reviews utilization by physicians and hospitals, attempts to correct wasteful practices, and subsequently drops health care providers with expensive and/or poor practice styles. In contrast to more traditional HMOs, point-of-service plans have more recently emerged. These plans enable clients to have freedom of choice with respect to providers and some treatment options but requires them personally to pay the balance for their chosen higher-priced services. If the patient goes to physicians, hospitals, and other providers within the network and follows rules about utilization and authorization, the out-of-pocket financial costs are minimal. The patient retains the option to go to an out-of-plan provider, pay the bill in full, and then be reimbursed for the limited amount established in the individual plan. The employer’s group contract with the managed care organization provides for limited and predictable premiums. The considerable costs of out-of-plan services thus are shifted from the group contract to the individual patient. The Future of HMOs Managed care plans will continue to monitor closely the treatment patterns of physicians and encourage them to prescribe cheaper medications, to develop standards that physicians are expected to follow in treatment of various diseases, and to hold utilization review panels that review patient records and decide which treatments a patient’s health plan will cover and which it will not. Because of the numerous consumer complaints that arose from actions resulting from the decisions of case managers, who often do not have medical training, nineteen states had passed comprehensive managed care laws by 1997. In that year alone, states passed a record 182 laws related to managed care, up from 100 in 1996. Legislation has and undoubt-
464 ✧ HMOs edly will continue to focus on issues such as adopting measures to ban physician gag clauses, to establish consumer grievance procedures, to require disclosure of financial incentives for physicians to withhold care, to hold external reviews of internal decisions to deny care, and to ensure the ability to sue an HMO for malpractice. The largest looming question regarding the future of HMOs is whether physicians and other health care workers, as well as client subscribers, will continue to enroll in and thus support the system. Managed care necessarily adds substantial administrative overhead, with the ongoing question of whether the final result is greater efficiency for the entire system or simply for subscribing employers. Another controversial topic of discussion involves the responsibility of an HMO to provide disability insurance, which becomes necessary when a client incurs loss of income resulting from sickness or an accident that is not covered by workers’ compensation. —Daniel G. Graetzer See also Ethics; Health care and aging; Health insurance; Law and medicine; Malpractice. For Further Information: Borowsky, Steven J., Margaret K. Davis, Christine Goertz, and Nicole Lurie. “Are All Health Plans Created Equal? The Physician’s View.” Journal of the American Medical Association 278, no. 11 (1997): 917-921. This article contains physician ratings of health plan practices with respect to what promoted or impeded delivery of quality care. Brink, Susan, and Nancy Shute. “Are HMOs the Right Prescription?” U.S. News and World Report 123, no. 4 (October 13, 1997): 60-65. Covered in this well-researched article is the growing dissatisfaction of subscribers with the quality of health care received with a rating of the best HMOs in the United States. Freeborn, D. K., and C. R. Pope. The Promise and Performance of Managed Care: The Prepaid Practice Model. Rev. ed. Baltimore: The Johns Hopkins University Press, 1999. This excellent text highlights the evolution of several common promises of HMOs that employ the prepaid practice model and evaluates their performance based on relevant criteria. Lairson, D. R., et al. “Managed Care and Community-Oriented Care: Conflict or Complement?” Journal of Health Care for the Poor and Underserved 8, no. 1 (1997): 36-55. This informative article evaluates models for community health planning and health care reform designed for the medically indigent, including programs that receive support by the U.S. government and programs which do not. Zelman, W. A. The Changing Health Care Market Place. San Francisco: JosseyBass, 1996. An excellent evaluation of past trends in HMOs and predictions of what the future might hold.
Holistic medicine ✧ 465
✧ Holistic medicine Type of issue: Mental health, social trends Definition: The practice of medicine to maintain both physical and psychological health as a natural deterrent to disease and as a way of realizing one’s highest potential. Although the phenomenon of holistic medicine gained increased attention in the latter half of the twentieth century, most of the associated principles have appeared in various forms and in various cultures over the centuries. Ironically, it may have been the progress of medical science generally and the widespread use by doctors of new drugs to treat disease that sparked what some would call holistic medicine’s call for a return to basics. For example, some proponents of holism oppose automatic reliance on surgical methods of treating some ailments for not recognizing either their cause or more beneficial modes of treatment. In addition, holists oppose a reliance on drugs not only because they hold certain maladies to be curable (or indeed totally avoidable) without them but also because of possible negative side effects. Principles and Approaches A number of sophisticated principles could fall under the presumed “basics” of the holistic approach to health. Primary among them is a conviction that—short of obvious conditions involving attacks by viruses and bacteria or chronic debilitation of certain organs of the body—increased awareness of the nature of bodily functions can help maintain a healthy level of balance within the total organism. Essential to the principle of balance is recognition of the importance of the mind in influencing one’s reactions, both psychological and physical, to circumstances in the surrounding environment. Some holists adhere to the Abraham Maslow school of psychology, which places strong emphasis on questions of drive toward “need fulfillment” in both the physical and psychological domains. Certain bodily states can easily be linked to biologically stimulated drives, including hunger and sexuality. Less apparent psychological drives, however, may also trigger physical reactions. Imbalances in fulfilling the natural drives for love or success are held responsible for many forms of physical disorder that could be averted, such as anorexia nervosa, ulcers, and stress. Several approaches to holistic medicine consider the end goal of good physical health to be not only the avoidance of disease but also the realization of a positive, life-enhancing experience. In some cases, the inspiration for such theories comes from long traditions in Asian philosophies and religions that assume close links between the psychic and the physical realms
466 ✧ Holistic medicine of life. An assumption that may or may not be shared between such philosophies and holists is that a “true” state of health leads to superior levels of awareness in both spheres. Physicians interested in holistic medicine need not, however, be tied solely to disease-specific or “consciousness-heightening” aspects of what can be a very general field. Some specialists in geriatrics, for example, adopt holistic approaches to counseling the elderly about natural stages of aging, preparing them to accept, with a minimum of anxiety, the gradual decline that accompanies the end of life. Growing emphasis on hospice care, for the terminally ill or aged, as opposed to hospitalization, is connected with this aspect of holistic medicine. Although individual physicians may espouse holistic approaches, many persons without formal medical training choose to practice it themselves to maintain their bodies and minds in the healthiest state possible. Such practices may be individual and personal, ranging from exercise and dietary habits to meditation. They may also involve group associations supported by the participation of trained physicians or laypersons. It has become possible to find method-specific holistic centers specializing in a range of techniques. These range from, for example, very general holistic health and nutrition institutes to highly specialized centers that strive to treat those suffering from chronic pain through localized electrical nerve stimulation. The Future of Holistic Medicine Two aspects of holistic approaches to health and daily life in the postindustrial world are likely to increase in importance in coming generations: concern over improving dietary habits and exercise patterns. The discovery of the possible long-term harm that can come from poorly balanced diets (particularly those with a high fat content or excessive chemical additives) has made such specialized practices of holists as vegetarianism and fasting more familiar and at least partly attractive to the wider public. Likewise, the holistic emphasis on regular physical exercise for people of all ages has increasingly become part of many general practitioners’ standard advice to their patients. —Byron D. Cannon See also Acupuncture; Aging; Alternative medicine; Biofeedback; Death and dying; Environmental diseases; Exercise; Exercise and children; Exercise and the elderly; Homeopathy; Hospice; Hypnosis; Meditation; Preventive medicine; Stress; Terminal illnesses; Yoga. For Further Information: Nordenfelt, Lennart. On the Nature of Health. 2d rev. and enlarged ed. Boston: Kluwer, 1995. Deals with the relationship between good health and the welfare of individuals and society as they interact.
Homeopathy ✧ 467 Pelletier, Kenneth R. Holistic Medicine. New York: Delacorte Press, 1979. A general text that seeks to strengthen the public image of holistic medicine, both for the prevention and for the treatment of disease, while discounting some popular myths. Salmon, J. Warren, ed. Alternative Medicines. New York: Tavistock, 1984. Offers comparative views of Western and Chinese approaches to holistic medicine but also includes other, less widely recognized alternatives, ranging from chiropractic to psychic healing. Woodham, Anne, and David Peters. The Encyclopedia of Healing Therapies. New York: Dorling Kindersley, 1997. This book explains holistic and complementary medicine and offers a guide to well-being. Also contains information on finding practitioners, a directory of associations, a glossary, and a bibliography.
✧ Homeopathy Type of issue: Medical procedures, social trends, treatment Definition: A system of medicine based on the principle that an ill patient can be provided effective and nontoxic treatment through the use of weak or very small doses of a substance that would cause similar symptoms in a healthy individual. Homeopathy is a therapeutic method that consists of prescribing for a patient weak or infinitestimal doses of a substance which, when administered to a healthy person, causes symptoms similar to those exhibited by the ill patient. Homeopathic remedies stimulate the defense mechanisms of the body, causing them to work more effectively and making them capable of curing the individual. While controversial and not accepted by most physicians, homeopathy is not intended to substitute for conventional medicine. Rather, it is a system of therapeutics which is meant to enlarge and broaden the physician’s outlook, and in some cases, it might bring about a cure not possible with the usual drugs. The Principles of Homeopathy The first and fundamental principle of homeopathy is the selection and use of the similar remedy, based on the patient’s symptoms and characteristics and the drug’s toxicology and provings. A second principle is the use of remedies in extremely small quantities. The most successful remedy for any given occasion will be the one whose symptomatology presents the clearest and closest resemblance to the symptom-complex of the sick person in question. This concept is formally presented as the Law of Similars, which
468 ✧ Homeopathy expresses the similarity between the toxicological action of a substance and its therapeutic action; in other words, the same things that cause the disease can cure it. For example, the effects of peeling an onion are very similar to the symptoms of acute coryza (the common cold). The remedy prepared from Allium cepa (red onion) is used to treat the type of cold in which the symptoms resemble those caused by peeling onions. In the same way, the herb white hellebore, which toxicologically produces cholera-like diarrhea, is used to treat cholera. The homeopathic principle is being applied whenever a sick person is treated using a method or drug that can cause similar symptoms in healthy persons. For example, conventional medicine uses radiation therapy, which causes cancer, to treat this disease. Orthodox medicine, however, does not follow other fundamental principles of homeopathy, such as the use of infinitesimal doses. Homeopathy stimulates the defense mechanism to make it work more effectively and works on the concept of healing instead of simply treating a disease, combating illness, or suppressing symptoms. In the United States, both the Food and Drug Administration (FDA) and traditional homeopaths have been concerned about the use of homeopathic remedies to treat serious problems, such as cancer, and their use by unlicensed practitioners. In some cases, the ability to prescribe homeopathic remedies has been restricted to osteopaths, naturopaths, and medical doctors. In some cases, homeopathy does not work; the reason is unknown. Diagnostic and Treatment Techniques The first step in treating an illness using homeopathy is taking the case history or symptom picture (the detailed account of what is wrong with the patient as a whole). The symptoms are divided in three categories: general, mental/ emotional, and physical. The homeopath then consults the Materia Medica (the encyclopedia of drug effects) and/or the Repertory (an index of symptoms from the Materia Medica listed in alphabetical order, used as a cross-referencing system between symptoms and remedies) to decide on the remedy to be used. The professional homeopath works with a number of Materia Medica texts compiled by different homeopaths. The classical homeopath will give only one remedy at a time in order to gauge its effect more efficiently. Homeopathic remedies are always nontoxic because of the small concentrations used. They come from the plant, mineral, and animal kingdoms. Plants are the source of more than half of the remedies. They are harvested in their natural state according to strict norms by qualified specialists and are used fresh after thorough botanical inspection. Mineral remedies include natural salts and metals, always in their purest state. Animal remedies may contain venoms, poisonous insects, hormones, or physiological secretions such as musk or squid ink.
Homeopathy ✧ 469 The starting remedy is made from a mixture of the substance itself, which has been steeped in alcohol for a period of time and then strained. This starting liquid is called a tincture or mother tincture. In the decimal scale, a mixture of one-tenth tincture and nine-tenths alcohol is shaken vigorously, a process known as succussion; this first dilution is called a 1X. (The number in the remedy reveals the number of times that it has been diluted and succussed; thus, 6X means diluted and succussed six times.) In the centesimal scale, the remedy is diluted using one part tincture in a hundred, and the letter C is used after the number. The number indicates the degree of the dilution, while the letter indicates the technique of preparation (decimal or centesimal). Insoluble substances are diluted by grinding them in a mortar with lactose to the desired dilution. The greater the dilution of a remedy, the greater its potency, the longer it acts, the deeper it heals, and the fewer doses are needed. Homeopathic remedies are most commonly available in tablet form, combined with sugar from cow’s milk. The tablets can be soft (so that they dissolve easily under the tongue and are easy to crush) or hard (so that they must be chewed and held in the mouth for a few seconds before being swallowed), or they can be prepared as globules (tiny round pills). The liquid remedies are dissolved in alcohol. Also available are powders that are wrapped individually in small squares of paper, wafers, suppositories, and liniments. Homeopathic tablets will keep their strength for years without deteriorating, but they must be stored in a cool, dark, and dry place with their bottle tops screwed on tightly, away from strong-smelling substances. The prescribed quantities are the same for babies, children, adults, and older people. The size of a dose is immaterial; it is how often it is taken that counts. The strength (potency) that is needed changes with the circumstances. The greater the similarity between the symptoms and the remedy, the greater the potency to be used (that is, the more dilute the remedy). Risks and Benefits As with all treatments, there are some dangers associated with homeopathic cures, such as unintentional provings. These take place when, after an initial improvement, the symptoms characteristic of the remedy appear, creating a worse situation for the patient. Sometimes, this reaction takes place because the individual has been taking the remedy for too long, and it can be stopped by discontinuing the remedy or by using an antidote. In other cases, there is a confused symptom picture, the effect being that the remedy is working in a limited way or curing a restricted number of symptoms. Homeopathy is important in the treatment of bacterial infections (where resistance to antibiotics can develop) and viral conditions. Homeopathic remedies stimulate the person’s resistance to infection without the side
470 ✧ Homeopathy effects of antibiotics, and they help the body without suppressing the organism’s self-protective responses. The remedies used are safer than regular medicines because they exhibit minimal side effects and counterreactions between medicines can be prevented. Homeopathic remedies are exempt from federal review in the United States. In 1938, any drug listed in the Homeopathic Pharmacopoeia of the United States was accepted by the FDA. Consequently, prescribed homeopathics do not have to undergo the rigorous safety and effectiveness testing the regulating agency requires of drugs used in orthodox medicine. Nonprescription homeopathics are also exempt and can be purchased in pharmacies, greengroceries, and health food stores throughout the country. The FDA requires that, as with any over-the-counter drug, a remedy can be sold only for a self-limiting condition (such as headaches, menstrual cramps, or insomnia) and that the indications be printed on the label. The ingredients and their dilution must also be listed. Nonhomeopathic active ingredients cannot be included in the preparation. The Status of Homeopathy The 1860’s through the 1880’s saw the heyday of homeopathy in the United States, with the institution of training programs, hospitals, and asylums and the training of thousands of homeopaths in the country. By the 1990’s, however, only five hundred to one thousand medical doctors used homeopathics in their practices, though the number of homeopaths and osteopaths prescribing them had probably increased. Although the American Medical Association (AMA) has no official statement on homeopathy, it is no longer part of the medical school curriculum. Homeopathy has exhibited a renaissance, and it is popular throughout the world, especially in France. Perhaps the reasons for this revived popularity include both skepticism surrounding conventional medicine and a need for alternatives in the face of challenging health problems: Homeopathy offers a safe alternative as it seeks to improve the general level of health of the whole person, emotionally as well as physically. It must not be forgotten, however, that this brand of medicine has a long way to go before its curative powers are proven. —Maria Pacheco See also Alternative medicine; Holistic medicine; Immunizations for children; Immunizations for the elderly; Medications and the elderly; Stress. For Further Information: Aubin, Michel, and Philippe Picard. Homœopathy: A Different Way of Treating Common Ailments. Translated by Pat Campbell and Robin Campbell. Bath, England: Ashgrove Press, 1989. An easy-to-read book which includes a
Hormone replacement therapy ✧ 471 critical analysis of orthodox medicine from the perspective of an orthodox doctor turned homeopath, a description of homeopathy, and a section on self-treatment with homeopathy. Castro, Miranda. The Complete Homeopathy Handbook: A Guide to Everyday Health Care. New York: St. Martin’s Press, 1991. Examines the principles underlying the theory of homeopathy, as well as how to prescribe and learn the best use of homeopathic medicines that are available over the counter. Written for the reader who has had some experience with homeopathy. Includes a Materia Medica and Repertory for internal and external remedies, as well as some sample cases. _______. Homeopathic Guide to Stress. New York: St. Martin’s Griffin, 1997. An introduction to homeopathy, with a focus on stress. Suggests several homeopathic treatments for more than four dozen specific emotional states, with instructions on how to choose the most appropriate solutions. McCabe, Vinton. Practical Homeopathy: A Beginner’s Guide. New York: St. Martin’s Press, 2000. McCabe, president of the Connecticut Homeopathic Association and a member of the faculty and board of the Hudson Valley School of Classical Homeopathy, joins philosophy and pharmacy in a practical way in this resource. Includes homeopathic remedies. Ullman, Dana. Discovering Homeopathy: Medicine for the Twenty-first Century. Rev. ed. Berkeley, Calif.: North Atlantic Books, 1991. Includes sections on the history and research methods of homeopathy and an excellent section on sources (books, computer programs, tapes) and general information on homeopathy. Lists pharmacies, organizations, schools, and training programs in the United States. Information on how to choose a practitioner and about the use of homeopathy in specific areas is presented.
✧ Hormone replacement therapy Type of issue: Medical procedures, treatment, women’s health Definition: The use of oral or injectable forms of hormones to replace inadequate gland secretions. Hormones are critical substances released by glands, the organs of the endocrine system. Hormone replacement therapy is needed when insufficient amounts of hormones are being produced. Glands can slow or cease secretion because of destruction by tumors, infections, poor nutrition, environmental toxins, normal aging, heredity, and trauma. The most common problems exist with the thyroid (hypothyroidism), pancreas (diabetes mellitus), and ovaries (the menopause). Both thyroid and pancreatic insulin hormone replacement are lifesaving therapies.
472 ✧ Hormone replacement therapy After careful testing reveals a hormone deficiency, hormones are administered as either pills or injections. While symptoms, simple blood tests, and X rays may point to a diagnosis, more sophisticated tests are often needed. A sensitive blood test called a radioimmunoassay can determine exact hormone levels. Nuclear scans, using injected radioactive materials, provide vivid images of the affected gland. Biopsies, which are samples of tissue taken from the gland through a needle or incision, can be viewed directly. Uses of Hormone Replacement Therapy Hormone replacement therapy reverses the symptoms of hormone deficiency diseases. Without treatment, the diabetic patient, lacking the insulin that regulates blood sugar levels, will suffer coma and death. The patient who lacks sufficient thyroid hormone to regulate the rate of metabolism will also have a fatal outcome if this condition is left untreated. Postmenopausal women, whose ovaries have ceased the production of estrogen and progesterone because of normal aging, may have uncomfortable and sometimes disabling symptoms which can be relieved by hormone replacement. Definite risks are associated with hormone use because it is very difficult to imitate the precision with which the body normally maintains the blood concentrations of internally produced hormones. Excess dosages can have devastating consequences: Excess amounts of thyroid or insulin hormones can lead to death. Considerable controversy surrounds postmenopausal hormone replacement because of its association with breast and uterine cancer, liver disease, and blood clots. As with all drugs, the benefits and risks of hormones must be weighed and blood levels carefully monitored. —Connie Rizzo, M.D. See also Diabetes mellitus; Genetic engineering; Hysterectomy; Menopause; Women’s health issues. For Further Information: Braunwald, Eugene, et al., eds. Harrison’s Principles of Internal Medicine. 15th ed. New York: McGraw-Hill, 2000. Dennerstein, Lorraine, and Julia Shelley, eds. A Woman’s Guide to Menopause and Hormone Replacement Therapy. Washington, D.C.: American Psychiatric Press, 1998. Goldstein, Steven R. The Estrogen Alternative. New York: Putnam, 1998. Jacobwitz, Ruth S. The Estrogen Answer Book: 150 Most-Asked Questions About Hormone Replacement Therapy. Boston: Little, Brown, 1999. Stolar, Mark. Estrogen. New York: Avon Books, 1997.
Hospice ✧ 473
✧ Hospice Type of issue: Ethics, mental health, social trends Definition: A holistic approach to caring for the dying and their families by addressing their physical, emotional, and spiritual needs. Hospice is a philosophy of care directed toward persons who are dying. Hospice care uses a family-oriented holistic approach to assist these individuals in making the transition from life to death in a manner that preserves their dignity and comfort. This approach, as Elisabeth Kübler-Ross would say, allows dying patients “to live until they die.” Hospice care encourages patients to participate fully in determining the type of care that is most appropriate for their comfort. By creating a secure and caring community sensitive to the needs of the dying and their families and by providing palliative care that relieves patients of the distressing symptoms of their disease, hospice care can aid the dying in preparing mentally as well as spiritually for their impending death. Unlike traditional health care, where the patient is viewed as the client, hospice care with its holistic emphasis treats the family unit as the client. In addition to the stress of caring for the physical needs of the dying, family members often feel tremendous pressure maintaining their own roles and responsibilities within the family itself. The conflict of caring for their own nuclear families while caring for dying relatives places a huge strain on everyone involved and can be a source of anxiety and guilt for the patient as well. Another area of stress experienced by family involves concern for themselves, that is, having to put their own lives on hold, maintaining their own health, dealing with their newly acquired time constraints, and viewing themselves as isolated from friends and family. Compounding this is the guilt that many caregivers feel over not caring for the dying relative as well or as patiently as they might, or secretly wishing for the caregiving experience to reach an end. Due to the holistic nature of the care provided, the hospice team is actually an interdisciplinary team composed of physicians, nurses, psychological and social workers, pastoral counselors, and trained volunteers. This medically supervised team meets weekly to decide on how best to provide physical, emotional, and spiritual support for dying patients and to assist the surviving family members in the subsequent grieving process. This type of care can be administered in three different ways. It can be home health-agency based, delivered in the patient’s own home. It can be dispensed in an institution devoted solely to hospice care. It can even be administered in traditional medical facilities (such as hospitals) that allot a certain amount of space (perhaps a wing or floor, or even a certain number of beds) to this type of care. Fewer than 20 percent of hospices are totally
474 ✧ Hospice independent and have no affiliation with one or more hospitals. Hospice care attempts to enhance the quality of dying patients’ final days by providing them with as much comfort as possible. It is predicated on the belief that death is a natural process with which humans should not interfere. The principles of hospice care, therefore, revolve around alleviating the anxieties and physical suffering that can be associated with the dying process, and not prolonging the dying process by using invasive medical techniques. Hospice care is also based on the assertion that dying patients have certain rights that must be respected. These rights include a right to absent themselves from social responsibilities and commitments, a right to be cared for, and the right to continued respect and status. The following seven principles are basic components of hospice care. Principles of Hospice Care The first principle is highly personalized and holistic care of the dying, which includes treating dying patients emotionally and spiritually as well as physically. This interpersonal support, known as bonding, helps patients in their final days to live as fully and as comfortably as possible, while retaining their dignity, autonomy, and individual self-worth in a safe and secure environment. This one-on-one attention involves what can be called therapeutic communication. Knowing that someone has heard, that someone understands and is concerned, can be profoundly healing. Another principle is treating pain aggressively. To this end, hospice care advocates the use of narcotics at a dosage that will alleviate suffering while, at the same time, enable patients to maintain a desired level of alertness. Efforts are made to employ the least invasive routes to administer these drugs (usually orally, if possible). In addition, pain medication is administered before the pain begins, thus alleviating the anxiety of patients waiting for pain to return. Since it has been shown that fear of pain often increases the pain itself, this type of aggressive pain management gives dying patients more time and energy to respond to family members and friends and to work through the emotional and spiritual stages of dying. This dispensation of pain medication before the pain actually occurs, however, has proven to be perhaps the most controversial element in hospice care, with some critics charging that the dying are being turned into drug addicts. A third principle is the participation of families in caring for the dying. Family members are trained by hospice nurses to care for the dying patients and even to dispense pain medication. The aim is to prevent the patients from suffering isolation or feeling as if they are surrounded by strangers. Participation in care also helps to sustain the patients’ and the families’ sense of autonomy. The fourth principle is familiarity of surroundings. Whenever possible, it is the goal of hospice care to keep dying patients at home. This eliminates
Hospice ✧ 475 the necessity of the dying to spend their final days in an institutionalized setting, isolated from family and friends when they need them the most. It is estimated that close to 90 percent of all hospice care days are spent in patients’ own homes. When this is not possible and patients must enter institutional settings, rules are relaxed so that their rooms can be decorated or arranged in such a way as to replicate the patients’ home surroundings. Visiting rules are suspended when possible, and visits by family members, children, and sometimes even pets are encouraged. The fifth principle is emotional and spiritual support for the family caregivers. Hospice volunteers are specially trained to use listening and communicative techniques with family members and to provide them with emotional support both during and after the patient’s death. In addition, because the care is holistic, the caregivers’ physical needs are attended to (for example, respite is provided for exhausted caregivers), as are their emotional and spiritual needs. This spiritual support applies to people of all faith backgrounds, as impending death tends to put faith into a perspective where particular creeds and denominational structures assume less significance. In attending to this spiritual dimension, the hospice team is respectful of all religious traditions while realizing that death and bereavement have the ability to both strengthen and weaken faith. The sixth principle is having hospice services available twenty-four hours a day, seven days a week. Because of its reliance on the assistance of trained volunteers, round-the-clock support is available to patients and their families. The seventh principle is bereavement counseling for the survivors. At the time of death, the hospice team is available to help families take care of tasks such as planning the funeral and probating the will. In the weeks after the death, hospice volunteers offer their support to surviving family members in dealing with their loss and grief and the various phases of the bereavement process, always aware of the fact that not all bereaved need or want formal interventions. Cost Because of hospice care’s reliance on heavily trained volunteers and contributions, and because death is seen as a natural process that should not be prolonged by invasive and expensive medical techniques, hospice care is much less costly than traditional acute care facilities. Because hospice care is a philosophy of care rather than a specific facility, though, legislation to provide monetary support for hospice patients took a great deal of time to be approved. In 1982, the U.S. Congress finally added hospice care as a Medicare benefit. In 1986, it was made a permanent benefit. Medicare requires, however, that there be a prognosis of six months or less for the patient to live. Hospice care is also reimbursable by many private insurance companies. —Mara Kelly-Zukowski
476 ✧ Hospitalization of the elderly See also Death and dying; Euthanasia; Hospitalization of the elderly; Nursing and convalescent homes; Terminal illnesses. For Further Information: Buckingham, Robert W. The Handbook of Hospice Care. New York: Prometheus Books, 1996. Covers the history and philosophy of hospice care while providing practical information as to its cost, how to find hospice programs in your own community, and how to manage grief. Focuses on two target populations for hospice care: children and AIDS victims. Byock, Ira. Dying Well: The Prospect for Growth at the End of Life. New York: Riverhead Books, 1997. President of the American Academy of Hospice and Palliative Medicine at the time he wrote this book, Dr. Byock uses the personal stories of his patients to show the best ways to die. Provides information for the families of the dying who wish to make their loved ones’ final days as comfortable and meaningful as possible. Corr, Charles A., and Donna M. Corr, eds. Hospice Care: Principles and Practice. New York: Springer, 1983. A collection of salient essays on hospice care addressing issues ranging from the needs of the dying to the stress associated with caregiving to the terminally ill. Contributors include Cicely Saunders, physicians, hospice directors, psychologists, and chaplains. Kübler-Ross, Elisabeth. On Death and Dying. New York: Macmillan, 1969. Landmark work which outlines the psychological stages of dying and the deficiencies in modern medicine’s ability to care for dying patients in an appropriate manner. Lattanzi-Licht, Marcia, John J. Mahoney, and Galen W. Miller. The Hospice Choice: In Pursuit of a Peaceful Death. New York: Simon & Schuster, 1998. Definitive resource from the National Hospice Organization. Provides practical information such as range of hospice services, methods of payment, and so on. Intersperses stories of families who have received hospice care with a thorough explanation of its history, principles, and benefits. Provides personal accounts of hospice nurses and volunteers with discussion of psychological and emotional responses to life-threatening illnesses.
✧ Hospitalization of the elderly Type of issue: Economic issues, elder health, public health, treatment Definition: The specific needs of the elderly in hospital settings, particularly pertaining to acute and long-term care. In 1996, those aged sixty-five and over accounted for 38 percent of the admissions to nonfederal, acute care hospitals. Those aged forty-five through
Hospitalization of the elderly ✧ 477 sixty-four accounted for 20 percent of all admissions. The average length of stay (ALOS) was 5.3 days for people forty-five through sixty-four and 6.5 days for those sixty-five and over. Although the major portion of inpatient services is provided in acute care community hospitals, elderly patients may also receive inpatient services in hospitals operated by the Department of Veterans Affairs or in proprietary facilities such as psychiatric hospitals. Approximately 97 percent of all hospital care in the United States is financed by third parties. The vast majority of Americans over the age of sixty-five (33.4 million people in 1996) had hospital insurance through the Medicare program. According to data compiled by the Health Care Financing Administration (HCFA), the administrative agency for the Medicare program, the largest component of national health expenditure is hospital care. Inpatient hospital care for beneficiaries resulted in costs to the Medicare program of $79.9 billion in 1996.
Older adults may find themselves hospitalized for acute illnesses, chronic illnesses, or injuries— all of which present higher risks for the elderly than for younger adults. (Digital Stock)
Cost and Payments Medicare pays most short-stay hospitalization under a prospective payment system (PPS) in which hospitals are reimbursed for services according to the diagnosis-related group (DRG) to which the patient is assigned. The DRG system is used to classify patients based on their principal diagnosis and other patient data, such as comorbidity or coexisting conditions. Medicare has set a fixed, preestablished amount of payment for each DRG based on
478 ✧ Hospitalization of the elderly the average cost of resources needed to treat a patient with that particular diagnosis. The PPS was instituted as a means of containing costs for hospital services by replacing the cost-plus payment system. Since the hospital is paid a fixed amount for each patient stay, the incentive is for the hospital to reduce the average length of stay per inpatient episode. The PPS has been effective in reducing the growth of short-stay hospitalization by providing financial incentives to shift services from inpatient to outpatient settings, to provide services in a more efficient manner, and to reduce the length of stay. These measures were effective in reducing the ALOS from 8.8 days in 1990 to 6.5 days in 1996 and reducing the portion of Medicare payments for inpatient services to 47.8 percent in the same year (from a high of 69.7 percent in 1974). Approximately 7 million Medicare recipients were hospitalized in 1996, representing 23.1 percent of all people enrolled and 79.1 percent of all Medicare payments for the year. Yearly payments for Medicare enrollees who had been hospitalized averaged $18,925, which was approximately thirteen times higher than payments for nonhospitalized enrollees. One factor that accounts for the higher costs is that in the last months of life, Medicare services, including hospital usage, intensify. During 1996, 6.4 percent (1.9 million) of all Medicare enrollees died; they accounted for 20.5 percent of all yearly Medicare payments. Diseases and Procedures Hospitalization for an elderly individual commonly occurs because of acute illness such as pneumonia; because of the exacerbation of a chronic illness, such as an episode of pulmonary edema caused by chronic heart failure; for a major operative procedure, such as coronary artery bypass surgery; because of injury, such as a fracture; or for complex diagnostic procedures, such as an endoscopy. The most frequent diagnostic category resulting in short-stay hospitalization for Medicare beneficiaries in 1996 was heart disease. These patients made up 20 percent of all Medicare hospitalizations—accounting for 23.7 percent of all payments—and had an ALOS of 5.6 days with an average cost of $7,893 per hospital stay. Related conditions include chest pain (angina), with an ALOS of 2.3 days; cardiac arrhythmia and conduction disorder, with an average cost per episode of $4,548; and coronary artery bypass surgery, with an average cost of $51,583 per patient. The second most common diagnostic category was cerebrovascular disease (stroke), accounting for 5.7 percent of all hospitalizations and 4.9 percent of all payments. The ALOS for this group was 6.0 days, and payments averaged $5,945 per patient. Pneumonia was the third most frequent cause of hospitalization, accounting for 5.6 percent of discharges, resulting in 5.2
Hospitalization of the elderly ✧ 479 percent of all payments, and having an ALOS of 7.4 days. Malignant neoplasms (cancers), the fourth leading cause of hospitalization, with 5.5 percent of all Medicare discharges affected, resulted in an ALOS of 7.9 days and accounted for 7.5 percent of all payments. The fifth-leading condition resulting in hospitalization was fractures, which accounted for 3.7 percent of all Medicare hospitalizations and 3.9 percent of all payments, with an ALOS of 6.6 days. The highest ALOS, at 14.9 days, was hospitalization for rehabilitative services. Of all Medicare payments, 74 percent were applied to hospitalizations involving a medical procedure. The most frequent procedure in 1996 was an endoscopy of the small intestines, which may have included a tissue biopsy, performed on 330,035 patients, or 4.9 percent of all Medicare admissions. The ALOS for this procedure was 6.7 days, and the average cost was $4,648. Cardiac catheterization was the second most common medical procedure performed on hospitalized patients, involving 4.4 percent of all patients. The ALOS for this group was 4.7 days, with an average cost of $5,882 per patient. Other medical procedures commonly performed during hospitalization were computed tomography (CT) scan, diagnostic ultrasound, and respiratory therapy. In 1996, the rate per 1,000 population for inpatient procedures was 62.9 in the fifteen through forty-five age group, 77.2 in the forty-five through sixty-four age group, and 196.5 for the sixty-five and over age group. Adverse Reactions Longer and more frequent hospitalizations place the elderly patient at higher risk for iatrogenic complications (those accidentally induced by the physician), nosocomial infections (those acquired in the hospital), and falls. The most frequently encountered problem in hospitalized elderly is an adverse drug reaction. The elderly are especially prone to adverse drug reactions because of age-related changes in body composition and function, resulting in altered ability to absorb, metabolize, and excrete medications. Elderly patients frequently require a number of medications (polypharmacy) to control multiple health problems, and additions to and changes in the medication regimen are common during hospitalization. Functional decline of the elderly person is a common problem leading to hospitalization, and deterioration in function can be worsened during hospitalization. Factors that contribute to a decline in functional level are the disease process itself, medical procedures and treatments, and deconditioning caused by restricted activity. Patients most likely to experience reduced functional ability during hospitalization are those who are older, those with cognitive impairments, and those who exhibited functional losses prior to hospitalization. Early recognition and intervention can decrease the likelihood of functional losses during and after hospitalization.
480 ✧ Hospitalization of the elderly Delirium or confusion develops in many hospitalized elderly. The development of delirium can have multiple causes, such as drug reactions, sepsis, or the disruption caused by hospitalization. Rapid identification and treatment of the cause is essential to prevent permanent impairment. Elderly patients are more likely to develop respiratory tract infections as a result of immobility, decreased immunity, and decreased respiratory function. They are also more susceptible to urinary tract infections caused by urinary stasis or the use of indwelling catheters. Age-related skin and circulatory changes often increase the older patient’s risk of developing pressure ulcers. Pressure, or decubital, ulcers (commonly called bedsores) are more likely to develop in patients who are immobile, incontinent, febrile, or malnourished, or in those who have poor circulation. Special attention to the skin care of the hospitalized elderly is important in preventing skin breakdown. Visitation by family members and friends plays a therapeutic role in the patient’s recovery. Interacting with familiar people helps keep the patient mentally alert and oriented, decreases the sense of loneliness, and increases motivation. Because of the special needs of elderly hospitalized patients, a team approach to treatment is suggested. Involvement by physical therapists, nutritionists, pharmacists, and social workers, as well as nurses and physicians, can be beneficial in promoting rapid and maximum recovery. Advance Directives The federal Patient Self-Determination Act, which went into effect on December 1, 1991, dictates that all Medicare providers, including hospitals, must have policies and procedures in place that ensure that all patients receive information about advance directives at the time of admission. Advance directives, such as “do not resuscitate” orders or living wills, allow competent people to extend their right of self-determination regarding health care into the future. Such directives ensure that the patient’s decisions regarding the acceptance or rejection of particular types of treatment will be respected should the patient become incompetent. At admission, patients should be asked whether they have an advance directive, and, if they do, it should be included in the medical record. Advance directives are especially important for elderly patients, since they are more prone to cognitive impairments caused by illness. —Roberta Tierney See also Aging; Cancer; Broken bones in the elderly; Health insurance; Heart attacks; Heart disease; Iatrogenic disorders; Illnesses among the elderly; Injuries among the elderly; Living wills; Medications and the elderly; Nursing and convalescent homes; Overmedication; Strokes; Terminal illnesses.
Hydrocephalus ✧ 481 For Further Information: Graves, Edmund J., and Maria F. Owings. “1996 Summary: National Hospital Discharge Survey.” In Data: Vital and Health Statistics of the Centers for Disease Control and Prevention/National Center for Health Statistics. Hyattsville, Md.: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Health Statistics, 1998. Health Care Financing Administration. Health Care Financing Review: Statistical Supplement. Baltimore, Md.: U.S. Department of Health and Human Services, 1998. Holmes, H. Nancy, ed. Mastering Geriatric Care. Springhouse, Pa.: Springhouse, 1997. Luggen, Ann Schmidt, ed. National Gerontological Nursing Association Core Curriculum for Gerontological Nursing. St. Louis: Mosby, 1996. Owings, Maria F., and Lola Jean Kozak. “Ambulatory and Inpatient Procedures in the United States, 1996.” In Data: Vital and Health Statistics of the Centers for Disease Control and Prevention/National Center for Health Statistics. Hyattsville, Md.: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Health Statistics, 1998.
✧ Hydrocephalus Type of issue: Children’s health, mental health Definition: A collection of excessive amounts of cerebrospinal fluid (CSF) within the cranial cavity, which can cause increased pressure within the brain and skull, leading to brain tissue damage and, in infants, enlargement of the skull. Frequently referred to as “water on the brain,” hydrocephalus is a disorder most commonly seen in newborns and infants but sometimes occurring in older children and adults. The water is actually a relatively small amount (about 10 cubic centimeters for every kilogram of body weight) of cerebrospinal fluid (CSF), which surrounds and cushions the brain and spinal cord on both the inside and the outside. Within the brain are four CSF-filled spaces called ventricles. The CSF is continuously formed here and then moves down through the central canal, a tube that runs the length of the spinal cord. From the base of the spine, the fluid moves upward on the outside of the spinal cord, returning to the skull, where it covers the outer surfaces of the brain. Here it is absorbed by the brain’s outer lining. If interference occurs in any part of this, CSF continues to accumulate in the brain. This usually causes increased pressure to develop within the skull.
482 ✧ Hydrocephalus Abnormally high pressure can lead to permanent brain damage and even death. In the infant, this accumulation also causes the skull to enlarge, since the growth regions of the skull have not yet become firm. Excessive CSF may develop due to overproduction of fluid in the brain, a blockage of the fluid’s circulation, or a blockage of fluid reabsorption on the brain’s surface. Hydrocephalus can be congenital or may develop as a result of a head injury, infection, brain hemorrhage, or tumor. Congenital hydrocephalus and most hydrocephalus that begins in infancy are characterized by an enlarged head, which continues to grow at an abnormally rapid pace. Symptoms and signs that accompany congenital hydrocephalus include lethargy, vomiting, irritability, epilepsy, rigidity of the legs, and the loss of normal reflexes. If left untreated, the condition causes drowsiness, seizures, and severe brain damage, leading to death possibly within days or weeks. Hydrocephalus is also often associated with other anomalies of the brain and nervous system, such as spina bifida. When hydrocephalus develops in older children and adults, the head size will not increase since the growth lines in the bones of the skull have hardened. If the CSF pressure increases, resulting symptoms include headaches, vomiting, vision problems, problems with muscle coordination, and a progressive decrease in mental activity. Treatment and Therapy Diagnosis of hydrocephalus and related nervous system defects sometimes can be made before birth, either by fetal ultrasound or by testing for the presence of an abnormal amount of a brain-associated protein, alpha-fetoprotein, in the pregnant woman’s blood. However, even with early diagnosis and surgical intervention promptly after birth, the prognosis is guarded. Older children and adults suspected of having hydrocephalus should be examined by a neurologist. A computed tomography (CT) scan or magnetic resonance imaging (MRI) of the brain can visualize the structure of the brain and the extent of the hydrocephalus. Surgical correction is the primary treatment for hydrocephalus. The excess pressure must be drained from within the brain or a balance between the production and elimination of CSF must be established. In some cases, a combination of surgery and medication is successful. For example, the drugs furosemide (Lasix) and acetazolamide (Diamox), when used for increased CSF pressure from brain hemorrhage, may reduce the amount of CSF fluid produced and thereby decrease the amount of swelling. Relieving the CSF pressure within the brain is generally achieved by the surgical insertion of a tube, called a shunt, through brain tissue into one of the cerebral ventricles. A one-way valve is attached to the tube; this allows CSF to escape from the skull cavity when the pressure exceeds a certain level. The tubing is then passed beneath the skin into either the right side of the
Hypertension ✧ 483 heart or the abdominal cavity, where the excessive CSF can be absorbed safely. Complications of this procedure are fairly common and include repeated infections, septicemia, peritonitis, or meningitis. The outcome of treated patients with hydrocephalus has improved over the years, but the condition is still associated with long-term problems. A modest percentage of newborns with congenital hydrocephalus will survive and achieve normal intelligence. —Cynthia Beres See also Birth defects; Childbirth complications; Children’s health issues; Meningitis; Mental retardation; Prenatal care; Spina bifida. For Further Information: Clayman, Charles B., ed. The American Medical Association Encyclopedia of Medicine. 3d ed. New York: Random House, 1994. Professional Guide to Diseases. 7th ed. Springhouse, Pa.: Springhouse, 2001.
✧ Hypertension Type of issue: Elder health, public health Definition: High blood pressure, usually defined as a systolic measurement of 140 millimeters or higher, and a diastolic measurement of 90 millimeters or higher. High blood pressure that is not controlled by medication or lifestyle can damage the body. The higher the blood pressure, the harder the heart must work to pump blood throughout the body. When the heart has to work harder, the heart muscle gets larger, or hypertrophies. An enlarged heart can work well at first, but as it gets larger, it does not function efficiently and begins to fail. Additionally, arteries get harder and less elastic with age. Having high blood pressure accelerates this process, resulting in further degradations in heart function. A serious concern of high blood pressure is the increased potential for a stroke, which has been the leading cause of disability in the United States. A stroke occurs when a blood vessel in the brain becomes clogged or bursts. The brain tissue that gets its blood from the affected vessel is deprived of oxygen and begins to die within minutes. The death of the brain tissue can cause paralysis, loss of vision, difficulty talking or hearing, or, in extreme cases, death. Another complication of hypertension is related to the kidneys. When systolic pressures get high, small blood vessels in the kidneys can rupture and bleed. Over time, this can destroy kidney cells, resulting in impaired
484 ✧ Hypertension function and higher blood pressure. In order to make the kidneys filter blood effectively after the damage, the body must increase the blood pressure, further complicating the health of the whole body. In the extreme cases, this process results in the need for kidney dialysis, which is very costly and a burden for the individuals involved. Blood vessel ruptures can cause complications with the eyes as well. High pressures can damage the eye’s retina tissues. In many cases, it can cause blindness. Hypertension is a major health problem by itself. When left untreated, it can complicate and contribute to many other health problems. Therefore, individuals must be screened periodically and make the necessary lifestyle modifications to minimize their risk of this disease. Diagnosis of Hypertension Because no symptoms are felt by individuals with hypertension, it is important to have one’s blood pressure checked periodically by a qualified person. Blood pressure is measured by a sphygmomanometer (blood pressure cuff) and a stethoscope. The cuff is wrapped around the upper arm and filled with air to compress the brachial artery. The pressure is slowly released while the health practitioner listens for blood flow through the stethoscope. When the pulsating blood is first heard, the systolic blood pressure is recorded. After the pulsating sound stops, the diastolic blood pressure is recorded. All values are measured in millimeters of mercury. Systolic blood pressure indicates the pressure the blood exerts against the blood vessel walls when the heart is contracting. A value of 140 millimeters or higher would be considered high blood pressure. In general, the greater the value is over 140, the more severe the hypertension. Diastolic blood pressure is the pressure the blood exerts against the blood vessel walls when the heart is at rest (between beats). A value of 90 millimeters or higher denotes high blood pressure. As with the systolic blood pressure, the greater the value is over 90, the more severe the hypertension. Although there are two different measures for blood pressure, only one of them has to be elevated to be diagnosed as hypertension. Diastolic and systolic blood pressures are highly correlated to one another. Additionally, both are correlated with cardiovascular disease when considered alone and when combined. Generally, the risks of complications are higher for elevated systolic blood pressure than for elevated diastolic blood pressure. An important factor to understand is that blood pressure fluctuates greatly over the course of a day. Therefore, one random reading that happens to be high should not immediately be used to diagnose hypertension. High values at rest on two or more days are required to make an accurate diagnosis.
Hypertension ✧ 485 Risk Factors for Hypertension Conditions that increase an individual’s likelihood of having a disease are called risk factors. There are several risk factors for high blood pressure. Some risk factors are controllable, while others are uncontrollable. Three risk factors have been identified that cannot be controlled. Heredity is one: Individuals from families with a history of high blood pressure, strokes, or heart attacks are more likely to have high blood pressure. Age is another uncontrollable risk factor: Individuals over the age of thirty-five are more likely to have hypertension than younger individuals. Ethnic background has also been found to be an uncontrollable risk factor: African Americans, Puerto Ricans, Mexican Americans, and Cuban Americans are more likely to have high blood pressure than European Americans. Fortunately, there are several risk factors that can be controlled. Individuals who are overweight are more likely to have high blood pressure. Also, individuals who consume more than one alcoholic drink per day are at a higher risk. Some individuals are sensitive to sodium (a major component of table salt). These individuals are more likely to have hypertension if they consume too much salt or other sodium-containing products. It has also been found that women who use some types of birth control pills are more likely to develop high blood pressure. Lack of exercise is another risk factor that can be controlled. Proper aerobic exercise has been found to decrease blood pressure. Risk factors indicate the likelihood for health problems. Not having any risk factors is no guarantee of good health. Therefore, medical experts urge all individuals to have their blood pressure checked at least annually (and more often if risk factors are present) to be sure the “silent killer” is not present. Lifestyle Management Based on the risk factors identified for high blood pressure, there are several activities that can decrease the likelihood of having hypertension. It is recommended that individuals maintain a proper weight and that overweight individuals implement a reduced-calorie diet. All individuals can benefit from regular exercise. Continuous, vigorous activities are best. Besides developing a stronger cardiovascular system, they can also help people lose weight. These exercises should be done three to four days per week. Long, steady walks can be as good as running for many people. Other controllable activities include using an alternative to birth control pills, decreasing or discontinuing the consumption of alcoholic beverages, and reducing the intake of sodium. For individuals who have been diagnosed with hypertension, strict adherence to the medication regimen is critical. High blood pressure medication works by getting rid of excess body fluids and sodium, opening up narrowed blood vessels, or preventing blood
486 ✧ Hypertension vessels from narrowing or constricting. It can lower the pressures substantially if taken as directed by a physician. A major problem exists with individuals forgetting or skipping doses and trading medicines with family and friends. It is critical that blood pressure medications be taken exactly as directed and other lifestyle modification recommendations are followed. A lifestyle habit that indirectly affects hypertension is smoking. Although smoking contributes no known, long-term risk, it does cause immediate, short-term increases in blood pressure. This can complicate an elevated blood pressure by pushing it even higher. Additionally, smoking has been found to increase the risk of coronary artery disease and stroke. Both of these major health problems are related to and complicated by hypertension. Hypertension can have serious negative effects on health. This disease can affect individuals at any age, but its incidence increases with age. Fortunately, proper lifestyle habits can significantly improve the chances of avoiding hypertension. It is important that people implement positive lifestyle habits early in life rather than waiting until after the problems develop later in life. —Bradley R. A. Wilson See also Aging; Alcoholism; Alcoholism among the elderly; Exercise; Exercise and the elderly; Heart attacks; Heart disease; Heart disease and women; Illnesses among the elderly; Nutrition and the elderly; Smoking; Strokes. For Further Information: American Heart Association. About High Blood Pressure. Dallas: Author, 1995. _______. Human Blood Pressure Determination by Sphygmomanometry. Dallas: Author, 1994. _______. Sodium and Blood Pressure. Dallas: Author, 1996. Delaney, Lisa. “The Ultimate High-Blood-Pressure Prevention Plan.” Prevention 45 (November, 1993). Smith, Susan C. “Take Control of High Blood Pressure in Two Weeks.” Prevention 50 (September, 1998).
Health Issues
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MAGILL’S C H O I C E
Health Issues Volume 2 Hypnosis – Zoonoses Index
edited by The Editors of Salem Press project editor Tracy Irons-Georges
SALEM PRESS, INC. Pasadena, California Hackensack, New Jersey
Copyright © 2001, by Salem Press, Inc. All rights in this book are reserved. No part of this work may be used or reproduced in any manner whatsoever or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission from the copyright owner except in the case of brief quotations embodied in critical articles and reviews. For information address the publisher, Salem Press, Inc., P.O. Box 50062, Pasadena, California 91115. The essays in Magill’s Choice: Health Issues were adapted from Women’s Issues (1997), Encyclopedia of Family Life (1998), Children’s Health (1999), Encyclopedia of Environmental Issues (1999), Aging (2000), Magill’s Choice: Psychology and Mental Health (2000), and Magill’s Medical Guide, Second Revised Edition (2002). All bibliographies have been updated, and formats have been changed. ∞ The paper used in these volumes conforms to the American National Standard for Permanence of Paper for Printed Library Materials, Z39.48-1992 (R1997). Library of Congress Cataloging-in-Publication Data Health issues / edited by the editors of Salem Press ; project editor, Tracy Irons-Georges p. cm. — (Magill’s choice) Includes bibliographical references and index. ISBN 0-89356-042-1 (set). — ISBN 0-89356-048-0 (v. 1). — ISBN 0-89356-049-9 (v. 2) 1. Public health. 2. Social medicine. I. Irons-Georges, Tracy. II. Salem Press. III. Series RA425.H39 2001 362.1—dc21 200102087 First Printing
printed in the united states of america
Table of Contents Hypnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487 Hysterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490 Iatrogenic disorders . . . . . Illnesses among the elderly . Immunizations for children . Immunizations for the elderly In vitro fertilization . . . . . Incontinence . . . . . . . . . Infertility in men . . . . . . . Infertility in women . . . . . Influenza . . . . . . . . . . . Injuries among the elderly . .
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495 497 504 508 511 515 520 525 530 535
Lactose intolerance Laparoscopy . . . . Laser use in surgery Law and medicine . Lead poisoning . . . Learning disabilities Lice, mites, and ticks Light therapy . . . . Liposuction . . . . . Living wills . . . . . Lung cancer . . . . Lyme disease . . . .
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537 538 541 544 550 552 558 563 565 567 568 571
Macular degeneration . . . . . Mad cow disease . . . . . . . . Malnutrition among children . Malnutrition among the elderly Malpractice . . . . . . . . . . . Mammograms . . . . . . . . . Mastectomy . . . . . . . . . . . Medications and the elderly . .
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574 577 580 586 590 594 599 604
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Health Issues
Meditation . . . . . . . . . . . . . . . . Memory loss . . . . . . . . . . . . . . . Meningitis . . . . . . . . . . . . . . . . Menopause . . . . . . . . . . . . . . . Menstruation . . . . . . . . . . . . . . Mental retardation . . . . . . . . . . . Mercury poisoning . . . . . . . . . . . Miscarriage . . . . . . . . . . . . . . . Mobility problems in the elderly . . . . Morning-after pill . . . . . . . . . . . . Multiple births . . . . . . . . . . . . . Multiple chemical sensitivity syndrome Münchausen syndrome by proxy . . . Muscle loss with aging . . . . . . . . .
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609 611 613 616 620 625 629 632 632 638 639 643 645 648
Natural childbirth . . . . . . . . . Necrotizing fasciitis . . . . . . . . Noise pollution . . . . . . . . . . Nursing and convalescent homes Nutrition and aging . . . . . . . . Nutrition and children . . . . . . Nutrition and women . . . . . . .
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651 654 656 658 663 666 673
Obesity . . . . . . . . Obesity and aging . . Obesity and children Occupational health Osteoporosis . . . . . Overmedication . . .
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675 681 684 689 692 697
Pain management . . . . . . . . Pap smears . . . . . . . . . . . . Parasites . . . . . . . . . . . . . Parkinson’s disease . . . . . . . Pesticides . . . . . . . . . . . . Phenylketonuria (PKU) . . . . Physical fitness tests for children Physical rehabilitation . . . . . Plague . . . . . . . . . . . . . . Poisoning . . . . . . . . . . . . Poisonous plants . . . . . . . .
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Table of Contents
Postpartum depression . . . Pregnancy among teenagers . Premature birth . . . . . . . Prenatal care . . . . . . . . . Preventive medicine . . . . . Prostate cancer . . . . . . . . Prostate enlargement . . . .
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735 736 741 744 747 751 755
Radiation . . . . . . . . . . Radon . . . . . . . . . . . . Reaction time and aging . . Recovery programs . . . . . Reproductive technologies Resuscitation . . . . . . . . Reye’s syndrome . . . . . .
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756 757 759 760 764 766 771
Safety issues for children . . . . . . . Safety issues for the elderly . . . . . . Schizophrenia . . . . . . . . . . . . . Scoliosis . . . . . . . . . . . . . . . . . Screening . . . . . . . . . . . . . . . . Seasonal affective disorder (SAD) . . Secondhand smoke . . . . . . . . . . Sexual dysfunction . . . . . . . . . . . Sexually transmitted diseases (STDs) . Sick building syndrome . . . . . . . . Skin cancer . . . . . . . . . . . . . . . Skin disorders with aging . . . . . . . Sleep changes with aging . . . . . . . Sleep disorders . . . . . . . . . . . . . Smog . . . . . . . . . . . . . . . . . . Smoking . . . . . . . . . . . . . . . . Snakebites . . . . . . . . . . . . . . . Speech disorders . . . . . . . . . . . . Spina bifida . . . . . . . . . . . . . . . Sports injuries among children . . . . Sterilization . . . . . . . . . . . . . . . Steroid abuse . . . . . . . . . . . . . . Stress . . . . . . . . . . . . . . . . . . Strokes . . . . . . . . . . . . . . . . . Sudden infant death syndrome (SIDS)
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Hypnosis ✧ 487
✧ Hypnosis Type of issue: Medical procedures, mental health, treatment Definition: The induction of an altered state of consciousness. The term “hypnosis” comes from the Greek word hypnos, meaning sleep. While scientists and researchers do not understand the exact nature of hypnosis, theorists agree that it is an altered state of consciousness occurring on a continuum of awareness. Hypnosis may occur naturally and spontaneously, as in the case of a daydream. The daydreamer is alert and awake but focuses attention inward rather than outward. The trance state, or hypnotic state, is characterized by an altered psychological state and minimal motor functioning. A trance can be recognized by the individual’s lack of mobility and unresponsiveness to external stimuli. A person in a trance state has a heightened receptivity to suggestion. Hypnosis, then, is a state that can be induced by another or by oneself (self-hypnosis) for a specific purpose. As a method of treatment, hypnosis, which is often used in conjunction with other approaches to alter psychophysiological states, promotes an understanding that allows for creative problem solving. In the hypnotic state, the subject is not necessarily docile or submissive and may reject a suggestion given by even the most expert hypnotist. Four basic types of suggestion have been described: verbal, which includes words and any kind of sound; nonverbal, which applies to body language and gestures; intraverbal, which relates to the intonation of words; and extraverbal, which utilizes the implications of words and gestures that facilitate the acceptance of ideas. Suggestions are also described as being direct or indirect. Suggestibility is a behavior that is not hindered by the individual’s logical processes but is enhanced by the subject’s motivation, expectation, and trust in the operator as well as by the frequency and manner in which a suggestion is given. The Use of Hypnosis in Medicine Hypnosis can be used alone or in combination with other approaches to overcome a variety of habit disorders. While some problems, such as thumbsucking, can be resolved relatively quickly, others, such as overeating, sometimes require extended treatment or a multidimensional approach. Smoking and bed-wetting are examples of habit disorders that can be managed through hypnosis. There is much evidence that children as a group are more responsive to hypnosis than adults, and that infants and young children frequently experience hypnosis as a natural part of their lives. Children can often be helped in a remarkably short period of time. Hypnosis has been used with children in the treatment of such diverse ailments as bed-wetting, soiling, asthma,
488 ✧ Hypnosis epilepsy, learning difficulties, some behavioral and delinquency problems, stuttering, nailbiting, and many others. Hypnosis has been used effectively as an adjunct to the treatment of numerous problems with autonomic (internal) nervous system components. For example, there have been many controlled studies and successful case reports on the use of hypnosis in the treatment of asthma, which is the most common of the psychophysiological respiratory disorders. Through hypnosis, a patient can be helped to break the vicious cycle in which anxiety and emotional upsets can trigger an acute asthma attack, which in turn can produce anxiety and fear of other attacks. In addition to being used to treat chronic conditions such as hypertension, hypnosis has been used to provide symptomatic relief of other chronic conditions, such as musculoskeletal disorders (for example, rheumatoid arthritis, osteoarthritis, fractures, and bursitis) and hemophilia. Since the mid-1970’s, there has been much research into immune system functioning. Studies of the effects of stress on immune system functioning are lending scientific support to anecdotal reports that indicate that hypnosis may be effective in altering the disease process in cancer and AIDS patients. Unless treatments for these illnesses are based on the premise that the mind, body, and emotions are all striving to achieve health, researchers have found that physical intervention alone (radiation or chemotherapy, for example) will not be effective. Pain Management and Anesthesia Hypnosis has also been used effectively in the control and relief of pain. Because pain is experienced psychologically as well as physiologically, hypnosis can help people alter the perception of pain. A patient can learn to block pain to specific areas of the body, lessen the sensation of pain, or move pain from one area of the body to another. This ability is useful in the management of many types of pain, including chronic back pain, postoperative pain, and the pain associated with illness, migraine headache, burns, childbirth, and medical procedures. Hypnosis has been used in dentistry for the relief of anxiety as well as pain and has been found to be helpful in teeth grinding (bruxism) and gagging. Modern hypnodontics is not primarily concerned with producing a surgical hypoanalgesia except in rare instances in which chemical anesthesia cannot be tolerated. The dentist is concerned with making visits to his or her office more tolerable and less threatening. In obstetrics and surgery, hypnosis has been used to induce relaxation and relieve anxiety and to reduce the amount of anesthetic necessary. Occasionally, no anesthetic is required. This is sometimes desirable in childbirth, when the mother prefers to be aware of the birth process, or in other surgical procedures in which a minimum of anesthetic is desirable.
Hypnosis ✧ 489 Hypnosis and Psychiatry Auguste Ambroise Leibeault (1823-1904) and Hippolyte Bernheim (18371919) were the first to regard hypnosis as a normal phenomenon. Sigmund Freud became interested in hypnosis at this same time and visited Leibeault and Bernheim’s clinic to learn their induction techniques. As Freud observed patients enter a hypnotic state, he began to recognize the existence of the unconscious. Although he was not the first to make this observation, he was the first to recognize the unconscious as a major source of psychopathology. Early in his research, however, Freud rejected hypnosis as the tool to unlock repressed memories, favoring instead his technique of free association and dream interpretation. With the rise of psychoanalysis in the first half of the twentieth century, hypnosis declined in popularity. Then, however, a reversal occurred. During World War II, interest in hypnosis was regenerated by the need for short-term therapy (it was often applied in cases of “battle fatigue”) and by the combination of hypnosis and more traditional analytic approaches. Mind control and “brainwashing” techniques that surfaced during the Korean War again sparked interest in the power of suggestion, especially when the subject was under duress. In the late 1960’s and early 1970’s, with the rise of public interest in alternative forms of mental health (Transcendental Meditation, biofeedback, yoga) and ways of coping with the stress of the modern world, hypnosis experienced a rebirth. Researchers found new and potent uses for it in therapy, and the trance state began to be recognized as a highly effective tool for modifying behavior and for healing. —Genevieve Slomski See also Alternative medicine; Asthma; Biofeedback; Meditation; Pain management; Stress. For Further Information: Brown, Peter. The Hypnotic Brain. New Haven, Conn.: Yale University Press, 1991. Suggests that the rhythmic variations in states of consciousness that occur throughout the course of the day are similar to the changes that the brain undergoes during hypnosis. Discusses the use of hypnosis in a variety of medical disorders. Extensive bibliography. Forrest, Derek, and Anthony Storr. The Evolution of Hypnotism. Forfar, England: Black Ace Books, 1999. This book offers a history of hypnotism and its predecessor, mesmerism. Traces the major figures of mesmerism, leading up through Sigmund Freud and into the late twentieth century. Hadley, Josie, and Carol Staudacher. Hypnosis for Change. 3d ed. New York: Ballantine Books, 1996. This popular account provides step-by-step details on the practice of self-hypnosis. It also offers a brief historical sketch of hypnosis, explores all facets of induction, and examines various aspects of hypnotic communication. Includes a bibliography.
490 ✧ Hysterectomy Pratt, George J., et al. A Clinical Hypnosis Primer. New York: John Wiley & Sons, 1988. A useful introduction to the many uses of hypnosis in medicine, psychology, and dentistry. The book provides valuable background information as well as practical instruction on hypnotic techniques. Contains references and appendices. Zahourek, Rothlyn P., ed. Clinical Hypnosis and Therapeutic Suggestion in Patient Care. New York: Brunner/Mazel, 1990. Representing a variety of disciplines, the contributors to this book argue that hypnosis is a natural, noninvasive tool that can be of use in patient care. After reviewing the theoretical, historical, and ethical issues surrounding hypnosis, the book focuses on the numerous clinical applications of hypnosis and suggestion with various populations. Contains an appendix and a useful list of readings.
✧ Hysterectomy Type of issue: Medical procedures, women’s health Definition: The removal of the uterus and sometimes the ovaries and surrounding tissues, which is usually performed as a treatment for invasive cancer. While hysterectomy refers to the removal of a woman’s uterus and, most commonly, the attached Fallopian tubes, there are several types of hysterectomies. Total hysterectomy, contrary to popular belief, does not mean that the ovaries are removed with the uterus. Rather, the term indicates the removal of the uterus and cervix. Subtotal, or partial, hysterectomy is the excision of the uterus above the cervix; the cervix is left in place. Either one or both ovaries may be removed with the uterus (oophorectomy or bilateral oophorectomy). Salpingo oophorectomy refers to the removal of one of the Fallopian tubes along with the accompanying ovary, while bilateral salpingo oophorectomy refers to the removal of both Fallopian tubes and ovaries. Most frequently, the surgery is accomplished through a 6- to 8-inch midline incision running either down from the navel or across the lower abdomen near or below the hairline. This procedure is referred to as an abdominal hysterectomy. Vaginal hysterectomy is the removal of the uterus through the vaginal canal, rather than through a surgical opening of the abdomen. This procedure is most often performed to resolve prolapse or when the uterus is not enlarged and can be pulled down and out through the vagina. If the hysterectomy is performed because of fibroid tumors, the abdominal approach is usually advised. Tumors so large that they require the removal of the uterus are generally too large to pass safely through the vagina.
Hysterectomy ✧ 491 Fibroid Tumors Fibroids are responsible for approximately two hundred thousand hysterectomies per year and are the most common and troublesome gynecologic complaint of women. The most common benign disease entities of the female reproductive tract, they are present in anywhere from 30 to 50 percent of all women between forty and fifty years of age, afflicting twice as many African American women as white women. Women who have never had children and nonsmokers also seem to be at greater risk of developing fibroids, although the reason for this is uncertain. Estrogen may play a role in their growth and development, since fibroids are never seen before puberty and seem to shrink after the menopause. In addition, fibroids tend to worsen during pregnancy, when estrogen levels are high. Fibroids can occasionally migrate from the uterus and invade the cervix, surrounding ligaments, or, on rare occasions, other abdominal organs containing smooth muscle. They can occur singularly, but multiple fibroids are more common. They can be so tiny that they are visible only under a microscope or so large as to weigh thirty pounds. Furthermore, the symptoms may have no direct bearing on the number or size of the tumors; a woman could have one the size of a full-term pregnancy that causes little or no discomfort. When symptoms do occur, they are usually heavier flow and perhaps more painful menstrual periods. Fibroids can also cause an abnormal pattern of bleeding, such as spotting between periods or bleeding after the menopause. Depending on its location, a fibroid may cause inflammation and pain. In addition, many women with fibroids suffer from a sensation of pressure in the back, legs, or lower abdominal region. Yet only 0.5 percent of fibroids become malignant. A cancerous fibroid, called a leiomyosarcoma, is suspected when a fibroid is observed to enlarge at an unusually rapid rate. Myomectomy is a surgical procedure whereby the fibroid tumors are removed and the remainder of the uterus is preserved and reconstructed. Because this surgery is complex and time-consuming, traditional physicians most often recommend hysterectomy, sometimes with oophorectomy, to women in their forties as a more appealing and permanent solution to their fibroids. Traditional physicians claim that myomectomy may cause greater blood loss, thus increasing the chance of a transfusion. Yet a woman, regardless of her childbearing plans, often has emotional reasons for wanting to preserve her uterus. Endometriosis and Other Conditions Hysterectomy is often recommended as a definitive treatment for endometriosis and adenomyosis (in which the endometrial tissue invades the deeper muscle layers of the uterus). From 1964 to 1984, the number of hysterecto-
492 ✧ Hysterectomy mies performed for endometriosis increased by 176 percent, more than for any other diagnosis, despite the fact that successful surgical techniques and drugs which can conserve organs were developed during this twenty-year period. Endometriosis refers to the growth of small portions of the normal tissue that line the uterus (the endometrium) outside their normal location. These bits of misplaced tissue, called endometrial implants, survive within the pelvic cavity—on the Fallopian tubes, ovaries, or bowels—and in rare cases, as far away as the lungs, thighs, chest, arms, or any other part of the body. Endometrial growths are not malignant. Each month, these foreign colonies of uterine tissue build up and then break down and bleed, as if they were still within the uterus. The result is internal bleeding, degeneration of the blood and tissue, inflammation of the surrounding areas, and the formation of scar tissue and adhesions. In rare cases, intestinal bleeding and obstruction, bladder difficulties, and kidney obstruction can occur. Endometriosis is a frequent cause of infertility. Traditionally, hysterectomy and oophorectomy were considered the definitive answer to this problem if childbearing was not an issue. Increasingly, however, female reconstructive surgery—microsurgery, laser surgery, or electrocautery—coupled with medication has been used successfully in the treatment of endometriosis. Hysterectomy has been the treatment of choice for a variety of life-threatening cancers: endometrial hyperplasia (overgrowth of uterine lining, in which the thickened cells may cause spotting or abnormal bleeding), endometrial cancer, cervical cancer, and ovarian cancer. While hysterectomy has been the standard treatment for uterine prolapse, the uterus can be repositioned and repaired. It is thought that in the majority of cases prolapse results from pregnancy and childbirth. When the uterus and surrounding support tissues expand to accommodate pregnancy and delivery, they may lose their ability to contract back to their normal position and elasticity. Prolapse also occurs, however, in women who have never been pregnant, perhaps because of the passage of time, hormone deprivation, the long-term effects of gravity, or a genetic predisposition to having less collagen and elastin in the tissue. Various other medical conditions, including excessive bleeding, cramps, problems after tubal ligation (in which the Fallopian tubes are cut and tied for the purpose of sterilization), and other menstrual or pelvic problems, have also been treated by hysterectomy. Complications and Side Effects The short-term operative complications of hysterectomy vary. Blood transfusion is common during hysterectomy. Some gynecologists routinely perform a transfusion before surgery if a woman is anemic. Other patients
Hysterectomy ✧ 493 require transfusion during surgery. The average blood loss during a hysterectomy is estimated at between 400 and 500 cubic centimeters (about a pint). Massive bleeding, however, can occur and may cause varying degrees of shock. Abdominal bleeding may occur as late as ten to fourteen days following a hysterectomy. In addition, blood clots may form one week after the hysterectomy. Urinary tract complications are most frequently caused by gynecological surgery; the rate varies from 1 to 10 percent of all cases. Retention of urine is a common complication of hysterectomy, particularly after a vaginal approach with anterior repair. Because the urine is not adequately expelled, bacteria can multiply within the bladder and cause cystitis, or bladder infection. Other complications include peritonitis (an infection of the membrane lining the abdominal cavity), ovarian infections, lung infections, bowel complications, severe adhesions, and general prolapse of other pelvic organs (including the intestines, bowels, bladder, and vagina). Among the long-term physical effects of hysterectomy is loss of ovarian function. With the loss of the ovaries following a hysterectomy-oophorectomy, the female hormones that stimulate the menstrual cycle, including estrogen and progesterone, stop circulating abruptly. The body is forced into a state of “surgical menopause.” Even ovaries left intact may fail in 30 to 50 percent of hysterectomy cases. Many studies have confirmed a link between premenopausal hysterectomy and cardiovascular disease (including heart attacks and high cholesterol). While the reasons for this link are uncertain, the loss of the ovaries appears to be a factor because estrogen may protect the circulatory system. In addition, the chemical prostacyclin may be created in the uterus and may provide some protection against coronary artery disease. Psychological Effects In addition to physiological complications, hysterectomy also has emotional complications. Much research has been conducted linking hysterectomy with psychiatric problems. The likelihood of hysterectomy causing severe psychological problems, including depression, depends on the reason for the surgery, the woman’s psychological state prior to surgery, the woman’s relationship to her husband/partner and her general sense of well-being, and her desire to bear children. In addition, the absence of the uterus and menstruation may represent a loss of youth, strength, vitality, and self-esteem to some women; there is often grief over this loss. Depression results not only from the surgical procedure but also from the loss of hormones following oophorectomy or ovarian failure. Some studies suggest that an imbalance in certain neurohormones is associated with such mood changes as crying spells, irritability, nervousness, and changes in sexual desire (libido). The metabolism of these hormones within the brain
494 ✧ Hysterectomy is believed to depend on estrogen levels. Scientists have found that depression and anxiety, as well as bone loss and decreased cardiovascular functioning, are alleviated in some women by hormone replacement therapy. Research shows deterioration in sexual activities after the operation. Frequent complaints include a decreased libido, decrease in coital activity, loss of orgasm, loss of lubrication (atrophic vaginitis), and painful intercourse (dyspareunia). Ethical Questions By the late 1980’s and early 1990’s, the trend among many gynecologists had shifted away from hysterectomy to more conservative treatments. Physicians, many of them women, began to question whether hysterectomies were, in some or even in most cases, medically necessary. This trend became apparent even in the treatment of cancers of the uterus and ovaries. While most conservative gynecologists who did not normally treat cancer considered this condition to be the one instance in which they could unequivocally recommend hysterectomy, gynecological cancer specialists began to revolutionize the field by giving women the option of keeping at least some of their reproductive organs. As more information became available to women regarding alternatives to hysterectomy, many women asserted their right to challenge their physicians when told that hysterectomy was the only possible solution to their gynecological problems. —Genevieve Slomski See also Birth control and family planning; Cancer; Cervical, ovarian, and uterine cancers; Endometriosis; Ethics; Hormone replacement therapy; Menopause; Menstruation; Sterilization; Women’s health issues. For Further Information: Cutler, Winnifred B. Hysterectomy: Before and After. Rev. ed. New York: Harper & Row, 1990. Written by a reproductive biologist. Discusses evidence showing the vital role of the uterus and ovaries in a woman’s well-being. Explains why, in most cases, hysterectomy should be avoided; how to obtain an accurate diagnosis; and when surgery is necessary. Addresses hormone replacement therapies, nutrition, and lifestyle changes after hysterectomy. Appendices and extensive references are included. Dennerstein, Lorraine, Carl Wood, and Ann Westmore. Hysterectomy: New Options and Advances. 2d ed. New York: Oxford University Press, 1995. This popular work on hysterectomy addresses all aspects of the procedure. Includes a bibliography and an index. Hufnagel, Vicki. No More Hysterectomies. New York: New American Library, 1988. Hufnagel, a pioneer in female reconstructive surgery, provides a
Iatrogenic disorders ✧ 495 comprehensive guide to gynecological health. Explains, in clear and easily understood language, the sometimes tragic consequences of unnecessary hysterectomy and provides the reader with a wealth of information about alternatives to traditional hysterectomy. Contains useful appendices and a bibliography. Payer, Lynn. How to Avoid a Hysterectomy. New York: Pantheon Books, 1987. Payer, a medical journalist who avoided a hysterectomy, relates her own and other women’s experiences and shares with readers the results of her systematic research, with doctors across the United States, on the best ways to avoid hysterectomy, if possible. Also contains a glossary of terms, a useful list of suggested readings, and a list of organizations.
✧ Iatrogenic disorders Type of issue: Ethics, public health Definition: Health problems caused by medical treatments. The average patient expects perfect cures for all diseases. This is not possible because some diseases have no cure and medical treatment always involves potential risk. In fact, a percentage—usually a small one—of patients treated for any disease develop unexpected health problems (adverse reactions) which can be diseases themselves. The term “iatrogenic disorder” is a catchall used to define the many different adverse reactions that accompany the practice of modern medicine. The number of such problems has grown as medical science has become more sophisticated. They are often blamed entirely on physicians and other medical staff involved in cases producing iatrogenic disorders. This blame is correctly directed in instances where a physician and other staff involved are uncaring, inattentive, careless, or incompletely educated. However, iatrogenic disorders often result from the nature of modern medicine. Doctors frequently attempt therapeutic methods that are innovative efforts but have some inherent risk of failure. They may also use therapeutic drugs that are powerful agents but that have side effects causing other health problems in some people who take them. In addition, doctors often utilize complicated overall therapy having adverse consequences that patients may not acknowledge despite physicians’ attempts to explain them orally and with consent forms. Minimizing Side Effects Patients are often unaware that no drug agent in use is ever perfectly safe. Even a clear physician description of the dos and don’ts associated with such
496 ✧ Iatrogenic disorders therapy may be flawed by biological variation among patients, causing problems in one individual but not others. Hence, several rules must be followed concerning therapeutic agents. First, wherever possible, these medications should be used only after other means fail and the benefits to be gained clearly outweigh the risks entailed. Second, therapy should begin with the lowest possible effective dose, and dose increase should be accompanied by frequent monitoring of symptom relief and toxicity. Third, patients and responsible family members must be made aware of all possible adverse symptoms, and how best to counter them, as well as the foods or other medications to be avoided to diminish iatrogenic potential. Surgical Risks Many iatrogenic disorders are caused by bacterial contamination of wounds and the fact that surgical maintenance of sterility is not absolutely perfect. For example, iatrogenesis occurs after 30 percent of surgical procedures carried out at heavily contaminated sites (such as emergency surgery of abdominal wounds). In addition, the use of antibiotics can be problematic. In many cases, the large doses of these therapeutic agents required to fight primary bacterial infection will cause superinfection by other microbes, such as fungi. Furthermore, wide antibiotic use in hospitals has led to the creation of antibiotic-resistant bacteria. For these reasons, treatment of surgical sites requires individualized attention. Clean wounds can be closed up immediately without high risk of infection, but deep wounds known to be contaminated prior to surgery are often best handled by closing up interior tissues and leaving skin and subcutaneous tissues open until infection is under control. Many patients are frightened by such procedures and the pain involved. Hence, they may resist treatment and accuse conscientious physicians of causing iatrogenic disorders. Misdiagnosis In some cases, misdiagnosis is caused by physician inadequacy, but more often such problems are attributable to the great difficulty in diagnosing a disease absolutely. It is essential for patients and physicians to communicate effectively. Such interaction lowers the occurrence of iatrogenic disorders because patients can decide to forgo treatment or to learn how to comply exactly with complex treatment protocols. Patients who do not receive adequate answers should seek treatment elsewhere. Physicians should explain potential problems associated with therapeutic procedures by oral communication, informative consent forms, and well-educated counselors. Because of the many iatrogenic disorders associated with medical ther-
Illnesses among the elderly ✧ 497 apy, physicians often believe that the best course of treatment—where a symptom is unclear and severe danger to patients is not imminent—is to allow nature to take its course so as to do no harm. This approach is often misunderstood by patients. To clarify the issue and to satisfy them, it should be explained—by the physician—that treatment can often be more dangerous than a perceived health problem. It is hoped that the continued development of medical science, careful and complete therapy explanations by medical staffs, and better medical understanding and better treatment compliance by patients will decrease the incidence of iatrogenic disorders. —Sanford S. Singer See also Antibiotic resistance; Ethics; Euthanasia; Hippocratic oath; HMOs; Hospitalization of the elderly; Law and medicine; Malpractice; Medications and the elderly; Overmedication. For Further Information: Carroll, Paula. Life Wish: One Woman’s Struggle Against Medical Incompetence. Alameda, Calif.: Medical Consumers, 1986. D’Arcy, P. F., and J. P. Griffin. Iatrogenic Diseases. 3d ed. New York: Oxford University Press, 1986. Preger, Leslie, ed. Iatrogenic Diseases. 2 vols. Boca Raton, Fla.: CRC Press, 1986. Sharpe, Virginia F., and Alan I. Faden. Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness. New York: Cambridge University Press, 1998. Vincent, Charles, Maeve Ennis, and Robert J. Audley, eds. Medical Accidents. Oxford, England: Oxford University Press, 1993.
✧ Illnesses among the elderly Type of issue: Elder health, epidemics, mental health, public health Definition: Diseases which appear with greater frequency, greater severity, and greater resultant functional impairment in older individuals than in younger groups. Physical and intellectual performance reach their peaks between the ages of twenty and thirty, followed by more or less rapid deterioration during the life span of the individual. Substantial reserve potentials are built into human physiological functions, including the cardiovascular, pulmonary, and musculoskeletal systems. These reserves decrease with time. Illnesses and diseases may subtract from these functions; the lesser reserves of older
498 ✧ Illnesses among the elderly individuals may result in a greater lessening of the ability to perform than would have occurred at an earlier age. The problems of older individuals can be compounded by the occurrence of multiple disorders, by atypical presentations, and by the withholding of important complaints and information, making diagnosis and treatment more difficult. What may be tolerated in youth may be lethal in old age. Infectious Diseases Older individuals are particularly vulnerable to attacks by the influenza viruses and by the pneumococcus, an organism associated with pneumonia. Although symptoms may vary, influenza is characterized by fever, aches, pains, and prostration. Susceptibility to secondary infections, particularly of the lungs, is greatly increased. Both influenza and pneumococcal infections can, to a substantial degree, be prevented through the timely administration of vaccines that, unfortunately, do not provide complete immunity. Influenza vaccines are designed each year to protect against the most prevalent strains. These vary from year to year so that administration of the vaccine must be done yearly. Pneumococcal vaccines protect against only twenty-three of the most prevalent serotypes (there are more than eighty). The effectiveness of the vaccines is limited in older individuals because the immune responses tend to diminish with age. Influenza vaccine is recommended for all adults. Pneumococcal vaccine is strongly recommended for all people age sixty-five and over, with a repeat every five years. This has become particularly important because of the emergence of pneumococcal strains resistant to most of the usual antibiotics. The Cardiovascular System Some individuals maintain essentially normal, although diminished, cardiac function as they age and as their cardiac reserve diminishes. Others, less fortunate, develop disorders of the heart’s rhythm or an inability to maintain a level of activity satisfactory for an enjoyable life. In still others, musculoskeletal problems may limit their physical activities so that declining cardiac function is not noticed. Among the more frequent problems of rate and rhythm are bradycardia (reduction of pulse to below sixty beats per minute) and skipped beats. Their appearance should be brought to the attention of a physician, as should other irregularities of rhythm. Shortness of breath on exertion, a change in exercise tolerance, feelings of heaviness or oppression, and precordial pain are frequent signals of cardiac problems mediated by inadequacy of the blood supply to heart muscle. Both large and small blood vessels can show changes with age. Atherosclerosis, the deposition of fatty substances on the interior walls of blood
Illnesses among the elderly ✧ 499 vessels, spares neither. The aorta, the main blood vessel from the heart, may be so damaged by atherosclerosis that the strength of its wall decreases, causing it to enlarge and form an aneurysm, or a saccular distension. Blood may leak into its wall and beyond, and it may suddenly rupture, causing a massive loss of blood, or it may compress arteries vital to organs, such as the kidneys. Decrease of the effective cross section of blood vessels can be caused by deposition of cholesterol, growth of plaques and calcification, and, not infrequently, occlusion by formation of clots on the plaques. This sequence can occur in the carotid arteries, which are major routes for bringing blood to the brain. Occasionally, small clots can detach and lodge in the brain, causing transient ischemic attacks (TIAs), essentially miniature strokes. Decreased pulsations of the carotid arteries can be felt but tested only one side at a time, and murmurs can often be heard through a stethoscope. In such an event, a physician’s attention should be sought. Similar changes can occur in the arteries to the kidneys, but such changes are reflected by the development of hypertension and the accumulation of waste products in the blood. The coronary vessels supply the blood required by the heart. If they are diseased, the blood flow through them may be adequate at rest but inadequate during exertion. Atherosclerosis of these vessels, occasionally found in young individuals, increases markedly with age. The gradual decrease of the cross section of these vessels by cholesterol deposition causes the breakdown of the continuity of the cellular lining (the endothelium), offering the opportunity for the formation of clots, which may completely block the circulation to an important part of the heart. The precordial sensations of heaviness or the dull ache felt with limitation of blood flow may eventually become severe pain and suggest the death of some muscle tissue, which, if extensive enough, can cause sudden death. When the changes in the blood vessels are more gradual, heart function deteriorates more slowly and, depending on which chamber of the heart is more affected, can lead to different symptoms. The right ventricle pumps blood through the lungs to the left side of the heart. The more dominant features of right-sided failure are swellings of the ankles and legs, sometimes extending to the abdomen because of fluid retention. In left ventricular failure, shortness of breath on exertion or on lying flat (orthopnea) are more prominent symptoms. Small-vessel disease from atherosclerosis is frequent in diabetes mellitus and can also occur from the deposition of proteinlike materials, as in amyloid disease. The decrease of the lumen of the vessels results in increases of blood flow inadequate to meet the demands of exercise. The result is pain in the muscles and the need to rest before continuing the exercise (intermittent claudication). Severe blood flow restriction can result in the death of tissue, gangrene, and the need for amputation. Early and appropriate attention may arrest this deterioration. Underlying much of these and other cardiocirculatory problems is the
500 ✧ Illnesses among the elderly tendency for more and more cholesterol to be deposited in the walls of arteries as individuals age. Paying earlier attention to reducing cholesterol intake from the diet and, if necessary, reducing cholesterol synthesis by the liver will increase the chances of reducing the levels of cholesterol in the blood. Those with a family history of early cardiac problems or elevated cholesterol levels may particularly benefit from such preventive measures. The Gastrointestinal System One of the more common disorders of gastrointestinal function in the aging process is difficulty in swallowing food and, in some instances, even liquids. This may result from neurological problems with a decreased motility of the esophagus, from obstruction because of scarring from an old injury, from a growth or malignancy, or from psychological problems. In the latter case, the swallowing difficulty is apt to be episodic, while the others are more likely to be unremitting and to increase in severity with time. Ulcers in the stomach, at the pylorus, and in the duodenum are common and may bleed. This can be marked by regurgitation of blood or by black stools. Benign ulcers are often caused by the microorganism Helicobacter pylori, which can be eradicated by appropriate antibiotics, resulting in the cure of the ulcer. In the stomach in particular, malignancies may present as ulcers; in such cases, direct examination of the lesion and a biopsy are essential. More benign disorders can also occur, such as the decrease in acid production and resultant poor digestion. Such disorders may signal the presence of an underlying pernicious anemia. The gallbladder, which stores bile produced by the liver and discharges it into the gastrointestinal tract and thus aids digestion, can be the site of infections, of stone formation, and, more rarely, of malignancies. Gallbladder attacks, as in acute cholecystitis (inflammation and infection of the gallbladder), more frequent in women but not sparing of men, occur about midlife and later. Symptoms include tenderness and severe pain in the region of the liver that may radiate to the back, chills and fever, and jaundice (if stones have blocked the ducts leading from the gallbladder to the duodenum). Fever suggests an infection. In younger individuals, such symptoms can lead to early diagnosis and intervention. In older individuals, the symptoms and signs may be lacking, and diagnosis may be delayed. Many individuals have stones in their gallbladders and manifest neither symptoms nor disease. The pancreas, which discharges insulin and bile by way of a common duct into the duodenum, plays an essential role in digestion. Lack of insulin results in diabetes mellitus. The latter disorder occurs frequently in older individuals as adult-onset diabetes (type II) and may require dietary control, the use of agents to lower the blood glucose, or the administration of insulin. Diabetes is often accompanied by circulatory problems because of associated small-vessel disease.
Illnesses among the elderly ✧ 501 Inflammatory diseases of the small intestine include regional enteritis (Crohn’s disease), which occurs mainly in younger people but has significant persistent residual effects from scarring. The large bowel (the colon) can be the site of similar inflammatory changes often referred to as ulcerative colitis, more usual in younger individuals but sometimes requiring colostomies, which can be a problem as the patients age. Quite common in older individuals is diverticulosis, outpocketings of the colon that can become infected and cause diverticulitis, which is occasionally accompanied by perforation and infection of the abdominal cavity. Large-bowel polyps are more frequent with age and may be the site of malignancies. Colon cancer often presents with rectal bleeding in men and obstruction in women. If detected early, the prognosis is excellent. However, hemorrhoids are probably the most common cause of rectal bleeding. Respiratory, Kidney, and Urinary Problems Cigarette smoking is a major risk factor in diseases of the respiratory tract. Smoking is a major cause of cancers in the nasopharyngeal passages and lungs, usually after many years so that the incidence increases greatly with aging. In addition, the natural decline in respiratory functions from age twenty on is accelerated in smokers and is often associated with chronic obstructive pulmonary disease and emphysema. Susceptible individuals who smoke cigarettes may become oxygen-dependent respiratory cripples by age sixty and die within a few years, while nonsmokers may live comfortably to eighty and beyond. Malignancies unrelated to smoking can also occur as individuals age. Periodic medical checkups with respect to pulmonary functions are appropriate, but chest X rays have not been found to be very effective because their resolution is not sufficient to detect the earliest stages of malignancies. However, new, more effective technologies are being developed. Kidney function declines with age so that, despite a substantial reserve in youth, the capacity of the kidneys to excrete waste and other products decreases. Adjustments must be made in the dosages of medications excreted by the kidneys, and the blood levels may have to be monitored closely. Excretion of urine, which is mostly water, is not affected unless there is disease of the heart, liver, kidneys, or lower urinary tract. Hypertrophy (enlargement) of the prostate can markedly affect the process of urination (dribbling, decrease in the force of the stream, or urinary retention). The hypertrophy may be benign or the result of a malignancy. Prostate cancer may occur in nearly 80 percent of the male population by the time the age of eighty has been reached. Systematic and regular rectal examinations, along with the prostate-specific antigen (PSA) test, provide the basis for early detection. Surgical procedures, local radiation, and, in case of spread, chemotherapeutic agents can be used, in most cases quite successfully.
502 ✧ Illnesses among the elderly Both sexes can develop renal (kidney) stones (calculi), which often produce extraordinary flank pain, requiring narcotics for control. The stones may pass spontaneously or may need to be broken up by ultrasonic radiation (lithotripsy). Surgical intervention is sometimes necessary. The stones can result from metabolic abnormalities or, more usually, from infection; the latter is often not suspected, particularly in older women. The frequency of stones and of urinary tract infections, whether of the bladder or of the kidneys, increases with age, as does urinary incontinence, a cause of major embarrassment to many older individuals. Chronic infection of the kidneys (pyelonephritis) is often unsuspected but frequent in those who have had lower urinary tract infections, incompetent sphincters, or obstruction to the flow of urine, as occurs in prostate enlargement. Small-vessel disease, such as occurs in diabetes mellitus and in lupus, is often associated with hypertension and the appearance of red cells and protein in the urine. The Central Nervous System The brain also suffers declines of function with aging. These are often related to a decrease in brain tissue, which can result in a condition called normal-pressure hydrocephalus, in which loss of brain tissue allows more water to accumulate in the brain. The blood flow to the brain may decrease or may not increase during stimulation to the extent seen in younger individuals. Symptoms include memory loss, attention lapses, increased caution in voluntary movements, and prolonged reaction times (of concern while driving). These individuals, in general, continue most of their mental and physical activities, which may serve to maintain the essential blood flow to the brain. Continuation of intellectual activity after retirement may be helpful in slowing the natural decay process. More disturbing, more profound, and more rapidly progressing are the changes seen in Alzheimer’s disease, which causes defects in memory (both recent and remote), difficulty in recognizing errors, reduction in attention span, decrease of coordination, limitations in abilities of self-care, and, distressing to all, nonrecognition of close family members. The patient’s awareness of the deterioration is not always lost. One estimate is that about one-half of the population over eighty-five has Alzheimer’s disease and that a total of nearly 2 million Americans are so affected. The disease occurs more frequently in women than in men and often manifests itself at a younger age. A family history of the disease puts the individual at higher risk than those who do not have such a history. The disease is associated with the occurrence in the brain of neurofibrillary tangles and the deposition of the protein beta amyloid. These abnormalities are under intensive study, and some means have been proposed that may prevent or even reverse their occurrence. Alzheimer’s disease, a major problem for its victims, is also a
Illnesses among the elderly ✧ 503 major problem for society because of the costs of the care that must be provided by families or in nursing homes or other institutions. Among the other major abnormalities of the brain that occur with increasing frequency with age is, in addition to the damage related to carotid artery changes, blockage of blood vessels by clots that form in the brain or that are brought there by the circulation. These produce infarcts, areas without blood flow in which the tissue is dead. Similar damage can be produced by rupture of blood vessels and hemorrhage into the brain substance. Small defects in the walls of cerebral arteries produce aneurysms, which may rupture, particularly when there is hypertension, and become a source of hemorrhages. Small infarcts and hemorrhages may have mainly transient effects, while large ones may lead to strokes, which often cause major losses of control (paralyses), speech (aphasia), or cognition. Death may occur. Other losses of central nervous system function that occur with age include those of hearing and smell (more common in males). Loss of vision may occur because of cataracts, macular degeneration, and retinal detachment or hemorrhages. The latter frequently occur with uncontrolled hypertension. Parkinson’s disease, manifested by uncontrollable tremors and a peculiar, rigid gait, imposes further limitations on physical activities. Other Threats Some degree of osteoarthritis occurs in practically all older and aging individuals. Fingers and toes, as well as major joints (such as knees and hips), may be affected. Pain and limitation of motion are common, and analgesics (painkillers) are often necessary. The deformities often limit activities and motion, sometimes severely. Medications and surgical procedures can provide relief from pain and a return to full activity. Osteoporosis (bone loss), which can lead to fractures of long bones and collapse of vertebrae, is most common in postmenopausal women and is largely preventable. Breast cancer in women and prostate cancer in men remain major problems, in spite of earlier detection and improvements in treatment. Lung cancers in women are increasing in relation to the increase in cigarette smoking. Liver malignancies associated with hepatitis C infections are on the increase and are likely to be a major problem later in life because of the long latent period. Brain tumors, as well as pancreatic and renal carcinomas, increase with increasing life spans, as do skin cancers and leukemias. —Francis P. Chinard See also Aging; Alzheimer’s disease; Breast cancer; Cancer; Cholesterol; Dementia; Diabetes mellitus; Emphysema; Heart disease; Hospitalization of the elderly; Hypertension; Immunizations for the elderly; Influenza; Macular degeneration; Medications and the elderly; Memory loss; Osteoporosis;
504 ✧ Immunizations for children Parkinson’s disease; Prostate cancer; Prostate enlargement; Strokes; Terminal illnesses; Vision problems with aging. For Further Information: Abrams, William B., Mark H. Beers, and Robert Berkow, eds. The Merck Manual of Geriatrics. 3d ed. Whitehouse Station, N.J.: Merck Research Laboratories, 2000. A convenient repository of useful information in an easily hand-held format. Accurate and concise. Cassel, Christine K., et al., eds. Geriatric Medicine. 3d ed. New York: Springer, 1997. Easier to read than but not as extensive as most specialized texts on the subject. Fauci, A. S., et al., eds. Harrison’s Principles of Internal Medicine. 15th ed. New York: McGraw-Hill, 2001. Contains several well-documented chapters on aging and associated illnesses. Hazzard, W. R., et al., eds. Principles of Geriatric Medicine and Gerontology. 4th ed. New York: McGraw-Hill, 1999. An excellent and in-depth text. Tallis, R., et al., eds. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology. 5th ed. New York: Churchill Livingstone, 1998. A thoroughly revised textbook with comprehensive presentations.
✧ Immunizations for children Type of issue: Children’s health, medical procedures, prevention, public health Definition: Exposure of a child to an infectious agent or chemical that confers resistance to that agent. The development of vaccines against specific infectious microbial agents resulted in the control or elimination of many diseases. Immunity to an antigen or disease may be induced using either of two methods. If preformed antibodies produced in another human or animal are inoculated into an individual, the result is passive immunity. Passive immunity can be advantageous in that the recipient achieves immunity in a short period of time. For example, if a person has been exposed to a toxin or has come into contact with an infectious agent, passive immunity can provide a rapid, short-term protection. Yet, since the individual does not generate the capacity to produce that antibody and the preformed antibodies are gradually removed from the body, no long-range protection is achieved. The stimulation of antibody production through exposure to antigens, such as those found in a vaccine, results in active immunity. Development of effective active immunity requires a time span of several days to several weeks. The immunity is long-term, however, often lasting for the life span of
Immunizations for children ✧ 505 Recommended Childhood Immunization Schedule (2001) Birth Hepatitis B
1 mo.
2 mos.
4 mos.
6 mos.
Diphtheria, pertussis, tetanus (DPT)
Doses 1, 2, 3
H. influenzae type B (HiB)
Doses 1, 2, 3 Doses 1, 2
Measles, mumps, rubella (MMR)
18 mos.
4-6 yrs.
11-12 yrs.
14-16 yrs.
Catch-up
Dose 3
Dose 4
Dose 3
Dose 1
Doses 1, 2, 3
Dose 5
Tetanus and Diphtheria Booster
Dose 4
Dose 1
Chickenpox Pneumococcal vaccine (PCV)
15 mos.
Dose 1 Dose 2
Polio
12 mos.
Dose 4 Dose 2 Catch-up
Dose 4
Approved by the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians.
the individual. Furthermore, each additional exposure to that same antigen, either through a vaccine booster or through natural exposure, results in a more rapid, greater response than those achieved previously. Creating Vaccines The actual material utilized in a vaccine is variable. Attenuated organisms are mutants that have lost the ability to cause disease but that retain the antigenic character of the virulent strain. The most notable application of attenuation is the Sabin oral poliovirus vaccine (OPV). By testing hundreds of virus isolates for the ability to cause polio in monkeys, Albert Sabin was able to isolate certain strains that did not cause disease. These strains formed the basis for his vaccine. Similar testing resulted in the development of attenuated virus vaccines against a wide variety of agents, including those against measles, mumps, and rubella. In some cases, the isolation of attenuated strains of microorganisms has proved difficult. For this reason, inactivated or killed microorganisms often serve as the basis for vaccine production. The Salk inactivated poliovirus vaccine represents the best-known example. By treating poliovirus with a solution of the chemical formalin, Jonas Salk was able to inactivate the organism. The virus retained its antigenic potential and served as an effective vaccine. A similar process has resulted in vaccines to protect against other bacterial diseases, such as bubonic plague, cholera, and pertussis
506 ✧ Immunizations for children (whooping cough), and against viral influenza. In some cases, the vaccine is not directed against the etiological agent itself but against toxic materials produced by the agent, as with diphtheria and tetanus. The vaccines are produced by treating the diphtheria and tetanus toxins secreted by these bacteria with formalin. The toxoids that result are antigenically similar to the actual toxins and so are able to induce immunity. They are incapable, however, of causing the deleterious effects of the respective diseases. Only those determinants of a virus or bacterium that stimulate neutralizing antibodies are necessary in most vaccines. For this reason, the use of genetically engineered vaccines was begun in the 1980’s. The first example put into use was the production of a vaccine against the hepatitis B virus (HBV). The gene that encodes the surface antigen of HBV was isolated and inserted into a piece of genetic material within the yeast Saccharomyces. The HBV antigen produced by the yeast was purified and subsequently found to be as effective in a vaccine as the whole virus. Since no live virus is involved, there is no danger of an attenuated strain reverting to its virulent parent. Recently, similar technology has been applied to produce vaccines that protect against chickenpox and hepatitis A virus. Immunizing Against Major Childhood Diseases The most significant advancement in twentieth century health care in the United States has been the elimination of most major childhood diseases. In addition to poliovirus immunization, children routinely receive a variety of early immunizations. Measles, mumps, and rubella (MMR) vaccines are administered in a single preparation at fifteen months of age. All three contain live attenuated viruses. The measles vaccine was first introduced in 1966 and resulted in a decline in reported measles cases of nearly 99 percent by the 1980’s. Beginning about 1986, however, increasing numbers of cases of measles were reported among young adults who had been previously immunized. For this reason, the AAP recommends that children receive boosters of measles vaccine prior to entering high school, at approximately eleven to twelve years of age. A series of the diphtheria, pertussis, and tetanus (DPT) vaccine is administered at two, four, six, and eighteen months, with tetanus and diphtheria boosters recommended at ten-year intervals throughout the remainder of life. With the elimination of most other major childhood illnesses, Hemophilus influenzae type B infections moved into the dubious position of being among the most significant causes of illness and death among young children. In 1985, a vaccine developed from the outer coat of the bacterium was licensed for use. The vaccine worked poorly in children under the age of two, the major population at risk. Consequently, an improved vaccine was developed and licensed by 1987. The second vaccine consisted of a portion of the
Immunizations for children ✧ 507 influenza coat joined to diphtheria toxoid. It was found to immunize children effectively at eighteen months of age; immunization with the vaccine is recommended by the age of fifteen months. By 1991, a total of nineteen vaccines had been licensed in the United States by the Food and Drug Administration (FDA) for uses in either children or adults. Aside from the eight previously described vaccines for children, eleven vaccines (five viral and six bacterial) are recommended for special circumstances. The use of genetic engineering, in which only the genes necessary to synthesize specific antigens are utilized, was first applied to the hepatitis B vaccine. It has recently been applied successfully to create vaccines against chickenpox and hepatitis A virus. A vaccine against hepatitis C virus is under development. This technology provides the potential for manufacturing vaccine “cocktails,” or combinations of such genes from a variety of infectious agents in a single vaccine. —Richard Adler; updated by L. Fleming Fallon, Jr., M.D., M.P.H. See also Childhood infectious diseases; Children’s health issues; Environmental health; Epidemics; Immunizations for the elderly; Influenza; Preventive medicine; Tuberculosis. For Further Information: Bittle, J. L., and F. A. Murphy, eds. Vaccine Biotechnology. San Diego: Academic Press, 1989. A discussion of the use of techniques in molecular biology and genetic engineering in vaccine development. The style and depth of coverage is appropriate to anyone with basic knowledge of biology. Brock, Thomas D., ed. Microorganisms: From Smallpox to Lyme Disease. New York: W. H. Freeman, 1990. A collection of readings from Scientific American magazine. Included is a section on the role of vaccines in the prevention of disease, including their role in the elimination of smallpox. Also found are articles on synthetic vaccines and vaccination in Third World countries. Plotkin, Stanley A., and Edward Mortimer, Jr., eds. Vaccines. 3d ed. Philadelphia: W. B. Saunders, 1999. An excellent description of the role of vaccines in the prevention of disease. Begins with a history of immunization practices. Each subsequent chapter deals with a specific disease and the role and history of vaccine production in its prevention. While enough detail is provided to interest someone in the field, the text is appropriate for nonscientists. Roitt, Ivan. Essential Immunology. 9th ed. Boston: Blackwell Scientific Publications, 1997. An excellent textbook. Much of the book is detailed and requires some background in biology. Nevertheless, the chapters which deal with infection and immunization are clear and contain much that will interest nonscientists. Numerous graphs illustrate material from the text.
508 ✧ Immunizations for the elderly
✧ Immunizations for the elderly Type of issue: Elder health, medical procedures, prevention, public health Definition: The administration of vaccines to prevent illnesses in older persons. As age increases, the body’s ability to counter infections successfully is reduced, which results in increased rates of complications and death. Pneumonia and influenza are among the leading causes of death in the elderly against which effective vaccines are available. Data suggest, however, that immunizations are underused in the elderly even though many infections and death can be prevented by the proper use of these vaccines. Some of the common reasons for underutilization include practitioners’ limited knowledge of specific recommendations, poor documentation of vaccination records, inadequate reimbursement, patients’ reluctance or refusal to be vaccinated, and poorly developed and insufficiently promoted programs for immunizing adults. The use of routine vaccination in the elderly not only decreases complications and death but also is highly cost effective. Each vaccine is administered according to its own guidelines, depending on the length of time that the immunity lasts or depending on the frequency with which the offending organism changes its properties, thus requiring new vaccine. Some of these vaccines require periodic boosters, which are added doses of vaccines to amplify the immune response of the body. Based on the current guidelines, all older persons should be vaccinated against influenza, pneumococcal pneumonia, tetanus, and diphtheria, of which the latter two are usually combined into one vaccine. Influenza Influenza is commonly referred to as flu, which begins with fever, sore throat, dry cough, and muscle aches, and usually lasts less than a week. It is caused by a virus. There is currently no treatment for this disease. It is associated with ten thousand to forty thousand excess deaths annually, and 80 to 90 percent of those deaths are among those over sixty-five years of age. Because of this high rate of complication in the elderly, it is important that all elderly persons should receive yearly influenza vaccine unless it is contraindicated. The vaccine is 40 to 80 percent effective in preventing illness in the elderly, and even if they get the disease, the vaccine will reduce the rates of complication and death. It must be given each year because the virus that causes influenza changes its protein components each year, making the previous vaccine ineffective. The vaccine is manufactured based on the predictions of the most likely viruses to circulate during the upcoming influenza season.
Immunizations for the elderly ✧ 509 Influenza vaccine cannot cause the disease, as is commonly believed, since it is made from inactive virus. It is given in the muscles of the upper arm in 0.5 milliliter doses and should ideally be given in mid-September; however, it can be given any time until mid-December. The vaccine causes antibody production against the influenza virus, and it takes about two to four weeks to reach protective levels. It is important that older persons should be vaccinated in the fall so that the body can produce sufficient antibody levels in time for the influenza season, which begins in early winter. Generally the vaccine is quite safe, but it may cause low-grade fever, muscle aches, and fatigue that lasts for one to two days. Persons with known allergies to egg products should not be given the vaccine because the viruses used to make the vaccine are grown in eggs. A person who can eat eggs without complications can receive influenza vaccine without the risk of severe allergic reaction. Pneumococcal Pneumonia The most common cause of pneumonia is caused by bacteria called pneumococci. It results in fever, chills, cough, phlegm, shortness of breath, weakness, and lethargy. Patients generally appear ill, and unless treated with appropriate antibiotics in a timely manner, they may have serious complications including death. It is responsible for an estimated forty thousand deaths per year in the United States, with rates highest among the elderly. Despite the high rates of complications, only about 14 percent of those over sixty-five years have received the pneumococcal vaccine. The vaccine is effective in about two-thirds of the adult population but is somewhat less effective in the elderly. The pneumococcal vaccine, which is also called pneumovax, contains materials from the twenty-three types of pneumococcal bacteria that cause 88 percent of pneumococcal infections. It is given in the muscles of the upper arm in the dose of 0.5 milliliter, and every adult over the age of sixty-five should be vaccinated at least once. It can be given at the same time as influenza vaccine. Most healthy adults develop protection within two to three weeks of vaccination. Older individuals and persons with impaired immune systems may have a blunted response. In most cases, the protection lasts for at least five years after vaccination. There is some controversy about routine revaccination. However, those with kidney disease or kidney transplantation and those who lack a spleen should receive a booster dose six years later. These individuals have declining antibody levels that put them at greater risk of fatal pneumonia. Side effects of pneumococcal vaccine include soreness and redness at the site of injection. Fever and muscle aches are rare and occur in less than 1 percent of patients. There are no contraindications for pneumococcal vaccine.
510 ✧ Immunizations for the elderly Tetanus and Diphtheria The conditions tetanus and diphtheria are discussed together because the vaccine is usually given as a combination. Tetanus is caused by the bacteria called Clostridium tetani. Spores of this organism, which are present in the soil, enter through a wound and, in an unimmunized individual, cause tetanus. The patient usually has slight pain and tingling at the site of wound followed by muscle spasms throughout the body. Most cases occur in those over the age of sixty and almost exclusively in persons who are unimmunized or inadequately immunized, or whose history of immunization is unknown. About 40 percent of the patients who develop tetanus die from this disease. Diphtheria is caused by Corynebacterium diphtheriae, which usually attacks the respiratory system. It causes runny nose, sore throat, fever, and fatigue and can cause serious heart and nervous system complications unless treated adequately with appropriate antibiotics. Since most physicians have not seen a case of diphtheria, they rarely think of this as an adult disease. The few cases that occur each year are in unimmunized patients. As many as 84 percent of those over the age of sixty lack adequate immunity to diphtheria. The vaccine for tetanus and diphtheria is available as a combination; the majority of individuals receive these shots as part of their childhood immunization. Those adults who have not received tetanus-diphtheria vaccine during childhood should complete a series of three vaccinations. They are usually given in the muscles of the upper arm in the dose of 0.5 milliliter. The second dose should be given one to two months after the first, and the third dose six to twelve months after the second. Every individual, regardless of whether he or she received immunization during childhood or adulthood, should receive a booster dose every ten years. It is recommended that a dose of tetanus-diphtheria vaccine be repeated every time there is an injury unless the last booster dose was less than five years ago. Almost all older persons develop protective levels of antibodies after completing the initial three doses of the vaccine. The duration of protective levels is somewhat reduced in older persons, and therefore it is important that they receive booster doses every ten years or at the time of injury if the last booster dose was less than five years ago. Side effects are mild and include soreness and redness at the site of injection. The only contraindication to the tetanus-diphtheria vaccine is a serious allergic reaction at the time of the last dose. Special Situations In addition to the above vaccines, older individuals may need additional vaccines depending on their level of risk, which is based on their lifestyle, preexisting diseases, occupation, or travel. These include hepatitis A and B, measles, mumps, rubella, and chickenpox vaccines. It is important to carefully review the immunization history for persons planning to travel outside
In vitro fertilization ✧ 511 the United States. Depending on the area to which they are traveling and the presence of diseases in those regions, they may require poliomyelitis, typhoid fever, cholera, Japanese encephalitis, meningococcus, or rabies vaccines. —Shawkat Dhanani See also Aging; Illnesses among the elderly; Immunizations for children; Influenza; Medications and the elderly; Preventive medicine. For Further Information: Bentley, David W. “Vaccinations.” Clinics in Geriatric Medicine 8, no. 4 (November, 1992). Gleich, Gerald S. “Health Maintenance and Prevention in the Elderly.” Primary Care: Clinics in Office Practice 22, no. 4 (December, 1995). Harward, Mary P. “Preventive Health for the Elderly: Role of Vaccination.” Journal of the Florida Medical Association 79, no. 10 (October, 1992). Long, Jennifer, and Kay Kyllonen. “Adult Vaccinations: A Short Review.” Cleveland Clinic Journal of Medicine 64, no. 6 (June, 1997). Plichta, Anna M. “Immunization: Protecting Older Patients from Infectious Disease.” Geriatrics 51, no. 9 (September, 1996).
✧ In vitro fertilization Type of issue: Ethics, medical procedures, women’s health Definition: The collection of eggs and sperm and their mixture in a dish in order to achieve fertilization, followed by the introduction of the resulting embryos into the uterus. In vitro fertilization, which allows sperm and eggs to meet in a culture dish, has become a successful method of overcoming infertility. Since the procedure must mimic in vivo events, its development was dependent upon detailed knowledge of in vivo fertilization. The first task is to collect a number of eggs by inducing multiple ovulations using the hormones that normally regulate the process of ovulation. Usually a mixture of folliclestimulating hormone (FSH) and luteinizing hormone (LH) is used, followed by a large dose of human chorionic gonadotropin, which stimulates a surge of LH and causes the maturation of multiple eggs within their follicles. Eggs are collected just prior to ovulation from their ripe follicles using a small suction needle inserted through the vagina, into the pelvic cavity. The needle is guided by ultrasonography (the use of ultrasonic waves to create a two-dimensional image). Eggs that are recovered are put into a culture
512 ✧ In vitro fertilization medium and incubated at body temperature (37 degrees Celsius) for six to twenty-four hours, until they mature. They are then combined with sperm. The sperm have been freshly collected or previously collected and held in frozen storage. It is critical that the sperm are artificially capacitated before they are used. Though it is not clear what specifically causes capacitation, it is fortunate that the culture medium used to wash the sperm serves this function. After several washes, the sperm that swim up through the culture medium are collected, ensuring that only vigorous swimmers are used, and provide a concentrated sample of about two hundred thousand sperm. Once fertilization takes place, the embryos are observed in vitro through the course of several cell divisions to ensure that development is taking place and that it appears to be normal. One of the problems that has been observed is polyspermy. Eggs that are immature or too old apparently are less able to mobilize their defenses against polyspermy. When healthy embryos reach the eight- to sixteen-cell stage, several embryos are introduced into the woman’s uterus. Though this method poses a risk of multiple births, it also provides a better chance for success. Seeking Fertility Treatment For many couples who are infertile, the disappointment of being unable to conceive children is too great to bear. For these people, in vitro fertilization has provided a welcome alternative route to conception. It has been estimated that one out of every eight couples of childbearing age is infertile. The causes are many. Often, the delicate Fallopian tubes are blocked or even missing. These tubes are easily damaged by inflammation, with about 40 percent of blocked Fallopian tubes resulting from the two most common sexually transmitted diseases, gonorrhea and chlamydia. Endometriosis, a condition in which cells from the lining of the uterus spread to other regions of the body, can also cause infertility, as can the presence of antibodies against sperm in the female reproductive tract or alterations in the cervical mucus. Up to 40 percent of infertility is attributable to low sperm counts or sperm deficiencies in the male. Though in vitro fertilization was originally designed to overcome infertility caused by blocked Fallopian tubes, it has been found to be effective in overcoming infertility in each of the causes listed above. Couples normally face an average of six to nine years of infertility before turning to an in vitro fertilization clinic. The demand for this technique is certainly great and the success rate of live births is 21 percent, about that achieved naturally; some clinics have a much higher success rate. In 1994 alone, there were 294 such clinics registered in the United States; 39,390 procedures were performed and 9,573 births occurred.
In vitro fertilization ✧ 513 Improved Techniques and Special Considerations Clinics concentrate on improving success rates and consequently have developed a number of variations in the technique. Improvements have been made in the method of transferring the embryo into the patient. Often, two to four embryos, which have been developing in culture for less than two days, are transferred into the uterus using a narrow gauge plastic catheter passed through the cervix and into the uterus. This is a safe, nonsurgical procedure. The disadvantage is that the embryos are being placed in the uterus at least two days prior to the time that they would arrive with in vivo fertilization. To overcome the problems that this early arrival might pose, new techniques have been developed, such as zygote intrafallopian transfer (ZIFT) and gamete intrafallopian transfer (GIFT), in which the embryos or gametes are transferred to the Fallopian tubes rather than to the uterus. This procedure only works, however, if the patient’s Fallopian tubes are functional. Moreover, it has the disadvantage of requiring two surgical procedures: one for obtaining the eggs and the second for inserting the embryos into the Fallopian tubes. In situations in which the male partner has abnormal sperm that cannot penetrate an egg, laboratory scientists may use a microneedle to inject a single sperm directly into the egg. This fertilization method, called intracytoplasmic sperm injection or ICSI (pronounced “ick-see”), is highly successful even with sperm surgically removed from the male reproductive tract. In situations that require specific knowledge of the embryo’s genetics, one or two cells called blastomeres can be removed from the eight- or sixteen-cell-stage embryo. Genetic material in the removed blastomeres can be chemically evaluated by a procedure called polymerase chain reaction (PCR). This evaluation can be very useful when there is a high probability that the embryo may have a life-threatening genetic disease. Embryos determined to be free of such disease can be selected for uterine transfer, none the worse for the lost blastomere. With microsurgery, it is even possible to remove the nucleus from an egg and replace it with the diploid nucleus from another cell of the organism providing the egg. This procedure enables duplicate copies called clones to be made of the animal providing the transplanted nucleus. This procedure offers great commercial promise for animal breeders, but its use in human medicine has been ethically renounced. The development of cryopreservation, or freezing, techniques have dramatically improved the process of in vitro fertilization. Embryos can be safely preserved at extremely low temperatures and then thawed for implantation. Generally, many more embryos are produced in an in vitro fertilization procedure than can be used. With cryopreservation, the unused embryos can be preserved and used in a second attempt at implantation, if the first fails. Success is often better in a second attempt, since the uterus has
514 ✧ In vitro fertilization recovered from the hormonal barrage required for the collection of eggs and has been prepared for implantation by the woman’s own natural cycle. Ethical complications can occur, for example, when frozen embryos remain after the death of the intended parents. Concerns and Controversy In vitro fertilization methods are extraordinarily safe. There is no increase in birth defects or mortality for the babies that are conceived using this technique. There is a marked increase in multiple births, however, which occur in 1 percent of in vivo fertilization cases and in 15 to 20 percent of in vitro fertilization cases. This increase can be avoided as techniques improve, making it less necessary to place multiple embryos in the patient. In vitro fertilization and its many permutations have opened many doors of opportunity and led to many heated controversies. Questions include “What is to be done with unused frozen embryos?” “What are the rights of gamete donors to the child that is born?” and “What are the rights of a surrogate mother or the rights of a child to knowledge of his or her parentage?” Some countries, such as Australia, Norway, Spain, and the United Kingdom, have already responded by passing extensive legislation regulating IVF. Other countries have been slower to respond. This vacuum of social consensus leaves decisions involving in vitro fertilization to physicians, scientists, and the courts. —Mary S. Tyler; updated by Armand M. Karow See also Birth control and family planning; Ethics; Genetic engineering; Infertility in men; Infertility in women; Multiple births; Reproductive technologies. For Further Information: Harkness, Carla. The Infertility Book: A Comprehensive Medical and Emotional Guide. Berkeley, Calif.: Celestial Arts, 1992. Harkness, a professional writer, describes IVF from a patient’s viewpoint. The book also includes a bibliography, four line drawings, a glossary, a resource directory, and an index. Sher, Geoffrey, Virginia Marriage Davis, and Jean Stoess. In Vitro Fertilization. Rev. ed. New York: Facts on File, 1998. Dr. Sher and his clinical associates describe for patients in words and line drawings the process of evaluating patients and the procedures involved in IVF. The book also includes a glossary and an index. Stephenson, Patricia, and Marsden G. Wagner, eds. Tough Choices: In Vitro Fertilization and the Reproductive Technologies. Philadelphia: Temple University Press, 1993. The editors assembled an international group of academic authorities to present an analysis of the effects of IVF on social
Incontinence ✧ 515 structure. Discussion includes clinical effectiveness, resource allocation, ethics, and legal issues. Although this book was written for the authors’ peers, it is accessible to the general reader. Weschler, Toni. Taking Charge of Your Infertility. New York: HarperPerennial, 1995. This book encourages women to become responsible consumers of their own reproductive health. Includes excellent discussions of infertility, natural birth control, and achieving pregnancy. Wisot, Arthur, and David Meldrum. Conceptions and Misconceptions. Vancouver: Harley and Marks, 1997. Written by two leading fertility experts, this book is an excellent guide through the maze of in vitro fertilization and other assisted reproductive techniques. Includes an excellent discussion of the basic physiology of conception and reproduction.
✧ Incontinence Type of issue: Elder health, mental health, women’s health Definition: The inability to control evacuative functions. Urinary incontinence is the second leading cause of early institutionalization of the elderly and is twice as common in women as in men. According to researchers in 1994, the annual cost in the United States of providing care for community-dwelling urinary incontinence sufferers was estimated to be $11 billion, while the cost of providing care for those of the nursing home population was another $5 billion. Fewer than one-half of the 13 million Americans with urinary incontinence have been evaluated or treated. One of the unanswered questions about urinary incontinence is why, given the high prevalence of incontinence, so few people report it and seek treatment. One reason may be that individuals, believing that incontinence is a normal aging-related condition, believe that they can manage urinary incontinence effectively on their own. When a person reports such symptoms as urgent, painful, and frequent urination, along with frequent night toileting, many health professionals fail to evaluate the problem because of the myths associated with urinary incontinence and the lack of knowledge regarding solutions. A persistent myth is that urinary incontinence is a normal occurrence of aging often associated with mental incompetence. The inability to control urine is unpleasant and distressing. One major consequence is that untreated incontinence often becomes progressively worse. Secondary problems, such as rashes, decubitus ulcers, and skin and urinary tract infections, can also occur. Psychological consequences, such as embarrassment, loss of self-esteem, social isolation, and even depression, are common. Studies have demonstrated that as many as 80 percent of urinary incon-
516 ✧ Incontinence tinent patients can be cured or significantly improved. Even incurable problems can be effectively managed to reduce complications, anxiety, and stress. When treatment is not completely successful, management can help make the problem more livable. Types of Incontinence The four basic types of urinary incontinence are stress, urge, overflow, and functional. Stress incontinence is apparent by the involuntary loss of small to moderate amounts of urine when pressure is placed on the pelvic floor, as when one coughs, sneezes, or laughs. It is caused by weak supporting pelvic muscles, estrogen deficiency, and obesity. This form of incontinence is common in women as they age, particularly those who have had several pregnancies, and men who have had prostate surgery. It may be caused by congenital weakness of the sphincter or acquired after exposure to radiation, trauma, or a sacral cord lesion. It is common to leak continuously or with minimal exertion. Behavioral approaches, such as habit training and pelvic muscle exercises, are useful in improving some stress incontinence; surgery may be needed in some situations. A sudden loss of moderate to large amounts of urine is characteristic of urge incontinence. Urge incontinence is the most common type, affecting an estimated 65 percent of all cases. It results from irritation or spasms of the bladder wall because of urinary tract infections, prostate enlargement, diverticulitis, or tumors of the bladder or pelvic region. Urge incontinence may also be caused by bladder stones, fecal impaction, stroke, dementia, suprasacral injury, and Parkinson’s disease. Highly spiced foods, artificial sweeteners, coffee (even decaffeinated), tea, cola, wine, chocolate, and medicines that contain caffeine may cause bladder irritation. Treatment of infections can correct the problem in some people with this form of incontinence. Since the person notes a sudden urge to urinate but is unable to reach the toilet in time, behavioral approaches, such as habit training, prompted voiding, and bladder retraining, can improve continence for some cases. A failure of the bladder muscles to contract or of the muscles around the urethra to relax causes retention of an excessive amount of urine in the bladder and, consequently, overflow incontinence. The main symptom of overflow incontinence is frequent or constant leaking (dribbling) of small amounts of urine. Bladder neck obstructions from an enlarged prostate, fecal impaction, or urethral stricture can be associated with overflow incontinence. Habit training can be used to completely empty the bladder. Functional incontinence is caused by factors outside the urinary tract. This occurs when the function of the lower urinary tract is intact but other factors, such as impaired mobility, impaired cognition, and environmental barriers, result in incontinence. This may be as simple as being unable to get
Incontinence ✧ 517 to the bathroom in time because of arthritis. People with cognitive impairments, such as Alzheimer’s disease, may be unable to understand the need to void, may be unfamiliar with the location of the bathroom, or may no longer remember the function of the toilet itself. Managing Incontinence Agency for Health Care Policy and Research (AHCPR) guidelines designate three treatment categories for urinary incontinence: behavioral, pharmacologic, and surgical. The least invasive and least dangerous technique, the behavioral one, is usually tried first. A number of behavioral techniques are available. Habit training is used for urge incontinence. The goal is to get the person to ignore the urge to void and to train the bladder to tolerate larger volumes of urine without urgency. The person is encouraged to gradually, consciously extend the time between voidings. This approach can sometimes be used with cognitively impaired people as well. Like habit training, bladder training also emphasizes scheduled voiding, but it also involves a substantial retraining effort through education and positive reinforcement, using booklets and other teaching aids. Using exercise to strengthen the pelvic muscles, which are frequently weakened by childbirth, extreme obesity, or the menopause, is another behavioral technique that can work for women. Kegel exercises involve squeezing and relaxing the pelvic muscles. Squeezing the muscles helps keep the urethra closed until it is time to void. Upon reaching the toilet, the woman can relax the muscles surrounding the urethra and allow it to open. At that point, the bladder contracts and forces urine out through the urethra. It has been documented that sixty to eighty Kegel exercises daily, done properly, can reduce significantly or even eliminate stress incontinence. Improvement can be seen within three weeks to nine months, with most women noting some progress by the end of the eighth week. To make sure women are contracting the right muscle, they are told to constrict the anus as if holding back stool or to try to stop and start the stream while urinating in the toilet. However, doing Kegel exercises routinely during urination can damage the urethra. Biofeedback helps ensure that the woman is doing the contractions correctly and is a good complement to Kegel exercises. The perineometer, a device used for biofeedback, has a manometer attached to a probe that can be inserted into the vagina. Vaginal cones can also help strengthen the pelvic floor. When one is inserted, wide end first, and it begins to slip out, the pelvic floor contracts to retain it. The woman holds the cone in place for fifteen minutes, twice per day. In time, she will be able to progress to heavier cones. In several studies, approximately 70 percent of the women using the cones reported significant improvement in their stress incontinence. Although the cones work faster than Kegel exercises, some women may be reluctant to use them.
518 ✧ Incontinence Depending on the type of urinary incontinence, behavioral techniques are not always successful, and the person may need to be referred for pharmacologic treatment. Urge incontinence caused by detrusor muscle instability and stress incontinence caused by urethral sphincter insufficiency may both be helped with medications. In posthysterectomy or postmenopausal women, stress incontinence may be treated with estrogen replacement therapy. If pharmacologic treatment is not appropriate, or if it fails, surgery may be recommended. Guidelines state that surgery may be necessary to return the bladder neck to its proper position in women with stress incontinence, to remove tissue that is causing a blockage, to support or replace severely weakened pelvic muscles, or to enlarge a small bladder to hold more urine. Before undergoing surgery to correct urinary incontinence, the patient should understand the procedure, its risks and benefits, and the expected outcome. Supportive Devices Once all the alternative approaches to resolving incontinence have been explored and exhausted, supportive devices—including intermittent, indwelling, and external (condom) catheters; penile clamps; pessaries; and absorbent pads and undergarments—may be considered. Performing self-catheterization intermittently may help people with overflow incontinence caused by an inoperable obstruction or other detrusor muscle problems. The caregivers and the involved individual must be both physically and psychologically able to insert a clean catheter tube into the bladder every three to six hours. When done properly, this procedure can be performed at home without any increased risk of infection. Only those with untreatable urinary retention should leave the catheter in place. Using an indwelling catheter for longer than two to four weeks greatly increases the risk of chronic bacteria in the urine and urinary tract infections. Men may be able to use external collection systems, or condom catheters, which are best for short-term use because of skin irritation. Men with chronic obstruction are advised not to use condom catheters. Urine-collecting devices are also available for women but are not as satisfactory, causing redness and perineal itching. As a temporary solution for males with stress incontinence that is caused by inadequate sphincter contraction, a penile clamp may be an option. The clamp must be removed every three hours to empty the bladder. Improper use can lead to penile and urethral erosion, penile swelling, pain, and obstruction. Women who have pelvic prolapse with or without urinary incontinence can obtain temporary relief by means of a pessary, a doughnut-shaped rubber or silicone device that is inserted into the vagina. The pessary may help frail, elderly women who have no other treatment options. A specially
Incontinence ✧ 519 trained physician or nurse fits and inserts the pessary, then monitors it frequently. A misused or neglected pessary can lead to ulceration of the vagina and fistulas. There is a growing trend to make use of absorbent pads and pants, largely because urinary incontinence is so often dismissed rather than treated. Although absorbent garments help people feel more secure about their incontinence, the AHCPR recommends that the person’s level of disability, preference, gender, and type and severity of incontinence be taken into account before absorbent products are used. Before choosing a product, the person and caregivers must consider the amount of urine voided per incontinent episode, the type of clothing the person usually wears, manual dexterity, and financial means. Regardless of which absorbent products are chosen, people are advised that they must maintain proper hygiene and change the garment or pad frequently to prevent urinary tract infections and skin problems. Urinary incontinence affects people of all age groups, especially those in the geriatric population. An overwhelming number are women. In fact, it has been estimated that one-half of all adult women suffer from loss of bladder control at some time in their lives. Yet the number of women and men who fail to seek treatment for urinary incontinence is surprisingly high. Many people think loss of bladder control is a normal part of growing old. Still others think urinary incontinence is just something one must live with. The truth is that urinary incontinence is not caused by aging. Usually, it is brought on by specific changes in the body function that result from infection, hormonal changes, diseases, pregnancy, or the use of certain medications. In most cases, it can be controlled or cured. Left untreated, however, urinary incontinence can make life miserable. It can increase the chance of skin irritation and the risk of developing bedsores, and it often leads to social isolation and personal frustration. —Maxine M. McCue See also Aging; Biofeedback; Prostate enlargement; Women’s health issues. For Further Information: Agency for Health Care Policy and Research (AHCPR). http://www.ahcpr.gov/ clinic. For free information on incontinence, see the on-line publications Helping People with Incontinence: Caregiver Guide (96-0683) and ALERT for Directors of Nursing (96-0063). Kennedy, K. L., C. P. Steidle, and T. M. Letizia. “Urinary Incontinence: The Basics.” Ostomy/Wound Management 41, no. 7 (August, 1995). A review of stress, urge, and overflow incontinence, and the various types of treatments available for urinary incontinence. Luft, Janis, and Amy Vriheas-Nichols. “Identifying the Risk Factors for
520 ✧ Infertility in men Developing Incontinence: Can We Modify Individual Risk?” Geriatric Nursing 19, no. 2 (March/April, 1998). Reviews various literature on risk factors. Mondoux, Linda C. “Patients Won’t Ask.” RN 57, no. 2 (February, 1994). Mondoux describes new treatment guidelines. Newman, D. K., J. Wallace, N. Blackwood, and C. Spencer. “Promoting Healthy Bladder Habits for Seniors.” Ostomy/Wound Management 42, no. 10 (November/December, 1996). Describes the development, implementation, and results of a health promotion project called Dry Expectations, aimed at providing incontinence education in the community.
✧ Infertility in men Type of issue: Men’s health, public health, social trends Definition: The inability to achieve a desired pregnancy as a result of dysfunction of male reproductive organs. The factors responsible for infertility may be infectious, chemical (from inside or outside of the body, such as illegal drugs, pharmaceuticals, or toxins), or anatomical. Genetic factors may be responsible as well, since genes control the formation of body chemicals (such as hormones and antibodies) and body structures. The process by which sperm are made begins in a man’s testis (or testicle). Because the transformation of testis cells into sperm is controlled by genes and hormones, abnormalities can cause infertility. Sperm released from the testis become mature in the epididymis. Sperm travel from the testis to the epididymis through ducts (tubes) in the male reproductive tract. A blockage of these ducts or premature release of sperm from the epididymis can cause infertility. A blockage of reproductive ducts can occur as a result of a bodily enlargement, such as swollen tissue, a tumor, or cancer. An infection usually causes tissue swelling and can leave ducts permanently scarred, narrowed, or blocked. Infection can have a direct detrimental effect on the production of normal sperm. Cancer and the drugs or chemicals used to treat cancer can also damage a man’s reproductive tract. Another factor that may be important to male fertility is scrotal temperature. The temperature in the scrotum, the sac that holds the testis, is somewhat cooler than body temperature. The normal production of sperm seems to be dependent upon a cool testicular environment. The leading cause of male infertility may be varicoceles, which occur when one-way valves fail in the veins that take blood away from the testicles. When these venous valves become leaky, blood flow becomes sluggish and causes the veins to swell. Many men with varicoceles are infertile, but the
Infertility in men ✧ 521 exact reason for this association is unknown. The reasons sometimes given are increased scrotal temperature and improper removal of materials (hormones) from the testis. Mature sperm capable of fertilizing an egg are normally placed in the female reproductive tract by the ejaculation phase of sexual intercourse. The sperm are accompanied by fluid called seminal plasma; together, they form semen. A blockage of the ducts that transport the semen into the woman or toxic chemicals, including antibodies, in the semen can cause infertility. Treating Male Infertility Treatment of male infertility may involve surgery, hormone therapy, or therapeutic (artificial) insemination. Therapeutic insemination is often performed when the couple is composed of a fertile woman and an infertile man. The first step for therapeutic insemination is for a physician to determine when an egg is ovulated or released into the Fallopian tube of the fertile woman. At the time of ovulation, semen is placed with medical instruments in the woman’s reproductive tract, either on her cervix or in her uterus. The semen used by the physician is obtained through masturbation by either the infertile man (the patient) or a fertile man (a donor), depending on the cause of the man’s infertility. The freshly produced semen from either source usually undergoes laboratory testing and processing. Tests are used to evaluate the sperm quality. An effort may be made to enhance the sperm from an infertile patient and then to use these sperm for therapeutic insemination or in vitro fertilization. Other tests evaluate semen for transmissible diseases. During testing, which may require many days, the sperm can be kept alive by cryopreservation. Freshly ejaculated sperm remains fertile for only a few hours in the laboratory if it is not cryopreserved. There are several processes that might enhance sperm from an infertile man. If the semen is infertile because it possesses too few normal sperm, an effort can be made to eliminate the abnormal sperm and to increase the concentration of normal sperm. Sperm may be abnormal in four basic ways: They may have abnormal structure, they may have abnormal movement, they may be incapable of fusing with an egg, or they may contain abnormal genes or chromosomes. Laboratory processes can often eliminate from semen those sperm with abnormal structure or abnormal movement. These processes usually involve replacing the seminal plasma with a culture medium. Removing the seminal plasma gets rid of substances that may be harmful to the sperm. After the plasma is removed, the normal sperm can be collected and concentrated. Pharmacologic agents can be added to the culture medium to increase sperm movement. Testing for transmissible diseases is especially important if donor semen is used; these diseases may be genetic or infectious.
522 ✧ Infertility in men The Preservation of Sperm Cryopreservation of sperm is important to therapeutic insemination for two major reasons. First, it gives time to complete all necessary testing. Second, it allows an inventory of sperm from many different donors to be kept constantly available for selection and use by patients. Sperm properly cryopreserved for twenty years, when thawed and inseminated, can produce normal babies. Cryopreservation involves treating freshly ejaculated sperm with a cryoprotectant pharmaceutical that enables the sperm to survive when frozen; the cryoprotectant for sperm is usually glycerol. Survival of frozen sperm is also dependent upon the rate of cooling, the storage temperature, and the rate of warming at the time of thawing. An environment of liquid nitrogen is often used to attain the proper storage temperature. This temperature must be kept constant to avoid the damaging effects of recrystallization. The cryopreservation procedure involves the actual formation of ice, although the ice is confined to the extracellular medium. Intracellular ice is lethal. Ice formation during cryopreservation causes the cells to lose water and to shrink. The cryoprotectant seems to replace intracellular water and thereby maintain cell volume. An alternative process for low-temperature preservation of sperm is called vitrification. Vitrification uses temperatures as cold as cryopreservation, but it avoids ice formation altogether. Instead of using one cryoprotectant, vitrification uses a mixture of several. It employs a much slower cooling rate and a much faster warming rate. Technically, vitrification is more difficult to perform; therefore, it is seldom used by clinical sperm banks. Human sperm can be shipped to almost any location for therapeutic insemination. Sperm is usually cryopreserved before shipment and thawed at the time of insemination. Choosing Who Will Be the Donor Although male-factor infertility is the situation that benefits most from insemination and semen cryopreservation procedures, these procedures might be requested by a fertile couple that is at risk for male-factor infertility. Such couples may fear that the man’s lifestyle, such as working with hazardous materials (solvents, toxins, radioisotopes, or explosives), may endanger his ability to produce sperm or may harm his genetic information. The man could be facing medical therapy that will cure a malignancy, such as Hodgkin’s disease or a testicular tumor, but may render him sterile. A man facing such a situation may benefit from having some of his semen cryopreserved for his own future use, in the event that he actually becomes infertile. Therapeutic insemination with a husband’s semen is usually not as effective as with donor semen, especially when cryopreservation is involved. Although cryopreservation keeps cells alive in the frozen state, not all the
Infertility in men ✧ 523 cells survive. Men selected to be semen donors have sperm that survive freezing much better than the sperm of most men (although the reason for this ability is unknown). If a man undergoing medical treatment is already sick at the time that the decision is made to store his sperm, his concentration of functioning sperm may be less than normal. There are ways to compensate for decreased semen quality. The semen may be processed in ways to increase the concentration of normal sperm. The processed semen may be placed directly into the woman’s uterus (intrauterine insemination) rather than on her cervix, or in vitro fertilization, a procedure in which the sperm and eggs are mixed in a laboratory and the resulting embryo implanted in the woman, may be used. All these techniques have proved helpful to infertile couples wanting children. Emotional Aspects Although the idea of therapeutic insemination is simple, it usually involves some very complicated emotions. Although a couple may be happy about all other aspects of their lives together, they are usually deeply disturbed to learn of the man’s infertility. It may be extremely difficult for them to discuss his infertility with anyone else. Some people incorrectly ridicule infertile men as being less virile or even being impotent. These feelings will influence the couple’s selection of a sperm donor. Later, they must decide whether to tell the child about the circumstances of his or her birth. Sometimes, a child who originated through therapeutic insemination will try to learn the identity of the donor. The donor must be considered as well. In a typical sperm bank, persons are subjected to a variety of tests before they are accepted as donors. Sperm donors are typically in their second decade of life, but some are older. These men are primarily, but not solely, motivated to be sperm donors by financial compensation. Payment effectively maintains donor cooperation for a period of several years. In addition to payment, the donor usually wants an assurance that he will not be held responsible, financially or legally, for the offspring produced by his semen. As a donor grows older, however, his attitude about his donation may change: He may wonder about the children he has helped to create. The Future of Male Infertility Treatment It has been estimated that infertility affects 8 to 15 percent of American marriages, which means that three to nine million American couples would like to, but cannot, have children without medical assistance. By the early 1990’s, therapeutic insemination produced more than thirty thousand American babies yearly. Recent research has shown a few promising new techniques: intracyto-
524 ✧ Infertility in men plasmic injection, which involves the placement of sperm into the ovum itself, and electroejaculation, which involves electrical stimulation of the penis to promote ejaculation. Intracytoplasmic injections are useful when the sperm are immotile or the woman’s own immune system aggressively rejects the man’s sperm. It is not always successful, however, and is affected by age and cycle. Electroejaculation has been successfully used in men with vascular compromise, as might be caused by diabetes mellitus, or with spinal cord injuries. It is also helpful in cases where men are unable to ejaculate for psychological reasons. Therapeutic insemination and other alternative means of reproduction give rise to thorny issues of personal rights of various “parents” (social, birth, and genetic) and their offspring. In the United States, a few states have addressed these issues by enacting laws, usually to grant legitimacy to offspring of donor insemination. In the United Kingdom, Parliament established a central registry of sperm and egg donors. Offspring in the United Kingdom have access to nonidentifying donor information; these children are even able to learn whether they are genetically related to a prospective marriage partner. —Armand M. Karow; updated by Paul Moglia See also Birth control and family planning; Condoms; Environmental diseases; In vitro fertilization; Infertility in women; Reproductive technologies; Sexual dysfunction; Sterilization; Stress. For Further Information: Baran, Annette, and Reuben Pannor. Lethal Secrets. New York: Warner Books, 1993. The authors, medical social workers, discuss the possible consequences of secrecy in donor insemination using a series of case histories. Glover, Timothy D., and C. L. R. Barratt, eds. Male Fertility and Infertility. New York: Cambridge University Press, 1999. The editors have assembled a collection of essays by experts in the field. Includes bibliographical references and an index. Noble, Elizabeth. Having Your Baby by Donor Insemination. Boston: Houghton Mifflin, 1987. Donor insemination is discussed from the recipient’s viewpoint. Reasons for insemination, options, methods, and issues are discussed. An excellent appendix locates medical resources. Schover, Leslie R., and Anthony J. Thomas. Overcoming Male Infertility: Understanding Its Causes and Treatments. New York: Wiley, 2000. Clinical psychologist Schover has long worked with infertile couples, as urologist Thomas has with male infertility. Their combined skills and knowledge make this a valuable book—patient-oriented, conveying a vast amount of information understandably, and maintaining an underlying sense of humor. Warnock, Mary. A Question of Life. New York: Basil Blackwell, 1993. This
Infertility in women ✧ 525 report, commissioned by the British Parliament, discusses medical procedures for alleviating infertility and social issues of family formation and inheritance.
✧ Infertility in women Type of issue: Public health, social trends, women’s health Definition: The inability to achieve a desired pregnancy as a result of dysfunction of female reproductive organs. Infertility is defined as the failure of a couple to conceive a child despite regular sexual activity over a period of at least one year. Studies have estimated that in the United States 10 percent to 15 percent of couples are infertile. In about half of these couples, it is the woman who is affected. The causes of female infertility are centered in the reproductive organs: the ovaries, oviducts, uterus, cervix, and vagina. The frequency of specific problems among infertile women is as follows: ovarian problems, 20 percent to 30 percent; damage to the oviducts, 30 percent to 50 percent; uterine problems, 5 percent to 10 percent; and cervical or vaginal abnormalities, 5 percent to 10 percent. Another 10 percent of women have unexplained infertility. Problems with the Ovaries, Uterus, and Cervix Anovulation (lack of ovulation) can result either directly—from an inability to produce luteinizing hormone (LH), follicle-stimulating hormone (FSH), or estrogen—or indirectly—because of the presence of other hormones that interfere with the signaling systems between the pituitary and ovaries. For example, the woman may have an excess production of androgen (testosterone-like) hormones, either in her ovaries or in her adrenal glands, or her pituitary may produce too much prolactin, a hormone that is normally only secreted in large amounts after the birth of a child. Besides ovulation, the ovaries have another critical role in conception since they produce hormones that act on the uterus to allow it to support an embryo. In the first two weeks of the menstrual cycle, the uterine lining is prepared for a possible pregnancy by estrogen from the ovaries. Following ovulation, the uterus is maintained in a state that can support an embryo by progesterone, which is produced in the ovary by the follicle that just ovulated, now called a corpus luteum. Because of the effects of hormones from the corpus luteum on the uterus, the corpus luteum is essential to the survival of the embryo. If conception does not occur, the corpus luteum disintegrates and stops producing progesterone. As progesterone levels
526 ✧ Infertility in women decline, the uterine lining can no longer be maintained and is shed as the menstrual flow. Failure of the pregnancy can result from improper function of the corpus luteum, such as an inability to produce enough progesterone to sustain the uterine lining. The corpus luteum may also produce progesterone initially but then disintegrate too early. These problems in corpus luteum function, referred to as luteal phase insufficiency, may be caused by the same types of hormonal abnormalities that cause lack of ovulation. Some cases of infertility may be associated with an abnormally shaped uterus or vagina. Such malformations of the reproductive organs are common in women whose mothers took diethylstilbestrol (DES) during pregnancy. DES was prescribed to many pregnant women from 1941 to about 1970 as a protection against miscarriage; infertility and other problems occur in the offspring of these women. Another critical site in conception is the cervix. Cervical problems that can lead to infertility include production of a mucus that does not allow sperm passage at the time of ovulation (hostile mucus syndrome) and interference with sperm transport caused by narrowing of the cervical canal. Such narrowing may be the result of a developmental abnormality or the presence of an infection, possibly a sexually transmitted disease. Problems with the Oviducts Infertility can result from scar tissue formation inside the oviduct, or Fallopian tube, resulting in physical blockage and inability to transport the ovum, sperm, or both. The most common cause of scar tissue formation in the reproductive organs is pelvic inflammatory disease (PID), a condition characterized by inflammation that spreads throughout the female reproductive tract. PID may be initiated by a sexually transmitted disease such as gonorrhea and chlamydia. Physicians in the United States have documented an increase in infertility attributable to tubal damage caused by sexually transmitted diseases. Damage to the outside of the oviduct can also cause infertility, because such damage can interfere with the mobility of the oviduct, which is necessary to the capture of the ovum at the time of ovulation. External damage to the oviduct may occur as an aftermath of abdominal surgery, when adhesions induced by surgical cutting are likely to form. An adhesion is an abnormal scar tissue connection between adjacent structures. Another possible cause of damage to the oviduct, resulting in infertility, is the presence of endometriosis, a condition in which patches of the uterine lining implant in or on the surface of other organs. The endometrial patches can lodge in the oviduct itself, causing blockage, or can adhere to the outer surface of the oviducts, interfering with mobility. Endometrial patches on the outside of the uterus can cause distortions in the shape or
Infertility in women ✧ 527 placement of the uterus, interfering with embryonic implantation. Ovulation may be prevented by the presence of the endometrial tissues on the surface of the ovary. Between 30 and 40 percent of women with endometriosis cannot conceive. Treating Female Infertility Damage to the oviducts can sometimes be repaired surgically, and surgical removal of endometrial patches is a standard treatment for endometriosis. Often, however, surgery is a last resort, because of the likelihood of the development of postsurgical adhesions, which can further complicate the infertility. Newer forms of surgery using lasers and freezing offer better success because of a reduced risk of adhesions. Some women with hormonal difficulties can be treated successfully with fertility drugs. There are actually several different drugs and hormones that fall under this heading: Clomiphene citrate (Clomid), human menopausal gonadotropin (HMG), gonadotropin-releasing hormone (GnRH), bromocriptine mesylate (Parlodel), and menotropins (Pergonal) are commonly used, with the exact choice depending on the woman’s particular problem. The pregnancy rate with fertility drug treatment varies from 20 percent to 70 percent. One problem with some of the drugs is the risk of multiple pregnancy (more than one fetus in the uterus). Hyperstimulation of the ovaries, a condition characterized by enlarged ovaries, can be fatal as a result of severe hormone imbalances. Other possible problems include nausea, dizziness, headache, and general malaise. Artificial insemination is an old technique that is still useful in various types of infertility. A previously collected sperm sample is placed in the woman’s vagina or uterus using a special tube. Artificial insemination is always performed at the time of ovulation, in order to maximize the chance of pregnancy. The ovulation date can be determined with body temperature records or by hormone measurements. In some cases, this procedure is combined with fertility drug treatment. Since the sperm can be placed directly in the uterus, it is useful in treating hostile mucus syndrome and certain types of male infertility. The sperm sample can be provided either by the woman’s partner or by a donor. The pregnancy rate after artificial insemination is highly variable (14 percent to 68 percent), depending on the particular infertility problem in the couple. There is a slight risk of infection, and, if donated semen is used, there may be no guarantee that the semen is free from sexually transmitted diseases or that the donor does not carry some genetic defect. Another infertility treatment is gamete intrafallopian transfer (GIFT), the surgical placement of ova and sperm directly into the woman’s oviducts. In order to be a candidate for this procedure, the woman must have at least one partially undamaged oviduct and a functional uterus. Ova are collected
528 ✧ Infertility in women surgically from the ovaries after stimulation with a fertility drug, and a semen sample is collected from the male. The ova and the sperm are introduced into the oviducts through the same abdominal incision used to collect the ova. This procedure is useful in certain types of male infertility, if the woman produces an impenetrable cervical mucus, or if the ovarian ends of the oviducts are damaged. The range of infertility problems that may be resolved with GIFT can be extended by using donated ova or sperm. The success rate is about 33 percent overall, but the rate varies with the type of infertility present. In vitro fertilization is known colloquially as the “test-tube baby” technique. In this procedure, ova are collected surgically after stimulation with fertility drugs and then placed in a laboratory dish and combined with sperm from the man. The actual fertilization, when a sperm penetrates the ovum, will occur in the dish. The resulting embryo is allowed to remain in the dish for two days, during which time it will have acquired two to four cells. Then, the embryo is placed in the woman’s uterine cavity using a flexible tube. In vitro fertilization can be used in women who are infertile because of endometriosis, damaged oviducts, impenetrable cervical mucus, or ovarian failure. As with GIFT, in vitro fertilization may utilize either donated ova or donated sperm, or extra embryos that have been produced by one couple may be implanted in a second woman. The pregnancy rate with this procedure varies from 15 percent to 25 percent. Embryo freezing is a secondary procedure that can increase the chances of pregnancy for an infertile couple. When ova are collected for the in vitro fertilization procedure, doctors try to collect as many as possible. All these ova are then combined with sperm for fertilization. No more than three or four embryos are ever placed in the woman’s uterus, however, because a pregnancy with a large number of fetuses carries significant health risks. The extra embryos can be frozen for later use, if the first ones implanted in the uterus do not survive. This spares the woman additional surgery to collect more ova if they are needed. The freezing technique does not appear to cause any defects in the embryo. Some women may benefit from nonsurgical embryo transfer. In this procedure, a fertile woman is artificially inseminated at the time of her ovulation; five days later, her uterus is flushed with a sterile solution, washing out the resulting embryo before it implants in the uterus. The retrieved embryo is then transferred to the uterus of another woman, who will carry it to term. Typically, the sperm provider and the woman who receives the embryo are the infertile couple who wish to rear the child, but the technique can be used in other circumstances as well. Embryo transfer can be used if the woman has damaged oviducts or is unable to ovulate, or if she has a genetic disease that could be passed to her offspring, because in this case the baby is not genetically related to the woman who carries it. Some infertile women who are unable to achieve a pregnancy themselves
Infertility in women ✧ 529 turn to the use of a surrogate, a woman who will agree to bear a child and then turn it over to the infertile woman to rear as her own. In the typical situation, the surrogate is artificially inseminated with the sperm of the infertile woman’s husband. The surrogate then proceeds with pregnancy and delivery as normal, but relinquishes the child to the infertile couple after its birth. Emotional, Financial, and Legal Complications One of the biggest problems that infertile couples face is the emotional upheaval that comes with the diagnosis of the infertility. Bearing and rearing children is an experience that most women treasure. When a woman is told that she is infertile, she may feel that her femininity and self-worth are diminished. More stress may be in store as the couple proceeds through treatment. The various treatments can cause embarrassment and sometimes physical pain, and fertility drugs themselves are known to cause emotional swings. For these reasons, a couple with an infertility problem is often advised to seek help from a private counselor or a support group. Along with the emotional and physical trauma of infertility treatment, there is a considerable financial burden as well. Infertility treatments, in general, are very expensive, especially the more sophisticated procedures such as in vitro fertilization and GIFT. Since the chances of a single procedure resulting in a pregnancy are often low, the couple may be faced with submitting to multiple procedures repeated many times. The cost over several years of treatment can be staggering. Many health insurance companies in the United States refuse to cover the costs of such treatment and are required to do so in only a few states. Some of the treatments are accompanied by unresolved legal questions. In the case of nonsurgical embryo transfer, is the legal mother of the child the ovum donor or the woman who gives birth to the child? The same question of legal parentage arises in cases of surrogacy. Does a child born using donated ovum or sperm have a legal right to any information about the donor, such as medical history? How extensive should governmental regulation of infertility clinics be? For example, should there be standards for assuring that donated sperm or ova are free from genetic defects? In the United States, some states have begun to address these issues, but no uniform policies have been set at the federal level. The basic problem underlying these issues is that these technologies challenge the traditional definitions of parenthood. —Marcia Watson-Whitmyre See also Birth control and family planning; Endometriosis; Environmental diseases; Hysterectomy; In vitro fertilization; Infertility in men; Menopause; Menstruation; Miscarriage; Reproductive technologies; Sexual dysfunction; Sterilization; Stress.
530 ✧ Influenza For Further Information: Harkness, Carla. The Infertility Book: A Comprehensive Medical and Emotional Guide. Berkeley, Calif.: Celestial Arts, 1992. Written as a guide for the infertile couple, this book offers emotional support as well as medical information. The text is augmented by firsthand accounts of individuals’ reactions to their infertility and the treatments. Quilligan, Edward J., and Frederick P. Zuspan, eds. Current Therapy in Obstetrics and Gynecology. 5th ed. Philadelphia: W. B. Saunders, 1999. This excellent handbook provides detailed information on procedures for various infertility causes and treatments, arranged alphabetically amid other gynecological subjects. Speroff, Leon, Robert H. Glass, and Nathan G. Kase. Clinical Gynecologic Endocrinology and Infertility. 2d ed. Baltimore: Williams & Wilkins, 1999. A good basic textbook that can help the reader understand the normal functioning of the female reproductive system and the events associated with infertility. Weschler, Toni. Taking Charge of Your Infertility. New York: HarperPerennial, 1995. This book encourages women to become responsible consumers of their own reproductive health. Includes excellent discussions of infertility, natural birth control, and achieving pregnancy. Wisot, Arthur, and David Meldrum. Conceptions and Misconceptions. Vancouver: Harley and Marks, 1997. Written by two leading fertility experts, this book is an excellent guide through the maze of in vitro fertilization and other assisted reproductive techniques. Includes an excellent discussion of the basic physiology of conception and reproduction.
✧ Influenza Type of issue: Epidemics, public health Definition: Any one of a group of commonly experienced respiratory diseases caused by viruses, responsible for many major, worldwide epidemics. There are three kinds of human influenza virus: type A, which is the major cause of severe influenza outbreaks; type B, which also causes influenza epidemics but less often and which is usually less severe than type A; and the rarest, type C, which causes a mild, coldlike illness. There are also different strains of virus within type A and type B, subtypes that are not identical but related. Within each subtype there are variants. Thus, the virus is capable of mutation. Influenza infection of one type does not necessarily immunize the victim against influenza of another type. This ability to mutate means that new influenza virus strains are constantly being developed—and are constantly threatening new waves of disease.
Influenza ✧ 531 In the eighteenth and nineteenth centuries, there were about twenty major epidemics of influenza in Europe and America. They were of varying severity—some mild, some harsh. In 1918, a pandemic of influenza became one of the worst afflictions ever endured by humankind. It came in three waves, the first in the spring of 1918. This wave was relatively mild and mortality rates were low, and it spread evenly through all age groups of the population. The second wave came in the fall, and it was the most devastating outbreak of disease seen since the great plagues of the Middle Ages. Up to 20 percent of its victims died, and about half the deaths were of people in the prime of life, twenty to forty years of age. The last wave came in the winter and was not as severe. By the time that the pandemic was over, more than 20 million people worldwide had died from it, with more than 500,000 deaths in the United States alone. In 1957, a new strain of influenza virus called the Asian flu came out of China and started a pandemic. Asian flu, or variants of it, caused the flu epidemics in the years from 1957 to 1968, but immunity to it spread so that the severity of the epidemics was gradually reduced. Then the Hong Kong flu, another new strain from the Far East, appeared. People had no immunity to it, so it caused another major pandemic. Hong Kong flu and its variants caused the epidemics that occurred in the next nine years. Then, in 1977, still another pandemic arose from a newer strain, also from Eastern Asia. In 1976, another type, swine flu, appeared in the United States. This virus infects pigs and humans and is apparently a distant descendant of the virus that caused the 1918 pandemic. It was evidently not as hardy as the 1977 virus, because that one replaced it and swine flu disappeared, although some experts predict its return. The Spread of Influenza To cause disease, the virus must be inhaled. Inside the upper respiratory tract, there is a layer of cilia-bearing cells (cells with small, hairlike filaments) that acts as a barrier against infection. Ordinarily, the tiny cilia spread a layer of mucus over respiratory tissues. The mucus collects infectious organisms and carries them to the stomach, where they are destroyed by stomach acids. The influenza virus causes the cilia-bearing cells to disintegrate, exposing a layer of cells beneath. The virus invades these and other host cells in the respiratory tract and begins replicating. Invasion and replication by the virus destroy the host cells. Destruction of the cells starts the inflammatory process that causes the symptoms of disease. Influenza infection grows rapidly, and symptoms can appear in only a few hours, although the incubation period in most people is two days or so. Fever, malaise, headache, muscular pain (particularly in the back and legs), coughing, nasal congestion, shivering, and a sore throat are common symp-
532 ✧ Influenza toms. The disease can spread quickly among populations because the virus is airborne. There is good reason to believe that the virus can remain infective in the air for long periods of time. It has been reported that the crew members on a ship sailing past Cuba during an epidemic there were infected with the disease, presumably from virus-laden particles carried from shore by the wind. The major complication of influenza is pneumonia, which can be caused by the influenza virus itself (primary influenza viral pneumonia), by infection from bacteria (secondary bacterial pneumonia), or by mixed viral and bacterial infection. Pneumonia is the major cause of death from influenza. In the severe pandemic of 1918, up to 20 percent of patients developed pneumonia and, of these, about half died. Primary influenza viral pneumonia can come on suddenly, and it often progresses relentlessly with high fever, rapidly accumulating congestion in the lungs, and difficulty in breathing. Pneumonia caused by secondary bacterial infection can be caused by a large number of pathogens. In nonhospitalized patients, both children and adults, the common causes are pneumococci, streptococci, and Haemophilus influenzae. In older, infirm, or hospitalized patients, the common causes are pneumococci, staphylococci, and Klebsiella pneumoniae. When influenza B is the pathogen, Reye’s syndrome can develop, most often in children under eighteen. This disease, which causes brain and liver damage, is fatal in about 20 percent of cases. Treating Influenza The first aim of therapy is to keep the patient comfortable, address the symptoms of the disease that can be treated, and deal with any complications that may arise. Bed rest is recommended, particularly during the most severe stages of the disease. Exertion is to be avoided, in order to prevent excessive weakness that could encourage further infection. Aspirin, acetaminophen, and other drugs are given for fever, and painkillers are given to relieve aches and pains. Cough suppressants and expectorants can relieve the hacking coughs that develop. Drinking large amounts of liquids is advised to replace the fluids lost as a result of high fever and sweating. Amantadine hydrochloride is sometimes given to patients with influenza A infection. It reduces fever and relieves respiratory symptoms. An analogue of amantadine, rimantadine, works similarly. In severe cases of influenza caused by either A or B virus, an antiviral drug called ribavirin can be administered as a mist to be breathed in by the patient. Ribavirin shortens the duration of fever and may alleviate primary influenza viral pneumonia. Primary influenza viral pneumonia is usually treated in the intensive care unit of a hospital, where the patient is given oxygen and other procedures are used to give respiratory and hemodynamic support. Secondary bacterial
Influenza ✧ 533 pneumonia must be treated with appropriate antibiotics. Identifying the precise bacterium will help the physician decide which antibiotic to prescribe. This identification is not always feasible, however, in which case broad-spectrum antibiotics will be used. They are effective against the most common bacteria that cause these secondary infections: Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae. Preventing the Spread of Influenza The first line of defense is to isolate the patient from susceptible persons and to initiate a program of vaccination. Because the influenza virus is constantly mutating, vaccines are regularly reformulated to confer immunity to the current pathogens. For the most part, the differences are not great between one year’s virus and the one causing the next year’s disease. Current vaccines may confer immunity or may require adjustment. If a major antigenic mutation has occurred, however, immunity cannot be conferred unless a new vaccine is developed against the new strain. Because it can take months to develop a new vaccine, there is the danger that the epidemic will have run its course and infected entire populations by the time that the vaccine is ready. Fortunately, major pandemics of influenza usually start slowly, so researchers have the time to identify the new strain, create a vaccine, and disseminate it. The usual recommendation is to vaccinate people who are at highest risk of complications from the disease. These people include those over sixty-five years of age; residents of nursing homes or other patients with chronic medical conditions; adults and children with chronic pulmonary or cardiovascular diseases, including children with asthma; adults and children who have been hospitalized during the previous year for metabolic disorders, such as diabetes mellitus, or for renal diseases, blood disorders, or immunosuppression; teenagers and children who are receiving long-term aspirin therapy (who may be at risk of developing Reye’s syndrome as a result of influenza infection); and pregnant women whose third trimester occurs in winter. When a family member brings influenza into the household, other members should be vaccinated. After vaccination, it usually takes about two weeks for immunity to develop. Amantadine may protect against influenza A in the meantime; it can be discontinued after immunity has been achieved. If, for any reason, a person cannot be vaccinated, amantadine should be given throughout the entire length of the epidemic, which may last six to eight weeks. Preventing Future Epidemics It is theoretically possible for a pandemic of the severity of 1918 to occur. If a new subtype of the influenza virus were to arise and its initial spread were
534 ✧ Influenza rapid, it could rage around the globe before an effective vaccine could be developed and made available. Mass devastation and death could result. So far, medical science has been able to produce vaccines capable of protecting against the new mutant viruses as they arise. Even when a significant portion of any society is vaccinated, however, some people still become infected and no available agents can kill the influenza virus. Furthermore, few therapeutic measures can do any more than alleviate individual symptoms. Basically, the body’s own immune system is the best therapy currently available. The search for antiviral agents is among the most urgent activities in medical science. When an agent is discovered that is safe and effective against influenza virus, it could be subject to the same limitations as the vaccines; that is, it may have to be modified periodically to remain effective against the new strains of influenza virus that are continually developing, and it may be necessary to develop new agents to deal with radically new mutants. —C. Richard Falcon See also Childhood infectious diseases; Children’s health issues; Epidemics; Health care and aging; Immunizations for children; Immunizations for the elderly; Reye’s syndrome; Zoonoses. For Further Information: Biddle, Wayne. Field Guide to Germs. New York: Henry Holt, 1995. This comprehensive book is easily accessible to the nonspecialist and includes a discussion of nearly every virus, bacterium, and fungus known to cause human and nonhuman animal disease. The history of the microbe and the treatment of diseases are included. Kiple, Kenneth F., et al., eds. The Cambridge World History of Human Disease. Cambridge, England: Cambridge University Press, 1993. The section on influenza gives a useful account of the epidemics and pandemics of influenza throughout the years. Kolata, Gina. Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It. New York: Farrar, Straus and Giroux, 1999. Kolata’s book vividly describes how the 1918 influenza outbreak, the most deadly pandemic the United States has ever faced, affected society. It offers not only an apocalyptic vision of the course of the disease but also details the ongoing efforts to track down its source. Larson, David E., ed. Mayo Clinic Family Health Book. 2d ed. New York: William Morrow, 1996. A good general medical text for the layperson. The section on influenza is short but thorough. Sahelian, Ray, and Victoria Dolby Toews. The Common Cold Cure: Natural Remedies for Colds and Flu. New York: Avery, 1999. The miseries of the common cold are many, and while a definitive medical cure remains
Injuries among the elderly ✧ 535 elusive, its most annoying symptoms can certainly be addressed and, as Sahelian and Toews maintain, its duration shortened without the use of over-the-counter pharmaceuticals.
✧ Injuries among the elderly Type of issue: Elder health, prevention Definition: Types of injury that become more common or more serious with age. Accidents are the seventh leading cause of death in people over the age of sixty-five and the fifth leading cause of death in those over the age of eighty-five. When such accidents do not result in death, they may lead to serious threats to the person’s health and functional abilities. Because elderly people often fear a recurrence of injury, accidents may cause a decrease in physical and social activity, as well as a loss of confidence. Poisoning and Choking Decreases in visual acuity may make some elderly people susceptible to taking poison that might be on a shelf or in the medicine cabinet, especially the wrong medication. Because of the poor eyesight, they may use something in their eyes for eye drop medication when in reality it is some other type of fluid that can damage the eyes or cause blindness. Decreases in the sense of smell and taste may lead people to eat spoiled food or inhale toxic fumes from substances in the home. Decreased gag and swallowing reflex may lead to choking, which can be fatal for someone who lives alone. Poorly fitted dentures, poor dental hygiene, or other factors that make chewing difficult may also increase the risk of choking. Burns and Injuries from Extreme Heat and Cold Burns account for 8 percent of the accidental deaths among the elderly. Burn injuries are most commonly caused by scalds from hot baths, showers, or fluids on the stove; flames from the ignition of clothing or flammable liquids; and house fires. A large percentage of fires started by elderly people are caused by the use of electrical equipment for cooking and heating and by careless smoking. The danger posed by fire is even greater among those elderly people who have a decreased sense of smell and therefore cannot detect smoke or the odor of leaking gas. Elderly people are often susceptible to temperature extremes. Those without air conditioning may be overcome by heat during the summer
536 ✧ Injuries among the elderly months. Diminished sense of thirst may lead to dehydration. In the winter, some elderly people may not be able to afford to heat their homes properly. Low body temperatures can lead to hypothermia, particularly among those who do not eat well enough to provide the energy necessary for the body to stay warm. The problem is exacerbated by the fact that aging reduces the body’s percentage of subcutaneous tissue, which helps keep the body warm. Traffic Accidents and Crime Approximately 25 percent of accidental deaths in people over sixty-five years of age are from motor vehicle accidents. Among the physiological changes that increase the risk of accidents are poor depth perception, decreased response time, sensory impairment, and alterations in musculoskeletal, nervous, and cardiovascular systems. Despite these changes, many elderly people continue to drive in order to maintain a certain degree of independence. Traffic injuries may also be sustained by pedestrians who step off the curb into traffic, often because they do not see well or hear the cars. Declining perceptions may decrease a person’s ability to judge the speed and distance of approaching traffic. The elderly are more likely to be attacked by strangers than other age groups. The reason is their vulnerability. Many poor elderly people are dependent on public transportation and live in high-crime neighborhoods. Many lack the physical strength to defend themselves, while others suffer from poor eyesight and may not be able to identify their attacker. An attack can cause physical damage—such as broken bones, heart and respiratory failure, or head injuries—and can also cause serious damage to pride and self-esteem. Victims may become so fearful of another attack that they will not leave Because the healing processes of the body become less efficient with age, older adults have a longer recovery their homes, even to buy food period after injury and may require physical therapy. or get medical care. —Mitzie L. Bryant (PhotoDisc)
Lactose intolerance ✧ 537 See also Aging; Broken bones in the elderly; Burns and scalds; Canes and walkers; Disabilities; Domestic violence; Drowning; Elder abuse; Electrical shock; Exercise and the elderly; Falls among the elderly; First aid; Foot disorders; Frostbite; Hospitalization of the elderly; Illnesses among the elderly; Medications and the elderly; Mobility problems in the elderly; Osteoporosis; Reaction time and aging; Safety issues for the elderly; Temperature regulation and aging; Vision problems with aging; Wheelchair use among the elderly. For Further Information: Barrow, Georgia M. Aging, the Individual, and Society. 7th ed. Belmont, Calif.: Wadsworth, 1999. Barrow discusses demographics, the effect aging has on society, and the influence aging has on the health of the individual. DeWit, Susan C. Essentials of Medical-Surgical Nursing. 4th ed. Philadelphia: W. B. Saunders, 1998. DeWit provides information on fractures, accidents, and burns in the elderly and how to prevent them. Murray, Ruth Beckmann, and Judith Proctor Zentner. Health Assessment and Promotion Strategies Through the Life Span. 7th ed. Englewood Cliffs, N.J.: Prentice Hall, 2000. Provides insight on contributing factors and prevention of injuries in the elderly. Rosdahl, Caroline Bunker, ed. Textbook of Basic Nursing. 7th ed. Philadelphia: Lippincott Williams & Wilkins, 1999. Discusses the normal physical signs of aging that can be associated with and contribute to injuries. Solomon, Jacqueline. “Osteoporosis: When Supports Weaken.” RN 61 (May, 1998). Solomon provides useful information on a condition of the bone common among the aged that causes fractures and weak muscles.
✧ Lactose intolerance Type of issue: Public health Definition: An inability to break down and absorb milk sugar, known as lactose, resulting in stomach pain, gas, and diarrhea if lactose is consumed. Lactose is a complex sugar commonly found in dairy products. It is composed of two simple sugars, glucose and galactose. In babies and young children, a gene produces an enzyme called lactase that breaks down lactose into its two component sugars, which are then absorbed into the bloodstream through the intestinal wall. In many people, sometime after early childhood, the lactase gene no longer synthesizes lactase, preventing the digestion and absorption of lactose. Normal bacterial inhabitants of the intestines synthesize lactase and
538 ✧ Laparoscopy break down the lactose molecules, producing large quantities of gas as a by-product. This can lead to cramping for the lactose-intolerant individual. The presence of lactose in the large intestine causes excessive amounts of water to move into the intestine, which can lead to diarrhea. Symptoms subside one to two days after the last lactose-containing food has been consumed. Lactose intolerance can often be misdiagnosed as a host of gastrointestinal disorders, largely as a result of the commonness of its major symptoms, cramps and diarrhea. Typically, a dietary history must be kept. Patients with lactose intolerance will note an association between their symptoms and the consumption of milk products containing lactose. After elimination of these products from the diet, symptoms should not recur. The vast majority of the world’s population is lactose intolerant, yet this disorder was not recognized in the United States until the latter third of the twentieth century. There is no treatment for lactose intolerance; prevention of symptoms is the general course of action. Avoidance of foods that contain lactose—including milk, ice cream, and cheese—is usually the best recourse. Over-the-counter lactase supplements are available to help prevent symptoms for lactose-intolerant people who choose to consume dairy products. Alternatively, some dairy products are being manufactured as lactose-free; they can be consumed safely by the lactose-intolerant population. —Karen E. Kalumuck See also Allergies; Food poisoning; Malnutrition among children; Malnutrition among the elderly; Nutrition and aging; Nutrition and children; Nutrition and women; Vitamin supplements. For Further Information: Carper, Steve. Milk Is Not for Every Body: Living with Lactose Intolerance. New York: Plume, 1996. Gracey, Michael, ed. Diarrhea. Boca Raton, La.: CRC Press, 1991. Greenberger, Norton J. Gastrointestinal Disorders: A Pathophysiologic Approach. 4th ed. Chicago: Year Book Medical Publishers, 1989. Janowitz, Henry D. Your Gut Feelings: A Complete Guide to Living Better with Intestinal Problems. New York: Oxford University Press, 1987.
✧ Laparoscopy Type of issue: Medical procedures, treatment Definition: The examination of the abdominal organs with a fiber-optic tube which can also be used to perform surgery to correct several disease conditions.
Laparoscopy ✧ 539 Laparoscopy is a surgical technique for examining the abdominal organs and for treating surgically many diseases of these organs. The instrument used, called a laparoscope, is a flexible tube that contains fiber optics for visualization purposes and a channel through which physicians can pass special surgical instruments into the abdominal cavity. Upon insertion of a laparoscope into the abdomen through a small surgical incision (usually near the navel), physicians can observe the liver, kidneys, gallbladder, pancreas, spleen, and exterior aspects of the intestines in both sexes. Hence the technique is useful for detecting cirrhosis of the liver, the presence of stones and tumors, and many other diseases of the abdominal organs. The female reproductive organs can also be examined in this manner. Before laparoscopy can be carried out, the patient must fast for at least twelve hours. The patient is given a local or general anesthetic, depending on the purpose of the procedure. In exploratory abdominal examinations, the instrument is inserted into the abdomen through a small incision in the abdominal wall after local anesthesia has numbed it. Often, especially when extensive surgery is anticipated, the procedure begins after general anesthesia produces unconsciousness. Upon the completion of exploration or surgery, the laparoscope is withdrawn and the incision is closed. Common Uses Laparoscopic abdominal examination is often used to detect endometriosis, the presence of endometrial cells outside the uterus. This procedure begins with the administration of local anesthesia when only exploration or biopsy is planned. General anesthesia is used when the removal of implants (endometrial tissue) is anticipated. The entry incision is made near the navel, and the laparoscope is inserted. The fiber-optics system is used to search the abdominal organs for implants. Visibility of the abdominal organs is usually enhanced by pumping in a harmless gas, such as carbon dioxide, to distend the abdomen. After the confirmation of endometriosis, surgical implant removal is carried out immediately, unless the decision is made to institute drug therapy instead. Full recovery from this surgery requires only a day of postoperative bed rest and a week of curtailing activities. Laparoscopy can also be employed for female sterilization. The patient is given a general anesthetic. After laparoscopic visualization of the Fallopian tubes in the gas-distended abdomen is achieved, surgical instruments for tube cauterization or cutting are introduced and the sterilization is carried out. The entire procedure often requires only thirty minutes, which is one reason for its popularity. In addition, patients can go home in a few hours and have fully recovered after a day or two of bed rest and seven to ten days of curtailing activities. Other common laparoscopic surgeries are cholecystectomy (gallbladder
540 ✧ Laparoscopy removal), gallstone and kidney stone removal, tumor resection, and the removal of biopsy samples from abdominal organs. Traditional uses of laparoscopy in female reproductive surgery are to identify and correct pelvic pain resulting from endometriosis, ectopic pregnancy, and pelvic tumors. Benefits and Risks Laparoscopy has several advantages. There is rarely a need for patients on chronic drug therapy to discontinue medication before laparoscopy. In addition, the use of laparoscopy dramatically lowers surgical incision size, surgical trauma, length of hospital stay, and recovery time. Laparoscopy should be avoided, however, in cases of advanced abdominal wall cancer, severe respiratory or cardiovascular disease, or tuberculosis. Extreme obesity does not disqualify a patient from undergoing laparoscopy but makes the procedure much more difficult to perform. As laparoscopic surgery has increased in scope, more procedures yield surgical tissues that are larger in size than the laparoscope channel (for example, the removal of gallbladders, gallstones, and ovaries). In many cases these organs and structures are cut into small pieces for removal. If potentially dangerous items are involved—such as malignancies that can spread on dissection—larger, more conventional incisions are often combined with laparoscopy. The Future of Laparoscopy Since the 1970’s, the uses of laparoscopy have constantly expanded. Once confined to the exploratory examination of the abdomen, the methodology has been applied to a large number of different types of surgery. Such versatility is attributable to the development of better laparoscopes, advanced instrumentation for diverse surgeries, and improved fiber-optic and video technologies. Many surgeons predict that most future abdominal surgery will be laparoscopic. The driving force for such innovation includes the public demand for quicker recovery times. In the United States, this desire is intensified by the requirements of insurance companies, employers, and the federal government for shorter hospital stays. Both changes are made possible by decreased severity of surgical trauma in laparoscopy when compared to traditional surgery, a result of the smaller incisions. The dramatic trend toward laparoscopy can be seen with cholecystectomies: Of those done in 1992, 70 percent were laparoscopic, compared to less than 1 percent in 1989. —Sanford S. Singer See also Cervical, ovarian, and uterine cancers; Endometriosis; Infertility in women; Sterilization.
Laser use in surgery ✧ 541 For Further Information: Graber, John N., et al., eds. Laparoscopic Abdominal Surgery. New York: McGrawHill, 1993. Lauersen, Niels H., and Constance DeSwaan. The Endometriosis Answer Book: New Hope, New Help. New York: Rawson Associates, 1988. Reddick, Eddie Joe, ed. An Atlas of Laparoscopic Surgery. New York: Raven Press, 1993. Zucker, Karl A. Surgical Laparoscopy. Philadelphia: Lippincott, Williams & Wilkins, 2000. Includes bibliographical references and an index.
✧ Laser use in surgery Type of issue: Medical procedures, treatment Definition: The application of laser technology to surgical procedures, such as the vaporization of blood clots or arterial plaque, the breaking up of kidney stones into small fragments, the removal of birthmarks, and the stoppage of retinal hemorrhage. A wide range of laser wavelengths (colors) has become available as a result of research efforts by physicists and optical engineers. Lasers have become much more rugged and dependable in construction. Some operate with a continuous beam, while others produce very short pulses, depending on the desired application. Also, lasers can be designed to operate at a low power level for diagnostic purposes or a high power level for surgery. Safety precautions must be followed when working with a laser. Not only the patient but also the surgical team must be protected from possible harmful radiation. The eyes must be protected from laser beam reflections from a shiny surface. Ultraviolet light is a special hazard because its highenergy photons can cause cell damage and genetic mutations. The great benefits of laser surgery can be negated by an inexperienced or careless surgeon. Laser Eye Surgery The first medical use of a laser beam was for surgery on the retina of the eye, in 1963. Diabetic patients in particular frequently develop excessive blood vessels in the retina that give their eyes a typically reddish color. In advanced cases, the blood vessels can hemorrhage and eventually cause blindness. The green light of an argon laser will pass through the clear cornea and lens of the eye, but when it hits the dark brown melanin pigment of the retina, it will be absorbed and cause a tiny hot spot. The physician uses a series of laser pulses, carefully focused on affected areas of the retina, to burn away the
542 ✧ Laser use in surgery extra blood vessels. The remarkable property of the laser beam in this procedure is that its energy penetrates to the rear of the eye, leaving the clear fluid unaffected. A particular problem following cataract surgery is that a secondary cataract may develop on the membrane behind the implanted artificial lens. About one-third of patients with such a lens implant require resurgery to remove the secondary cataract. A YAG laser beam will pass through the cornea and artificial lens but can be focused to produce a hot spot at the site of the secondary cataract to destroy it. More than 200,000 such procedures are performed each year in the United States, and the result is a dramatic, almost instantaneous improvement of vision. A third form of laser eye surgery reshapes the curvature of the cornea of the eyeball to overcome myopia (nearsightedness) or hyperopia (farsightedness) and astigmatism. Farsighted people, for example, are unable to focus nearby objects onto the retina unless they wear eyeglasses. Increasing the curvature of the cornea through surgery can replace the extra focal strength previously provided by the glasses. An ultraviolet-light pulsed laser can remove thin layers of tissue from selected sites on the cornea to change its curvature. The procedure, called corneal sculpting, is promising but has hazards. Surgeons must learn to use a laser beam like a delicate scalpel. The healing process after surgery and the long-term effects on the cornea need further study. Treating Obstructions, Bleeding, and Birthmarks Another dramatic medical application of the laser is the breaking up of stones in the kidney, ureter, or gallbladder. Such calcified, hard deposits previously could only be removed by surgery. It is now possible to insert an optical fiber of less than half a millimeter in diameter through the urethra and then transmit the laser beam to the site of the stone. High-power light pulses of very short duration (less than one-billionth of a second) create a shock wave that breaks the stone into small fragments that the body can eliminate. Another promising application of laser surgery that has received much publicity is laser angioplasty, which is used to open up a blood vessel near the heart that is partially or wholly blocked by a deposit of plaque. Laser angioplasty involves inserting a catheter that contains a fiberscope, an inflation cuff, and an optical fiber into the artery of the arm and advancing it into the coronary artery. The fiberscope enables the physician to see the blockage, the cuff is used to stop the blood flow temporarily, and the optical fiber transmits the laser energy that vaporizes the plaque. Sometimes, the laser method is used only to open up a small channel, after which balloon angioplasty is used to stretch the walls of the blood vessel. The main risk in using the laser beam is that the alignment of the optical
Laser use in surgery ✧ 543 fiber inside the artery may be deflected and cause a puncture of the blood vessel wall. Improvements in the imaging system are needed. Also, further work must be done to see which light wavelengths are most effective in removing plaque and preventing recurrence of the obstruction. The heating effect of a laser beam has been used by surgeons to control bleeding. For example, bleeding ulcers in the stomach, intestine, and colon have been successfully cauterized with laser light transmitted through an optical fiber. A similar procedure has been used to treat emphysema patients. An optical fiber is inserted through the wall of the chest, and the laser’s heat is used to shrink the small blisters that are present on the surface of the lungs. Also, the heat from a laser has been used during internal surgery to seal the surrounding capillaries that contribute to bleeding. One notable success of laser surgery has been the removal of birthmarks. Reddish-purple birthmarks called port-wine stains can be quite unsightly, especially when located on the face of a person with an otherwise light complexion. To remove such a birthmark, the laser beam has to burn out the network of extra blood vessels under the skin. A similar procedure can be used to remove unwanted tattoos. The color of the laser must be chosen so that its wavelength will be absorbed efficiently by the dark purple stain. If a purple laser beam were used, its light would be reflected rather than absorbed by a purple object, and it would not produce the desired heating. Yellow or orange is most effectively absorbed by a purple object. The surgeon must be careful that the laser light is absorbed primarily by the purple birthmark without harming the normal, healthy tissue around it. Experimental Cancer Treatment Experimental work is being done to determine whether lasers can be used to treat cancer. Small malignant tumors in the lungs, bladder, and trachea have been treated with a technique called photodynamic therapy. The patient is injected with a colored dye that is preferentially absorbed in the tumor. Porphyrin, the reddish-brown pigment in blood, is one substance that has been known for many years to become concentrated in malignant tissue. The suspected site is irradiated with ultraviolet light from a krypton laser, causing it to glow like fluorescent paint, which allows the surgeon to determine the outline of the tumor. To perform the surgery, an intense red laser is focused on the tumor to kill the malignant tissue. Two separate optical fibers must be used for this procedure, one for the ultraviolet diagnosis and one for the red laser therapy. The three traditional cancer treatments of surgery, chemotherapy, and radiation therapy all seek to limit damage to healthy tissue surrounding a tumor. Photodynamic surgery by laser must develop its methodology further to accomplish the same goal. —Hans G. Graetzer
544 ✧ Law and medicine See also Arteriosclerosis; Cancer; Heart disease; Skin cancer; Skin disorders with aging; Tattoos and body piercing; Ulcers; Vision problems with aging. For Further Information: Berns, Michael W. “Laser Surgery.” Scientific American 264, no. 6 (June, 1991): 84-90. An excellent article describing how lasers can be used as medical tools. Contains photographs showing blood vessels in the retina before and after surgery, a urinary tract stone being fragmented by a laser, colored dye being made to fluoresce with laser light to diagnose malignant cancer, and other applications. Cameron, John R., James G. Skofronick, and Roderick M. Grant. Medical Physics: Physics of the Body. Madison, Wis.: Medical Physics, 1992. A wellwritten textbook for college students planning a career in the health professions. The section on lasers in medicine gives an excellent discussion of eye surgery, relating the laser beam spot size, power level, wavelength, exposure time, and resulting tissue damage. Ehrlich, Matthew. How to See Like a Hawk When You’re Blind as a Bat. Venice, Fla.: Doctor’s Advice Press, 1999. Ehrlich, an opthalmologist, provides a thorough description of various eye problems and whether Lasik eye surgery can be used to correct them. He draws on statistics from a group of Lasik patients to show final outcomes and the proportion of people who experience various complications. Fitzpatrick, Richard E., and Mitchel P. Goldman. Cosmetic Laser Surgery. St. Louis, Mo.: Mosby, 2000. Includes bibliographical references and an index. IEEE Journal of Quantum Electronics 26, no. 12 (December, 1990). A special issue on lasers in biology and medicine. This journal is the professional publication of the Institute of Electrical and Electronic Engineers. The articles require some technical background on the part of the reader. Good descriptions of well-established techniques of laser surgery as well as applications under development.
✧ Law and medicine Type of issue: Economic issues, ethics Definition: The use of medicine in legal contexts—to determine whether a person has been injured by the act of another, the extent of such an injury and its treatment, and whether a defendant was physically or emotionally capable of committing a crime or tort—and in related ethical and philosophical contexts—to determine when life begins or how one evaluates “quality of life.”
Law and medicine ✧ 545 Medicine as it relates to law is referred to as forensic medicine. Forensic medicine plays a part in three basic areas of the law. The first two involve the practical application of medicine in civil law and in criminal law. The third area involves the use of medical science to help in defining philosophical or ethical issues, such as when life begins and ends. In both civil and criminal cases, medical science is called upon to provide evidence that can be used to prove or disprove a party’s case. In a civil case, the parties will often resort to medical experts to determine the extent of a plaintiff’s mental and physical injuries. These experts are doctors who act as witnesses in their areas of expertise and testify in a court of law. For example, a plaintiff in a civil suit might claim that he or she was born with birth defects as a result of drugs that the mother had taken during pregnancy and may present evidence of that injury and its cause by the testimony of doctors and medical research experts specializing in those related areas of medicine. Such testimony would be presented to the jury to show that the plaintiff’s claim of birth defects being caused by such a drug is supported by medical research. Expert Witnesses Versus Treating Doctors As medical science reveals more about the causes of disease, injuries, and the workings of the body, more distinct specialties have been created. This trend is reflected in the increasing number of expert witnesses: At the beginning of the twentieth century, a general practitioner was considered qualified to testify on most areas of medicine; today, the courts require expert witnesses to be specifically qualified in the area of medicine about which they testify. The practice of using highly qualified and specialized doctors as expert witnesses has long been accepted by courts as an effective way to educate a jury regarding the extent, cause, and treatment of the injury in question, but there are some limitations on the use of such testimony. In order for the court to allow a medical expert to testify as to specific facts from which conclusions are to be drawn, the facts must be outside what is considered to be the general or common knowledge of a lay jury. For example, a court may not allow a party to use a medical expert to explain sprained ankles. The court would, however, allow a medical expert to explain toxic shock syndrome, because the existence, causes, and effects of that impairment are not common knowledge. The reasoning behind this limitation is that the jury members are supposed to form their own opinions when such opinions do not involve or require specialized knowledge. Only when it is necessary or helpful to the jury to be educated in a specialized area of knowledge is expert testimony usually allowed. The court also recognizes a distinction between testimony from a medical expert and testimony from the plaintiff’s treating doctor. Whereas the
546 ✧ Law and medicine former educates the jury regarding an area of medicine that is relevant to the case, the latter does not. Instead, the treating doctor is called to testify to actual events or facts of the case that the doctor personally witnessed: that the plaintiff was examined on a certain date, the extent of his or her injuries, and so on. Thus, although an expert witness may not be allowed by the court to educate the jury on the subject of a sprained ankle or other topic of common knowledge, the fact that the plaintiff sustained a sprained ankle and was treated for it may be testified to by the treating doctor. In a civil suit, the plaintiff must prove that he or she was injured by some act of the defendant. That injury can be economic (the loss of property or money), physical (such as a torn muscle or broken leg), or mental (stress or anxiety). Over the years, more and more types of injuries have become recognized as compensable injuries in civil cases. The term “pain and suffering” has been used to describe physical and emotional symptoms that a plaintiff may claim were caused by the defendant. Medical facts can help determine the existence and extent of all these types of injury. Sometimes the expert will testify only hypothetically (that is, based on the doctor’s expertise). The expert may be asked to render an opinion based on certain assumptions concerning the plaintiff’s condition. Sometimes, however, a medical expert will need to examine a plaintiff. It is not unusual for such examinations to take place years after the injury occurred, and the doctor will have to determine whether the injury exists, the extent of the injury, the cause of the injury, what (if any) limitations are caused by the injury, the treatment that is indicated, and the probable duration of the injury (perhaps based on the average rate of recovery for such an injury). In the criminal justice system, medical experts may testify on a variety of scientific and medical issues. In the case of a murder, for example, it may be necessary to identify blood, tissue, bone, or some other human remains and to determine the source of those remains—namely, whether the remains belong to the alleged victim or perpetrator of the crime. Doctors who specialized in forensic medicine are often called upon to conduct special tests, such as deoxyribonucleic acid (DNA) testing, to identify whose blood or tissue was found at the scene of a crime or on a murder weapon. Forensic experts can also determine the approximate time and cause of death. Testimony on these issues helps a jury determine the guilt or innocence of the accused. Psychiatric Evaluations Criminal cases occasionally also require the testimony of a forensic psychiatrist, who is an expert in mental and emotional disorders as they relate to legal principles. Testimony from such an expert assists in determining whether the defendant is “insane.” According to section 4.01 of the Modern Penal Code, a person is insane if he or she “lacks substantial capacity either
Law and medicine ✧ 547 to appreciate the criminality [wrongfulness] of his conduct or to conform his conduct to the requirements of the law.” Psychiatric evaluations of the accused are performed to determine whether the defendant fit this definition at the time the crime was committed. Testimony regarding the defendant’s insanity would significantly affect the case’s outcome and sentencing. A separate issue, unrelated to the defendant’s mental condition at the time of the crime, is the defendant’s “competency” to stand trial. According to Black’s Law Dictionary (5th ed., 1979), a defendant “lacks competency to stand trial if he or she lacks capacity to understand the nature and object of the proceedings, to consult with counsel, and to assist in preparing his or her defense.” The law ensures that an accused person’s rights are protected by requiring that the defendant be capable of understanding these proceedings and their implications before he or she is allowed to stand trial. If either of the attorneys, or the judge, asserts that the defendant is not competent to stand trial, the court will hold a competency hearing to decide whether the defendant is “competent.” In determining the competency of the defendant, the court will hear the testimony of psychiatric experts. If the defendant is determined to be incompetent at the time of the trial, the defendant will not be tried but may instead be sent to a mental institution until such time as he or she is competent to stand trial. Medicine in Philosophical and Ethical Debates In addition to being used in civil cases and criminal cases, medical science is used to provide scientific information to support or disprove wholly nonscientific determinations. Such philosophical and ethical issues include abortion and euthanasia. In the long-running debate over the legality of abortion, for example, many issues and circumstances come into play, including rape and the possibility that pregnancy may endanger the woman’s life. One central and hotly contested question, however, is “When does life begin?” This question may also involve an equally difficult and controversial one: “What is life?” The courts and various state legislatures have turned to medical science to address these profound, and possibly unanswerable, questions. Medical science has identified two key concepts to answer these questions: the concept of “viability” (that is, the ability of the fetus to survive outside the womb) and the distinction between the first, second, and third trimesters of a pregnancy. The distinction of trimesters was originally based on the concept of viability: A fetus generally could not survive outside the womb during the first trimester (that is, was not viable), while a fetus was generally considered viable during the third trimester. Thus, the courts and legislature would often use the concept of trimesters in determining a cutoff date after which an abortion could not be performed. These concepts have been used as the basis for legislation to regulate and authorize abortions. Medical science is, however, a rapidly evolving field.
548 ✧ Law and medicine Because it is now possible for a human egg, once fertilized, to become viable outside the womb, the legal foundation upon which abortions are based is becoming more unstable. The Range of Forensic Investigation In criminal cases, particularly cases of homicide, forensic medicine often provides the key and fundamental evidence upon which the entire case is based. During the investigations of the assassination of President John F. Kennedy in the 1960’s, the forensic evidence played a vital, although controversial, role. The testimony presented by the doctors who examined the president’s body was used to reconstruct the crime. Forensic science was used to interpret the angle of entry of the bullets that killed Kennedy and thereby to extrapolate the source of the shots. Furthermore, forensic science was called upon to demonstrate how many shots were fired and the paths of the bullets upon entering the bodies of the president and Governor John Connally. Using medical evidence, along with other evidence, the Warren Commission concluded that the bullets all came from the book depository building behind the presidential caravan. Also using medical evidence and experts, critics of the Warren Commission’s findings have alleged that the injuries suffered by the president could have been caused only by a bullet entering from the front of the president’s neck and exiting the rear of the skull. In another case, forensic evidence was able to reach a conclusive determination that certain bones were those of the Nazi war criminal Dr. Josef Mengele, known as the Angel of Death. In 1992, forensics experts discovered, using a method known as DNA testing, that some bones retrieved from a grave in Brazil were those of Mengele. In order to make this determination, doctors compared the DNA found in the blood of Mengele’s son with DNA from the bones found in the grave. They found that the DNA from both sources was identical. Because DNA constitutes a “genetic fingerprint” that remains the same from parent to offspring, the doctors were able to conclude that the remains found in Brazil were those of Mengele. DNA testing is now also commonly used in suits to determine the father of an infant. According to the Genetics Institute, DNA testing is at least 99.8 percent accurate. Medical science has so refined its ability to chart DNA “fingerprints” that the chance of coming upon two identical DNA patterns is approximately one in six billion. Prior to DNA testing, a blood testing method called human leukocyte antigen (HLA) typing was used to determine paternity, but this typing was only 95 percent accurate. Some medical or scientific tests, while accepted by the courts, remain subject to much controversy. The Breathalyzer test, used to determine blood alcohol levels, is one such test. While the courts regularly accept the results of such tests to determine whether a suspect was intoxicated, the test is based on several assumptions and averages. Based on the alcohol content in the
Law and medicine ✧ 549 suspect’s breath, the test extrapolates a probable amount of alcohol in the suspect’s blood. The reliability of this test depends on the correct calibration of the equipment and the care of the person taking the readings. Since the tests are taken by nonmedical or nonscientific personnel in the field, mistaken readings are not uncommon. Furthermore, if the suspect used a spray breath freshener just before the test, the readings may be skewed, since such breath fresheners are usually alcohol-based. The Medicalization of Law With the advent of new technologies in the later part of the twentieth century, medical science began to present “hard” (more precise) data that became more frequently accepted by the courts as reliable and relevant evidence. Even so, it took some time before medical scientists were able to present enough data to persuade the courts that the evidence of such methods as DNA “fingerprinting” was truly reliable. The acceptance of DNA testing, for example, was a long and hard-fought battle among legions of medical experts on both sides of the issue. Finally, DNA testing was accepted by the courts as a reliable source of evidence. As forensic medicine advances, no doubt its contribution to the law will also advance. The ability of the medical and other scientific professions to determine reliable conclusions relating to court cases is progressing rapidly with increases in scientific knowledge, methods, and technology. In an ironic twist, however, this progress has clouded other areas of the law, including the constitutional rights of accused persons. In the early twentieth century, for example, no one could have dreamed of the technology that makes life support possible. With the advent of kidney dialysis machines, pacemakers, respirators, and other life support devices, medical science has achieved the ability to prolong an individual’s bodily functioning. Whether this functioning alone is sufficient to define “life,” however, remains a question that cannot be addressed by medical science alone but must be considered in the light of philosophical, ethical, and other values. Medicine is therefore becoming as much an area with which the law must contend as it is a tool for aiding existing law. Issues concerning abortion and the point at which life begins, euthanasia, the individual’s right not to have life extended by extraordinary means if there is no hope of recovery, the right to reveal an individual’s genetic predisposition toward disease, egg implantation, and genetic engineering have all challenged the existing, and inadequate, laws. Medical science not only has propagated these dilemmas but also has been called upon to solve them. —Larry M. Roberts See also Abortion; Child abuse; Death and dying; Domestic violence; Elder abuse; Ethics; Euthanasia; Genetic engineering; Hippocratic oath;
550 ✧ Lead poisoning Iatrogenic disorders; In vitro fertilization; Malpractice; Occupational health; Screening. For Further Information: Black, Henry Campbell. Black’s Law Dictionary. 7th ed. St. Paul, Minn.: West, 1999. The fundamental legal dictionary, containing definitions and examples of how the terms have been interpreted by courts. Loring, Charles A., ed. California Jury Instructions, Civil: Book of Approved Jury Instructions. 7th ed. 2 vols. St. Paul, Minn.: West, 1986. Sets forth the standard jury instructions, covering various aspects of civil duties and liabilities. Tarantino, John A., and Patricia K. Rocha. Estimating and Proving Personal Injury Damages. Santa Ana, Calif.: James, 1988. A brief, step-by-step approach to pursuing personal injury damages. Generally geared for the attorney, but written in simple English. Contains helpful information on quantifying medical injuries for purposes of determining money damages in a personal injury lawsuit. Witkin, B. E. Summary of California Law. 9th ed. 13 vols. San Francisco: Bancroft-Whitney, 1987-1990. This multivolume set (with a supplemental volume published in 1991) contains a brief explanation and analysis of almost every aspect of California civil law. The author has not only analyzed the law but also provided numerous examples of how the courts use and interpret the law. A fundamental source in legal research.
✧ Lead poisoning Type of issue: Children’s health, environmental health, industrial practices, public health Definition: Excessive, long-term exposure to lead—which has been used in the manufacture of gasoline, paint, and water pipes, among other things— leading to severe health problems and even death. Lead is the fifth most commonly used metal in the world. The majority of lead is used for the manufacture of lead acid batteries, but much of the lead mined in the twentieth century was used for the production of antiknock compounds (such as tetraethyl lead) that were added to gasoline. Lead has also been used in the manufacture of some paints, ceramic glazes, ammunition, and solder, and it is the preferred material for shielding X rays. Because of the widespread burning of gasolines with tetraethyl lead and the transport of lead compounds throughout the atmosphere, lead may be the most widely distributed heavy metal. Measured levels of lead in remote areas range from three to five times that of natural background levels.
Lead poisoning ✧ 551 About 60 percent of the lead exposure for adults comes from food, both fresh and canned. Lead is naturally taken into plants, but it also accumulates in food because of dry deposition from the atmosphere and storage in cans. Approximately 30 percent of the lead in humans comes from the inhalation of air, although this exposure has dramatically decreased since leaded gasoline was phased out of use for most vehicles in the United States in the late 1970’s. Lead is also released into the atmosphere through the burning of solid waste, coal, and oil. Tobacco smoke is an additional source of airborne lead exposure. The remaining 10 percent comes from water. Much of the exposure through water is the result of lead pipes, fixtures, or solders used in older plumbing. An additional significant exposure route for children is through ingestion of lead-based paint chips used on many homes or from the eating of dirt containing lead paint residues. Lead is a toxic element that can cause both acute effects from short-term high-dosage exposure and chronic effects that result from long-term exposures at lower levels. Children and pregnant women are at particularly high risk with regard to lead exposure. Children may ingest higher levels of lead from soil, and the effects of lead poisoning in children begin at lower blood levels. Pregnant women are at high risk because lead can substitute for calcium in bones and may be mobilized during calcium deficiencies such as pregnancy. The lead released into the blood can cross the placenta and cause damage to the fetus or even a miscarriage. Effects of Lead Poisoning At high levels, lead poisoning can cause severe brain damage, gastrointestinal disorders, kidney damage, and even death. At lower levels, the symptoms of lead poisoning are not as severe and include constipation, vomiting, abdominal pains, and loss of muscular coordination. Because these symptoms may result from other causes, it is not always clear when lead poisoning has occurred. The long-term chronic effects of low-level lead exposure may lead to many health problems, primarily with the circulatory and central nervous systems. Most of the lead that is absorbed ends up in the blood, and its general residence time is between two and three weeks. Long-term exposure can lead to disruption of the formation of heme in the blood and cause other enzymatic disorders. Anemia can result, with the symptoms arising at much lower blood lead levels in children. Lead is also a neurotoxin that primarily affects workers in lead-related mining and manufacturing, as well as children. In children, exposure to lead may lead to lower mental capabilities, but it is not yet clear to what extent this can be established. It is known that lead can cause hearing disorders and even slow the growth of children. Chronic exposure in humans can cause blood-pressure problems and interference with vitamin D metabolism. Re-
552 ✧ Learning disabilities productive problems such as lower sperm counts and spontaneous abortions have also been linked to lead exposure. It is not yet clear whether lead is a carcinogen. Studies on workers in lead industries have been inconclusive with regard to links between cancer and lead exposure, but animal studies have shown an increase in cancers of the kidney. The Environmental Protection Agency (EPA) considers lead to be a probable human carcinogen and has classified it as a Group B2 carcinogen. Because of its highly toxic nature, lead has been extensively studied and closely regulated in the United States and many other countries. Lead was one of the six primary pollutants regulated by the Clean Air Act, and the EPA was required to establish ambient outdoor air-quality standards for this pollutant. The removal of leaded gasoline from the United States market reduced the concentrations of lead in the atmosphere by 93 percent between 1979 and 1988. In addition, the removal of most lead-based paints has reduced the risk of accidental ingestion of lead by children. As a result of these and other regulations, the lead exposure of most adults and children has been significantly reduced. However, lead levels in the blood of many children indicate that exposure is still a great concern. —Jay R. Yett See also Children’s health issues; Environmental diseases; Learning disabilities; Mental retardation; Occupational health; Poisoning; Screening. For Further Information: Brookins, Douglas. Mineral and Energy Resources. Columbus, Ohio: Charles E. Merrill, 1990. An excellent source for information about the use of lead and environmental problems associated with lead and other metals. Harte, John, et al. Toxics A to Z. Berkeley: University of California Press, 1991. A good source on toxics and toxicology which includes general information about toxicology and a section on each of the major toxicants, including lead. Timbrell, J. A. Introduction to Toxicology. New York: Taylor & Francis, 1995. A more detailed but readable text on toxicology.
✧ Learning disabilities Type of issue: Children’s health, mental health Definition: A variety of disorders involving the failure to learn an academic skill despite normal levels of intelligence, maturation, and cultural and educational opportunity; estimates of the prevalence of learning disabilities in the general population range between 2 and 20 percent.
Learning disabilities ✧ 553 People with learning disabilities are a highly diverse group of individuals with a wide variety of characteristics. Consequently, differences of opinion among professionals remain to such an extent that presenting a single universally accepted definition of learning disabilities is not possible. Definitional differences most frequently center on the relative emphases that alternative groups place on characteristics of these disorders. For example, experts in medical fields typically describe these disorders from a disease model and view them primarily as neurological dysfunctions. Conversely, educators usually place more emphasis on the academic problems that result from learning disabilities. The most commonly accepted definitions, those developed by the United States Office of Education in 1977, the Board of the Association for Children and Adults with Learning Disabilities in 1985, and the National Joint Committee for Learning Disabilities in 1981, do include some areas of commonality. Difficulty in academic functioning is included in the three definitions. Academic deficits may be in one or more formal scholastic subjects, such as reading or mathematics. Often the deficits will involve a component skill of the academic area, such as problems with comprehension or word knowledge in reading or difficulty in calculating or applying arithmetical reasoning in mathematics. The academic difficulty may also be associated with more basic skills of learning that influence functioning across academic areas; these may involve deficits in listening, speaking, and thinking. Dyslexia, a term for reading problems, is the most common academic problem associated with learning disabilities. Because reading skills are required in most academic activities to some degree, many view dyslexia as the most serious form of learning disability. The presumption of a neurological dysfunction as the cause of these disorders is included, either directly or indirectly, in each of the three definitions. Despite this presumption, unless an individual has a known history of brain trauma, the neurological basis for learning disabilities will not be identified in most cases because current assessment technology does not allow for such precise diagnoses. Rather, at least minimal neurological dysfunction is simply assumed to be present in anyone who exhibits characteristics of a learning disorder. The three definitions all state that individuals with learning disabilities experience learning problems despite possessing normal intelligence. This condition is referred to as a discrepancy between achievement and ability or potential. Finally, each of the three definitions incorporates the idea that learning disabilities cannot be attributed to another handicapping condition such as mental retardation, vision or hearing problems, emotional or psychiatric disturbance, or social, cultural, or educational disadvantage. Consequently, these conditions must be excluded as primary contributors to academic difficulties.
554 ✧ Learning disabilities Reports on the prevalence of learning disabilities differ according to the definitions and identification methods employed. Consequently, statistics on prevalence range between 2 and 20 percent of the population. Many of the higher reported percentages are actually estimates of prevalence that include individuals who are presumed to have a learning disorder but who have not been formally diagnosed. Males are believed to constitute the majority of individuals with learning disabilities, and estimated sex ratios range from 6:1 to 8:1. Some experts believe that this difference in incidence may reveal one of the causes of these disorders. Possible Causes of Learning Disabilities A number of causes of learning disabilities have been proposed, with none being universally accepted. Some of the most plausible causal theories include neurological deficits, genetic and hereditary influences, and exposure to toxins during fetal gestation or early childhood. The number and variety of proposed causes not only reflect differences in experts’ training and consequent perspectives but also suggest the likelihood that these disorders can be caused by multiple conditions. Evidence to support a link between neurological dysfunction and learning disabilities has been provided by studies using sophisticated brain imaging techniques such as positron emission tomography (PET) and computed tomography (CT) scanning and magnetic resonance imaging (MRI). These studies have indicated subtle abnormalities in the structure and electrical activity in the brains of individuals with learning disabilities. Genetic and hereditary influences also have been proposed as causes. Supportive evidence comes from research indicating that identical twins are more likely to be concordant for learning disabilities than fraternal twins and that these disorders are more common in certain families. A genetic cause of learning disabilities may be associated with extra X or Y chromosomes in certain individuals. The type and degree of impairment associated with these conditions vary according to many genetic and environmental factors, but they can involve problems with language development, visual perception, memory, and problem solving. Despite evidence to link chromosome abnormalities to those with learning disabilities, most experts agree that such genetic conditions account for only a portion of these individuals. Exposure to toxins or poisons during fetal gestation and early childhood can also cause learning disabilities. During pregnancy nearly all substances the mother takes in are transferred to the fetus. Research has shown that mothers who smoke, drink alcohol, or use certain drugs or medications during pregnancy are more likely to have children with developmental problems, including learning disabilities. Yet not all children exposed to toxins during gestation will have such problems, and the consequences of
Learning disabilities ✧ 555 exposure will vary according to the period when it occurred, the amount of toxin introduced, and the general health and nutrition of the mother and fetus. Two other conditions associated with gestation and childbirth have been linked to learning disabilities. The first, anoxia or oxygen deprivation, occurring for a critical period of time during the birthing process has been tied to both mental retardation and learning disabilities. The second, and more speculative, involves exposure of the fetus to an abnormally large amount of testosterone during gestation. Differences in brain development are proposed to result from the exposure causing learning disorders, among other abnormalities. Known as the embryological theory, it may account for the large number of males with these disabilities, since they have greater amounts of testosterone than females. The exposure of the immature brain during early childhood to insecticides, household cleaning fluids, alcohol, narcotics, and carbon monoxide, among other toxic substances, may also cause learning disabilities. Lead poisoning resulting from ingesting lead from paint, plaster, and other sources has been found in epidemic numbers in some sections of the country. Lead poisoning can damage the brain and cause learning disabilities, as well as a number of other serious problems. Treating Learning Disabilities If a student is identified with a learning disability, based on information gathered by a multidisciplinary team, the team then develops an individual education plan to address identified educational needs. An important guideline in developing the plan is that students with these disorders should be educated to the greatest extent possible with their nonhandicapped peers, while still being provided with appropriate services. Considerable debate has occurred regarding how best to adhere to this guideline. Programs for students with learning disabilities typically are implemented in self-contained classrooms, resource rooms, or regular classrooms. Selfcontained classrooms usually contain ten to twenty students and one or more teachers specially trained to work with these disorders. Typically, these classrooms focus on teaching fundamental skills in basic academic subjects such as reading, writing, and mathematics. Depending on the teacher’s training, efforts may also be directed toward developing perceptual, language, or social skills. Students in these programs usually spend some portion of their day with their peers in regular education meetings, but the majority of the day is spent in the self-contained classroom. The popularity of self-contained classrooms has decreased significantly since the 1960’s, when they were the primary setting in which students with learning disabilities were educated. This decrease is largely attributable to the stigmatizing effects of placing students in special settings and the lack of
556 ✧ Learning disabilities clear evidence to support the effectiveness of this approach. Students receiving services in resource rooms typically spend a portion of their day in a class where they receive instruction and assistance from specially trained teachers. Students often spend one or two periods in the resource room with a small group of other students who may have similar learning problems or function at a comparable academic level. In the elementary grades, resource rooms usually focus on developing basic academic skills, whereas at the secondary level time is more typically spent in assisting students with their assignments from regular education classes. Resource room programs are viewed as less restrictive than self-contained classrooms; however, they too have been criticized for segregating children with learning problems. Other criticisms center on scheduling difficulties inherent in the program and the potential for inconsistent instructional approaches and confusion over teaching responsibilities between the regular classroom and resource room teachers. Research on the effectiveness of resource room programs also has been mixed; nevertheless, they are found in most public schools across the United States. Though they remain a minority, increasing numbers of students have their individual education plans implemented exclusively in a regular classroom. In most schools where such programs exist, teachers are given assistance by a consulting teacher with expertise in learning disabilities. Supporters of this approach point to the lack of stigma associated with segregating students and the absence of definitive research supporting other service models. Detractors are concerned about the potential for inadequate support for the classroom teacher, resulting in students receiving poor quality or insufficient services. The movement to provide services to educationally handicapped students in regular education settings, termed the Regular Education Initiative, has stirred much debate among professionals and parents. Resolution of the debate will greatly affect how individuals with learning disabilities are provided services. No one specific method of teaching these students has been demonstrated to be superior to others. A variety of strategies have been developed, including perceptual training, multisensory teaching, modality matching, and direct instruction. Advocates of perceptual training believe that academic problems stem from underlying deficits in perceptual skills. They use various techniques aimed at developing perceptual abilities before trying to remedy or teach specific academic skills. Multisensory teaching involves presenting information to students through several senses. Instruction using this method may be conducted using tactile, auditory, visual, and kinesthetic exercises. Instruction involving modality matching begins with identifying the best learning style for a student, such as visual or auditory processing. Learning tasks are then presented via that mode. Direct instruction is based on the principles of behavioral psychology. The method involves developing precise educational goals, focusing on teaching the
Learning disabilities ✧ 557 exact skill of concern, and providing frequent opportunities to perform the skill until it is mastered. With the exception of direct instruction, research has generally failed to demonstrate that these strategies are uniquely effective with students with learning disabilities. Direct instruction, on the other hand, has been demonstrated effective but has also been criticized for focusing on isolated skills without dealing with the broader processing problems associated with these disorders. More promisingly, students with learning disabilities appear to benefit from teaching approaches that have been found effective with students without learning problems when instruction is geared to ability level and rate of learning. —Paul F. Bell See also Attention-deficit disorder (ADD); Autism; Birth defects; Children’s health issues; Down syndrome; Dyslexia; Mental retardation; Speech disorders. For Further Information: Cordoni, Barbara. Living with a Learning Disability. Rev. ed. Carbondale: Southern Illinois University Press, 1990. Written by a professor of special education and the mother of two children with learning disabilities, this book focuses on the social skill problems associated with these disorders. Offers suggestions to parents and professionals regarding effective counseling, teaching, and coping strategies. Included is a helpful explanation of the laws governing education for students with learning disabilities. Hallahan, Daniel P., James M. Kauffman, and John Wills Lloyd. Introduction to Learning Disabilities. 2d ed. Boston: Allyn & Bacon, 1999. This text addresses different learning disabilities and the education of the learning disabled. Includes a bibliography and indexes. Lovitt, Thomas. Introduction to Learning Disabilities. Needham Heights, Mass.: Allyn & Bacon, 1989. This book is exceptionally well written and comprehensive in its review of topics associated with learning disabilities, including assessment and treatment issues, the history of these disorders, and recommendations for future efforts in the field. Provides balanced coverage of alternative views regarding the controversial aspects of learning disabilities. MacCracken, Mary. Turnabout Children: Overcoming Dyslexia and Other Learning Disabilities. Boston: Little, Brown, 1986. Written by an educational therapist, this publication includes case histories of children with learning disabilities who have been successful in adapting to the unique difficulties that they face. Includes descriptions of assessment instruments and effective remedial techniques. Snowling, M. J., and M. E. Thomson, eds. Dyslexia: Integrating Theory and Practice. London: Whurr, 1991. This publication includes selected papers
558 ✧ Lice, mites, and ticks from the second International Conference of the British Dyslexia Association, held in 1991. Chapters include detailed descriptions of theoretical and practical aspects of reading disabilities and reviews of treatment strategies for individuals from early childhood to adulthood.
✧ Lice, mites, and ticks Type of issue: Public health Definition: Parasites that live on the human body, causing severe itching, skin rashes, and sometimes more serious diseases. Lice, mites, and ticks are parasites that live on human beings. Two species of lice survive on human blood: body lice and crab lice. Body lice are divided into two subspecies, the head louse (Pediculus humanus capitis) and the body louse (Pediculus humanus corporis). Head lice live on the scalp among the hairs of the head. Body lice actually live in and on clothing. They move off clothes and attach themselves to human skin to feed on blood frequently during the day. It is very difficult to tell the difference between these types of lice. They are both flat, wingless, grayish in color, and very small. The body louse is about 0.08 to 0.16 inch long, slightly larger than the head louse, which measures only 0.04 to 0.08 inch. Body lice are a slightly lighter shade of gray than are head lice. The Life Cycle of a Louse Both subspecies of body lice live by sucking blood from their victims. These insects of the order Anoplura have three pointed tubes on their bodies called stylets that can jab into the skin and draw out blood. When not in use, the stylets are tucked away in a pouch. Body lice begin their lives as eggs dropped into the folds of clothing by mature adult females. Head lice eggs are glued to the base of a strand of hair on the top of a child’s head. The eggs, called nits, are about one-fourth the size of a mature female. After about seven to ten days, the nits hatch into young nymphs. Because hair grows about 0.3 millimeter a day, the nits hatch about 3.0 millimeters away from the scalp. After the nymph emerges, it leaves behind an empty egg shell still tightly cemented to the hair. Nymphs begin sucking blood as soon as they hatch. Within nine days, the nymph molts three times before a full adult louse is formed. Adults then live about two weeks, with females laying about ten eggs every day. Lice are passed from head to head only by direct contact. This usually happens at school, often on the playground or in the gym. Head lice have different effects on different people. Some experience only slight itching,
Lice, mites, and ticks ✧ 559 while others are terribly irritated and develop a swollen and inflamed scalp. An itching scalp is the most obvious symptom of head lice. Nits are visible upon inspection of hair near the scalp. On girls, they are usually found behind the ears, while on boys, they are most likely to be found attached near the top of the head. Parents should be very careful in treating head lice; they too can be infected. Head lice can be the transmitters of several dangerous infectious diseases, such as epidemic typhus, relapsing fever, and trench fever. Body lice are less often found on children than are head lice. They thrive in clothing and bodies that are unclean for long periods of time. Body lice are especially troublesome and numerous on Magnified representations of a louse, a mite (norhomeless people, prisoners of mally microscopic) and a tick. (Hans & Cassidy, war, and others living in dirty Inc.) conditions. (Cleanliness, on the other hand, is not a factor with head lice; they can thrive in clean or dirty hair.) Body lice have helped spread a number of contagious diseases, the most deadly of which is typhus. This disease starts with flulike symptoms, followed by a high fever and rash. During World War II, more than three million Russian prisoners of war died from louse-spread typhus. In recent years, however, typhus has been rare. Crab lice (Phthirus pubis) are usually found living in pubic hair and are most likely to infect adults. Like all lice, they are very small, 0.083 inch in length when fully grown, but they cause great discomfort. As adults, they firmly grab pubic hair with their crablike legs (six per louse), insert their barbed tongue into the skin, and suck blood. The female lays its eggs about .08 inch from the skin. When the eggs hatch, the nymphs begin to feed and stop only while molting. Feeding causes intense itching and a rash. Rarely, but occasionally, the lice spread to the chest, eyebrows, or armpits. They can be passed on only by human carriers through direct contact. Crab lice
560 ✧ Lice, mites, and ticks cannot live on any other species except humans, and about 3 percent of people have them. Crab lice do not carry sexually transmitted diseases but are often associated with them. Ticks and Mites Ticks are members of a blood-sucking family of insects called Ixodidae. Several different species suck blood from warm-blooded vertebrates, such as human beings, cows, and dogs. Common species in the United States and Canada include hard ticks and the American dog tick. Ticks have a hard, shieldlike plate on their backs called a scutum that makes them very difficult to crush. A female tick can swell up to the size of a pea when ingesting blood and can lay from four thousand to six thousand eggs within four to ten days. The eggs hatch after about a month and six-legged larvae, called seed ticks, emerge. A seed tick waits on the tip of a leaf of grass or other low-growing plant until a suitable animal walks by. The seed tick grabs onto its meal and after sucking enough blood, molts into its next stage, an eight-legged nymph called a yearling tick. It finds another host, sucks more blood, and then molts one more time into an adult. After another week of feeding, adults mate and the female produces its eggs, as the three-stage cycle begins all over again. Ticks are very good survivors: Eight-legged nymphs can live more than a year without food, while adults can go without a meal of blood for more than two years. Ticks carry many dangerous diseases, including Rocky Mountain spotted fever, Colorado tick fever, tularemia, anaplasmosis, and Lyme disease. Mites are actually related to spiders, rather than insects. Dust mites (Dermatophagiodes pteronyssinus), the chief living forms found in house dust, are among the most numerous inhabitants of human environments. One study of 150 houses in Holland found mites in every one of them. Dust mites measure about .01 inch in diameter. They have eight legs, like all spiders, and are closely related to ear mites found in dogs and cats and scab mites found in sheep. House dust mites spend all of their life stages, from birth to death, in dust. There can be as many as five hundred mites in every gram of house dust. This measures out to about fourteen thousand mites per ounce of dust. They survive by eating human skin that is shed daily, scabs that fall off, and dandruff, which is about 10 percent fat and which they digest with the help of a fungus also found in house dust. Dust mites are responsible for some allergies and asthma attacks. They can also invade the skin and cause allergic reactions such as dermatitis. Although dust mites cannot penetrate the surface of the skin, they can live in ulcers, fungal infections, scabs, and other skin openings. The scabies mite (Sarcoptes scabei) does burrow into the skin in search of its preferred food, skin cells and intestinal fluids. Female scabies mites are about .016 inch long, while males are only about half as big. The female lays
Lice, mites, and ticks ✧ 561 its eggs only a few hours after mating and can lay two to three eggs a day for up to four weeks. The eggs hatch after only three to four days. The larvae often move about on the skin surface until they find a suitable space, usually between the fingers or at the bend in the knee, elbow, or wrist. The underarms, breasts, and genitals can also be invaded by these travelers. Frequently, they travel all the way down to the ankles or between the toes. Sometimes it takes up to six weeks before the pests are noticed by the person acting as their host. Children are especially sensitive to the feces and eggs of scabies mites, which can cause an agonizing itch that is particularly irritating at night. Scabies mites are most active in the fall and winter, but they are transmissible at any time. They can be spread by shaking hands, by touching the infected areas of another person, and even by having contact with the clothes or bedsheets of the infected individual. Scabies mites do not carry any major diseases, but they do cause a good deal of itching and discomfort. Debugging Methods Treatments for lice, mites, and ticks vary according to the type and severity of infestation. The only way to protect a child against head lice is through regular inspection of the head. The hair should be combed and brushed every night; this will injure the lice, which will not be able to survive. Treatment involves an insecticidal shampoo such as Proderm, which contains malathion, or Kwell, which contains lindane or gamma benzene hexachlorine. These shampoos kill both the lice and the nits. Removing lice by hand or crushing them is a difficult and usually impossible task. The force required to remove a nit from a hair is greater than most parents can provide. Crushing a louse requires direct pressure of about five hundred thousand times the weight of a louse. The crushed body of a louse can also cause infection. The best treatment for body lice is washing clothes and infected areas with soap. Soap and hot water usually kill body lice. If an infection of either head or body lice is discovered, all members of a family should be checked and a doctor should be consulted. If a child has head lice, his or her school should always be notified. If crab lice are discovered, a physician should be contacted immediately. Pubic lice can be treated with insecticides such as pyrethrin pediculicide. Pyrethrins are available over-thecounter in drugstores. Stronger treatments require a prescription. Crab lice can be controlled by washing clothing and bedding and drying them in a very hot dryer. Ticks are very difficult to remove from the body. A tick should not be pulled or yanked out because its head, filled with jagged teeth, can remain in the wound and cause an infection. Ticks have to be removed so that their mouthparts do not break off. Unattached ticks can be brushed off with a hand, but an attached tick should not be removed with bare fingers. To remove a tick, the hands should be covered with a tissue or gloves. Then, the
562 ✧ Lice, mites, and ticks tick is grabbed with a pair of tweezers as close to its head as possible. Gentle, steady pressure is applied until the tick comes out. The tick should not be twisted or crushed until it is fully out. Body fluids from the tick can carry Lyme disease organisms, which can enter the body through broken skin. The safest way to kill the tick is to drown it in soapy water or crush it with the tweezers, avoiding contact with the hands. The site of the bite should be washed and checked carefully to see if any part of the head is still embedded. Anything that remains should be removed with tweezers, which will help prevent infection. If all parts cannot be removed, the spot should be rubbed with an antiseptic. A doctor should be consulted if the site becomes inflamed or filled with pus. Scabies mites can be controlled by insecticidal lotions containing lindane or sulfur. The pesticide lindane is the one most commonly used for scabies mites, but it has been linked to cancer in some tests. Sulfur is preferred by most physicians because it is safer and more widely available. Sulfur requires three applications over three days, however, and frequently leaves stains on bedding and clothes. The fastest-acting miticide is permethrim. It usually requires only one application to be effective, but it is more toxic than sulfur. Scabies mites can be controlled by washing the clothing, bedding, and towels used by the infected person. If scabies mites are found, other people with whom the child has had contact should be told so that they can seek treatment, even though they might not have started to itch. Scabies mites cannot live long if detached from their hosts, usually no more than two to three days. Sealing infected clothes in a plastic bag for a week or so will also kill most of the mites. Dust mites can be controlled by reducing their sources of food. This can be accomplished by covering mattresses in plastic, keeping pets away from beds and sleeping areas, reducing humidity in the house, and vacuuming once a week. Killing dust mites requires vacuuming with a water vacuum or one with special dust filters, washing sheets and pillowcases in hot soapy water, freezing or heating blankets, or using pesticides such as mosquito repellents containing diethyl-m-toluamide (DEET) or products containing boric acid. New chemicals have proven very effective in the treatment of diseases spread by lice, mites, and ticks. Louse-spread typhus, once responsible for millions of deaths, is no longer a great danger. Improved standards of cleanliness have done much to eliminate the problem of body lice in all but the poorest populations in the United States. Unfortunately, head lice cannot be controlled simply by keeping things clean, so they continue to cause itching and scratching when contracted even by the cleanest children. Lice, mites, and ticks will always be with humans, but the diseases that these parasites spread, with a few exceptions such as Rocky Mountain spotted fever and Lyme disease, are now much less deadly because of new medicines and drug treatments. —Leslie V. Tischauser
Light therapy ✧ 563 See also Allergies; Asthma; Lyme disease; Parasites; Zoonoses. For Further Information: Beaver, Paul Chester, Rodney Clifton Jung, and Eddie Wayne Cupp. Clinical Parasitology. 9th ed. Philadelphia: Lea & Febiger, 1984. Considered to be the authority on the subject. Includes a summary of information about dust mites. Berenbaum, May R. Ninety-Nine Gnats, Nits, and Nibblers. Urbana: University of Illinois Press, 1989. A scientist describes how insects affect human lives. Offers an informative description of the life cycles and habits of lice, mites, ticks, and other troublemakers. Olkowski, William, Sheila Daar, and Helga Olkowski. Common-Sense Pest Control. Newton, Conn.: Taunton Press, 1991. A very useful book by a biologist that describes the best methods of dealing with all kinds of insect problems, including lice, mites, and ticks. Offers detailed descriptions of how to remove these pests from your children and the environment safely. Pratt, Harry D., and Kent S. Littig. Ticks of Public Health Importance and Their Control. Atlanta: U.S. Department of Health, Education, and Welfare, Public Health Service, Centers for Disease Control, 1974. A useful introduction to ticks and how they affect human life. Taplin, David, and T. L. Meinking. Head Lice Infestation: Biology, Diagnosis, Management. Miami: University of Miami School of Medicine, 1988. A well-illustrated pamphlet on how to treat head lice. Compares various compounds, such as lindane and pyrethrins, used as treatments.
✧ Light therapy Type of issue: Medical procedures, mental health, treatment Definition: A noninvasive procedure using exposure to light as the mechanism for clinical treatment. Light therapy, or phototherapy, treats a variety of disorders. By exposing individuals to different kinds of light (for example, monochromatic, polychromatic, ultraviolet), symptoms can often be delayed, reduced, and eradicated. Immunological and neuroendocrine systems are thought to play key roles in response to this type of treatment. Best known in psychiatry, light therapy has been used to treat seasonal affective disorder (SAD), or winter depression; bulimia nervosa; sleep disorders; and “sundowner’s syndrome,” the late afternoon confusion and agitation sometimes accompanying Alzheimer’s disease. Reduced environmental light is thought to be a factor in the etiology, onset, or maintenance of these
564 ✧ Light therapy disorders. Thus, treatment involves exposing individuals to bright, full-spectrum light for fixed periods of time. Duration of exposure and light intensity vary by the disorder and individual treated. In dermatology and oncology, light therapy has been used to treat psoriasis, skin ulcers, tumors, and esophageal cancers. The type of light and the intensities used, however, vary considerably from those applied for the treatment of psychiatric disorders. Uses and Complications The side effects of light therapy are best documented in psychiatry: Insomnia, mania, and (less frequently) morning hot flashes have been noted. Careful monitoring by medical providers of the patient’s response to treatment is necessary. Additionally, morning administrations of light therapy are advised in order to avoid these effects. Light therapy is not effective universally; some patients may experience no improvement. For seasonal affective disorder, evidence suggests that younger individuals whose depression involves weight gain and increased sleep may be most likely to respond to treatment. For psoriasis, complementary treatments, such as psychotherapy, may be needed to facilitate a response to treatment. Light and dark cycles are a biological reality; thus, it is no surprise that light affects physical, emotional, and mental well-being. As the interest in noninvasive interventions increases, the attention given to environmental treatments such as light therapy is likely to increase as well. Recent developments in the use of light therapy for sleep and behavioral disorders are also likely to fuel interest in this procedure. —Nancy A. Piotrowski See also Alternative medicine; Alzheimer’s disease; Depression; Depression in children; Depression in the elderly; Seasonal affective disorder (SAD); Skin disorders with aging; Sleep changes with aging; Sleep disorders. For Further Information: Goldberg, Burton, comp. Alternative Medicine: The Definitive Guide. Puyallup, Wash.: Future Medicine, 1993. Jacobs, Jennifer, ed. The Encyclopedia of Alternative Medicine: A Complete Family Guide to Complementary Therapies. Boston: Journey Edition, 1996. Kastner, Mark, and Hugh Burroughs. Alternative Healing: The Complete A-Z Guide to over 160 Different Alternative Therapies. La Mesa, Calif.: Halcyon, 1993. Lam, Raymond W., ed. Seasonal Affective Disorder and Beyond: Light Treatment for SAD and Non-SAD Conditions. Washington, D.C.: American Psychiatric Press, 1998.
Liposuction ✧ 565
✧ Liposuction Type of issue: Medical procedures, social trends, women’s health Definition: The removal of fat deposits with a cannula and a suction pump in order to recontour body areas. Persons who have undesired, unattractive fat deposits as a result of age, heredity, or obesity may undergo cosmetic surgery to remove them, such as so-called tummy tucks. Such major procedures, however, often remove muscle along with fat and cause considerable scarring. Liposuction is a relatively easy way to lose unattractive body fat; it also is seen as a fast way to reverse obesity and is touted as more permanent than dieting. Liposuction has become a very popular cosmetic surgery procedure for the abdomen, arms, breasts, hips, knees, legs, and throat; many pounds can be removed from large areas such as the abdomen. The Liposuction Procedure Liposuction begins with the administration of antibiotics and the anesthesia of the area to be recontoured. Local anesthesia is safer, but general anesthesia is used when necessary. The process usually begins after a 1.3-centimeter (0.5-inch) incision is made in a fold of the treated body region, so that the scar will not be noticeable after healing. At this time, a sterile cannula is introduced under the skin of the treatment area. Next, the surgeon uses suction through the cannula to remove the fat deposits. Liposuction produces temporary tunnels in adipose tissue. Upon completion of the procedure, the incision is closed and the surgical area is wrapped with tight bandages or covered with support garments. This final stage of recontouring helps the tissue to collapse back into the desired shape during healing. In most patients, the skin around the area soon shrinks into the new contours. When this does not happen easily, because of old age or other factors, liposuction is accompanied by surgical skin removal. Uses and Risks Liposuction can only be used for body recontouring when undesired contours are attributable to fat deposits; those attributable to anatomical features such as bone structure cannot be treated in this manner. A major principle on which liposuction is based is the supposition that the body contains a fixed number of fat cells and that as people become fatter, the cells fill with droplets of fat and expand. The removal of fat cells by liposuction is deemed to decrease the future ability of the treated body
566 ✧ Liposuction part to become fat because fewer cells are available to be filled. Dieting and exercise are less successful than liposuction because they do not diminish the number of fat cells in adipose tissue, only decreasing fat cell size. Hence, when dieters return to eating excess food again or exercise stops, the fat cells expand again. Another aspect of liposuction which is becoming popular is the ability to remove undesired fat from some body sites and insert it where the fat is wanted for recontouring. Most often, this transfer involves enlarging women’s breasts or correcting cases in which the two breasts are of markedly different size. Liposuction also can be used to repair asymmetry in other body parts as a result of accidents. Liposuction has associated risks and complications. According to reputable practitioners, however, they are temporary and relatively minor, such as black-and-blue marks and the accumulation of blood and serum under the skin of treated areas. These complications are minimized by fluid removal during surgery and by the application of tight bandages or garments after the operation. Another related complication is that subcutaneous fat removal leads to fluid loss from the body. When large amounts of fat are removed, shock occurs if the fluid is not replaced quickly. Therefore, another component of successful liposuction is timely fluid replacement. The more extensive and complex the liposuction procedure attempted, the more likely it is to cause complications. Particularly prone to problems are liposuction procedures in which major skin removal is required. Hence, surgeons who perform liposuction suggest that potential patients be realistic about the goals of the surgery. It is also recommended that patients choose reputable practitioners. The Future of Liposuction Liposuction, currently viewed as relatively safe cosmetic surgery, originated in Europe in the late 1960’s. In 1982, it reached the United States. Since that time, its use has burgeoned, and about half a million liposuction surgeries are carried out yearly. Although its first use was as a purely cosmetic procedure, liposuction is now done for noncosmetic reasons, including repairing injuries sustained in accidents. Women were once the sole liposuction patients. Now, men make up about one-quarter of treated individuals. In the United States, liposuction is not presently accepted by insurance companies or considered tax deductible. This situation may change because several studies have found that obese people have a greater chance of developing cardiovascular disease and cancer. It must be noted, however, that liposuction offers only temporary relief from body fat. Although it does decrease fat deposition in a treated region, lack of proper calorie intake and exercise will deposit fat elsewhere in the body. —Sanford S. Singer
Living wills ✧ 567 See also Cosmetic surgery and aging; Cosmetic surgery and women; Eating disorders; Obesity; Obesity and aging; Obesity and children; Weight changes with aging; Weight loss medications. For Further Information: Coleman, William P., C. William Hanke, and William R. Cook, Jr. Body Contouring: The New Art of Liposculpture. Carmel, Ind.: Cooper, 1997. Grazer, Frederick M., ed. Atlas of Suction-Assisted Lipectomy in Body Contouring. New York: Churchill Livingstone, 1992. Schein, Jeffery R. “The Truth About Liposuction.” Consumers Digest 30 (January/February, 1991): 71-74. Tcheupdjian, Leon. Liposuction: New Hope for a New Figure Through the Art of Body Contouring. Chicago: Liposuction Institute, 1988.
✧ Living wills Type of issue: Economic issues, elder health, social trends Definition: A directive to physicians giving instructions as to what methods of life-prolonging medical treatment should or should not be used when individuals have a terminal condition and are unable to make their wishes known. Living wills are not wills in the traditional sense. Traditional wills do not take effect until after persons die. Living wills come into effect while individuals are still alive but are unable to make their wishes known (for example, if they are in a coma) or when they do not have the mental ability to legally make their wishes known (for example, if they have Alzheimer’s disease or dementia). Living wills are also known as medical directives, advance directives, or directives to physicians. Living wills are directives to physicians and other health care personnel to perform or not to perform medical treatments that artificially prolong life, such as resuscitation, force feeding, or breathing assistance. Persons may also say that they want drug therapy to alleviate pain. Living wills are valid only in the case of terminal illnesses in most states, and in some states doctors are permitted only to withhold treatment. Over the years the right to die with dignity and without the expense of large medical bills has been discussed by federal and state legislators. The U.S. Supreme Court in Cruzan v. Director, Missouri Department of Health (1990) decided that individuals have the right to control their medical treatment. Individuals’ desires come first, even if they choose to forgo life-prolonging medical treatment while family members or physicians want to prolong life. Sometimes individuals can make such decisions themselves. For example, they can ask to be discharged from the hospital and return home. However,
568 ✧ Lung cancer when persons are near the end of an illness or are involved in severe accidents, they are often no longer capable of making their wishes known. It is in such circumstances that living wills take effect, directing physicians to take or not to take action. Physicians who are not willing to abide by individuals’ wishes must turn such cases over to other physicians. Because accidents can happen to persons of all ages, living wills are not just for the elderly. It is easy to make a living will. Most hospitals and physicians have standard forms that have been approved by the state. When people are admitted to the hospital, they are usually asked if they have a living will. If not, they will be given the opportunity to make one. If they have specific wishes, they may decide to have attorneys draw up a living will. One of the problems with living wills is that persons must decide in advance, without taking future circumstances into account. Another problem with them is that they only take effect when a patient’s condition is terminal. Persons in the early stages of Alzheimer’s disease, although not terminally ill, may not be mentally fit to make health care decisions. A durable power of attorney for health care or health care proxies allows individuals to deal with all these problems. —Celia Ray Hayhoe See also Alzheimer’s disease; Death and dying; Euthanasia; Health care and aging; Hospice; Hospitalization of the elderly; Law and medicine; Nursing and convalescent homes; Terminal illnesses. For Further Information: Ferdinand, Rosemary. “‘I’d Rather Die than Live This Way.’” American Journal of Nursing 95, no. 12 (December, 1995): 42-48. Meyer, Charles. “End-of-Life Care: Patients’ Choices, Nurses’ Challenges.” American Journal of Nursing 93, no. 2 (February, 1993). Parkman, Cynthia A., and Barbara E. Calfee. “Advance Directives: Honoring Your Patient’s End-of-Life Wishes.” Nursing 27, no. 4 (April, 1997). Pinch, Winifred J., and Mary E. Parsons. “The Ethics of Treatment Decision Making: The Elderly Patient’s Perspective.” Geriatric Nursing 14, no. 6 (November/December, 1993). Pokalo, Cheryl. “Understanding the Patient Self-Determination Act.” Journal of Gerontological Nursing 18, no. 3 (March, 1992).
✧ Lung cancer Type of issue: Environmental health, occupational health, public health Definition: The appearance of malignant tumors in the lungs, which is usually associated with cigarette smoking.
Lung cancer ✧ 569 Most forms of lung cancer fall within one of four categories: squamous cell carcinomas and adenocarcinomas, small or oat cell carcinomas, and large cell carcinomas. Each of these forms can be further categorized on the basis of cell differentiation within the tumor: either well differentiated (resembling the original cell type) or moderately or poorly differentiated. Upon biopsy, stage groupings are also determined on the basis of size, invasiveness, and possible extent of metastasis. Oat or small cell carcinomas usually consist of small, tightly packed, spindle-shaped cells, with a high nucleus-to-cytoplasm ratio within the cell. Oat cell carcinomas tend to metastasize early and widely, often to the bone marrow or brain. As a result, by the time that symptoms become apparent, the disease is generally widely disseminated within the body. Coupled with a resistance to most common forms of radiation and chemotherapy, oat cell carcinomas present a particularly poor prognosis. In general, patients diagnosed with this form of cancer have a survival period measured, at most, in months. Adenocarcinomas are tumors of glandlike structure, presenting as nodules within peripheral tissue such as the bronchioles. Often these forms of tumors may arise from previously damaged or scarred tissue, such as has occurred among smokers. The development of adenocarcinoma of the lung is not as dependent upon smoke inhalation, however, as are other forms of lung cancer. Squamous cell, also called epidermoid, carcinomas tend to be slowergrowing malignancies which form among the flat epithelial cells on the surface of a variety of tissues, including the bladder, cervix, or skin, in addition to the lung. The cells are often polygonal in shape, with keratin nodes on the surface of lesions. Squamous cell carcinomas tend to metastasize less frequently than other forms of lung cancer, allowing for a more optimistic prognosis as compared to other forms. Large cell carcinomas are actually a more general form of cancer in which the cells are relatively large in size, with the cell nucleus being particularly enlarged. Often these carcinomas have arisen as either squamous cell carcinomas or adenocarcinomas. Metastasis, when it occurs, is frequently within the gastrointestinal tract. Causes and Symptoms of Lung Cancer There is no question that the single leading cause or factor resulting in lung cancer is smoking. Persons who do not smoke, and indeed even smokers who smoke fewer than five cigarettes per day, are at relatively low risk of developing any form of lung cancer. Those who smoke more than five cigarettes per day, however, run an increased risk of developing lung cancer at rates approaching two hundred times that of the nonsmoker. This risk is greatest for oat cell carcinomas and least for adenocarcinomas (but still approximately a tenfold risk over that for nonsmokers). The relative risk is
570 ✧ Lung cancer related to the number of cigarettes smoked. In addition, though other environmental hazards can be related to the development of lung cancers, the risk associated with those hazards is without exception amplified by cigarette smoke. Exposure to other specific environmental factors has also been associated with the formation of certain forms of pulmonary cancers. Individuals chronically exposed to materials such as asbestos, hydrocarbon products (coal tars or roofing materials), nickel, vinyl chloride, or radiochemicals (uranium and pitchblende) are at increased risk. Chronically damaged lungs, for whatever reason, are at significantly increased risk for development of cancer. The symptoms of lung cancer may represent the damage caused by the primary tumor or may be the result of metastasis to other organs. The most common symptom is a persistent cough, sometimes accompanied by blood in the sputum or difficulty breathing. Chest pain may be present, especially upon inhalation. There may also be repeated attacks of bronchitis or pneumonia that tend to persist for abnormal periods of time. Treating Lung Cancer The treatment of lung cancer is dependent on the form of the disease and on the extent of its spread. Surgery remains the preferred method of treatment, but because of the nature of the disease, less than half the cases are operable at the time of diagnosis. Of these, a large proportion are beyond the point at which the surgical removal of the cancer and resection of remaining tissue are possible. A variety of chemotherapeutic measures are available and along with the use of radiation therapy can be used to produce a small number of cures or at least temporary alleviation of symptoms. Nevertheless, only a small proportion of lung cancers, perhaps 10 percent, respond with a permanent remission or cure. Lung cancer represents the leading cause of cancer deaths among American men and the second leading cause of cancer deaths among American women. By the 1990’s, however, lung cancer was gaining among women and was poised to surpass breast cancer as the major cause of cancer deaths for this group. Each year, between 150,000 and 175,000 new cases of lung cancer are diagnosed in the United States, with about 50,000 deaths. The prognosis for most forms of lung cancer remains poor. —Richard Adler See also Addiction; Cancer; Chemotherapy; Environmental diseases; Secondhand smoke; Smog; Smoking; Tobacco use among teenagers. For Further Information: Murphy, G., L. Morris, and D. Lange. Informed Decisions: The Complete Book of
Lyme disease ✧ 571 Cancer Diagnosis, Treatment, and Recovery. New York: Viking Press, 1997. This text from the American Cancer Society is intended for the layperson. It is exemplary in its discussion of cancer. Pass, Harvey I., et al. Lung Cancer: Principles and Practice. Philadelphia: Lippincott-Raven, 1996. This illustrated text addresses neoplasms of the lungs. Includes a bibliography and an index. Patterson, James T. The Dread Disease: Cancer and Modern American Culture. Cambridge, Mass.: Harvard University Press, 1987. A general text dealing with all major forms of cancer. Steen, R. Grant. A Conspiracy of Cells: The Basic Science of Cancer. New York: Plenum Press, 1993. Provides a fine discussion on a variety of factors which cause cancers to develop. Williams, C. J. Lung Cancer: The Facts. 2d ed. Oxford, England: Oxford University Press, 1992. A work that deals specifically with pulmonary cancer.
✧ Lyme disease Type of issue: Environmental health, epidemics, public health Definition: A mild-to-serious infection caused by a bacterium spread by the bite of infected ticks. Lyme disease is a multistage, multisystem, bacterial infection caused by the spirochete Borrelia burgdorferi spread exclusively through bites from infected ticks (not insects). The infected deer tick is much smaller than common dog or cattle ticks and feeds on the white-footed mouse, the white-tailed deer, other mammals, and birds. Ticks transmit Lyme disease during their nymph stage, going unnoticed during this point in their development because of their small size (less than 2 millimeters) and dark brown color. Ticks most likely transmit infection following several days of feeding, which involves inserting their mouth into hidden, often-hairy body areas such as the groin, armpits, and scalp. The tick’s body remains outside the host’s skin and slowly fills with blood. Ticks do not jump or fly; they crawl from grasses and shrubs (not trees) onto hosts that come into physical contact with the vegetation. Outdoor recreationalists and workers building new homes in wooded, brushfilled areas are most commonly exposed. The early stages of Lyme disease are marked by one or more of the following: fatigue, malaise, chills and fever, headache, muscle and joint pain, swollen lymph nodes, and a warm, nonpainful skin rash called erythema migrans. This characteristic rash is seen in 75 percent of cases and varies in size and shape; the rash center often clears as it enlarges, resulting in a bulls’-eye appearance.
572 ✧ Lyme disease Signs and symptoms of the later stages of Lyme disease may not appear for years following infection. These include arthritis (brief bouts of pain and swelling in large joints such as the knees), nervous system abnormalities such as numbness, pain, Bell’s palsy (paralysis of the muscles on one side of the face), lymphocytic meningitis (fever, stiff neck, and severe headache), and conduction disturbances between the atria and ventricles of the heart. Diagnosis, Treatment, and Prevention Lyme disease can be deceptive to diagnosis because its characteristic symptoms mimic other diseases or never develop at all. Fever, muscle aches, and fatigue can be mistaken for viral infections such as influenza or infectious mononucleosis. Joint pain can be confused with other types of arthritis, such as rheumatoid arthritis, and neurologic signs can mimic conditions such as multiple sclerosis. Allergic reactions to tick saliva that occur hours to days after a tick bite, do not expand, and disappear rapidly are often mistaken for Lyme disease. Occasionally, erythema migrans never develops and the first and only sign of Lyme disease is migratory arthritis or nerve impairment. Early treatment of Lyme disease with oral antibiotics such as tetracycline or penicillin for ten to twenty days generally enables a rapid and complete recovery. Although patients nearly always respond to antibiotics, untreated Lyme disease can progress to arthritic, neurologic, and cardiac problems. About 10 percent of chronic cases require hospitalization, 40 to 60 percent involve joint disease, 15 to 20 percent involve neurologic disease, and about 8 percent involve carditis. Patients not treated until advanced disease progression may require intravenous antibiotics for one month or longer, but they still often respond well. Persisting infections rarely continue or recur, but they do have the potential to cause permanent damage and even death. Tick prevention measures include clearing tall brush and leaves away from houses and gardens, managing high deer traffic areas, and regularly checking domestic animals. Acaricide chemicals are toxic to ticks and are often applied under supervision by a pest control professional, but their effectiveness and environmental safety remain controversial. Personal protection from tick bites involves avoiding tick-infested areas, wearing a hat and long-sleeved light-colored clothing to enable better visibility of ticks, and tucking pantlegs into socks or footwear and shirts into pants and taping these areas to discourage ticks from crawling underneath. Spraying repellent containing DEET on clothes and exposed skin other than the face and applying permethrin, which kills ticks on contact, are also effective. After outdoor activities, clothing should be removed immediately and then washed and dried at high temperatures. After showering, one should inspect the body carefully. Any ticks must be removed using tweezers, grasping the tick close to the skin surface and pulling straight back with a slow, steady force without crushing the tick’s body against the skin. All ticks suspected of
Lyme disease ✧ 573 Borrelia burgdorferi infection should be submitted in a sealed container of alcohol to local health department officials. Research Prospects Lyme disease was classified in 1975 after a mysterious juvenile arthritis outbreak in the region surrounding Lyme, Connecticut. It has since accounted for more than 90 percent of vector-borne illnesses reported in North America. The annual total of reported cases increased thirty-two-fold between 1982 and 1996, with a cumulative total of more than 99,000 cases during this period. In 1996, more than 16,000 cases were reported in the United States in forty-eight states. In most states, only 2 percent of ticks are thought to be infected, but figures up to 50 percent in highly infected areas have been recorded. Lyme disease is most prevalent in northern temperate regions with a constant high relative humidity. The United States experiences the highest incidence of Lyme disease in the Northeast (from Massachusetts to Maryland), in the north-central states (especially Wisconsin and Minnesota), and on the West coast (particularly in northern California). Ongoing research will continue to explore the habitats where infected ticks thrive, what measures provide optimal protection, and which chemicals are most effective in various kinds of habitats. Improved reliability and validity of diagnostic tests and antibiotic regimens, vaccine development, the influence of maternal infection on the developing fetus, and the mechanisms by which Lyme disease infects the joints and nervous system are also under investigation. —Daniel G. Graetzer See also Arthritis; Chronic fatigue syndrome; Environmental diseases; Epidemics; Lice, mites, and ticks; Parasites; Zoonoses. For Further Information: Bennett, C. E. “Ticks and Lyme Disease.” Advances in Parasitology 36 (1995): 343-405. Cutler, S. J. “Lyme Borreliosis: An Update.” British Journal of Hospital Medicine 56, no. 11 (1997): 581-584. Evans, J. “Lyme Disease.” Current Opinion in Rheumatology 9, no. 4 (1997): 328-336. Rahn, Daniel W., and Janine Evans, eds. Lyme Disease. Philadelphia: American College of Physicians, 1998. Vanderhoof-Forschner, Karen. Everything You Need to Know About Lyme Disease and Other Tick-Borne Disorders. New York: Rosen, 2000.
574 ✧ Macular degeneration
✧ Macular degeneration Type of issue: Elder health Definition: Degeneration of the central region of the retina, leading to blindness in the center of the visual field while retaining peripheral vision. Age-related macular degeneration (ARMD), a degenerative condition of the macula or central retina, affects about 15 percent of the U.S. population by age fifty-five and over 30 percent by age seventy-five. It is the leading cause of legal blindness in people over the age of sixty-five. The macula is the tiny central region of the retina in the eye. It is made up of millions of light-sensing cells that help to produce central vision and provide maximum visual acuity. When the macula is damaged, a blind spot called drusen, made up of tiny yellow drops, develops in the central field of vision, and central vision becomes blurred or distorted. Central vision is needed to see clearly and to perform everyday activities such as reading, writing, driving, and recognizing people and things. Macular degeneration does not cause complete blindness since peripheral (side) vision is not affected. There are two forms of ARMD: dry and wet. The dry form involves thinning of the macular tissues and disturbances in its pigmentation. About 70 percent of patients have the dry form. The remaining 30 percent have the wet form, which can involve bleeding within and beneath the retina, opaque deposits, and eventually scar tissue. The wet form accounts for 90 percent of all cases of legal blindness in macular degeneration patients. Symptoms and Causes Neither dry nor wet macular degeneration causes pain. The most common early sign of dry macular degeneration is blurring vision that prevents people from seeing details less clearly in front of them, such as faces or words in a book. In the early stages of wet macular degeneration, straight lines appear wavy or crooked. This is the result of fluid leaking from blood vessels and lifting the macula, distorting vision. The root causes of macular degeneration are still unknown, but medical authorities consider a number of factors as probable factors. Aging is the leading cause, with genetics, nutrition, smoking, and sunlight exposure all playing a role. Age is the most important risk factor for macular degeneration. The older the patient, the higher the risk. Studies have shown that having a family with a history of macular degeneration raises the risk factor. Because macular degeneration affects most patients later in life, however, it has proven
Macular degeneration ✧ 575 difficult to study cases in successive generations of a family. Heavy smoking, at least a pack of cigarettes a day, can double a person’s risk of developing ARMD. The more a person smokes, the higher the risk of macular degeneration. Moreover, the adverse effects of smoking persist, even fifteen to twenty years after quitting. Poor dietary habits contribute as well. A diet high in saturated fats may clog the vessels leading to the eyes, thus reducing the flow of nutrient-rich blood. Excess fat may deposit itself directly in the membrane behind the retina. In this case, nutrients might not be able to pass through the “fat wall” to reach the cells that nourish the retina. There is evidence that eating fresh fruits and dark green leafy vegetables (such as spinach and collard greens) may delay or reduce the severity of age-related macular degeneration. Some studies indicate that the mineral zinc might affect the development of macular degeneration. Zinc is important to chemical reactions in the retina. It is highly concentrated in the eye, particularly in the retina and the tissues surrounding the macula. Older people may have low levels of zinc because of poor diet or poor absorption from food. Some doctors believe that zinc supplements may slow down the progress of macular degeneration. Studies are not complete, however, and there are some adverse side effects of zinc supplements. They might interfere with other important trace metals such as copper, and in some people, the long-term use of zinc can cause digestive problems and anemia. Strong sunlight seems to accelerate macular degeneration. Wearing special sunglasses may decrease the progress of the disease. Tests and Adjustments An effective test to determine if a person has wet macular degeneration is fluorescent angiography. A special dye is injected into a vein in the patient’s arm and then flows to the blood vessels in the eye. Photographs are taken of the retina. The dye highlights any problems in the blood vessels and allows the doctor to determine if they can be treated. Annual eye examinations that include dilation of the pupils are also useful in early detection. Early detection is important because a person destined to develop macular degeneration can sometimes be treated before symptoms appear, which may delay or reduce the severity of the disease. Anyone who notices a change in vision should contact an ophthalmologist immediately. People with macular degeneration learn to make use of the areas just outside the macula to see details. This ability to look slightly off center usually improves with time, though vision is never as good as it was before the macula was damaged. A number of aids can help people with ARMD make the most of their remaining vision. Some low-vision aids include magnifying glasses, special lenses, electronic systems, and large-print books and newspapers. Sound
576 ✧ Macular degeneration aids include books on audiotape and products equipped with voice synthesizers such as calculators and computers. Using lamps that provide direct lighting for reading or tasks that require close vision, keeping curtains open, and painting walls and ceilings white make it easier for macular degeneration patients to see in the home. Treatment There is no proven medical treatment for dry macular degeneration. In some cases of wet macular degeneration, laser photocoagulation is effective in sealing leaking or bleeding vessels. Laser photocoagulation usually does not restore vision but does prevent further loss. The surgery can be performed in a doctor’s office or in an eye clinic on an outpatient basis. Three other treatments have shown promise. One is surgery to reposition the retina. The doctor cuts through the outer layer of the eye to gain access to the retina, which can then be detached and repositioned without cutting. This technique enables the surgeon to maneuver the center of the macula away from the leaking blood vessels and place it next to healthier eye tissue. Low-level radiation can also be used to stop blood vessel proliferation. The radiation is carefully measured to be high enough to stop the growth but low enough so that the retina is not damaged. The third treatment is to inject photosensitive chemicals into the bloodstream of people with macular degeneration and to use lasers to stimulate those chemicals in the eye. When activated, the substances halt the proliferation of blood vessels. If blood vessels begin to grow again, repeat doses can be administered without adverse side effects. A radical and controversial treatment was made by a team of doctors from the University of Chicago Medical Center in 1997. They took cells from the retina of an aborted fetus and surgically transplanted them into the severely impaired left eye of an eighty-four-year-old patient. The transplanted cells proliferated, forming minute projections that stretched toward the patient’s macula. Fetal cells can divide and thus increase in number. Also they are likely to continue functioning for a number of years. Because the fetal cells are immature, they provoke little or no response from a transplant recipient’s immune system. In the short term, the transplant appeared successful, but long-term results were not yet available. Because of the radical nature of the operation, the patient selected was severely impaired and had no other hope for improvement. Moreover, some people protested the use of cells from an aborted fetus. The need for severely impaired patients and ethical concerns virtually stopped research into this surgical procedure. —Billie M. Taylor See also Aging; Disabilities; Smoking; Vision problems with aging.
Mad cow disease ✧ 577 For Further Information: Nash, J. Madeleine. “In Search of Sight.” Time 150, no. 19 (Fall, 1997). Pennisi, Elizabeth. “Gene Found for the Fading Eyesight of Old Age.” Science 277, no. 5333 (September 19, 1997). Ross, Linda M., ed. Ophthalmic Disorders Sourcebook. Detroit: Omnigraphics, 1997. Seppa, Nathan. “New Treatments for Macular Degeneration.” Science News 152, no. 13 (September 27, 1997). Shapiro, Sara. “Tests and Treatments for Old-Age Eye Conditions.” Eye Q, Spring, 1997. Wolfe, Yun Lee. “‘Rays’ Your Eyesight: Radiation May Stabilize Age-Related Blindness.” Prevention 49, no. 4 (April, 1997).
✧ Mad cow disease Type of issue: Environmental health, epidemics, industrial practices, public health Definition: Bovine spongiform encephalopathy (BSE), a cattle disease of the central nervous system first identified in 1986 in Great Britain. BSE is believed to be related to new-variant Creutzfeldt-Jakob disease (nvCJD), a fatal human illness. It is marked by brain tissue deterioration and progressive degeneration of the central nervous system, which cause symptoms such as impaired physical coordination, staggering, unusual aggression, and other abnormal behavior. Since its discovery, BSE has become epidemic in Great Britain. Substantial numbers of infected cattle have also been found in Ireland, Switzerland, Portugal, and France. Scattered cases have occurred in Germany, Italy, the Netherlands, Luxembourg, Oman, Canada, Denmark, and the Falkland Islands. BSE is a transmissible spongiform encephalopathy (TSE), a class of diseases so named because of the brain damage that characterizes them— the tissue is left riddled with small holes, like a sponge. Other species affected by TSEs include deer, elk, and antelope (chronic wasting disease); sheep and goats (scrapie); mink (transmissible mink encephalopathy); cats (feline spongiform encephalopathy, or FSE), and humans (kuru, GertsmannSträussler-Scheinker syndrome, fatal familial insomnia, and CreutzfeldtJakob disease, or CJD). Diagnosis is confirmed only through autopsy and examination of the brain tissue. At present, all known TSEs are incurable, untreatable, and fatal. BSE is believed to have arisen because of an infectious agent in cattle feed during the 1970’s and 1980’s. Meat-and-bone meal, a protein concentrate produced by rendering plants (facilities that process animal carcasses and
578 ✧ Mad cow disease slaughterhouse wastes into commercial products), was added to cattle feed as a nutritional supplement with increasing frequency during the 1980’s. Among the rendered wastes from which the supplement was made were the carcasses of sheep that died from scrapie. Through infected protein supplement, scrapie is thought to have crossed the species barrier from sheep into cattle and become a new TSE. An increase in Great Britain’s sheep population during the late 1970’s and early 1980’s elevated the number of scrapie cases, and thus more infected material was rendered. Coincidentally, at about this time Britain’s rendering industry made changes to the rendering process—eliminating the solvent extraction of fats and a subsequent steamstripping treatment—that may have allowed more infectious agent to pass into the finished product. The BSE Epidemic in Great Britain Not long after it was first identified, BSE reached epidemic proportions in Great Britain. The epidemic peaked in 1992, with 37,487 confirmed cases. Mandatory reporting of BSE cases and destruction of symptomatic animals began in 1988, as did a ban on the feeding of ruminants (cattle, sheep, goats, and deer) with ruminant-derived protein. In 1989 the British government banned the human consumption of cattle brains and other “specified offals” believed to be possible carriers of infection. In 1990 a British domestic cat was diagnosed as the first victim of FSE, causing public concern over the possible spread of BSE beyond livestock and a temporary drop in the nation’s beef consumption. That year, the British government established a system for reporting and tracking CJD to monitor possible BSE effects on people. In 1993 the British National CJD Surveillance Unit began to receive reports of unusual CJD cases. While CJD typically affects one person in one million between the ages of fifty-five and eighty, CJD was appearing in younger patients, with uncharacteristic patterns of brain damage, and with atypical frequency. By early 1996 eight cases of nvCJD in people under forty-two years of age had been identified. Global attention turned to Britain’s mad cow crisis in March, 1996, when British health secretary Stephen Dorrell announced that ten cases of nvCJD had been confirmed and that they were most likely the result of exposure to BSE-contaminated beef before the 1989 specified offal ban. The announcement triggered a nationwide panic in Britain, caused a sharp drop in British beef sales, and exacerbated political and economic friction between Britain and the rest of the European Union. Researchers have since found more conclusive evidence linking BSE and nvCJD. However, they have yet to determine the exact cause of these and other TSEs. One of the more widely accepted theories is that the illnesses are induced by tiny proteinaceous infectious particles, or prions. Prions resemble an abnormally folded version of prion protein, a harmless, natu-
Mad cow disease ✧ 579 rally occurring protein found in the brains of all mammals. Prions do not break down in mammalian digestive systems and provoke no immune response. Lacking genetic material (unlike more familiar infectious agents such as bacteria, viruses, and fungi), prions are believed to spread by invading cells and converting normal prion protein into the aberrant form. As the prions accumulate, they damage brain cells and ultimately kill the organism. Whatever the agent that causes BSE, it is highly resistant to ultraviolet light, pH and temperature extremes, ionizing radiation, and many chemical disinfectants. British efforts to contain a livestock epidemic that is only partially understood, protect human health, and allay public fears about beef consumption have created new problems. In a government-instituted culling program, more than 3.8 million animals considered at risk have been slaughtered. Neither the designated rendering plants that process the remains nor the designated incinerators that burn the rendered product are able to keep up with the slaughter rate. The resulting backlog of hundreds of thousands of tons of waste beef and rendered products has been warehoused pending disposal. Incineration plans have proved unpopular with Britons unconvinced that burning cull material is safe. Public concern has also arisen over the possible groundwater contamination risk posed by land-filled cattle carcasses and liquid rendering wastes discharged to the environment during the early years of the epidemic. Between 1993 and August, 1998, twentyseven cases of nvCJD were diagnosed in Britain, with an additional case confirmed in France. It is not known how many other people may be incubating the disease. —Karen N. Kähler See also Environmental diseases; Epidemics; Food poisoning. For Further Information: Lyman, Howard F., and Glen Merzer. Mad Cowboy: Plain Truth from the Cattle Rancher Who Won’t Eat Meat. New York: Scribner, 1998. Written from Lyman’s perspective as a former Montana cattle rancher turned vegetarian environmentalist activist, discusses BSE and other health and environmental consequences of cattle- and dairy-industry practices. Rampton, Sheldon, and John Stauber. Mad Cow U.S.A.: Could the Nightmare Happen Here? Monroe, Maine: Common Courage Press, 1997. Investigates how corporate and government public relations efforts and public policy influenced the course of Great Britain’s epidemic and explores the possibility of a similar outbreak in the United States. Rhodes, Richard. Deadly Feasts: The “Prion” Controversy and the Public’s Health. New York: Simon & Schuster, 1997. A highly readable account of the discovery and study of TSEs and the social consequences of BSE and nvCJD.
580 ✧ Malnutrition among children
✧ Malnutrition among children Type of issue: Children’s health, public health Definition: Impaired health caused by an imbalance, either through deficiency or excess, in nutrients. Malnutrition literally means “bad nutrition.” It can be used broadly to mean an excess or deficiency of the nutrients that are necessary for good health. In industrialized societies, malnutrition typically represents the excess consumption characterized by a diet containing too much energy (kilocalories), fat, and sodium. Malnutrition is most commonly thought, however, to be undernutrition or deficient intake, the consumption of inadequate amounts of nutrients to promote health or to support growth in children. The most severe form of undernutrition is called protein energy malnutrition, or PEM. It commonly affects children, who require nutrients not only to help maintain the body but also to grow. Two types of PEM occur: kwashiorkor and marasmus. The Varieties of Malnutrition Kwashiorkor is a condition in which a person consumes adequate energy but not enough protein. It usually is seen in children between one and four who are weaned so that the next baby can be breast-fed. The weaning diet consists of gruels made from starchy foods that do not contain an adequate supply of amino acids, the building blocks of protein. These diets do, however, provide enough energy. Diets in many developing countries are high in bulk, making it nearly impossible for a child to consume a sufficient volume of foods such as rice and grain to obtain an adequate amount of protein for growth. The outward signs of kwashiorkor are a potbelly, dry unpigmented skin, coarse reddish hair, and edema in the legs. Edema results from a lack of certain proteins in the blood that help to maintain a normal fluid balance in the body. The potbelly and swollen limbs often are misinterpreted as signs of being “fat” among the developing world cultures. Other signs requiring further medical testing include fat deposits in the liver and decreased production of digestive enzymes. The mental and physical growth of the child are impaired. Children with kwashiorkor are apathetic, listless, and withdrawn. Ironically, these children lose their appetites. They become very susceptible to upperrespiratory infection and diarrhea. Children with kwashiorkor also are deficient in vitamins and minerals that are found in protein-rich foods. There are symptoms caused by these specific nutrient deficiencies as well. Marasmus literally means “to waste away.” It is caused by a deficiency of both Calories (kilocalories) and protein in the diet. This is the most severe
Malnutrition among children ✧ 581 form of childhood malnutrition. Body fat stores are used up to provide energy, and eventually muscle tissue is broken down for body fuel. Victims appear as skin and bones, gazing with large eyes from a bald head with an aged, gaunt appearance. Once severe muscle wasting occurs, death is imminent. Body temperature is below normal. The immune system does not operate normally, making these children extremely susceptible to respiratory and gastrointestinal infections. A vicious cycle develops once the child succumbs to infection. Infection increases the body’s need for protein, yet the PEM child is so protein deficient that recovery from even minor respiratory infections is prolonged. Pneumonia and measles become fatal diseases for PEM victims. Severe diarrhea compounds the problem. The child is often dehydrated, and any nourishment that might be consumed will not be adequately absorbed. The long-term prognosis for these PEM children is poor. If the child survives infections and is refed, PEM returns once the child goes home to the same environment that caused it. Children with repeated episodes of kwashiorkor have high mortality rates. Children with PEM are most likely victims of famine. Typically, these children either were not breast-fed or were breast-fed for only a few months. If a weaning formula is used, it has not been prepared properly; in many cases, it is mixed with unsanitary water or watered down because the parents cannot afford to buy enough to use it at full strength. It is difficult to distinguish between the cause of kwashiorkor and that of marasmus. One child ingesting the same diet as another may develop kwashiorkor, while the other may develop marasmus. Some scientists think this may be a result of the different ways in which individuals adapt to nutritional deprivation. Others propose that kwashiorkor is caused by eating moldy grains, since it appears only in rainy, tropical areas. Vitamin and Mineral Deficiencies Another type of malnutrition involves a deficiency of vitamins or minerals. Vitamin A is necessary for the maintenance of healthy skin, and even a mild deficiency causes susceptibility to diarrhea and upper respiratory infection. Diarrhea reinforces the vicious cycle of malnutrition, since it prevents nutrients from being absorbed. With a more severe vitamin A deficiency, changes in the eye and, eventually, blindness result. Night blindness is usually the first detectable symptom of vitamin A deficiency. The blood that bathes the eye cannot regenerate the visual pigments needed to see in the dark. Eventually, the tissues of the eye become infected and total blindness results. Vitamin A deficiency, the primary cause of childhood blindness, can result from the lack of either vitamin A or the protein that transports it in the blood. If the deficiency of vitamin A occurs during pregnancy or at birth, the skull does not develop normally and the brain is crowded. An older child
582 ✧ Malnutrition among children deficient in vitamin A will suffer growth impairment. Diseases resulting from B-vitamin deficiencies are rare. Strict vegetarians called vegans, who consume no animal products, are at risk for vitamin B12 deficiency resulting in an anemia in which the red blood cells are large and immature. Too little folate (folic acid) in the diet can cause this same anemia. Beriberi is the deficiency disease of thiamine (vitamin B1) in which the heart and nervous systems are damaged and muscle wasting occurs. Ariboflavinosis (lack of riboflavin) describes a collection of symptoms such as cracks and redness of the eyes and lips; inflamed, sensitive eyelids; and a purple-red tongue. Pellagra is the deficiency disease of niacin (vitamin B3). It is characterized by “the Four Ds of pellagra”: dermatitis, diarrhea, dementia, and death. Isolated deficiency of a B vitamin is rare, since many B vitamins work in concert. Therefore, a lack of one hinders the function of the rest. Scurvy is the deficiency disease of vitamin C. Early signs of scurvy are bleeding gums and pinpoint hemorrhages under the skin. As the deficiency becomes more severe, the skin becomes rough, brown, and scaly, eventually resulting in impaired wound healing, soft bones, painful joints, and loose teeth. Finally, hardening of the arteries or massive bleeding results in death. Rickets is the childhood deficiency disease of vitamin D. Bone formation is impaired, which is reflected in a bowlegged or knock-kneed appearance. In adults, a brittle bone condition called osteomalacia results from vitamin D deficiency. Malnutrition of minerals is more prevalent in the world, since deficiencies are observed in both industrialized and developing countries. Calcium malnutrition in young children results in stunted growth. Osteoporosis occurs when calcium reserves are drawn upon to supply the other body parts with calcium. This occurs in later adulthood, leaving bones weak and fragile. General loss of stature and fractures of the hip, pelvis, and wrist are common, and a humpback appears. Caucasian and Asian women of small stature are at greatest risk for osteoporosis. Iron-deficiency anemia is the most common form of malnutrition in developing societies. Lack of consumption of iron-rich foods is common among the poor, especially in women who menstruate. This deficiency, which is characterized by small, pale red blood cells, causes weakness, fatigue, and sensitivity to cold temperatures. Anemia in children can cause reduced ability to learn and impaired ability to think and to concentrate. Deficiencies of other minerals are less common. Although these deficiencies are usually seen among people in developing nations, they may occur among the poor, pregnant women, children, and the elderly in industrialized societies. Severe growth retardation and arrested sexual maturation are characteristics of zinc deficiency. With iodine deficiency, the cells in the thyroid gland enlarge to try to trap as much iodine as possible. This enlargement of the thyroid gland is called simple or endemic goiter. A more
Malnutrition among children ✧ 583 severe iodine deficiency results from a lack of iodine that leads to a deficiency of thyroid hormone during pregnancy. The child of a mother with such a deficiency is born with severe mental and/or physical retardation, a condition known as cretinism. The causes of malnutrition, therefore, can be difficult to isolate, because nutrients work together in the body. In addition, the underlying causes of malnutrition (poverty, famine, and war) often are untreatable. The Aftereffects of Malnutrition Treatment for PEM involves refeeding with a diet adequate in protein, Calories, and other essential nutrients. Response to treatment is influenced by many factors, such as the person’s age, the stage of development in which the deprivation began, the severity of the deficiency, the duration of the deficiency, and the presence of other illnesses, particularly infections. Total recovery is possible only if the underlying cause that led to PEM can be eliminated. PEM can result from illnesses such as cancer and acquired immunodeficiency syndrome (AIDS). Victims of these diseases cannot consume diets with enough energy and protein to meet their body needs, which are higher than normal because of the illness. Infections also increase the need for many nutrients. The first step in treatment must be to cure the underlying infection. People from cultures in which PEM is prevalent believe that food should not be given to an ill person. Prevention of PEM is the preferred therapy. In areas with unsafe water supplies and high rates of poverty, women should be encouraged to breast-feed. Education about proper weaning foods provides further defense against PEM. Other preventive efforts involve combining plant proteins into a mixture of high-quality protein, adding nutrients to cereal products, and using genetic engineering to produce grains with a better protein mix. The prevention of underlying causes such as famine and drought may not be feasible. Prekwashiorkor can be identified by regular plotting of the child’s growth. If treatment begins at this stage, patient response is rapid and the prognosis is good. Treatment must begin by correcting the body’s fluid imbalance. Low potassium levels must be corrected. Restoration of fluid is followed by adequate provision of Calories, with gradual additions of protein that the patient can use to repair damaged immune and digestive systems. Treatment must happen rapidly yet allow the digestive system to recover— thus the term “hurry slowly.” Once edema is corrected and blood potassium levels are restored, a diluted milk with added sugar can be given. Gradually, vegetable oil is added to increase the intake of Calories. Vitamin and mineral supplements are given. Final diet therapy includes a diet of skim milk and other animal protein sources, coupled with the addition of vegetables and fat.
584 ✧ Malnutrition among children The residual effects of PEM may be great if malnutrition has come at a critical period in development or has been of long duration. In prolonged cases, damage to growth and the digestive system may be irreversible. Mortality is very high in such cases. Normally, the digestive tract undergoes rapid cell replacement; therefore, this system is one of the first to suffer in PEM. Absorptive surfaces shrink, and digestive enzymes and protein carriers that transport nutrients are lacking. The Effect on Developmental Stages Another critical factor in the treatment of PEM is the stage of development in which the deprivation occurs. Most PEM victims are children. If nutritional deprivation occurs during pregnancy, the consequence is increased risk of infant death. If the child is carried to term, it is of low birth weight, placing it at high risk for death. Malnutrition during lactation decreases the quantity, but not always the nutritional quality, of milk. Thus, fewer Calories are consumed by the baby. Growth of the child is slowed. These babies are short for their age and continue to be shorter later in life, even if their diet improves. During the first two years of life, the brain continues to grow. Nutritional deprivation can impair mental development and cognitive function. For only minimal damage to occur, malnutrition must be treated in early stages. Adults experiencing malnutrition are more adaptive to it, since their protein energy needs are not as great. Weight loss, muscle wasting, and impaired immune function occur, and malnourished women stop menstruating. Successful treatment of a specific nutrient deficiency depends on the duration of the deficiency and the stage in a person’s development at which it occurs. Vitamin A is a fat-soluble vitamin that is stored in the body. Thus, oral supplements or injections of vitamin A can provide long-term protection from this deficiency. If vitamin A is given early enough, the deficiency can be rapidly reversed. By the time the child is blind, sight cannot be restored, and frequently the child dies because of other illnesses. Treatment also is dependent upon adequate protein to provide carriers in the blood to transport these vitamins. Treatment of the B-vitamin deficiencies involves oral and intramuscular injections. The crucial step in treatment is to initiate therapy before irreversible damage has occurred. Scurvy (vitamin C deficiency) can be eliminated in five days by administering the amount of vitamin C found in approximately three cups of orange juice. Treatment of vitamin D deficiency in children and adults involves an oral dose of two to twelve times the recommended daily allowance of the vitamin. Halibut and cod liver oils are frequently given as vitamin D supplements. Successful treatment of a mineral deficiency depends on the timing and duration of the deficiency. Once the bones are fully grown, restoring calcium to optimal levels will not correct short stature. To prevent osteoporosis,
Malnutrition among children ✧ 585 bones must have been filled to the maximum with calcium during early adulthood. Estrogen replacement therapy and weight-bearing exercise retard calcium loss in later years and do more than calcium supplements can. Iron supplementation is necessary to correct iron-deficiency anemia. Iron supplements are routinely prescribed for pregnant women to prevent anemia during pregnancy. Treatment also includes a diet with adequate meat, fish, and poultry to provide not only iron but also a factor that enhances absorption. Iron absorption is also enhanced by vitamin C. Anemias caused by lack of folate and vitamin B12 will not respond to iron therapy. These anemias must be treated by adding the appropriate vitamin to the diet. Zinc supplementation can correct arrested sexual maturation and impaired growth if it is begun in time. In areas where the soil does not contain iodine, iodine is added to salt or injections of iodized oil are given to prevent goiter. Cretinism cannot be cured—only prevented. —Wendy L. Stuhldreher, R.D. See also Anorexia nervosa; Breast-feeding; Children’s health issues; Eating disorders; Failure to thrive; Malnutrition in the elderly; Nutrition and children; Obesity; Obesity and children; Vitamin supplements; Weight loss medications. For Further Information: Christian, Janet L., and Janet L. Greger. Nutrition for Living. 4th ed. Redwood City, Calif.: Benjamin/Cummings, 1994. This introductory textbook of nutrition is easy to understand. It provides brief explanations of various vitamin and mineral deficiencies, as well as of PEM. Photographs showing symptoms are included. Garrow, J. S., and W. P. T. James, eds. Human Nutrition and Dietetics. 10th ed. New York: Churchill Livingstone, 2000. Several chapters in this book provide information on malnutrition, from PEM to specific nutrient deficiencies. History, causes, symptoms, and treatments of the disorders are covered. An excellent list of references is provided. Photographs of victims of deficiency diseases are included. Wardlaw, Gordon M., Paul M. Insel, and Marcia F. Seyler. Contemporary Nutrition. St. Louis: Mosby Year Book, 1991. Chapter 18 of this text covers undernutrition. This chapter emphasizes the types of undernutrition and hunger found in America. Whitney, Eleanor Noss, and Sharon Rady Rolfes. Understanding Nutrition. 8th ed. St. Paul, Minn.: West, 1999. This is an introductory nutrition textbook. Various chapters have information about the different nutrient deficiencies and malnutrition. Winick, Myron, Brian L. G. Morgan, Jaime Rozovski, and Robin Marks-Kaufman, eds. The Columbia Encyclopedia of Nutrition. New York: G. P. Putnam’s
586 ✧ Malnutrition among the elderly Sons, 1988. Brief synopses of marasmus and kwashiorkor are provided. Descriptions of isolated nutrient deficiencies also can be found in the sections on specific nutrients.
✧ Malnutrition among the elderly Type of issue: Elder health, public health Definition: Both excess and deficient intakes of calories or nutrients. Malnutrition literally means “bad nutrition”—that is, impaired health caused by an imbalance of specific nutrients or a deficiency or excess of energy (calories). However, malnutrition is most commonly thought to denote undernutrition or deficient intake, meaning consumption of inadequate amounts of nutrients to promote health. Malnutrition in the elderly is a complex phenomenon. Contributing factors include poor physical health, functional disability, psychological problems, and socioenvironmental factors. The frail elderly, who are typically underweight and may suffer from a chronic illness, may require higher nutrient and caloric levels just to sustain health. Some of the illnesses associated with such malnutrition are emphysema, cancer, stroke, and endstage Alzheimer’s disease. Without adequate amounts of such nutrients as protein, vitamin B6, iron, and zinc, the immune system is compromised, leaving the elderly susceptible to infections and further deterioration. For example, bedridden elderly are prone to bedsores, which are aggravated by malnutrition. Undernutrition among the elderly frequently results from other conditions, such as a chronic disease, poverty, isolation, depression, or poor dental health. The most severe form of undernutrition is called protein energy malnutrition (PEM). In PEM, body fat stores are used up to provide energy, and eventually muscle tissue is broken down for body fuel. This type of wasting away is frequently associated with diseases such as cancer, end-stage Alzheimer’s disease, emphysema, and other chronic degenerative diseases. PEM is sometimes identified among the elderly living in long-term care facilities and among those who are hospitalized. PEM is accompanied by multiple nutrient deficiencies. Malnutrition and Vitamins Classic vitamin deficiency diseases, such as scurvy (vitamin C deficiency) and pellagra (niacin deficiency), are not as common among the elderly as conditions related to long-term inadequate nutrient intakes. Years may pass before the symptoms of long-term nutrient inadequacies surface.
Malnutrition among the elderly ✧ 587 Heart disease is thought to be associated with overnutrition: excess dietary fat, saturated fat, and cholesterol. However, low intakes, and consequently low blood levels, of certain B vitamins have been linked to heart disease. High levels of an amino acid derivative called homocysteine are associated with heart disease. Vitamins B6, B12, and folate are involved in clearing this from the blood. High levels of homocysteine are not always a result of a poor diet. Many elderly, especially those over sixty, develop a common stomach condition in which damaged stomach cells produce less stomach acid. Stomach acid is needed for the absorption of those B vitamins. Thus, inadequate absorption causes higher homocysteine levels in the blood and places one at risk for heart disease. Absorption of vitamin B12 requires a special protein called intrinsic factor. Some aging people produce less of this factor. As with other B vitamins, stomach acid is required for vitamin B12 absorption. Without intrinsic factor or stomach acid, a deficiency disease known as pernicious anemia develops. Since vitamin B12 is responsible for the maintenance and growth of nerve cells, its absence may lead to paralysis of the nerves and muscles; if not identified and treated with an injection of vitamin B12, this condition may cause permanent damage to the spinal cord. Researchers continue to investigate the role of antioxidant nutrients in retarding aging. Inadequate intakes of antioxidant nutrients such as beta carotene and vitamins C and E may be related to increased risk of several diseases, such as cardiovascular disease, cancer, cataracts, and even immune dysfunction. Malnutrition and Minerals Osteoporosis is one of the best-known mineral deficiency diseases of aging. During adolescence and into early adulthood, bones become thicker and denser as calcium is deposited. Between ages thirty and forty, bone loss begins to exceed bone formation. If calcium intake has historically been poor, an inadequate amount of calcium has been deposited to compensate for bone loss during aging. Bones become brittle and susceptible to fracture. Osteoporosis is a major cause of disability and death for the elderly and places a heavy financial burden on society. Research has revealed that osteoporosis is not exclusively a calcium-deficiency disease. Calcium is only one of several known osteoporosis risk factors; other factors include hormone status, body weight, physical activity, and vitamin D. Vitamin D works more like a hormone in the body and is responsible for enhancing calcium absorption. For several reasons, vitamin D levels in the blood are often lower as one ages. The primary source of vitamin D in the diet is milk, but many elderly people tend to decrease the amount of milk in their diet for various reasons. Even though the body can make vitamin D if the skin is exposed to sunlight, the elderly often avoid sun
588 ✧ Malnutrition among the elderly exposure, use sunscreens, or are homebound, making sunlight a less reliable source of vitamin D. In addition, the body must activate functional vitamin D, and activation declines with age. Aging individuals may suffer from iron-deficiency anemia. The cause may be blood loss rather than dietary inadequacy. The most likely causes of anemia are gastrointestinal blood loss caused by chronic use of drugs such as aspirin, or blood loss from tumors. Low intake of zinc in the aging population can cause problems such as poor immune response and reduced taste perception for salt. One of the best sources of zinc is meat, but because some elderly people may not be able to afford meat or chew it, zinc intake may be inadequate. Overnutrition As people grow older, many suffer from diseases caused by overnutrition such as heart disease, diabetes (type II), osteoarthritis, some cancers, and gout. The prevalence of obesity increases with aging and often contributes to such diseases. The most important risk factor for heart disease is a high intake of saturated fat. Other contributing nutrients are dietary fat and cholesterol. Although overconsumption of dietary sodium is blamed for high blood pressure (hypertension), obesity is more often the cause. Obesity is also associated with endometrial and breast cancers and osteoarthritis. Type II diabetes, also known as noninsulin-dependent diabetes mellitus, typically has its onset in adulthood and is characterized by the inability of body cells to use insulin. Many elderly people with diabetes suffer severe complications such as kidney disease, loss of vision, heart disease, and destruction of sensory function. Malnutrition and Brain Function Proper nutrition is important for normal brain function. Dietary inadequacies of vitamins B12 and C have been associated with short-term memory loss; low intakes of riboflavin, folate, vitamin B12, and vitamin C have been associated with poor performance in problem-solving tests; and inadequate intakes of thiamine, niacin, zinc, and iron have been associated with diminished cognition, degeneration of brain tissue, and dementia. Brain communication chemicals called neurotransmitters are synthesized from components of protein. One example is serotonin, which the body makes from an amino acid (protein building block) called tryptophan. Senile dementia is loss of brain function beyond that which is considered the normal memory loss of aging. There is evidence that people with senile dementia of the Alzheimer’s type require more calories to maintain weight, perhaps because of the fidgeting and pacing behaviors that accompany the disease. Further complications include the inability to remember to eat or how to use
Malnutrition among the elderly ✧ 589 utensils. Because it is important that these people maintain adequate body weight, they must be provided with nutritious meals and snacks that are easy to eat. Treating Malnutrition The biggest challenge faced by nutritionists is matching the type of nutritional support to the aging individual to best promote health. Special screening initiatives have been promoted to help increase the public awareness of malnutrition in the elderly population so that needy individuals can be identified. Special attention must be given to drug and nutrient interactions. Medications may compromise nutrition status by altering absorption or increasing excretion of nutrients. Attention must be given to physiological declines in the senses of smell and taste. Poor dentition and improperly fitting dentures can affect food consumption. Elderly people who have suffered from strokes may have difficulty swallowing, causing inadequate food intake. Poverty, depression, alcoholism, and social isolation are important contributing factors to malnutrition. Special attention must be given to frail aging people who are recovering from illness to ensure that they are receiving enough calories as well as adequate amounts of other nutrients. Without both caloric and nutrient adequacy, the frail person can deteriorate rapidly. Therefore, nutritional supplementation in the form of liquid meal replacement or other fortified products may be necessary. For the overnourished and obese individual, nutritional support must provide high-quality, nutritious foods within a reasonable caloric intake to prevent further weight gain. Malnutrition as a result of poverty is exacerbated by lack of nutritional knowledge and poor food choices. Therefore, overall treatment of malnutrition involves addressing numerous psychosocial issues as well as the diet. —Wendy L. Stuhldreher, R.D. See also Aging; Alzheimer’s disease; Cancer; Cholesterol; Diabetes mellitus; Heart disease; Heart disease and women; Lactose intolerance; Nutrition and aging; Nutrition and women; Obesity; Obesity and aging; Osteoporosis; Vitamin supplements; Weight changes with aging. For Further Information: Rolfes, Sharon, Linda K. DeBruyne, and Eleanor Whitney. Life Span Nutrition: Conception Through Life. 2d ed. Belmont, Calif.: West/Wadsworth, 1998. Schlenker, Eleanor D. Nutrition in Aging. 3d ed. Boston: McGraw-Hill, 1998. Wardlaw, Gordon M. Perspectives in Nutrition. Boston: McGraw-Hill, 1999. Whitney, Eleanor N., and Sharon R. Rolfes. Understanding Nutrition. 8th ed. Belmont, Calif.: West/Wadsworth, 1999.
590 ✧ Malpractice
✧ Malpractice Type of issue: Economic issues, ethics Definition: The failure to care for patients in accordance with professional standards, for which injured patients are allowed to sue for compensation. As the word’s elements imply, “malpractice” simply means the poor execution of duties. The first recourse of a patient who feels inadequately cared for is to discuss the complaint with the doctor. This measure clears up many complaints, since most are based on simple misunderstandings. A patient receiving no satisfaction from the doctor may file a complaint with the state board of medical examiners, which is each state’s official government body, staffed by doctors, that issues medical licenses and disciplines physicians and surgeons. In both cases, the doctor or a panel of peers will decide if the patient’s complaint meets the professional standards of “poor.” A patient who is not pleased with this decision may bring suit in civil court. No patient, however, can press a lawsuit for malpractice simply because he or she feels wronged. For legal action to have any chance of succeeding, the doctor must have injured the patient because of negligent care. Even then, lawyers for the patient must rely on expert testimony from other doctors to establish that the physician gave the patient poor care. All official avenues of redress therefore depend on the medical profession’s own standards. The Requirements of Proper Care Four basic standards guide doctors in ethically performing their professional duties, and failure in any one of them may constitute malpractice. First, doctors must inform their patients about treatments for an ailment and receive their explicit consent. The patient must understand the doctor’s plan of treatment and any procedure’s potential risks and benefits; if a patient cannot understand because of age or mental condition, a guardian must consent, except in some emergency situations. The consent may be verbal unless an invasive technique, such as surgery, is involved, in which case the law requires a signed consent form. Without the patient’s consent, a physician performing a medical procedure not only may be subject to a malpractice lawsuit but also can be charged with assault under criminal law. Second, a doctor must treat a patient with reasonable skill, as defined by accepted medical practice. This point is crucial. Doctors do not have to render the best aid possible, or even the best aid of which they are capable; they must only meet professional guidelines for any specific diagnostic, palliative, or corrective measure. The concepts of “reasonable” and “ac-
Malpractice ✧ 591 cepted medical practice” vary among regions and schools of medicine. Rural physicians cannot be expected to give the level of care available in cities, since cities have more specialists available and support technology; nor are general practitioners expected to have the skill of a specialist, such as a cardiologist. Third, physicians are responsible for what other health care workers under their charge do to patients. If other doctors (such as medical residents), nurses, physical therapists, or medical technicians act on a doctor’s orders, that doctor is ultimately responsible for supervising their performance. Fourth, a doctor accepting responsibility for a patient enters a contractual obligation and may not abandon that obligation without either finding another physician to take his or her place or notifying the patient well in advance so the patient can engage another doctor. At the same time, however, the patient’s obligation is to follow the doctor’s medical advice. Types of Malpractice Litigation Doctors are not the only health care workers who can be charged with malpractice. If other medical personnel act as a team with a doctor or surgeon, they may also be held liable. For example, during surgery a surgeon is assisted by an anesthesiologist and various nurses, any of whom may separately fail in his or her duties and be sued as a result. Thus, whenever a patient suffers at the hands of a medical team, the trend has been to sue each member. Furthermore, if the facilities or personnel employed by a hospital prove substandard, the hospital itself may be liable. Tort liability and contractual responsibility govern the legal treatment of malpractice, both of which fall under civil law. This classification assumes that doctors inadvertently cause harm; if they intentionally injure a patient, they are subject to charges under criminal law. A patient may sue for breach of contract if his or her doctor has broken that contract—usually by abandoning the patient without proper notice. This sort of lawsuit is by far the least common. Tort liability means that the doctor is responsible for any injury (tort) caused to the patient through negligence. The patient may seek compensation for a tort by suing the doctor for damages. The presumption is that money, which is almost always the form of compensation sought, can make up for the harm done. Damages can be awarded for two types of injury. Concrete physical injury is the most typical, and damages may include money to cover medical bills, lost wages, convalescent care, and other expenses relating directly to the disability. A jury may also grant damages for pain and suffering, a difficult type of injury on which to place a price; such damages account for some of the largest monetary awards.
592 ✧ Malpractice The Costs of Malpractice Litigation Because damages may amount to millions of dollars, most doctors who lose a malpractice suit cannot hope to pay them without help. Insurance provides that help, which usually takes one of three forms. First, for monthly payments (premiums), traditional insurance companies offer policies to doctors that will guarantee money up to a certain amount to pay damages. Also, if its client is sued, the insurance company assigns attorneys who handle the legal negotiations and the defense in court. Second, hospitals or other large organizations may pay for malpractice damages from a pool of money reserved for that purpose alone. Third, doctors and other health care providers may set up an insurance company of their own for mutual coverage, often called “bedpan mutuals.” Malpractice litigation in the United States is a ponderous, expensive business. In the mid-1970’s, malpractice insurance began to rise sharply; between 1983 and 1985 alone, the cost increased 100 percent. Doctors pass on some or all of these costs to patients by charging higher fees. If a patient sues, however, the insurance cannot cover every type of loss. The amount of time that doctor must spend with lawyers, the time in court, and the overall distraction from practicing mean reduced earnings. Yet the cost is not only to the doctor. The plaintiff pays attorneys by contingency fee, which means that the attorney receives a percentage (usually 20 to 30 percent) of money from any settlement. A patient losing a suit still must pay the lawyer’s expenses, which can quickly amount to thousands of dollars. Finally, when suits reach court, public funds contribute to the court’s expenses, and those expenses climb if a decision is appealed or retried, as is sometimes the case. Patients and doctors alike complain that soaring malpractice litigation in the United States since 1960 has been destructive, introducing suspicion into the doctor-patient relationship. In addition to its emotional impact, the suspicion concretely affects medical practice, most medical economists claim. Because physicians fear lawsuits, they perform more diagnostic tests than are called for by medical protocols. Often the chances are remote that these tests will reveal any useful information, yet doctors order them to show that they have done everything possible for the patient if they are sued. The extra tests cost money, which either the patient or the insurance company must pay. In either case, the expenditures inflate the cost of medicine. The practice of such “defensive medicine” has also led some doctors to refuse to perform high-risk procedures except in hospitals that have extensive facilities. Obstetricians provide a signal case in point. Fearing lawsuits for any complications that may arise, many obstetricians will not deliver babies at home or in small hospitals, forcing rural patients to rush long distances to the nearest big-city hospital for delivery. Studies have found that only a fraction of injuries are ever compensated. Moreover, the system, based on adversarial disputation, seems hostile and
Malpractice ✧ 593 dauntingly complex to both patient and physician. Yet, although no one thinks it perfect, the system evolved in accordance with two widely held American attitudes toward regulation in general: It limits abuses, and it preserves professional autonomy. Attempts at Reform Estimates in 1993 claimed that defensive medicine had increased the annual cost of American health care from $10 billion to $36 billion. Combined with increasing fees for medical services and other costs, defensive medicine has helped drive up the cost of medical insurance. Because of these financing problems, legislatures around the country have tried to control the increasing numbers of malpractice suits with tort reform, arbitration or review panels, and legal fee limits. Tort reforms include a number of measures that modify the procedures or awards of malpractice litigation. Two reforms are designed to shorten the process. One method is to reduce the statute of limitations for malpractice claims— the period after injury when a lawsuit can be started. The second involves limiting the rules governing the discovery phase of pretrial action. Two further reforms restrict the amount of damages. The most popular of these is to impose maximum amounts for types of injury, especially pain and suffering. In the second reform, jury damages must be reduced by the amount of money from other sources, such as health insurance, that a patient receives for the injury. Several states have instituted review panels or required arbitration before a suit can proceed to court. Laypeople and judges, as well as doctors, make up the review panels, which try to identify and disallow frivolous suits. Arbitration panels actually decide on the amount of damages, if any, to be made, and their decisions cannot be appealed. Finally, some states, and the federal government, have limited the percentage of a settlement that lawyers can claim in contingency fees. The limits are intended to discourage lawyers from filing marginal suits. These reforms have only slowed the rate of lawsuits and the rise in the amount of money spent on paying damages and fees. Whatever its defects, the tort system has succeeded in making doctors wary of negligence. Critics insist, however, that the system for addressing malpractice has punished all physicians, not simply the incompetent, and has contributed to the increasingly litigious tenor of American society. —Roger Smith See also Death and dying; Ethics; Euthanasia; HMOs; Hippocratic oath; Hospitalization of the elderly; Iatrogenic disorders; Law and medicine; Living wills; Resuscitation.
594 ✧ Mammograms For Further Information: Edwards, Frank John. Medical Malpractice: Solving the Crisis. New York: Henry Holt, 1989. Edwards is a physician who began writing about malpractice after a suit was initiated against him. His approach is an intensely personal physician’s view of malpractice litigation—both its rationale and its effects on medicine. His writing is readable, often dramatic, and ruminative. Includes an excellent brief history of malpractice in English law. Groopman, Jerome E. Second Opinions: Stories of Intuition and Choice in the Changing World of Medicine. New York: Viking, 2000. Among other examples, Groopman describes the case of a woman with leukemia wrongly diagnosed as having asthma, a patient with melanoma who became the object of professional infighting about the availability and advisability of interferon treatment, and a young physicist told that he had fewer than six months to live and the ensuing tussle between specialists about the usefulness of bone marrow transplant. Isaacs, Stephen L., and Ava C. Swartz. The Consumer’s Legal Guide to Today’s Health Care: Your Medical Rights and How to Assert Them. Boston: Houghton Mifflin, 1992. Only the last chapter of this handbook pertains to malpractice; it contains a sensibly cautionary explanation of the basic procedures and concepts by Isaacs, a lawyer, and an example of physicians’ negligence suffered by Swartz, a journalist. The whole book, however, is a valuable resource for people uncertain of their rights during medical treatment. Sloan, Frank A., Randall R. Bovbjerg, and Penny B. Githens. Insuring Medical Malpractice. New York: Oxford University Press, 1991. This study is primarily economic. Evaluates objectively the methods for providing malpractice insurance and the industry’s share in the crises of the 1970’s and 1980’s in a presentation designed for policymakers who must decide how to control the system. Readers should come to the book with some understanding of the insurance industry and financing. Zobel, Hiller B., and Stephen N. Rous. Doctors and the Law: Defendants and Expert Witnesses. New York: W. W. Norton, 1993. Hiller, a judge, and Rous, a physician, give advice to physicians on how best to endure a malpractice suit. The step-by-step account of the legal proceedings, evidential requirements, and possible psychological effects on the physician make insightful reading for nonphysicians as well.
✧ Mammograms Type of issue: Medical procedures, prevention, women’s health Definition: A method of imaging that has become routine in the screening and diagnosis of breast cancer; the fundamental objective of mammography is the early detection of abnormalities in breast tissue.
Mammograms ✧ 595 Mammography has repeatedly proved to be the most effective procedure for the early detection of breast cancer. The objective of the examination is to provide optimal image quality for visualizing pathology, at the minimum possible risk to the patient. Mammography requires high-quality images to detect small breast cancers. It also requires greater sharpness and contrast than does general radiographic imaging. Mammography is an X-ray examination of the breast that produces a picture of breast structures on film. The image of the breast results from differential absorption of X rays by breast tissues, based on their density and thickness. With film-screen mammography, a light-intensifying screen is used to produce results with a low dosage of radiation. This is called a low-dose examination. The screen generates light when exposed to X rays; thus, it is principally the light that exposes the film. As a result, a relatively small number of X rays are required. Recent advances in X-ray film and light-intensifying screen technology have resulted in further reduction in the radiation dose to the breast. These developments permit the high resolution necessary for quality images. Film-screen mammography has the advantage of broad area contrast, which aids in the visualization of mass lesions in the breast. There are fewer technical failures with the film-screen imaging technique, reducing the need to retake images. Because of the narrow exposure latitude of the film-screen combination, the breast must be tautly compressed between rigid plates in an effort to reduce the thickness variations from front to back. This compression is also important in reducing the dosage of X rays needed for optimal imaging. The Fine Points of Mammography A screening mammography examination should consist of at least two views of each breast: a side view (also called lateral or oblique) and a top-down view (more technically referred to as craniocaudal). For film-screen mammography, the mediolateral-oblique is the most efficient single projection. This is a side view that is taken at a slight angle in an attempt to capture the advantages of both views with a single exposure to X rays. It depicts the greatest amount of breast tissue and includes the deeper structures found in the portion of breast nearest to the armpit. This is where the highest percentage of cancers occurs. A direct side view in conjunction with a craniocaudal view is essential to determine the exact location of a breast lesion that cannot be felt with the fingers. Although the chest wall is not included on the film-screen image, a properly performed mammography examination includes most or all of the breast tissue. Early detection of breast cancer depends on high-quality imaging techniques. Paramount among the imaging techniques for breast cancer detection is positioning of the person being screened. Optimal positioning is achieved by understanding the capabilities of the dedicated mammography
596 ✧ Mammograms equipment and applying this understanding to take full advantage of natural breast mobility in overcoming various anatomic limitations. Breast compression is one of the critical aspects of positioning in a mammography. Appropriate compression improves resolution by bringing breast structures closer to the film and by preventing breast motion. It also decreases the required radiation dose by reducing the thickness of the breast. Compression separates overlapping structures and aids in the differentiation of cystic and solid masses. Most patients accept the taut compression requirement for filmscreen mammography when they understand its importance. The degree of compression used feels tight and may be uncomfortable, but it should not be painful. The Benefits of Screening The first significant study to demonstrate the value of screening mammography was started in 1963 by the Health Insurance Plan of Greater New York. In this study, 31,000 women were screened annually using both mammography and physical examination and then compared to a control group of 31,000 women who sought medical attention only as the need arose. By 1975, the experimental group showed a 30 percent decrease in the rate of breast cancer mortality. A 1982 follow-up study continued to demonstrate a 23 percent decrease in death from breast cancer. A similar large-scale project was launched in Europe. The ongoing Two County Swedish Study evaluated more than 130,000 women, who were randomly assigned to either a mammography group or a control group. In the absence of a physical examination, the mammography group showed a 25 percent deAlthough the results are not always clear, mammograms crease in the rate of breast are still the best screening method for breast cancer. cancers that are stage II and beyond, as well as a 31 per(PhotoDisc)
Mammograms ✧ 597 cent reduction in breast cancer mortality. As the number describing the stage of cancer increases, the chances for long-term survival decrease. The benefits of a lower stage at the time of detection and reduced mortality result from screening mammography alone. This study obtained only one image for each mammogram to accomplish this benefit. Other investigations have shown that single-view mammography misses 8 to 11 percent of cancers. Thus, even greater benefit would probably have been achieved in the Swedish study had two-view mammography been utilized. Several large studies report the sensitivity of mammography in detecting breast cancer to be 86 to 95 percent. Of even greater consequence is that these studies demonstrate between 20 and 49 percent of breast cancers were detected solely by mammography. One should not conclude that physical examination is not necessary. Although mammography can detect the majority of breast cancers, there are some that elude X-ray detection yet may be detected by palpation with the fingers. The American Cancer Society recognizes the complementary nature of physical examination and mammography. It thus recommends clinical breast examination by a physician every three years between the ages of twenty and thirty-nine and annual examinations after the age of forty. The Cancer Society also encourages women to perform monthly breast self-examinations after age twenty, despite the fact that mortality reduction from this method has not been shown objectively. A major risk factor for breast cancer is aging. Multiple medical organizations—including the National Cancer Institute, American Medical Association, American College of Radiology, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, and College of American Pathologists—have compiled specific recommendations, which differ slightly, for the screening of asymptomatic women. They have all endorsed and accepted various parts of the recommendations put forth by the American Cancer Society, which currently recommends annual or biannual screening mammography between the ages of forty and forty-nine and annual mammograms after the age of fifty. This is an area of ongoing change and controversy. Individuals are best advised to consult with their own physicians. Overcoming Reluctance and Maintaining Quality Most women do not undergo screening mammography. Multiple research surveys reveal similar reasons for noncompliance. Both physicians and patients state that they avoid mammograms because of cost, fear of radiation exposure, doubts about the sensitivity of mammograms, and inconvenience. Another repeated reason given by patients for not having a mammogram is that their physicians did not recommend it. Yet, one out of four doctors has stated that some patients do not comply with his or her recommendations.
598 ✧ Mammograms Significant efforts are devoted to overcoming the barriers to screening, including cost reduction, increased physician and patient education, and implementation of mandatory reimbursement for screening mammography. It is essential that mammography be of high quality. To ensure this, the American College of Radiology Mammography Accreditation Program was begun in 1987. The program evaluates mammography equipment, radiation dose, and the qualifications of radiologists, radiologic technologists, and radiologic physicists. The goals of the program are to establish standards of quality for mammography and to provide a mechanism for radiologists to compare their own performance with national standards. Further, the program seeks to collect and disseminate data on the current practice of mammography, to encourage quality assurance practices in mammography, and to ensure reproducible high-quality images at a low radiation dose to the patient. The program has been designed to make the accreditation process instructive, encouraging compliance while pointing out potential deficiencies in mammography practice. A successful review of the facility results in accreditation for a period of three years, after which reevaluation is necessary. If there are no accredited facilities nearby, the American College of Radiology advises women to choose one that possesses all the following qualities and credentials, because such a facility is likely to produce good images with minimal radiation exposure. The radiologist should be certified by the American Board of Radiology. Technologists should be certified by either the American Registry of Radiological Technologists or their state licensing board. Equipment used to produce mammograms should be specifically designed for breast imaging and should be calibrated, at least once a year, by a certified radiologic physicist. Both radiologists and technologists should have taken special courses or additional training in mammography. Finally, the radiologist who performs the mammography procedure should do so often as a regular part of practice. —Stan Liu, M.D., and Lawrence W. Bassett, M.D.; updated by L. Fleming Fallon, Jr., M.D., M.P.H. See also Breast cancer; Breast surgery; Cancer; Mastectomy; Preventive medicine; Radiation; Screening; Women’s health issues. For Further Information: Gamagami, Parvis. Atlas of Mammography: New Early Signs in Breast Cancer. London: Blackwell Science, 1996. This interesting book provides many examples of mammogram images that will help laypeople to understand a mammogram. Homer, Marc J. Mammographic Interpretation: A Practical Approach. 2d ed. New York: McGraw-Hill, 1997. This book is not intended to be a scholarly text.
Mastectomy ✧ 599 Rather, it is designed as an easy-to-follow guide and directly focuses on the day-to-day needs of the working radiologist. It is a faithful translation into print of Homer’s popular, successful postgraduate mammography course. Jatoi, Ismail. Breast Cancer Screening. New York: Chapman & Hall, 1997. The controversial area of mammographic screening of women under the age of fifty is addressed by Dr. Kopans, who argues in favor of screening, and by Dr. Jatoi, who argues against screening. Dr. Kopans’ chapter includes an interesting history of National Cancer Institute (NCI) decrees and the inconsistencies in NCI policies. Kinne, David W., ed. Multidisciplinary Atlas of Breast Surgery. Philadelphia: Lippincott-Raven, 1997. Both professional and general readers will find this text to be useful. Five breast surgeons, two radiologists, four plastic surgeons, two pathologists, and one radiation oncologist have joined forces to present their primary techniques for breast surgery pertaining to cancer and subsequent reconstruction. An abundance of quality illustrations enhance the highly detailed text, which includes helpful tips, potential pitfalls, and guidance for special cases. Kopans, Daniel B., ed. Breast Imaging. Philadelphia: Lippincott-Raven, 1998. This volume is well written and comprehensive as well as being an important reference in the field. Each chapter includes extensive scientific documentation with references to the literature, both classic and up-to-date. Thoughtfully organized, beginning with the anatomy, histology, and physiology of breast cancer, followed by an epidemiology of the disease.
✧ Mastectomy Type of issue: Medical procedures, mental health, treatment, women’s health Definition: A surgical procedure for the treatment of breast cancer in which one or both breasts are removed. The type of breast cancer with which a woman is diagnosed can have a major influence on treatment choices. Essentially, breast cancer exists in two major forms, corresponding to the two basic functional units of the breast: the lobules and the ducts. Under each of these categories, there are two major subdivisions: invasive and in-situ (also called noninvasive). As a general rule, noninvasive breast cancer is unlikely to spread, whereas the invasive type is made up of cells that are often able to spread to local lymph nodes and/or to other parts of the body. Because of this, as well as many other factors, noninvasive breast cancer is treated differently from invasive breast cancer.
600 ✧ Mastectomy Mastectomy Versus Lumpectomy and Radiation During the 1970’s and 1980’s, research studies were conducted throughout the world that changed scientists’ understanding of the disease and its treatment. The largest was conducted in the United States and was called the National Surgical Adjuvant Breast and Bowel Project (NSABP) Trial B-06. It was founded by Bernard Fisher, a surgeon who believed that it was not necessary to remove the entire breast to treat breast cancer effectively. The B-06 trial began in the mid-1970’s and represented a radical departure from the belief of most surgeons that breast cancer spread systematically from the breast to the lymph nodes to other parts of the body, and that if the breast and lymph nodes were removed quickly enough, the patient could be potentially cured of the disease. Fisher believed that breast cancer cells were unique in their ability to spread and that if the cancer had the biological characteristics to do so, it could spread to other parts of the body without necessarily being present in the lymph nodes. He further theorized that as long as the tumor was removed from the breast, the patient would do just as well as if she had her entire breast removed. To test his theories, women and their doctors were asked to participate in the B-06 study. This research study started out by identifying patients who had been diagnosed with invasive breast cancer but had not yet been treated for the disease. To participate, all women had to have been diagnosed within thirty days of entry into the trial. More than eighteen hundred women throughout the United States agreed to participate in the B-06 research study. The participants agreed to accept, by chance, one of three treatments for their disease: lumpectomy, lumpectomy with radiation treatment to the breast, or mastectomy. A lumpectomy refers to the removal of a lump with a rim of normal breast tissue around it; oftentimes, this is accomplished at the time of the biopsy to diagnose the cancer. All women had the lymph nodes under their arm removed. Radiation therapy was given five days a week for about six weeks if a woman was assigned to the radiation therapy group. Any woman in any group who had positive lymph nodes (nodes to which the tumor had spread) had chemotherapy to kill tumor cells that may have spread beyond the lymph nodes to other parts of the body. The patients were then followed closely by their doctors to monitor for tumor recurrence, just as any breast cancer patient would be. At the end of five years, the percentage of women who were alive and who had no sign of the tumor returning to parts of the body separate from the breast was checked in each group. The percentages were the same in each group, proving that Fisher’s theory was correct for at least a five-year follow-up. These results were made known to the medical world in 1985. In 1988, eight-year follow-up results showed that the percentage of women in each group who were alive with no sign of the tumor returning in parts of the body separate from the breast was the same. An important finding, however, was that women in the group that had lumpectomy alone
Mastectomy ✧ 601 had breast cancer recur in the breast almost half of the time; treatment for this recurrence meant a mastectomy in most cases. In the group that had a lumpectomy with the addition of radiation therapy, only 10 percent of the patients had cancer come back in the breast after eight years of follow-up. The women who had a mastectomy obviously could not have breast cancer recurrence, but about 8 percent had tumor recurrence in the mastectomy incision or on the chest wall. Many women are surprised to learn that breast cancer can recur at the surgical site even if they choose a mastectomy. In summary, the NSABP B-06 trial demonstrated that equal results could be achieved with breast preservation techniques (lumpectomy plus radiation therapy) as compared with mastectomy. Lobular Carcinoma In-situ Lobular carcinoma in-situ (LCIS), or noninvasive lobular carcinoma, is viewed by most pathologists and breast cancer specialists as a “marker” for the development of breast cancer in the future, rather than as a true cancer that needs to be treated aggressively. Most of the time, LCIS does not form a lump in the breast, nor does it appear as an abnormality on a mammogram. Instead, it is usually found incidentally when a woman has a breast biopsy for any one of a number of different reasons. Although the number of studies about this disease is low, almost all that exist demonstrate that about 30 percent of women diagnosed with LCIS will develop this cancer in the breast that had the original diagnosis of LCIS, the rest in the opposite breast. In addition, about half of the women develop the lobular form of breast cancer, the other half the ductal form. If a woman is examined by a health care provider every four or six months and is willing to undergo yearly mammography, many breast specialists will suggest that the woman needs no treatment for LCIS but does need close follow-up. The only other logical treatment, if a woman either cannot be followed closely or if she chooses to have treatment, is bilateral mastectomies, meaning the removal of both breasts. Ductal Carcinoma In-situ Ductal carcinoma in-situ (DCIS), intraductal carcinoma, and noninvasive ductal carcinoma all refer to the same process: cancer that arises from the duct but that has not spread outside it. DCIS is being increasingly diagnosed. Unfortunately, it is a much more serious kind of cancer than LCIS. It is not, however, nearly as serious as invasive breast cancer. DCIS can present as a lump in the breast, but more commonly it presents as a mammographic abnormality exclusively. DCIS is considered an early form of breast cancer, but there are many subtypes of it, and some behave more aggressively than others.
602 ✧ Mastectomy In the past, most women who were diagnosed with DCIS had the involved breast removed. The only way, then, to do research to determine what would happen to women who were diagnosed with DCIS who did not have mastectomy was to review thousands of slides of benign biopsy results and find cases where the proper diagnosis was actually DCIS. Predictably, only a few cases could be found that would fall into that category. Those women were then contacted to establish what had happened to them. The studies show that an average of about 40 percent of women had breast cancer recur in the breast; of those who did, almost all represented the ductal type of breast cancer, and almost all recurred not only in the same breast but also in the same part of the breast as the original diagnosis. Because of these findings, the treatment recommendations for DCIS are totally different than those for LCIS. One of the biggest problems with DCIS is that the optimum treatment is currently unknown. For many years, breast removal was considered curative, and in the great majority of women, it was, and still is. Many surgeons seriously question, though, whether removal of the entire breast is necessary in cases of DCIS, especially because the NSABP B-06 data revealed breast preservation to be equivalent to mastectomy for most patients with a much more aggressive type of breast cancer—the invasive type. Currently, clinical trials are underway to try to help sort out the treatment dilemmas faced by patients and their surgeons regarding the best treatment for DCIS. Invasive Breast Cancer Invasive breast cancer is the most common type of breast cancer diagnosed, and the ductal variety is by far the type that affects most of these women. Much is known about the optimal treatment of the invasive disease. The basic surgical decision to be made is whether an individual woman is eligible for breast preservation; almost all women are eligible for the mastectomy option. About 75 percent (or more) of women are candidates for breast preservation; the National Cancer Institute has issued a statement that breast preservation is the preferred treatment in most women with breast cancer, whether it had spread to the lymph nodes or not. Factors that may disqualify a patient from breast preservation therapy include pregnancy, previous radiation therapy to the breast, no radiation treatment center available, more than one cancer in the breast, or a tumor size in relation to breast size that would make the cosmetic results undesirable. For those who require or desire mastectomy, immediate or delayed reconstruction is an option that many women choose. Many also choose a mastectomy alone. To find out the best treatment options available, women are advised to consult with surgeons experienced in breast preservation therapy, as well as with one or more radiation oncologists. It is especially helpful to seek the opinion of the entire team of treating physicians prior to making a final
Mastectomy ✧ 603 decision about what treatment choice is preferred. This team includes a surgical oncologist or general surgeon, a radiation oncologist, a medical oncologist, and often a plastic surgeon. These physicians will work together to provide recommendations most optimal for an individual patient. Second opinions are to be encouraged. Advances in Breast Cancer Treatment Until the mid-1980’s, most women who were diagnosed with breast cancer presented to their doctors with a self-discovered breast lump or were found to have a mass in the breast on a routine breast examination. Thinking that this situation represented a true medical emergency, women were often advised to have surgery within one to two days, so that the cancer would have minimal opportunity to spread. The routine at that time was to perform almost all surgical procedures as inpatient procedures under general anesthesia. The women were almost always asked to sign a consent form that read similar to “breast biopsy possible modified radical mastectomy.” With this consent, the woman gave her permission to have her breast removed if the lump proved to represent cancer. Since that time, much has been learned about the biology of breast cancer—how it grows, when it might spread, and how quickly it does so. This knowledge has changed the approach to the diagnosis and treatment of the disease. At the same time, the American Cancer Society began an active campaign to promote screening mammography as a method to detect breast cancer earlier than it might be felt as a lump in the breast. In one large study, called the Breast Cancer Detection and Demonstration Project (BCDDP), 40 percent of women diagnosed with breast cancer were diagnosed solely on the basis of mammography, 45 percent of the women had both an abnormal physical exam and an abnormal mammogram, and 15 percent of the women with breast cancer had an abnormal physical examination but a normal mammogram. Mammograms are great tools for helping to detect breast cancer in early stages, but they are not fool-proof. Any woman with a breast lump needs to have it evaluated, even if the mammogram result is “normal.” As mammography came into more widespread use, and tumors were diagnosed that were smaller in size, it became more difficult for pathologists to tell surgeons whether the small abnormality removed really represented cancer while the patient was still in the operating room. This change contributed to the trend toward diagnosing the lump or abnormal mammogram during one operation, and treating the cancer in a separate operation. Consequently, a woman was given some time to think about the fact that she had cancer, to learn about the disease and to ask questions about it, and to learn about her treatment options. It also allowed her time to make arrangements for an upcoming hospitalization for breast cancer treatment. Concurrent with this trend was the increased understanding that breast
604 ✧ Medications and the elderly cancer grows much more slowly than was originally thought. Most breast cancer experts agree that the first cancerous cell that appears in the breast is probably present about eight to ten years before it can be detected, even by mammography. This knowledge has contributed to the understanding that it is perfectly safe to treat breast cancer within a few days or weeks after the diagnosis, after the patient and family have had time to absorb the diagnosis and get answers to their questions. —Janet Rose Osuch, M.D. See also Breast cancer; Breast surgery; Cancer; Chemotherapy; Mammograms; Radiation; Women’s health issues. For Further Information: Baker, Lawrence H. “Breast Cancer Detection Demonstration Project: FiveYear Summary Report.” CA: A Cancer Journal for Clinicians 37 (1987): 194. Ball, Adrian Shervington, and Peter M. Arnstein. Handbook of Breast Surgery. London: Edward Arnold, 1999. Kushner, Rose. Alternatives. Cambridge, Mass.: Kensington Press, 1984. Love, Susan M. Dr. Susan Love’s Breast Book. 3d ed. Reading, Mass.: AddisonWesley, 2000.
✧ Medications and the elderly Type of issue: Elder health, treatment Definition: The use of drugs to alleviate physical and mental ailments and diseases. Older people are the largest users of prescription medications; in fact, 50 percent of all drug consumption is attributed to them Misuse of Drugs Belief by the aged and the population at large that there is a “magic bullet” for every complaint is widespread. Elders living at home consume between three and seven drugs daily, whereas those living in nursing homes take, on average, four to seven different medications. In addition, when five or more drugs are ingested, the incidence of drug poisoning rises 50 percent; when eight or more are taken together, the incidence rises 100 percent. Overuse, underuse, and erratic use of medications constitute a major problem among older people. Between 12 and 17 percent of hospital admissions among elders involve adverse drug reactions. Of these, approximately 80 percent are reactions from commonly prescribed medications.
Medications and the elderly ✧ 605 Drugs for mental and nervous system disorders are among the ten most prescribed drugs, yet these disorders account for less than 7 percent of problems in older people. It is estimated that 40 percent of older people living in their own homes experience drug reactions. Overdoses involving barbiturates, sedatives, tranquilizers, and alcohol are common occurrences. Physical Changes of Aging It is well known that absorption, distribution, metabolism, and elimination of medications markedly differ in older persons. As a person ages, lean body mass, decreased functional tissue, and an increased number of fat deposits create differences in the ability of the body to use standard doses of drugs. Chemical changes in the body also affect how drugs act on the body. The type, the intensity, and the duration of drug action depend on these changes. The time required for medication to enter the general circulation is termed absorption. In older people, change in gastric motility seems to be the one factor that influences absorption. Increase or decrease in movement of medications through the digestive tract may enhance or interfere with their purpose. For example, coated tablets may pass through the digestive tract slowly and be delayed too long. Because of the delay, their action may inadvertently begin in the stomach, causing nausea and irritation. Distribution, or transport, depends on a healthy circulatory system. Some older people have decreased cardiac output and sluggish circulation that may delay delivery of medication to the target site, retard the release of a drug from storage tissue, and stall excretion of a drug. A drug like Coumadin (warfarin), a common blood thinner, attaches to protein in the blood. Some is available for use, and some stays bound to the protein. Older people have less protein in the blood, so more drug freely circulates, creating a climate of potential toxicity. As a result, the dose of a proteinbound drug like Coumadin may need to be adjusted downward to avoid too much circulating drug. Also, a person in a poor nutritional state, with poor protein reserves, would need close monitoring to derive benefit from or avoid an adverse reaction to a drug such as Coumadin. The vehicle through which a medication is delivered is important. Medicines come in various forms, such as capsules, coated beads, layered tablets, or plastic matrix tablets. Drugs are prepared by manufacturers in a certain way to provide the most therapeutic effect—to make certain that an accurate dose reaches the target area. Altering the form in any way may change drug effects or destroy their effectiveness altogether. Medications are prepared with special coatings or substances to avoid destruction by stomach acid. Crushing or manipulating tablets meant for sustained release spills all of a drug in one location and destroys its intended long-acting effect. In older people, the amount of fatty tissue increases in relation to a
606 ✧ Medications and the elderly decrease in muscle mass. Vitamins such as A, D, E, and K are fat-soluble. Fat-soluble medications are stored and not readily passed, leading the way to toxic accumulation. Generally these vitamins must be taken with food to ensure more efficient absorption and distribution in the body. Older people who take vitamin A, D, E, and K supplements freely subject themselves to serious consequences. Vitamins A, D, and E are sold in various forms over the counter. Elders should seek the advice of a physician, pharmacist, or nurse before taking fat-soluble supplements. Relative body water declines in older people. When there is a decrease in relative body water, drug levels are elevated and sustained. This means that water-soluble drugs are not distributed evenly or adequately. Cimetidine (Tagamet), a drug sold over the counter and frequently taken by elders for gastric irritation, is water-soluble. Digoxin, a frequently prescribed heart medication, is also water-soluble and must be closely monitored in older adults. Elders must drink plenty of fluids and remain well hydrated to derive benefit from these drugs. Each person metabolizes medications in a unique way. Genetic differences and ethnic variations explain why people react to drugs in different ways. Body composition, weight, and gender, as well as nutritional status and disease, determine how drugs are metabolized. Smokers metabolize drugs more rapidly and experience both adverse and toxic drug effects. The liver is the organ that breaks down, detoxifies, and removes by-products of drugs metabolized by the body. Decreased blood flow through the liver decreases metabolism, which means that ingested drugs will stay in the body longer. Because common drugs such as acetaminophen (Tylenol) and ibuprofen (Advil or Motrin)—two widely used drugs for pain—are detoxified in the liver, they must be taken with caution and only when needed. Routine use of these common over-the-counter (OTC) medications should be discouraged as their excessive use can cause irreversible liver damage. Most drugs are excreted in the urine, some in the bile. Antibiotics and some cardiac drugs are excreted solely by the kidneys. Kidney function is very important in older adults, as toxic accumulation of drug by-products, particularly antibiotics, can cause retention of substances that will damage kidneys. Diuretics are drugs that remove water from the body and decrease the amount of fluid circulating in the bloodstream. Many older people take diuretics as treatment for high blood pressure and other heart ailments. When taking these drugs, timing and hydration are two important factors. “Water pills” should be taken in the morning and not in the evening to accommodate frequent trips to the bathroom and allow for undisturbed sleep. Drinking water, decaffeinated beverages, and citrus juices restores the chemical balance in the body, keeps the older adult well hydrated, and prevents kidney problems as well as erratic heartbeat. Because of visual and perceptual changes associated with aging, older people often confuse pill colors or misinterpret shapes. Some elders cannot
Medications and the elderly ✧ 607 read the small print of drug labels. Impaired hearing and unclear instructions by health care providers preclude proper timing of medications. Lapses in memory interfere with routine dosing and aggravate existing symptoms. Stiff hands make opening bottles difficult. Some elders skip meals, especially when alone, and inadvertently skip medications ordinarily taken with meals. Some medications have embarrassing side effects that cause older people to eliminate doses when away from home or when at social gatherings. Polypharmacy The use of multiple medications is common among older adults. Some older people see many doctors for a variety of ailments. In doing so, the risk of hoarding a variety of medications that interact and cause unfavorable results is likely. Elders take OTC medications as well as prescription drugs and are often unaware of potential toxic effects. Laxatives interfere with the action of blood pressure drugs, and calcium-based antacids and those containing aluminum and magnesium cut the absorption rate of tetracycline antibiotics by 90 percent. Use of OTC medications can also mask signs of serious infection or serious undiagnosed disorders. Some OTC medications, like inhaled sprays used to relieve temporary symptoms of asthma, are dangerous in diabetics and those with high blood pressure. The underlying airway disease remains undiagnosed, and the OTC medications can cause fatal reactions such as cardiac arrest or diabetic coma. Necessary Information For satisfactory treatment it is important to know how often a person sees a physician, what medications are prescribed from all sources, and what OTC medications the older person is taking. Equally important are questions about herbal remedies. Diverse populations of elders follow cultural preferences and do not consider herbs “medicines.” In the same vein, most older adults do not include vitamin and mineral supplements in the category of medicines. Therefore, it is important to ask older people on a daily basis what drugs prescribed they take, how often they take them, and what vitamin and mineral supplements and OTC medications are in their arsenal of self-medication. “Back-fence” is a term used to describe the common practice of sharing medications among friends, relatives, and neighbors. Elders share information with neighbors who often have a prescribed remedy that seems to suit the symptom. Sharing medications follows among friends, neighbors, and family members. However well intended, this sharing can have dire consequences. Some clinics that follow an older clientele have so-called brown bag days.
608 ✧ Medications and the elderly Elders are asked to put all medicines they have at home in a brown paper bag and bring them to the clinic for review. Expired drugs, different doses of the same prescribed drugs, herbal remedies, and OTC drugs are commonly found by health care personnel. Elderly clients are advised to throw away expired medications, keep the most recently prescribed dose of the one-and-the-same drug, and dispose of all other multiple doses. They are also asked questions about their herbs and OTC medications. Because of vision changes and cultural differences, labels should be read and questions asked if information is unclear. Communication problems lead to drug problems. Medication problems increase with the use of multiple pharmacies and physicians. Some pharmacies have a central repository of information that can locate all medications prescribed for one person. To some degree this controls duplication and provides the margin of safety needed. However, it does not record OTC medications or information on supplements. A close relationship with a local pharmacist is wise. Printed information given to elders at the time of drug dispensing is helpful. At that time, the pharmacist should review side effects of the medication; discuss when and how to take it; alert the older person to prominent adverse effects; and advise the person to seek medical advice if any unusual changes in feeling, behavior, or function occur. Preventing Problems Several strategies can be used to decrease adverse interactive effects of medications associated with the normal physical changes of aging and ensure a smooth therapeutic course. If an older person takes multiple medications, a pill box that holds a seven-day supply is a good idea. The box is labeled by day of the week, and the compartments of the box are loaded once a week. Each compartment can be opened only on the day of the week marked and at the preset time the medicine is to be taken. Another method to ensure accuracy is a check-off chart. Medicine bottles are color-coded with colors easily identified by the older person. The chart lists the name of the medication in the same color as the medicine bottle. When the medicine is taken, the chart is checked off. Elders should be advised to take medications on time. If a dose is missed, it is inadvisable to double up on the medicine. The dose should be taken as soon as remembered and the next dose rescheduled according to the time frame prescribed. Medicines retain their potency when stored in cool, dry places, unless otherwise directed. The worst place to store medicines is in the bathroom medicine cabinet, where humidity will either decompose the drug or decrease its potency. Dark containers prevent light from entering and thus prevent medicines from decomposing. Elders should not change contain-
Meditation ✧ 609 ers. In this same vein, it is inadvisable to mix old and new medicines. Elders are advised to use all pills contained in one bottle and to dispose of expired or hardly used medicines. Potency ensures therapeutic effect; expired drugs are not efficacious. The best advice to elders is to be aware of what to do if feeling poorly after ingesting medications. Phone numbers of the pharmacist, physician, or nurse should be readily available for quick reference. —Maureen C. Creegan See also Addiction; Aging; Malnutrition among the elderly; Nutrition and aging; Overmedication; Poisoning; Vitamin supplements. For Further Information: Graedon, Joe, and Teresa Graedon. The People’s Pharmacy. Rev. ed. New York: St. Martin’s Press, 1996. Chapters provide information on OTC medications, drug and food allergies, self-medicating, and interactive effects of OTC drugs and prescribed drugs. Hussar, Daniel A. Drug Interactions in the Elderly. East Hanover, N.J.: Sandoz Pharmaceuticals, 1991. Booklet prepared by a pharmaceutical company on mechanisms of drug interaction in the elderly, with attention to OTC interactions. Multiple tables and charts of drug-to-drug interactions are provided. Marsa, Linda, and Hillary Broome. “Hey, Who Needs a Prescription?” Los Angeles Times 115, Mag. 10 (September 29, 1996). A comprehensive discussion by physicians, pharmacists, and pharmacologists of over-thecounter medication misuse and abuse. Suggestions for proper use of OTC drugs and prevention of interactive effects as well as warnings are presented. Pronsky, Zaneta M. Powers and Moore’s Food-Medication Interactions. 11th ed. Birchrunville, Pa.: Food-Medication Interactions, 2000. Spiral-bound pocket guide that offers information about specific drugs and how food and nutritional status can effect older people on multiple medications. U.S. Department of Health and Human Services. Using Your Medicines Wisely: A Guide for the Elderly. Rockville, Md.: U.S. Government Printing Office, 1990. Free booklet of tips on “dos and don’ts” for older people. A handy pocket guide with helpful information on how to take medications and pitfalls to avoid.
✧ Meditation Type of issue: Mental health Definition: A mental exercise that may be used in stress reduction.
610 ✧ Meditation A wide variety of methods are employed in the different schools of meditation (as varied as Anglican and Zen). All these methods aim toward the concentration of the mind and the mastery of both external and internal distractions. A certain bodily posture may be employed, such as kneeling or sitting. A particular activity may be used, such as speaking (chanting a hymn or mantra, repeating a specific syllable), gazing (staring at an object to focus attention, such as a candle, a cross, a circle, or a spot), and breathing (rhythmically exhaling and inhaling). These exercises can be done either privately or publicly with a tutor or master. Meditation experts suggest that it occur daily, at set times (usually morning, noon, and evening) and for a duration of at least ten to twenty minutes per session. A conducive environment, free of audible and visual distractions, is preferred. The Increase of Medical Interest in Meditation Although meditation has been an integral part of the Western spiritual tradition, it was regarded with indifference by the medical profession until the birth of modern psychology. Scholars such as William James (18421910), an American physician and psychologist, suggested that it might be worth study. Recent empirical studies have indicated that meditation does have a regenerative impact on the body, reducing tension, the heart rate, blood pressure, and the consumption of oxygen while increasing the production of alpha waves in the brain. With the increased interest in stress reduction and anxiety control, meditation will have a more important role in health care in the future. Though long connected with religion as a preparation for contemplation (deep reflection on a theological issue) and prayer (personal conversation with God), meditation can be practiced for its psychological benefits apart from involvement within a faith tradition. By the 1960’s, the Maharishi Mahesh Yogi had popularized Transcendental Meditation (TM) in the Western world as a means of reducing stress, enhancing the quality of life, and fulfilling one’s potential. —C. George Fry See also Alternative medicine; Biofeedback; Hypnosis; Stress; Yoga. For Further Information: Davis, Martha, Elizabeth Robbins Eshelman, and Matthew McKay. The Relaxation and Stress Reduction Workbook. 3d ed. Oakland, Calif.: New Harbinger, 1988. Thondup, Tulku. Boundless Healing: Meditation Exercises to Enlighten the Mind and Heal the Body. Boston: Shambhala, 2000. Umlauf, Mary Grace. Healing Meditation. Nurse as Healer Series. Albany, N.Y.: Delmar, 1996.
Memory loss ✧ 611
✧ Memory loss Type of issue: Elder health, mental health Definition: An impairment of memory which may be total or limited, sudden or gradual. Memory impairment is a common problem, especially among older people. It occurs in various degrees and may be associated with other evidence of brain dysfunction. Amnesia is complete memory loss. In benign forgetfulness, the memory deficit affects mostly recent events; it seldom interferes with the individual’s professional activities or social life. Benign forgetfulness is selective and affects only trivial, unimportant facts. For example, one may misplace the car keys or forget to return a phone call, respond to a letter, or pay a bill. Cashing a check or telephoning someone with whom one is particularly keen to talk, however, will not be forgotten. The person is aware of the memory deficit, and written notes often are used as reminders. Patients with benign forgetfulness have no other evidence of brain dysfunction and maintain their ability to make valid judgments. Types of Dementia In dementia, the memory impairment is global, does not discriminate between important and trivial facts, and interferes with the person’s ability to pursue professional or social activities. Patients with dementia find it difficult to adapt to changes in the workplace, such as the introduction of computers. They also find it difficult to continue with their hobbies and interests. The hallmark of dementia is no awareness of the memory deficit, except in the very early stages of the disease. Although patients with early dementia may write themselves notes, they usually forget to check these reminders or may misinterpret them. For example, a man with dementia invited to dinner at a friend’s house may write a note to that effect and leave it in a prominent place. He may then go to his host’s home several evenings in succession, forgetting that he already has fulfilled this social engagement. As the disease progresses, patients are no longer aware of their memory deficit. In dementia, the memory deficit does not occur in isolation but is accompanied by other evidence of brain dysfunction, which in very early stages can be detected only by specialized neuropsychological tests. As the condition progresses, these deficits become readily apparent. The patient is often disoriented regarding time and may telephone relatives or friends very late at night. The disorientation affects the patient’s environment: A woman with dementia may wander outside her house and be unable to find her way back, or she may repeatedly ask to be taken back home when she is already
612 ✧ Memory loss there. In later stages, patients may not be able to recognize people whom they should know: A man may think that his son is his father or that his wife is his mother. This stage is particularly distressing to the caregivers. Patients with dementia may often exhibit impaired judgment. They may go outside the house inappropriately dressed or at inappropriate times, or they may purchase the same item repeatedly or make donations that are disproportional to their funds. Alzheimer’s disease is one of the most common causes of dementia in older people. Multiple infarct dementia is caused by the destruction of brain cells by repeated strokes. Sometimes these strokes are so small that neither the patient nor the relatives are aware of their occurrence. When many strokes occur and significant brain tissue is destroyed, the patient may exhibit symptoms of dementia. Usually, however, most of these strokes are quite obvious because they are associated with weakness or paralysis in a part of the body. One of the characteristic features of multiple infarct dementia is that its onset is sudden and its progression is by steps. Every time a stroke occurs, the patient’s condition deteriorates. This is followed by a period during which little or no deterioration develops until another stroke occurs, at which time the patient’s condition deteriorates further. Very rarely, the stroke affects only the memory center, in which case the patient’s sole problem is amnesia. Multiple infarct dementia and dementia resulting from Alzheimer’s disease should be differentiated from other treatable conditions which also may cause memory impairment, disorientation, and poor judgment. Other Causes of Memory Loss Depression, particularly in older patients, may cause memory impairment. This condition is quite common and at times is so difficult to differentiate from dementia that the term “pseudo-dementia” is used to describe it. One of the main differences between depression that presents the symptoms of dementia and dementia itself is insight into the memory deficit. Whereas patients with dementia are usually oblivious of their deficit and not distressed (except those in the early stages), those with depression are nearly always aware of their deficit and are quite distressed. Patients with depression tend to be withdrawn and apathetic, given a marked disturbance of affect, whereas those with dementia demonstrate emotional blandness and some degree of lability. Amnesia is sometimes seen in patients who have sustained a head injury. The extent of the amnesia is usually proportional to the severity of the injury. In most cases, the complete recovery of the patient’s memory occurs, except for the events just preceding and following the injury. Memory impairment is a serious condition which can interfere with one’s ability to function independently. Every attempt should be made to identify
Meningitis ✧ 613 the underlying condition because, in some cases, a treatable cause can be found and the memory loss reversed. Furthermore, it may soon be possible to arrest the progress of amnesia and memory loss and even to treat the dementias which now are considered as irreversible, such as Alzheimer’s disease and multiple infarct dementia. —Ronald C. Hamdy, M.D., and Louis A. Cancellaro, M.D. See also Aging; Alzheimer’s disease; Dementia; Depression; Depression in children; Depression in the elderly; Sleep disorders; Stress; Strokes. For Further Information: Cummings, Jeffrey L., and D. Frank Benson. Dementia: A Clinical Approach. 2d ed. Boston: Butterworth-Heinemann, 1992. Cummings, Jeffrey L., and Bruce L. Miller, eds. Alzheimer’s Disease. New York: Marcel Dekker, 1990. Hamdy, Ronald C., et al., eds. Alzheimer’s Disease: A Handbook for Caregivers. 3d ed. St. Louis: Mosby Year Book, 1998. Terry, Robert D., ed. Aging and the Brain. New York: Raven Press, 1988. West, Robin L., and Jan D. Sinnott, eds. Everyday Memory and Aging. New York: Springer-Verlag, 1992.
✧ Meningitis Type of issue: Epidemics, public health Definition: An inflammation of the meninges of the brain and spinal cord. The meninges is the three-layered covering of the spinal cord and brain. The layers are the outer dura mater, inner pia mater, and middle arachnoid. Meningitis is the inflammation or infection of the arachnoid and pia mater. It is characterized by severe headaches, vomiting, and pain and stiffness in the neck. These symptoms may be preceded by an upper-respiratory infection. The age of the patient may affect which signs and symptoms are displayed. Newborns may exhibit either fever or hypothermia, along with lethargy or irritability, disinterest in feeding, and abdominal distension. In infants, examination may find bulging of the fontanelles (the soft areas between the bones of the skull found in newborns). The elderly may show lethargy, confusion, or disorientation. As pressure in the skull increases, nausea and vomiting may occur. With meningococcal meningitis, a rash of pinpoint-sized or larger dots appears.
614 ✧ Meningitis Types of Meningitis Most cases of meningitis are the result of bacterial infection. These cases are sometimes referred to as septic meningitis. The bacteria invade the subarachnoid space and may have traveled from another site of infection, having caused pneumonia, cellulitis, or an ear infection. It is unclear if the bacteria make their way from the original area of infection to the meninges by the bloodstream or the lymphatic system. Once they have entered the subarachnoid space, they divide without inhibition since there is no impediment posed by defensive cells, as the cerebrospinal fluid (CSF) contains very few white blood cells to inactivate the bacteria. More rarely, some bacteria may be introduced into the area by neurological damage or surgical invasion. The most common cause of bacterial meningitis in adults and older children is meningococcus. The incidence of meningococcal meningitis is 2 to 3 cases per 100,000 people per year; it most often affects schoolchildren and military recruits. Haemophilus influenzae is the most common culprit infecting babies between two months and one year of age. Complications or residual effects often follow bacterial meningitis, including deafness, delayed-onset epilepsy, hydrocephalus, cerebritis, and brain abscess. In addition, for several weeks after resolution of the disease the patient may experience headaches, dizziness, and lethargy. Aseptic meningitis is meningitis attributable to causes other than bacteria. These causes include neurotropic viruses, such as those that cause poliomyelitis or encephalitis; other viruses such as those that cause mumps, herpes, mononucleosis, hepatitis, chickenpox, and measles; spirochetes; bacterial products from brain abscesses or previous cases of bacterial meningitis; and foreign bodies, such as those found in the air or chemicals, in the CSF. Most cases of aseptic meningitis are viral in origin. The signs and symptoms are similar to those of bacterial meningitis. Onset is usually gradual, with symptoms starting mildly. The slight headache becomes worse over the course of several days, the neck becomes characteristically stiff, and photophobia (dislike of bright light) occurs. Tuberculous meningitis is different from most other forms of meningitis because it lasts longer, has a higher mortality rate, and affects the CSF less. It mostly strikes children and is usually the result of a bacillus infection from the respiratory tract or the lymphatic system that has relocated to the meninges. When the bacilli are translocated to the central nervous system, they form tubercles that release an exudate. If tuberculous meningitis is left untreated, death may occur within three weeks. Even with treatment, it may result in neurologic abnormalities. Diagnosis, Treatment, and Prevention If meningitis is suspected, the first testing procedure is an examination of the CSF. To obtain CSF, a lumbar puncture, sometimes called a spinal tap,
Meningitis ✧ 615 is made. Opening pressure, protein and glucose concentrations, total cell count, and cultures of microbes are determined. In cases of meningitis, the CSF is almost always cloudy and generally comes out under higher-thannormal pressure. An elevated white blood cell count in the CSF would be one indication that the patient has bacterial meningitis; another would be lowered serum glucose but slightly raised protein concentration, especially albumin. About 90 percent of bacterial meningitis cases show gram-positive staining. Further cultures and a repeat puncture are necessary to pinpoint the kind of meningitis and to check the effect of the treatment. Bacterial meningitis should be promptly treated with antibiotics specific for the causative bacteria. The success of treatment is contingent on the magnitude of the bacterial count and the quickness with which the bacteria can be controlled. Virtually all bacterial cases are treated with ampicillin or penicillin. Cases aggressively treated with very large doses of antibiotics are the most successful. If antibiotics do not destroy the areas of infection, surgery should be considered. Surgery is especially effective if meningitis is recurrent or persistent. Viral meningitis may be treated with adenine arabinoside if the cause is herpes simplex. No medication will kill other viruses causing the infection. The condition usually resolves itself in a few days, even without treatment. When necessary, supportive therapy should be employed, including blood transfusions. Young children with open fontanelles often undergo subdural taps to relieve pressure caused by CSF buildup. Mortality rates in meningitis vary with age and the pathogen responsible. Those suffering from meningococcal meningitis have a fatality rate of only 3 percent. Newborns suffering from gram-negative meningitis, however, have a 70 percent mortality rate. In addition, the younger the patient, the more likely the incidence of lasting neurological damage. There are two basic ways to prevent meningitis: chemoprophylaxis, for likely candidates of the disease, and active immunization. Those exposed to a known case are usually treated with rifampin for four days; rifampin is especially useful in inactivating H. influenzae. Active immunization is suggested for toddlers eighteen to twenty-four months of age, especially for those in situations where there is a high risk of exposure (such as day care centers). —Iona C. Baldridge See also Antibiotic resistance; Childhood infectious diseases; Children’s health issues; Epidemics; Headaches; Herpes; Immunizations for children. For Further Information: Biddle, Wayne. Field Guide to Germs. New York: Henry Holt, 1995. Clayman, Charles B., ed. The American Medical Association Family Medical Guide. 3d rev. ed. New York: Random House, 1994. Coe, R. P. K. “Primary Mumps Orchitis with Meningitis.” Lancet 1, no. 6333 (January 13, 1945): 49-50.
616 ✧ Menopause Schiefer, W., M. Klinger, and M. Brock. Brain Abscess and Meningitis: Subarachnoid Hemorrhage. New York: Springer-Verlag, 1981. Shaw, Michael, ed. Everything You Need to Know About Diseases. Springhouse, Pa.: Springhouse Press, 1996.
✧ Menopause Type of issue: Elder health, women’s health Definition: The entire process during which a woman ceases ovulating and having menstrual periods. The term “menopause” is commonly used to refer to the entire process during which a woman ceases ovulating and having menstrual periods. The word comes from the Greek words meaning “monthly” and “cessation”— thus, “the monthly flow ceases.” More correctly, natural menopause is one phase in the process called the climacteric. The climacteric is the phase of the aging process in which a woman transitions from the reproductive stage of life to the nonreproductive stage. It covers several years, typically beginning sometime in the forties and generally extending into the fifties. Women who have never been pregnant, vegetarians, women who have been malnourished or anorexic, and women who smoke typically go through the menopause earlier than the average age. The process is divided into three phases: perimenopause, menopause, and postmenopause. During perimenopause, a woman’s ovaries stop producing eggs, and her levels of reproductive hormones decline significantly. Menstruation generally becomes irregular until it finally ceases. Cessation— known as amenorrhea—marks the actual menopause. The definition of postmenopause varies: Some use it only to refer to the year after a woman’s last menstrual period, whereas others use it in reference to the several years after the last menstrual period during which a woman’s body adjusts to its lessened hormonal activity. The menopause may be surgically induced rather than natural. Oophorectomy, a procedure in which a woman’s ovaries are removed (usually in conjunction with a hysterectomy), precipitates sudden menopause. Hysterectomy by itself (that is, the surgical removal of the uterus) typically does not cause the menopause; it may, however, encourage or exacerbate the experience of natural menopause. Although the menopause marks a significant life change, both physically and emotionally, it is not a disease. Nevertheless, because of hormonal deficiencies caused by waning ovarian activity, women typically experience one or more physical symptoms beyond the irregularity of their periods. Hot flashes are one of the most common. These are caused by blood vessel
Menopause ✧ 617 dilation in response to the decrease in estrogen; dilation forces blood to the surface of the skin, causing perspiration, flushing, and an increase in pulse rate and temperature. When hot flashes occur at night, they disrupt sleep patterns and cause fatigue and irritability during the day. It is estimated that 75 to 85 percent of menopausal women in the United States and Canada experience hot flashes to some degree. Other physical changes include thinning, drying, and loss of elasticity of the vagina; swelling of the breasts; heart palpitations; water retention; and the frequent need to urinate. Some women report depression and difficulty focusing on or remembering things. Fluctuating hormones also have been implicated in the emergence of new allergies and food intolerances. Menopause appears to contribute to heart disease and osteoporosis. Before the age of fifty, women are six times less likely to suffer from heart diseases than are men of the same age, but after the menopause, women’s risks escalate significantly. The menopause also contributes to osteoporosis, the loss of bone density that is responsible for shrinkage in height and an increase in bone fractures. A decline in estrogen has been strongly implicated in both of these diseases. Hormones and Alternative Therapies Although most women in the United States and Canada experience some noticeable effects during the process of the menopause, only 10 to 15 percent have symptoms so severe and disruptive as to require medical attention. As most of the physical symptoms, and perhaps some of the psychological or emotional ones, are directly related to the loss of estrogen, hormone replacement therapy (HRT) is often recommended by doctors. Estrogen also has been shown to protect against heart disease and osteoporosis. Nevertheless, HRT is a controversial topic in many circles. The medical basis for the controversy lies in the fact that, based on statistics gathered from long-term use of estrogen-containing birth control pills, estrogen is implicated in increasing the risk of breast cancer. Studies have shown that concern over this risk has been one of the biggest reasons women choose not to use HRT. Data from studies of women taking birth control pills are not directly generalizable to HRT for menopausal women, however, because birth control pills, particularly in the 1960’s and 1970’s, contained significantly higher doses of estrogen than the formulation used for menopausal women in the 1990’s. HRT may consist of estrogen only; estrogen and progesterone; progesterone only; estrogen and testosterone, with or without progesterone; or low-dose birth control pills (generally used only for perimenopausal women for whom birth control is still a concern). The hormones may be taken daily or on a cyclic schedule; they may be administered as pills, creams, suppositories, or injection or through a transdermal patch.
618 ✧ Menopause Estrogen is the most commonly prescribed hormone for menopausal women. Because estrogen used alone causes an increased risk of uterine cancer in women who have not had a hysterectomy, women who take estrogen usually also take progesterone during part of the month. This causes the uterine lining to be shed monthly, similar to natural menstrual periods, significantly decreasing the risk of uterine cancer. In the 1990’s, synthetic progestin was the most commonly prescribed form of progesterone supplementation. Many women taking synthetic progestins reported disturbing side effects, similar to those of premenstrual syndrome (PMS), such as depression, irritability, and bloating. Many women who react poorly to synthetic progestin find better results with formulations of natural progesterone, a plant-based substance that mimics the progesterone a woman’s body naturally produces. Commercial progestin compounds are less expensive and more readily available in the United States and Canada than is natural progesterone, but the latter became more available in the mid1990’s. In the 1990’s, a new therapeutic regimen, an estrogen-testosterone combination, sometimes with progesterone added, was prescribed for some women. Prior to the menopause, women normally produce a small amount of testosterone—about 5 percent of the amount a man normally produces. Half of this is produced by the ovaries and half by the adrenal glands. In about half of women, the ovaries stop producing testosterone at the menopause, which can cause lack of energy and loss of libido. For such women, testosterone or a synthetic compound may be useful. Some women have found relief from menopausal symptoms through alternative remedies or lifestyle changes. Many foods and herbs contain substances that mimic estrogen or progesterone; nutritionists, herbalists, and alternative health care practitioners provide information on such topics. Researchers have noted that Japanese women, whose diets are higher in vegetables and soy-based products (which contain estrogen-like compounds) and lower in meat and dairy products, have fewer menopausal symptoms. Many women have found that decreasing their intake of dairy products, red meat, sugar, caffeine, and alcohol lessens their symptoms. Vitamin and mineral supplements have also proved effective for some women, particularly calcium and Vitamin E. Exercise has been found to have a positive effect on many symptoms, in addition to its known benefits in decreasing the risks of heart disease and osteoporosis. Social Issues Many women and their doctors routinely assume the menopausal years to be a time for medical intervention. This is, in part, a result of the fact that women are less likely to see doctors unless they have problems. This may be changing, however, as the menopause became a regular topic in the media
Menopause ✧ 619 in the 1990’s. Armed with new studies regarding the benefits and risks of HRT, U.S. and Canadian women have been seeking information and making changes in their lifestyles and diets in the early stages of perimenopause. A small but vocal minority criticize what they consider to be the inappropriate medicalization of a natural event. Certain feminist writers, notably Germaine Greer, writing in The Change (1992), have asserted that cosmetics and pharmaceutical companies and doctors (particularly gynecologists and plastic surgeons) look on the rising numbers of menopausal women as a vast marketing target. Such critics assert that promotion of these agendas is self-serving and conditions women to consider the menopause as a debilitating and embarrassing event to be avoided and subverted as much as possible. In their view, the menopause is not a physically or emotionally negative event of itself but a too-seldom-seized opportunity for women to escape from societally imposed roles and find increased independence and selfknowledge. —Irene Struthers See also Aging; Depression; Depression in the elderly; Exercise and the elderly; Falls among the elderly; Hormone replacement therapy; Hysterectomy; Menstruation; Osteoporosis; Women’s health issues. For Further Information: Barbach, Lonnie. The Pause: Positive Approaches to Menopause. New York: E. P. Dutton, 1993. Easy-to-read, basic information. Epilogue addressed to male partners of menopausal women; appendix listing symptoms and various solutions, including herbal remedies and hormonal treatments. Corio, Laura E., M.D., and Linda G. Kahn. The Change Before the Change: Staying Healthy During Perimenopause. New York: Bantam Doubleday Dell, 2000. Helps women navigate these years in peak physical and emotional health. Explores options for controlling symptoms and explains the hormonal shifts that affect every part of the body and the impact of stress and diet. Greer, Germaine. The Change: Women, Aging, and the Menopause. New York: Alfred A. Knopf, 1992. Scholarly exploration of views of women, aging, and the menopause in different cultures and different eras, which challenges current cultural beliefs. Strident tone; biased against use of hormone replacement therapy. Index. Maas, Paula, Susan E. Brown, and Nancy Bruning. Natural Medicine for Menopause and Beyond. New York: Dell, 1997. This concisely written text addresses a host of symptoms and dispenses the current wisdom from a host of alternative medical traditions, including ancient Chinese medicine, acupressure, herbal therapy, and homeopathy. Includes suggestions for nutrition and exercise to prevent or relieve symptoms. Sheehy, Gail. The Silent Passage. Rev. ed. New York: Pocket Books, 1998. A
620 ✧ Menstruation personal look at the menopause, including interviews with more than one hundred women from their forties to their sixties. Also incorporates information from doctors, scientists, psychologists, sociologists, and anthropologists.
✧ Menstruation Type of issue: Women’s health Definition: The monthly discharge of blood and tissue by girls and women of childbearing age, caused by changes in hormonal levels. Menstruation is the monthly discharge of bloody fluid from the uterus that occurs in humans and other primates. The menstrual fluid consists of blood, cells and debris from the endometrial lining of the uterus, and mucus and other fluids. The color of the discharge varies from dark brown to bright red during the period of flow. The menstrual discharge does not normally clot after leaving the uterus, but it may contain endometrial debris that resembles blood clots. The flow lasts from four to five days in most women, with spotting possibly continuing another day or two. The volume of fluid lost ranges from 10 to 80 milliliters, with a median of about 40 milliliters. The blood in the menstrual discharge amounts to only a small fraction of the body’s total blood volume of about 5,000 milliliters, and so normal physiological functioning is not usually impaired by the blood loss that occurs during menstruation. The first menstruation (menarche) begins when a girl goes through puberty at the age of twelve or thirteen; the last episodes of menstruation occur some forty years later at the time of menopause. Menstruation does not occur during the months of pregnancy or for the first few months after a woman has given birth. Menstruation is the most visible event of the woman’s monthly menstrual cycle. The average length of the menstrual cycle in the population is about 29.1 days, but it may vary from 16 to 35 days, with variation occurring between different individuals and in one individual from month to month. Girls who have just gone through puberty and women who are approaching the menopause tend to have more variation in their cycles than do women in the middle of their reproductive years. There is also an age-related change in cycle length: Cycles tend to be relatively long in teenagers, then decrease in length until a woman is about forty years old, after which cycles tend to lengthen and become irregular.
Menstruation ✧ 621 The Normal Menstrual Cycle Uterine function is regulated by the hormones estrogen and progesterone, which are produced in the ovaries. In turn, the production of estrogen and progesterone is controlled by follicle-stimulating hormone (FSH) and luteinizing hormone (LH), both of which are produced in the pituitary gland. The hormones from the ovaries and the pituitary have mutual control over each other. In the first half of the cycle, the follicular phase, a predominant negative feedback effect keeps pituitary hormone levels low while allowing estrogen to increase. Day 1 of the menstrual cycle is defined as the day of the onset of the menstrual flow. During the days of menstrual bleeding, levels of estrogen and progesterone are low, but FSH levels are high enough to cause the growth of follicles in the ovary. As the follicles start to grow, they secrete estrogen, and increasing amounts are secreted as the follicles continue to enlarge over the next five to ten days. The estrogen exerts negative feedback control over the pituitary: FSH and LH production is inhibited by estrogen, so levels of these hormones remain low during the follicular phase. The growing follicles contain ova that are maturing and preparing for ovulation. Meanwhile, estrogen acts on the uterus to cause the growth of the endometrial lining. The lining becomes thicker and its blood supply increases; glands located in the lining also grow and mature. These uterine changes are known as endometrial proliferation. As the woman nears the middle of her cycle, the increasing secretion of estrogen shifts the hormonal system into a positive feedback mode, whereby an increase in estrogen stimulates the release of LH and FSH from the pituitary instead of inhibiting it. Thus, at the middle of the cycle (around day 14), simultaneous peaks in levels of estrogen, LH, and FSH occur. The peak in LH triggers ovulation by causing changes in the wall of the follicle, allowing it to break open to release its ovum. Although a group of follicles had matured up to this point, usually only the largest one ovulates, and the remainder in the group die and cease hormone production. Following ovulation, negative feedback is reestablished. The follicle that just ovulated is transformed into the corpus luteum, which produces estrogen and progesterone throughout most of the second half of the cycle, the luteal phase. During this phase, the combined presence of estrogen and progesterone reestablishes negative feedback over the pituitary, and LH and FSH levels decline. A second ovulation is prevented because an LH peak is not possible at this time. The combined action of estrogen and progesterone causes the uterus to enter its secretory phase during the second half of the cycle: The glands in the thickened endometrium secrete nutrients that will support an embryo if the woman becomes pregnant, and the ample blood supply to the endometrium can supply the embryo with other nutrients and oxygen. If the woman becomes pregnant, the embryo will secrete a hormone ensuring the continued production of estrogen and progesterone
622 ✧ Menstruation and the uterus will remain in the secretory condition throughout pregnancy. Menstruation does not occur during pregnancy because of the high levels of estrogen and progesterone, which continually support the uterus. If the woman does not become pregnant, the corpus luteum automatically degenerates, starting at about the twenty-fourth day of the menstrual cycle. It fails to produce estrogen and progesterone, so levels of these hormones decrease. As the amounts of estrogen and progesterone drop, the uterus begins to produce prostaglandins, chemicals that cause a number of changes in uterine function: Blood flow to the endometrium is temporarily cut off, causing the endometrial tissue to die, and the uterine muscle begins to contract. The decreased blood flow and the muscle contractions contribute to the cramping pain that many women feel just before and at the time of menstrual bleeding. Menstrual bleeding starts when the blood flow to the endometrium is reestablished and the dead tissue is sloughed off and washed out of the uterus. This event signals the start of a new menstrual cycle. Amenorrhea, Dysmenorrhea, and Menorrhagia Amenorrhea is defined as the absence of menstruation. It is usually coincident with lack of ovulation. In primary amenorrhea, the woman has never menstruated; in secondary amenorrhea, menstrual cycles that were once normal have stopped. The condition is usually associated with abnormal patterns of hormone secretion, which may itself be merely the symptom of some other underlying disorder. A common situation leading to both primary and secondary amenorrhea is low body weight, caused by malnutrition, eating disorders, or sustained exercise. Body fat provides energy for tissue growth and cell functions and contributes to circulating estrogen levels. Loss of body fat may cause the reproductive system to cease to function; the result is amenorrhea. Emotional or physical stress may also cause amenorrhea, because stress results in the release of hormones that interfere with reproductive hormones. Ideally, amenorrhea is treated by removing its cause; for example, a special diet or a change in an exercise program can bring about an increase in body fat stores, or stress level can be reduced through changes in lifestyle or with counseling. Ironically, sometimes birth control pills are prescribed for women with amenorrhea. The pills do not cure the amenorrhea, but they counteract some of the long-term problems associated with it, such as changes in the endometrial lining and loss of bone density. Dysmenorrhea refers to abnormally intense uterine pain associated with menstruation. It is estimated that 5 to 10 percent of women experience pain intense enough to interfere with their school or work schedules. Primary dysmenorrhea occurs in women with no known disease, while secondary dysmenorrhea is caused by a tumor or infection. Studies have shown uterine
Menstruation ✧ 623 prostaglandin levels to be correlated with the degree of pain perceived in primary dysmenorrhea, and drugs that interfere with prostaglandins offer an effective treatment for this condition. These drugs include aspirin, acetaminophen, ibuprofen, and naproxen. Secondary dysmenorrhea is best managed by removing the underlying cause; if this is not possible, antiprostaglandin drugs may be useful in controlling the pain. Menorrhagia is excessive menstrual blood loss, usually defined as more than 80 milliliters of fluid lost per cycle. This condition can have serious health consequences because of the loss of red blood cells, which are essential for carrying oxygen to tissues. Women who have given birth to several children are more likely to suffer from menorrhagia, possibly because of enlargement of the uterine cavity and interference with the mechanisms that limit menstrual blood flow. Women who have diseases that interfere with blood clotting may also have menorrhagia. Treatment for menorrhagia may begin with iron and vitamin supplements to induce increased red blood cell production, or transfusions may be used to replace the lost red blood cells. If this is unsuccessful, treatment with birth control pills, destruction of the endometrium by laser surgery, or hysterectomy may be necessary. Premenstrual Syndrome Premenstrual syndrome (PMS) is a set of symptoms that occurs in some women in the week before the start of menstruation, with the symptoms disappearing once menstruation begins. The list of possible symptoms is lengthy and varies from woman to woman and even within one woman from month to month. The possible symptoms include psychological and physical changes: irritability, nervous tension, anxiety, moodiness, depression, lethargy, insomnia, confusion, crying, food cravings, fatigue, weight gain, swelling and bloating, breast tenderness, backache, headache, dizziness, muscle stiffness, and abdominal cramps. A diagnosis of PMS requires that the symptoms show a clear relation to the timing of menstruation and that they recur during most menstrual cycles. From 3 to 5 percent of women have PMS symptoms so severe that they are incapacitating, but milder symptoms occur in about 50 percent of women. Because of the variability in symptoms, some researchers believe that there are several subtypes of PMS, each with its own cluster of symptoms. It is possible that each subtype has a unique cause. Suggested causes of PMS include an imbalance in the ratio of estrogen to progesterone following ovulation, changes in the hormones that control salt and water balance, increased levels of prolactin, changes in amounts of brain chemicals, altered functioning of the biological clock that determines daily rhythms, poor diet or sensitivity to certain foods, and psychological factors such as attitude toward menstruation, stresses of family or professional life, and underlying
624 ✧ Menstruation personality disorders. Current treatments for PMS include dietary therapy, hormone administration, and psychological counseling, but no treatment has been found effective in all PMS patients. —Marcia Watson-Whitmyre See also Cervical, ovarian, and uterine cancers; Endometriosis; Hormone replacement therapy; Hysterectomy; Infertility in women; Menopause; Women’s health issues. For Further Information: Covington, Timothy R., and J. Frank McClendon. Sex Care: The Complete Guide to Safe and Healthy Sex. New York: Pocket Books, 1987. Parts 1 and 2 deal with contraception and sexually transmitted diseases, but part 3 covers some topics directly related to menstruation: premenstrual syndrome, toxic shock syndrome, feminine hygiene, and various myths. Golub, Sharon. Periods: From Menarche to Menopause. Newbury Park, Calif.: Sage Publications, 1992. An exceptionally complete book that presents information on all aspects of the menstrual cycle. The chapters dealing with scientific studies are accurate and easy to read. The author includes her thoughts on how society could make menstruation easier for women and on further research that needs to be done. Laws, Sophie. Issues of Blood: The Politics of Menstruation. Basingstoke, England: Macmillan, 1990. Written by a sociologist, the text explores the results of the author’s interviews with men about their attitudes toward menstruation. It is the premise of the author that the dominant group in a society determines the beliefs of the oppressed; thus, women’s feelings about menstruation can be understood by referring to what men think. Highly recommended. Quilligan, Edward J., and Frederick P. Zuspan, eds. Current Therapy in Obstetrics and Gynecology 4. 5th ed. Philadelphia: W. B. Saunders, 1999. A standard medical reference on treatment for women’s disorders, arranged in an encyclopedia format, with short articles on each topic. There is a particularly good description of premenstrual syndrome, written by Guy E. Abraham and Richard J. Taylor. This article describes the authors’ classification of PMS into four different subtypes and presents detailed information on a dietary treatment program that they have devised. Riddick, Daniel H., ed. Reproductive Physiology in Clinical Practice. New York: Thieme Medical Publishers, 1987. This text is noteworthy for its scientific yet understandable approach to human reproduction, including a complete description of the menstrual cycle and the functioning of the endometrium.
Mental retardation ✧ 625
✧ Mental retardation Type of issue: Children’s health, mental health Definition: Significant subaverage intellectual development and deficient adaptive behavior accompanied by physical abnormalities. Mental retardation is a condition in which a person demonstrates significant subaverage development of intellectual function, along with poor adaptive behavior. Diagnosis can be made fairly easily at birth if physical abnormalities also accompany mental retardation. An infant with mild mental retardation, however, may not be diagnosed until problems arise in school. Estimates of the prevalence of mental retardation vary from 1 to 3 percent of the world’s total population. Diagnosis of mental retardation takes into consideration three factors: subaverage intellectual function, deficiency in adaptive behavior, and earlyage onset (before the age of eighteen). Intellectual function is a measure of one’s intelligence quotient (IQ). Four levels of retardation based on IQ are described by the American Psychiatric Association. An individual with an IQ between 50 and 70 is considered mildly retarded, one with an IQ between 35 and 49 is moderately retarded, one with an IQ between 21 and 34 is severely retarded, and an individual with an IQ of less than 20 is termed profoundly retarded. A person’s level of adaptive behavior is generally defined as the ability to meet social expectations in the individual’s own environment. Assessment is based on development of certain skills: sensorymotor, speech and language, self-help, and socialization skills. Tests have been developed to aid in these measurements. Causes of Mental Retardation More than a thousand different disorders that can cause mental retardation have been reported. Some cases seem to be entirely hereditary, others to be caused by environmental stress, and others the result of a combination of the two. In a large number of cases, however, the cause cannot be established. The mildly retarded make up the largest proportion of the mentally retarded population, and their condition seems to be a recessive genetic trait with no accompanying physical abnormalities. From a medical standpoint, mental retardation is considered to be a result of disease or biological defect and is classified according to its cause. Some of these causes are infections, poisons, environmental trauma, metabolic and nutritional abnormalities, and brain malformation. Infections are especially harmful to brain development if they occur in the first trimester of pregnancy. Rubella is a viral infection that often results in mental retardation. Syphilis is a sexually transmitted disease which affects
626 ✧ Mental retardation adults and infants born to them, resulting in progressive mental degeneration. Poisons such as lead, mercury, and alcohol have a very damaging effect on the developing brain. Lead-based paints linger in old houses and cause poisoning in children. Children tend to eat paint and plaster chips or put them in their mouths, causing possible mental retardation, cerebral palsy, and convulsive and behavioral disorders. Traumatic environmental effects that can cause mental retardation include prenatal exposure to X rays, lack of oxygen to the brain, or a mother’s fall during pregnancy. During birth itself, the use of forceps can cause brain damage, and labor that is too brief or too long can cause mental impairment. After the birth process, head trauma or high temperature can affect brain function. Poor nutrition and inborn metabolic disorders may cause defective mental development because vital body processes are hindered. One of these conditions, for which every newborn is tested, is phenylketonuria (PKU), in which the body cannot process the amino acid phenylalanine. If PKU is detected in infancy, subsequent mental retardation can be avoided by placing the child on a carefully controlled diet, thus preventing buildup of toxic compounds that would be harmful to the brain. The failure of the neural tube to close in the early development of an embryo may result in anencephaly (an incomplete brain or none at all), hydrocephalus (an excessive amount of cerebrospinal fluid), or spina bifida (an incomplete vertebra, which leaves the spinal cord exposed). Anencephalic infants will live only a few hours. About half of those with other neural tube disorders will survive, usually with some degree of mental retardation. Research has shown that if a mother’s diet has sufficient quantities of folic acid, neural tube closure disorders will be rare or nonexistent. Microcephaly is another physical defect associated with mental retardation. In this condition, the head is abnormally small because of inadequate brain growth. Microcephaly may be inherited or caused by maternal infection, drugs, irradiation, or lack of oxygen at birth. Abnormal chromosome numbers are not uncommon in developing embryos and will cause spontaneous abortions in most cases. Those babies that survive usually demonstrate varying degrees of mental retardation, and incidence increases with maternal age. A well-known example of a chromosome disorder is Down syndrome, in which there is an extra copy of chromosome 21. Gene products caused by the extra chromosome cause mental retardation and other physical problems. Other well-studied chromosomal abnormalities involve the sex chromosomes. Both males and females may be born with too many or too few sex chromosomes, which often results in mental retardation. Mild retardation with no other noticeable problems has been found to run in certain families. It occurs more often in the lower economic strata of
Mental retardation ✧ 627 society and probably reflects only the lower end of the normal distribution of intelligence in a population. The condition is probably a result of genetic factors interacting with environmental ones. It has been found that culturally deprived children have a lower level of intellectual function because of decreased stimuli as the infant brain develops. Degrees of Care Individuals with an IQ of 50 to 70 have mild-to-moderate retardation and are classified as educable mentally retarded (EMR). They can profit from the regular education program when it is somewhat modified. The EMR can achieve some success in academic subjects, make satisfactory social adjustment, and achieve minimal occupational adequacy if given proper training. Persons with moderate-to-severe retardation generally have IQs between 21 and 49 and are classified as trainable mentally retarded (TMR). These individuals are not educable in the traditional sense, but many can be trained in self-help skills, socialization into the family, and some degree of economic independence with supervision. They need a developmental curriculum which promotes personal development, independence, and social skills. The profoundly retarded are classified as totally dependent and have IQs of 20 or less. They cannot be trained to care for themselves, to socialize, or to be independent to any degree. They will need almost complete care and supervision throughout life. They may learn to understand a few simple commands, but they will only be able to speak a few words. Meaningful speech is not characteristic of this group. Education for the Mentally Retarded EMR individuals need a modified curriculum, along with appropriately qualified and experienced teachers. Activities should include some within their special class and some in which they interact with students of other classes. The amount of time spent in regular classes and in special classes should be determined by individual needs in order to achieve the goals and objectives planned for each. Individual development must be the primary concern. For TMR individuals, the differences will be in the areas of emphasis, level of attainment projected, and methods used. The programs should consist of small classes that may be held within the public schools or outside with the help of parents and other concerned groups. Persons trained in special education are needed to guide the physical, social, and emotional development experiences effectively. A systematic approach in special education has proven to be the best teaching method to make clear to students what behaviors will result in the
628 ✧ Mental retardation successful completion of goals. This approach has been designed so that children work with only one concept at a time. There are appropriate remedies planned for misconceptions along the way. Progress is charted for academic skills, home-living skills, and prevocational training. Decisions on the type of academic training appropriate for a TMR individual are not based on classification or labels, but on demonstrated ability. Counselors help parents identify problems and implement plans of action. They can also help them determine whether goals are being reached. Counselors must know about the community resources that are available to families. They can help parents find emotional reconciliation with the problems presented by their special children. It is important for parents to be able to accept the child’s limitations. They should not lavish special or different treatment on the retarded child, but rather treat this child like the other children. Placing a child outside the home is indicated only when educational, behavioral, or medical controls are needed which cannot be provided in the home. Physicians and social workers should be able to do some counseling to supplement that of the trained counselors. Those who offer counseling should have basic counseling skills and relevant knowledge about the mentally retarded individual and the family. Adult Life EMR individuals will usually marry, have children, and often become selfsupporting. The TMR will live in an institution or at home or in foster homes for their entire lives. They will probably never become self-sufficient. The presence of a TMR child has a great impact on families and may weaken family closeness. It creates additional expenses and limits family activities. Counseling for these families is very important. Sheltered employment provides highly controlled working conditions, helping the mentally retarded to become contributing members of society. The mildly retarded may need only a short period of time in the sheltered workshop. The greater the degree of mental retardation, the more likely shelter will be required on a permanent basis. Those in charge must consider both the personal development of the handicapped worker and the business production and profit of the workshop. Failure to consider the business success of these ventures has led to failures of the programs. There has been a trend toward deinstitutionalizing the mentally retarded, to relocate as many residents as possible into appropriate community homes. Success will depend on a suitable match between the individual and the type of home provided. This approach is most effective for the mentally retarded if the staff of a facility is well trained and there is satisfactory interaction between staff and residents. It is important that residents not be ignored, and they must be monitored for proper evaluation at each
Mercury poisoning ✧ 629 step along the way. Top priority must be given to preparation of the staff to work closely with the mentally impaired and handicapped. —Katherine H. Houp See also Birth defects; Children’s health issues; Down syndrome; Failure to thrive; Fetal alcohol syndrome; Genetic counseling; Genetic diseases; Hydrocephalus; Learning disabilities; Malnutrition among children; Nutrition and children; Phenylketonuria (PKU); Spina bifida. For Further Information: Clarke, Ann M., Alan D. B. Clarke, and Joseph M. Berg. Mental Deficiency: The Changing Outlook. 4th ed. New York: Free Press, 1985. A classic text in the field of mental retardation which summarizes the tremendous amount of knowledge that has been amassed on the subject. Covers the genetic and environmental causes of mental retardation, prevention, help, intervention, and training. Dudley, James R. Confronting the Stigma in Their Lives: Helping People with a Mental Retardation Label. Springfield, Ill.: Charles C Thomas, 1997. This book is written for anyone concerned about combating the negative effects of being labeled as having a mental disorder. Jakab, Irene, ed. Mental Retardation. New York: Karger, 1982. A clearly written text for training health professionals who work with the mentally retarded. Contains useful, practical information and emphasizes those things which can be done to improve the quality of life for the mentally retarded. Matson, Johnny L., and Rowland P. Barrett, eds. Psychopathology in the Mentally Retarded. 2d ed. Boston: Allyn & Bacon, 1993. This book addresses an often-neglected topic: the psychological problems that may be found in mentally retarded individuals. Discusses special emotional problems of various types of mentally retarded persons based on the causation of their deficiency. Descriptions of major disorders and their treatments are given. Tyler, Carl V. Medical Issues for Adults with Mental Retardation/Developmental Disabilities. Homewood, Ill.: High Tide Press, 1999. Includes bibliographical references.
✧ Mercury poisoning Type of issue: Environmental health, industrial practices, public health Definition: A highly toxic element that can cause acute episodes of poisoning and chronic health effects.
630 ✧ Mercury poisoning Mercury, often called quicksilver, is found in the environment in elemental and combined forms; people are exposed to its various forms in the workplace, at home, and through mercury-laden foods. Numerous federal regulations have set standards of minimum exposure for humans and have helped reduce the occurrence of mercury poisoning. Mercury and its inorganic compounds have been used in producing caustic soda, dry-cell batteries, scientific measuring devices, dental amalgams, and mercury vapor lamps. Workers in factories making these products may be exposed to relatively high levels of mercury vapors and compounds. Dental assistants may also be exposed to relatively high levels of mercury vapor. Mercury is also released into the environment by the waste incineration of these products and may eventually accumulate in food sources such as grains and fish. Mercury was also used as an additive to latex paints to inhibit the growth of bacteria and fungi, but this use was eliminated in the United States in 1991. Mercury compounds have also been used in agriculture as a fungicide and may cause health effects in workers who handle these compounds. Finally, mercury mines and smelters may release considerable amounts of mercury into the surrounding regions. Some bacteria can convert inorganic mercury into organic compounds, such as methyl mercury. Methyl mercury bioaccumulates in biotic systems and biomagnifies until the highest members of the aquatic food chain have high levels of mercury in their fatty tissues. The greatest exposure to mercury is through eating mercury-rich fish; individuals who rely heavily on fish such as tuna, pike, swordfish, and shark may therefore suffer adverse health effects. Since elemental mercury is a liquid at room temperature and easily volatilizes, it can be inhaled and cause damage to the central nervous system, lungs, and kidneys. Mercury is a strong neurotoxin that can cause a series of effects such as memory loss, tremors, and excitability at low levels; higher levels may cause more severe mental problems and even death. Inhalation of high concentrations of mercury leads to hallucinations, delirium, and even suicide in some cases. It is not clear whether elemental mercury causes cancer in humans; the Environmental Protection Agency (EPA) classifies elemental mercury in Group D (not classifiable as to human carcinogenicity). The inorganic forms of mercury are not easily absorbed by the body and pose a relatively small health risk. Oral ingestion of inorganic mercury can cause nausea, stomach pains, and vomiting. The EPA states that the acute lethal dose of most inorganic mercury compounds for a normal adult is 1 to 4 grams (14 to 57 milligrams per kilogram for a 70 kilogram person). The EPA classifies inorganic mercury in Group C (a possible human carcinogen).
Mercury poisoning ✧ 631 The Health Risks of Mercury Organic mercury compounds, particularly methyl mercury, are absorbed easily and constitute the greatest health risk for most people. Methyl mercury exposure is greatest from consuming fish and fish products. Low-level poisoning by methyl mercury may cause vision problems, paresthesia (the sensation of prickly skin), speech difficulties, shyness, and a general malaise. Acute exposure causes numerous central nervous problems, including blindness, deafness, and loss of consciousness. The EPA estimates that the minimum lethal dose of methyl mercury is 20 to 60 milligrams per kilogram for a 70 kilogram person. Lower doses are lethal for more sensitive people, particularly children. Methyl mercury has been shown to have significant developmental effects on babies born to women who ingested high levels during their pregnancy. The infants from such pregnancies may exhibit mental retardation, visual problems (including blindness in some), and cerebral palsy. Methyl mercury is a Group C carcinogen. Mercury has caused serious environmental and human health problems when released into ecological systems and when used inappropriately. The most infamous incident was the mercury poisoning at Minamata Bay in Japan. In the 1950’s and early 1960’s, inorganic mercury waste was released into the bay, and bacteria converted the inorganic mercury to methyl mercury. The mercury was then consumed by marine organisms and passed up the food chain, eventually resulting in human mercury poisoning. At least forty-three people died of “Minamata disease” from eating fish and other marine organisms that contained high levels of mercury. Even more people were killed in Iraq by the inappropriate use of methyl mercury fungicide. In 1972 more than 460 people died from mercury poisoning after eating bread made from wheat that had been treated with the fungicide. Many of the animals and plants within the area were also poisoned by the methyl mercury. —Jay R. Yett See also Birth defects; Children’s health issues; Environmental diseases; Food poisoning; Hazardous waste; Lead poisoning; Mental retardation; Occupational health; Pesticides; Poisoning. For Further Information: Bakir, F., et al. “Methyl Mercury Poisoning in Iraq.” Science 181 (1973). The best discussion of the Iraqi mercury poisoning. Brookins, Douglas. Mineral and Energy Resources. Columbus, Ohio: Charles E. Merrill, 1990. A cogent description of the origin of mercury deposits and the uses of the element. Harte, John, et al. Toxics A to Z. Berkeley: University of California Press, 1991. A discussion of the toxic effects of mercury, as well as laws governing its use.
632 ✧ Miscarriage
✧ Miscarriage Type of issue: Women’s health Definition: The preterm delivery of a nonviable fetus. Miscarriages, also known as spontaneous abortions, typically occur during the first three months of pregnancy, when the fetus is not fully developed and is unable to survive outside the uterus. A stillbirth occurs when the fetus dies while still in the uterus. A stillbirth may require the induction of labor, or the woman may wait for the natural onset of labor. If labor is to be induced, the woman may be given oxytocin, a hormone that stimulates the onset of contractions. If the decision is made to wait for the natural onset of labor, contractions will usually occur within three weeks. Parents experiencing a miscarriage or stillbirth go through the same grieving process that occurs with the death of any child. This grieving process will be more difficult if family and medical professionals fail to provide support for the parents. Medical professionals should also involve the parents in decisions concerning their offspring. Parents should be involved in deciding whether to induce labor, whether to see the baby after delivery, and how they will dispose of the fetus. —Diane E. Wille See also Amniocentesis; Birth defects; Childbirth complications; Death and dying; Depression; Fetal alcohol syndrome; Genetic counseling; In vitro fertilization; Postpartum depression; Pregnancy among teenagers; Premature birth; Prenatal care. For Further Information: Gabbe, Steven G., Jennifer R. Niebyl, and Joe Leigh Simpson, eds. Obstetrics: Normal and Problem Pregnancies. 3d ed. New York: Churchill Livingstone, 1996. Hotchner, Tracie. Pregnancy and Childbirth. Rev. ed. New York: Avon Books, 1997. Scher, Jonathan. Preventing Miscarriage: The Good News. New York: Harper & Row, 1990.
✧ Mobility problems in the elderly Type of issue: Elder health Definition: The inability of some elders to move freely under their own volition.
Mobility problems in the elderly ✧ 633 Mobility limitations are defined as health conditions lasting six months or longer that make it difficult for individuals to go outside the home alone without help. In the U.S. census of 1990, data on civilian and noninstitutionalized persons sixty years and older indicated that mobility limitations increase with age: 3.4 percent for people aged sixty to sixty-four, 4.9 percent for people aged sixty-five to seventy-four, 11.1 percent for people aged seventy-five to eighty-four, and 21.9 percent for people aged eighty-five years or older. Causes and Consequences of Decreases in Mobility Any health conditions that result in movement restrictions could decrease an individual’s mobility. These medical conditions include stroke, Parkinson’s disease, hip fractures, severe arthritis, and other neuromuscular diseases. One of the common causes of decreasing mobility in older people is fear of falling, caused by experiencing a fall. Such fear may lead the elderly to restrict their own activity, especially mobility. Regardless of physical trauma, the response to a fall and decreased mobility consequently determines emotional, psychological, or social changes. Thus, these changes affect older people’s quality of life significantly. In 1997, the journal Age and Ageing published an article titled “Fear of Falling and Restriction of Mobility in Elderly Fallers” by Bruno J. Vellas and associates. The article reported the results of a study on 487 people over sixty years old who lived independently in the community. During a two-year study period, 219 study participants (45 percent) experienced a fall. Among those who had a fall, 70 (32 percent) reported a fear of falling afterward. As a result of the fear, mobility level decreased among these older people. Compared to men, women were more than twice as likely to develop fear of falling (74 percent in women versus 26 percent in men). The same study also showed that those who were afraid of falling again after a fall had poor balance and gait disorders at the beginning of the study, which indicates that older individuals appear to have quite an accurate perception of problems with their own balance and gait. Thus, if any balance and gait disorder can be prevented or treated, it could decrease older people’s subsequent fear of falling and self-imposed reduction in mobility. Preserving Mobility in Older People There is a cycle in older people of age-related loss of muscle strength, falls, fear of falling, decrease of mobility, and further loss of muscle strength. To preserve mobility in older people, this negative cycle needs to be broken. Two common ways to prevent or delay this cycle and maintain mobility are exercise and trophic factors. Exercise, particularly strength training (such as weight lifting), preserves
634 ✧ Mobility problems in the elderly muscular performance and mobility. Many research studies have confirmed that higher levels of physical activity are associated with greater muscular performance, better mobility, and a lower risk of falls. Although there is some concern that high levels of physical activity may increase the risk of falls and injuries, physically active older people appear to have less disability even after accounting for the illness due to exercise. In the 1970’s, it was questioned whether muscles in older people could even respond to exercise training. However, more recent research shows that strength training increases skeletal muscle strength even in older people, as studies conducted with Devices such as canes, walkers, and wheelchairs can eighty- and ninety-year-old ingive older adults greater mobility. (Digital Stock) dividuals report increases in strength with resistance training. Strength training affects muscle physiology as well as function in older people. When older and younger individuals are trained in the same program at the same relative intensity, their increments in maximum oxygen consumption are similar. Thus, the fitness response to an endurance training program in previously sedentary but healthy older people is comparable to that of younger people. Study results are also available to evaluate the effects of strength and endurance training on mobility measured by gait speed and balance. Several randomized clinical trials reported that strength and endurance training improves gait speed by a modest amount, although there are some other trials that have failed to find such an effect. The controversy between findings could be explained partially by the variation in frequency, duration, and intensity of training. Whether or not strength training improves mobility by improving balance in healthy older people is still unclear; however, strength training has been shown to improve balance in weak individuals in nursing homes. Trophic factors are related to hormones that can enhance muscular performance. The idea of using hormones to improve muscular performance was initiated in the 1980’s when it became possible to produce large quantities of hormones with new technologies. The hormones that can
Mobility problems in the elderly ✧ 635 enhance muscular performance include growth hormone, estrogen, and testosterone. Growth hormone can increase muscle mass; however, there are side effects from using growth hormones, including glucose intolerance (an early stage of diabetes). Also, one study reported that growth hormone supplementation has no effect on mobility and functional limitations. Use of estrogen, also called hormone replacement therapy, is much more common in postmenopausal women. Research evidence indicates estrogen decreases the chance of developing heart disease and osteoporosis in older women. Evidence about the effect of estrogen on muscle strength and mobility is limited and inconsistent. An epidemiologic (population) study reported that estrogen use is correlated with the preservation of muscle strength in postmenopausal women. Testosterone can increase muscle strength in young men, but less information is available on older men, and the effects of testosterone on mobility and functional limitation in older people remains unclear. In conclusion, regular physical activities, especially strength training, are recommended for older people to preserve their muscular performance and mobility. However, studies show that only 5 to 6 percent of older men and 1 to 3 percent of older women report doing activities like weight lifting to increase muscle strength. A recent U.S. Surgeon General’s report affirmed the accumulating evidence favoring the health benefits of strength training in older people. It recommends that cardiorespiratory endurance activity should be supplemented with strength-developing exercises at least twice per week for adults in order to improve musculoskeletal health, maintain independence in performing the activities of daily life, and reduce the risk of falls. Driving and Mobility As the proportion of elderly people rises, the number of older drivers is increasing rapidly. The percentage of licensed drivers in people aged sixtyfive years or older increased from 60 percent in 1980 to 70 percent in 1989. In the late 1990’s, over 13 percent of all drivers were sixty-five years of age or older. Although older people travel less and drive fewer miles than do the rest of the population, they still depend on the car for most trips. In the 1990’s, the number of trips made by private automobiles increased in people age sixty-five years or older, and the trends show that the mileage will continue to increase in the future. National survey data show that for people aged sixty-five years or older, more than three-fourths of the trips were made by private vehicles. Particularly for people sixty-five to seventy-four years old, private vehicles accounted for more than 84 percent of their trips. Public transportation accounts for less than 4 percent of trips made by older people. Taxis were rarely used by older people, who considered them either too expensive or not convenient. Walking as a mode of transportation was
636 ✧ Mobility problems in the elderly more often seen in older people than in the younger population. About 10 percent of the trips by older people were done by walking, and the older the individual, the greater was the proportion of walking for transportation. Community-provided transportation services for older people, such as senior citizen’s vans, are seen more often. Older people usually do not depend on automobiles for long trips but use them regularly for short trips, such as going to the doctor’s office, grocery shopping, or visiting relatives or friends. Thus, in older people outdoor mobility and independent living are closely associated with the ability to drive an automobile. However, at some point in late life, one has to stop driving due to financial reasons or physical conditions. Some older people give up driving because of limited income and the increased cost of purchasing and maintaining a car, but most older people stop driving because of health problems. The common medical conditions resulting in driving cessation are vision impairment, muscle or joint weakness (or mobility limitations), and mental problems (such as dementia). Currently, the decision of the time to stop driving is mostly made by older people themselves or their family. Medical doctors or other health professionals may provide recommendations to stop driving for older people with certain medical conditions. Police departments may also be responsible for stopping some unsafe older drivers. Whether it is safe to drive at an advanced age depends on the individual. Some healthy and fit older drivers may drive as safely as younger people, while others may have more difficulties driving in certain situations, such as at night, during rush hours, on snowy days, on highways, or at intersections. Every year about 10 percent of fatal car crashes occur in drivers sixty-five years or older. If car crash involvement rates are evaluated by the number of drivers in different age groups, drivers of sixteen to nineteen years old are four times as likely to be involved in a traffic accident than older drivers. The crash involvement rates decrease as age increases, and the absolute number of crashes is lowest in the oldest age group. However, when adjusting the number of crashes with the total mileage traveled by members of each age group, the older drivers and youngest drivers have the same high-risk levels to be involved in a car crash compared to middle-aged people. Thus, older people drive less and have a lower chance of being involved in a car crash, but for every driven mile, an older driver experiences an increased risk of being involved in a car crash. To ensure the safety of older drivers and other drivers on the road, some states in the United States have legal restrictions regarding renewal of licensure in older drivers. Several states require vision testing as part of a driver’s license renewal. Some states require written or road tests and shorter intervals between renewals for older drivers.
Mobility problems in the elderly ✧ 637 Services Available to Meet Mobility Needs Society recognizes the value of older people meeting their own mobility and transportation needs and keeping older drivers on the road as long as possible. Many programs are available to help older drivers retain the skills necessary for safe driving, including the American Association of Retired Persons (AARP), 55 Alive, the Mature Driving Program, and the Safe Driving for Mature Operators by the American Automobile Association (AAA). These courses are offered in many locations around the United States. Some insurance companies provide a reduction in auto insurance premiums for older drivers who have completed such a course. Physical or occupational therapists have developed driver retraining programs to treat individuals whose driving ability has been impaired by disease, injury, or the aging process. These programs can help people adapt to disability and train older drivers with functional limitations to drive. Also, these programs provide the use of special adaptive driving equipment, which compensates for many types of deficits in older drivers. In general, older individuals who experience outdoor mobility problems are usually those who are unable to own and operate their own vehicles. Lack of such ability produces barriers to travel in older people, limits their independence, restricts their activities, and impairs their ability to take advantage of desirable services. People who have never driven or who stopped driving have significantly lower numbers of activities outside the home than those who are current drivers. Where they exist, adequate public transportation systems can help older people overcome their mobility problems. —Kimberly Y. Z. Forrest See also Aging; Arthritis; Broken bones in the elderly; Canes and walkers; Exercise and the elderly; Muscle loss with aging; Osteoporosis; Parkinson’s disease; Safety issues for the elderly; Strokes; Vision problems with aging; Wheelchair use among the elderly. For Further Information: Buchner, David. “Preserving Mobility in Older Adults.” The Western Journal of Medicine 167, no. 4 (October, 1997). This article intensively reviews the study findings of the methods available for preserving mobility in older people. Ray, Wayne. “Safety and Mobility of the Older Driver: A Research Challenge.” JAMA 278, no. 1 (July, 1997). Discussion of safety and mobility problems in older drivers. Schwarts, R. S. “Exercise in the Elderly: Physiologic and Functional Effects.” In Principles of Geriatric Medicine and Gerontology, edited by W. R. Hazzard. New York: McGraw-Hill, 1993. Detailed discussion of effects of exercise on physical functioning in older people.
638 ✧ Morning-after pill U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta: Centers for Disease Control and Prevention, 1996. An overview of exercise and health, and guidelines of exercise for all ages. Vellas, Bruno, et al. “Fear of Falling and Restriction of Mobility in Elderly Fallers.” Age and Ageing 26, no. 3 (May, 1997). A report of a study on the relationship between falls, fear of falling, and mobility in older people.
✧ Morning-after pill Type of issue: Ethics, social trends, treatment, women’s health Definition: A type of drug that can be used to abort or prevent pregnancy. The most common “morning-after” pill is known medically as diethylstilbestrol (DES). Taken within forty-eight hours after intercourse, it induces the body to expel any egg present in the woman’s uterus, thus preventing pregnancy. Follow-up medication may be necessary to avoid unwanted side effects of the drug. In the United States, DES is used only in the case of rape or incest, and then only as ordered by a doctor. Ironically, this same drug was once given to pregnant women in an effort to avoid miscarriage; the result was birth defects and higher-than-average cancer rates for both mothers and their daughters. Another related pill is RU-486, which contains the active ingredient mifepristone. Also known in the United States as the French abortion pill, it can be taken months after conception and induces the body to expel the embryo or fetus from the uterus, thus terminating the pregnancy. Controversy began in the 1980’s over whether to legalize fully and market such morning-after pills in the United States. Many feminists held the view that the U.S. government and conservative elite were purposely keeping DES and RU-486 out of the hands of American women for political reasons—that is, to further the cause of antiabortion groups and to strip women of their rights. Advocates claimed that RU-486 had been adequately tested and safely used in Europe since 1980. They argued that morning-after pills expand a woman’s reproductive choices, optimizing her quality of life while reducing the risk of physical, psychological, social, and economic disadvantage through unwanted pregnancies or surgical abortions. The opposition questioned the safety and morality of morning-after pills. Although such pills allow a woman to avoid the invasive surgery required by standard abortion procedures, both drugs were viewed as dangerous and undertested. Some feared that this option would inhibit access to safe abortion, especially in underdeveloped countries, while others feared that it would cause abortion rates and incidents of unprotected sex to climb.
Multiple births ✧ 639 Nevertheless, the Food and Drug Administration (FDA) authorized the use of RU-486 in the United States in 2000. —Leslie Pendleton See also Abortion; Abortion among teenagers; Birth control and family planning; Condoms; Ethics; Miscarriage; Pregnancy among teenagers. For Further Information: American Medical Women’s Association. “Medical Abortion Supplement 2000.” Journal of the American Medical Women’s Association 55, no. 3 (2000). A collection of essays. Lader, Lawrence. RU 486: The Pill That Could End the Abortion Wars and Why American Women Don’t Have It. Reading, Mass.: Addison-Wesley, 1991. The author is a longtime campaigner for abortion rights and was prominently cited by the Supreme Court in the landmark Roe v. Wade decision that legalized abortion in the United States.
✧ Multiple births Type of issue: Children’s health, women’s health Definition: The birth of two or more babies from the same pregnancy. Multiple births are rare events. The most common are twins; this occurs in approximately one out of every eighty complete pregnancies. Triplets occur once in approximately eight hundred completed pregnancies. Quadruplets occur once in every eight thousand completed pregnancies. Quintuplets occur naturally in approximately one out of every eighty thousand completed pregnancies. As the number of fetuses increases, the chances that all will survive decreases. Types of Twins In a normal menstrual cycle, only a single egg is released. If two eggs are released, both can be fertilized. A newly fertilized egg is called a zygote. If both zygotes succeed in attaching to the uterine walls, a fraternal twin pregnancy begins. Usually, this dual insemination occurs during a single release of semen in a single copulation, so that the embryos have the same father. Occasionally, the two eggs may be fertilized in separate copulations during the same ovulation, a phenomenon called superfecundation. It is then possible for fraternal twins to have different fathers. Fraternal twins have separate placentas and membranes in the womb. The placenta comprises maternal and fetal tissues interconnected by blood
640 ✧ Multiple births vessels. Nutrients pass from mother to the fetus through the placenta. Waste products are removed from the fetus by a reverse process. Sometimes, the placentas press against each other in the womb and fuse. Having had separate placentas or one fused together, however, does not affect the nature of the twins after birth. Fraternal twins, even though they share the same birthday, are no more similar in appearance or manner than two siblings from separate births. Identical twins originate when a single egg spontaneously divides after penetration by a sperm cell. Each half develops separately. Most identical twin fetuses share the same placenta but have different inner or chorionic sacs. The reason for this division is not known. One theory holds that sometimes the fertilized ovum does not implant in the uterus right away. During the delay, the chromosomes double and the zygote halves, with each half then implanting and becoming a separate embryo. Another theory suggests that early in the pregnancy, a genetic mutation occurs in one of the cells. Later, while the embryo is still no more than a few hundred cells, the unmutated cells recognize the genetic difference and reject the mutant cells. The rejected group of cells develops separately. If this theory proves to be true, identical twins are not completely identical. Cases in which one identical twin has a genetic disease and the other remains healthy appear to support this theory, although mutation in one twin may occur after splitting rather than causing the split. Identical twins can vary in birth weight, develop at different rates, and die from unrelated natural causes. As a rule, however, they share an overwhelming majority of traits. When siblings share a trait, they are considered to be concordant for that trait. Typically, body structures and coloration will be strikingly concordant. Features such as facial shape, hair texture and color, eye color, and height are typical examples of concordance. “Mirror” twins show mirror image symmetry in some traits. For example, one may be left-handed while the other is right-handed. Conjoined twins share some tissue, ranging from simple joining of skin on the head or shoulder to having one heart or kidney or two torsos and a single pair of legs. Conjoined twins are created by incomplete cell division during early fetal life. The portion of cells that divide normally continue to develop in a normal fashion. The cells that did not divide completely also develop normally. The result is a portion of the body that is duplicated and a portion that is not. If the incomplete division occurred early in fetal development, the amount of shared tissue is likely to be greater than with an incomplete division that occurred later in fetal development. Multiple pregnancies (triplets and more) are usually combinations of twins. Identical triplets do rarely occur, but triplets consisting of two identical and one fraternal sibling are the norm. Multiple births of four or more infants are almost always combinations of twins. Physicians can ascertain the status of multiple birth siblings by examining placentas and chorionic sacs.
Multiple births ✧ 641 About one-third of all twin births result in identical twins. The proportion of males and females is approximately equal. The incidence of identical twins remains constant throughout the world’s diverse ethnic populations. Fraternal twins, however, show different proportions and distributions. About half the pairs have the same gender (with a nearly equal number of male-male and female-female pairs); about half are male-female pairs. Fraternal twin births occur most frequently among rural Nigerians (45 pairs per 1,000 births) and least frequently among Chinese and Japanese parents (4 pairs per 1,000 births). European and American rates, for both blacks and whites, are halfway between these extremes. The Risks Associated with Multiple Births Multiples are more difficult to carry in the womb and to nurture through infancy than singletons. While multiples are smaller, so that vaginal deliveries are easier, many physicians recommend birth by Cesarean section to manage complications better. Most twins are born healthy, but they must be monitored carefully. As the number of fetuses increases, their size decreases. Because they are not fully mature, this increases the chances for medical problems. A multiple pregnancy strains the mother’s body and is particularly subject to medical complications. Typically, a mother carrying multiple fetuses gains from 30 to 80 pounds, about twice the weight of a single pregnancy. The added weight can cause skeletal and muscular problems. The fetuses’ demands on the mother’s body may also worsen preexisting medical conditions, such as heart or kidney disease. As the multiple fetuses develop, their size stretches the uterus, which can initiate early labor. For this reason, the premature birth rate is higher for multiple fetuses than for single fetuses. Twins occasionally reach full term; triplets and greater multiples do not. Similarly, multiple pregnancies miscarry at more than three times the rate of singletons. Occasionally, one fetus will develop at the expense of the other by drawing a disproportionate amount of nutrients from the mother, a condition called twin transfusion syndrome. In about two-thirds of these cases, the undernourished fetus dies in the womb. If one fetus dies for any reason, the mother’s body may reabsorb it partially or completely, a phenomenon known as the vanishing twin. Some doctors believe that because of unobserved vanishing twins, miscarriages, and induced abortions, the number of twin conceptions has been underestimated. The prematurity and low birth weight common in multiple infants means that many are placed on life support. Studies have found that multiple infants suffer congenital defects as much as three times more often than singletons. Identical siblings are the most likely to have abnormalities. Heart malformations are most common. Closed esophagus, clubfeet, excess fingers or toes, and forms of mental retardation such as Down syndrome occur at a slightly higher rate.
642 ✧ Multiple births Fertility Treatments and Large-Set Multiple Births Triplets have historically had a reasonable chance for survival. Before the advent of support equipment for premature babies, lung immaturity was the factor that usually determined life or death. Surfactant is a chemical that is secreted in the seventh month of pregnancy. Without surfactant, lung tissues stick together and infants cannot breathe. Because of the combined size of all fetuses, many multiple infants are born before the seventh month of gestation. The Dionne quintuplets, who were born in the 1930’s, were unusual in that all five survived into adulthood. Modern support technology has helped several sets of sextuplets (six infants) to survive. In November, 1997, the same technology permitted all the McCaughey septuplets (seven infants) to survive. (The chances of naturally conceiving septuplets are one in eight to ten million conceptions.) Advances in assisted reproduction have increased the odds of multiple pregnancies. Women who have difficulty conceiving are initially treated with drugs that cause more than one egg to be released during ovulation. This increases the chance of pregnancy but also increases the chance of carrying multiple fetuses. Couples who seek medical assistance to achieve pregnancy routinely use fertility drugs. A woman will have several eggs or zygotes implanted to improve the odds of successfully initiating a pregnancy. The result of this approach is an increased number of multiple births. In 1988, twelve fetuses, which were miscarried, resulted from a fertility drug. Artificially induced pregnancies have posed ethical dilemmas for many who believe that scientists should not manipulate human biological processes. Multiple births raise other moral and ethical questions as well. Genetic tests can identify potential fetal defects in the womb early enough that surgeons can remove a defective fetus without harming a healthy one, a procedure called selective birth, selective abortion, or selective fetocide. Those who hold abortions to be immoral have reservations about selective fetocide even when the defective fetus has little chance of surviving and may threaten the lives of the remaining healthy fetuses. That selective fetocide may be used simply because a mother does not want to rear more than one child has caused greater concern. Since the procedure is tricky to perform and can result in the death of all fetuses, most doctors find selective fetocide for nonmedical reasons to be ethically indefensible. —Roger Smith; updated by L. Fleming Fallon, Jr., M.D., M.P.H. See also Abortion; Amniocentesis; Birth control and family planning; Birth defects; Childbirth complications; Ethics; In vitro fertilization; Infertility in women; Miscarriage; Premature birth; Prenatal care; Reproductive technologies. For Further Information: Clegg, Averill, and Anne Woolett. Twins: From Conception to Five Years. New
Multiple chemical sensitivity syndrome ✧ 643 York: Ballantine Books, 1988. Thoroughly practical, accessible and filled with illustrations and photos, this guidebook takes parents from the biological formation of twins during pregnancy to the best game plans for handling two energetic five-year-olds. Malmstrom, Patricia Maxwell, and Janet Poland. The Art of Parenting Twins: The Unique Joys and Challenges of Raising Twins and Other Multiples. New York: Ballantine Books, 1999. Covers bonding with more than one baby, breast-feeding techniques, coping with multiples, managing sibling rivalry, helping children achieve independent identities, understanding the special twin relationship, and financing the children’s future. Noble, Elizabeth. Having Twins: A Parent’s Guide to Pregnancy, Birth and Early Childhood. 2d ed. New York: Houghton-Mifflin, 1991. This book is well written and easy to understand. The author is a professional with many years of experience with multiple births. Novotny, Pamela P. The Joy of Twins and Other Multiple Births: Having, Raising, and Loving Babies Who Arrive in Groups. Avenel, N.J.: Crown Books, 1994. The author provides interesting information for parents of multiple infants. Rothbart, Betty. Multiple Blessings: From Pregnancy Through Childhood—A Guide for Parents of Twins, Triplets, or More. San Francisco: Hearst Books, 1994. In a clear presentation of all the facts, the author helps parents through all stages of pregnancy, providing advice on feeding, home care, juggling hectic schedules, and other critical issues related to the raising of twins and triplets. This book is very readable.
✧ Multiple chemical sensitivity syndrome Type of issue: Environmental health, occupational health, public health Definition: An increasing intolerance to commonly encountered chemicals at concentrations well tolerated by other people. Multiple chemical sensitivity syndrome (MCS), reactive airway dysfunctions, and the “sick building” syndromes are overlapping disorders caused by intolerance of environmental chemicals. Exactly how many people are affected by MCS is unknown. The onset is often associated with initial acute chemical exposure; patients may report the onset of MCS after moving into a new home, after exposure to chemicals in the workplace, or following the use of pesticides in the home. Patients often describe an increasing intolerance to commonly encountered chemicals at concentrations well tolerated by other people. Symptoms usually wax and wane with exposure and are more likely to
644 ✧ Multiple chemical sensitivity syndrome occur in patients with preexisting histories of migraine or classical allergies. Idiosyncratic medication reactions (especially to preservative chemicals) are common in MCS patients, as are dysautonomic symptoms (such as vascular instability), poor temperature regulation, and food intolerance. It is thought that patients with MCS have organ abnormalities involving the liver, the nervous system (including the brain and the limbic, peripheral, and autonomic systems), the immune system, and perhaps porphyrin metabolism, probably reflecting chemical injury to these systems. There is often a substantial overlap of MCS symptoms with fibromyalgia and chronic fatigue syndrome. Symptoms, Triggers, and Treatment The common clinical symptoms may include headaches (often migraine), chronic fatigue, musculoskeletal aching, chronic respiratory inflammation (rhinitis, sinusitis, laryngitis, asthma), attention-deficit disorder, and hyperactivity (affecting younger children). Less common complaints include tremor, seizure, and mitral valve prolapse. Agents associated with the onset of MCS include gasoline, kerosene, natural gas, pesticides (especially chlordane and chlorpyrifos), organic solvents, new carpet and other renovation materials, adhesives and glues, fiberglass, carbonless copy paper, fabric softener, formaldehyde and glutaraldehyde, carpet shampoo (lauryl sulfate) and other cleaning agents, isocyanates, combustion products (poorly vented gas heaters, overheated batteries), and medications (dinitrochlorobenzene for warts, intranasally packed neosynephrine, prolonged antibiotics, and general anesthesia with petrochemicals). It is believed that the mechanisms that lead to MCS may be multifactorial and include neurogenic inflammation (respiratory, gastrointestinal, and genitourinary symptoms), kindling and time-dependent sensitization (neurologic symptoms), and immune activation or impaired porphyrin metabolism (multiple-organ symptoms). Pathological findings of MCS have rarely been examined. A preliminary study of nasal pathology of these patients indicate that they are characterized by defects in the junctions between cells, desquamation of the respiratory epithelium, glandular hyperplasia, lymphocytic infiltrates, and peripheral nerve fiber proliferation. A consistent physiologic abnormality in these patients has not been established. Psychiatric, personality, cognitive/neurologic, immunologic, and olfactory studies have been conducted comparing MCS subjects with various control groups. Thus far, the most consistent finding is that patients with MCS have a higher rate of psychiatric disorders across studies and relative to diverse comparison groups. Since these studies are cross-sectional, however, causality cannot be implied. Various working groups have proposed several research questions addressing the relationship between neurogenic
Münchausen syndrome by proxy ✧ 645 inflammation and toxicant-induced loss of tolerance with the development of MCS. The management of patients with MCS at present is symptomatic and supportive therapy. There is a general consensus among researchers and clinicians that in order to treat patients with MCS effectively, a double-blind, placebo-controlled study performed in an environmentally controlled facility, with rigorous documentation of both objective and subjective responses, is needed to help elucidate the nature and origin of MCS. —Shih-Wen Huang, M.D. See also Allergies; Chronic fatigue syndrome; Environmental diseases; Occupational health; Pesticides; Sick building syndrome. For Further Information: Dwyer, John M. The Body at War: The Miracle of the Immune System. 2d ed. New York: Penguin Books, 1993. Gaudin, Anthony J., and Kenneth C. Jones. Human Anatomy and Physiology. New York: Harcourt Brace Jovanovich, 1989. Life, Death, and the Immune System. New York: W. H. Freeman, 1994. Mazure, Carolyn, ed. Does Stress Cause Psychiatric Illness? Washington, D.C.: American Psychiatric Press, 1995. Shaw, Michael, ed. Everything You Need to Know About Diseases. Springhouse, Pa.: Springhouse Press, 1996.
✧ Münchausen syndrome by proxy Type of issue: Children’s health, ethics, mental health Definition: A disorder in which a parent fabricates, simulates, or induces a medical condition in a child in order to receive attention and acknowledgment as the source of information about the child’s health. Münchausen syndrome by proxy may occur in different forms. In its least invasive form, this syndrome involves lying about a child’s medical problems. For example, a father may claim that his child stopped breathing or had a seizure. The harm to the child comes from the medical studies that are ordered by the physician in an attempt to evaluate and diagnose the condition. A second situation involves the simulation of symptoms in the child. For example, a mother may maintain that her child is experiencing hematuria, and examination of the urine reveals the presence of blood. The blood comes not from the child but from some external source, such as the mother’s menstrual blood or animal blood from packaged meat. Again, the child is subjected to needless diagnostic tests, some of which can be invasive.
646 ✧ Münchausen syndrome by proxy The most injurious form of Münchausen syndrome by proxy comes when a parent induces the symptoms in the child. This can be done in many ways: The parent can administer syrup of ipecac to induce vomiting, administer substances such as diphtheria-pertussis-tetanus (DPT) vaccine to cause a fever, or inject fecal materials into already existing intravenous lines to induce a bacterial bloodstream infection. Parental induction of an apparent life-threatening event (ALTE) has been documented through the use of covert video surveillance. Parents have been observed placing their hands or other objects over the infant’s face. Many of these children demonstrated bleeding from the mouth or gums, a finding not reported in any of the control infants who were experiencing an ALTE. In addition to being subjected to multiple and invasive diagnostic procedures, some children die as a direct result of their parent’s actions. Some families have a history of sudden or unexplained deaths of siblings that may be attributable to Münchausen syndrome by proxy or other types of child abuse. Identifying the Patient A physician should become concerned about the possibility of Münchausen syndrome by proxy in a child with multiple health care visits in whom an explanation for the problems is elusive. The most common complaints include bleeding, vomiting, apnea, seizures, and fever. In each case, the chronic nature of the problems and the constant switching of health care providers should be clues. Statements by experienced physicians such as “I’ve never seen anything like this” should also signal that the child may be the victim of Münchausen syndrome by proxy. Some physicians become trapped in the process of ordering multiple studies for fear of missing an exotic disease. On the other hand, some parents represent the “worried well.” These people bring their children in for many minor complaints: every runny nose, low-grade temperature, or nonapparent skin rash. Their motivation is not personal attention. Rather, they are fearful and view their children as vulnerable. The psychologic profile of the parent helps to distinguish the overly concerned mother from the one with Münchausen syndrome by proxy. The usual perpetrator is the child’s mother. The father is often detached, distant, and not involved in the child’s care, although cases in which the father is the perpetrator have been documented. Most perpetrators are believed to have borderline personalities and narcissistic personality disorders. They enjoy the attention that they receive in a medical setting. Medical staff members often characterize these individuals as excellent parents because they are knowledgeable about their child’s health, attentive to their needs, and cooperative with the staff. Many of the mothers have some type of medical or science background, which facilitates their understanding medical con-
Münchausen syndrome by proxy ✧ 647 ditions. Some have worked in physicians’ offices, making them knowledgeable about medical terminology or procedures. Psychological assessment is needed to help define parental pathology. Members of the medical staff may be disbelieving of the diagnosis, since they often find the parent to be nice and helpful. Many parents deny the accusations and are resistant to psychiatric intervention. The task of the medical team is to entertain the diagnosis, obtain evidence, and protect the child. In some institutions, covert video surveillance is used to catch the parent in the act of inflicting the symptoms. Although there is concern about issues of privacy, the legal counsel at most institutions have supported the use of covert video surveillance because it assesses the situation of the child. An Elusive Syndrome Münchausen syndrome by proxy was initially described by Roy Meadow in 1977. In the twenty years after his initial report, more than three hundred cases were reported in the literature. The diversity of ways in which this syndrome is inflicted on children has expanded with each case report. In many cases, the prognosis for affected children is somewhat guarded because of the complexity of establishing the diagnosis on a legal level. Once separation between the child and the parent occurs, the symptoms resolve. Cases may be difficult to substantiate in court, without the presence of concrete evidence. Some children suffer from long-term sequelae, sometimes behaving like invalids because of the role in which they have been cast since childhood. There are reports of self-destructive behavior and Münchausen syndrome in some survivors. Psychological counseling is critical to ensure the well-being of these children. In most cases, the children cannot be returned to the parental perpetrator because of the intractable nature of the parent’s problem. —Carol D. Berkowitz, M.D. See also Child abuse; Children’s health issues; Factitious disorders; Law and medicine. For Further Information: Eminson, Mary, and R. J. Postlethwaite, eds. Münchausen Syndrome by Proxy Abuse: A Practical Approach. Boston: Butterworth-Heinmann, 2000. Aimed at the health professional, this book brings together a collection of essays discussing different aspects of this syndrome. Chapters deal with confirming factitious illness and the child protection process. Meadow, Roy. “Munchausen Syndrome by Proxy: The Hinterland of Child Abuse.” Lancet 2 (August 13, 1977): 343-345. Rosenberg, D. A. “Munchausen Syndrome by Proxy.” In Child Abuse: Medical
648 ✧ Muscle loss with aging Diagnosis and Treatment, edited by Robert M. Reece. Philadelphia: Lea & Febiger, 1994. Southall, D. P., M. C. Plunkett, and M. W. Banks et al. “Covert Video Recordings of Life-Threatening Child Abuse: Lessons for Child Protection.” Pediatrics 100, no. 5 (November, 1997): 735-760.
✧ Muscle loss with aging Type of issue: Elder health, public health Definition: Reduction in muscle mass with aging is associated with weakness, decreased physiological functioning, and decreased physical activity, which can result in functional impairment, disability, loss of independence, and increased risk of fall-related fractures. Sarcopenia, when translated from its Greek roots, means “flesh” (sarx) “loss” (penia). Thus, the syndrome for the loss of muscle mass (also known as lean body mass or fat-free mass) that often accompanies aging is called sarcopenia. This is differentiated from the general terms “wasting,” which refers to the unintentional loss of weight attributable to a loss of both fat and muscle mass from insufficient caloric intake, and “cachexia,” which refers to the loss of muscle mass without weight loss as a result of an overactive metabolism. Therefore, the term “sarcopenia” is often used to describe muscle wasting in old age. Prevalence The extent of sarcopenia in the aged population suggests that less than 25 percent of persons under seventy years of age are afflicted with this syndrome, whereas more than 50 percent of those aged eighty or more are likely to be affected. Beginning in the seventh decade of life, approximately 25 percent of people report difficulty in walking and carrying heavy packages. Those older than seventy years of age report decreased ability to carry out common daily activities such as going down stairs or performing housework, and some even have difficulty using the toilet without assistance. These self-reported difficulties in functional ability occur regardless of gender, ethnicity, income, or other health behaviors. The combination of inadequate dietary intake combined with decreased strength from declining muscle mass results in a progressive decline in physical activity and accelerates muscle atrophy, or shrinkage, as a result of disuse. This condition adversely affects functional mobility, as evidenced by slower walking speeds, shorter walking strides, and a decrease in the amount of work a muscle can tolerate.
Muscle loss with aging ✧ 649 Etiology Since skeletal muscle stores great quantities of protein for the body, tracking protein synthesis can verify subsequent muscle mass loss. A reduction in muscle mass occurs when muscle protein content is reduced. The protein content is determined by assessing the balance between protein synthesis and protein breakdown. With aging, protein synthesis slows, thereby resulting in decreased muscle synthesis. This can be aggravated by poor nutritional status, low caloric intake, and low protein intake. Nutritional surveys have reported that individuals over age sixty-five consume an average of 1,400 Calories (kilocalories) a day, or less than 25 Calories per kilogram of body weight (1 kilogram = 2.2 pounds; 1 pound = 3,500 Calories). This average daily caloric intake of 1,400 Calories is approximately 500 Calories less than that which is recommended for optimal health for individuals over fifty years of age. Thus, based upon the average energy allowance recommendations, older adults should be consuming 5 Calories more for every kilogram of their body weight if they are to meet or exceed the current U.S. recommended daily allowances (RDAs) for caloric intake and optimal health. Lower caloric intakes imply lower nutritional status: less fat, carbohydrate, and/or protein consumption, potentially leading to nutritional deficiencies in important vitamins and minerals. The current nutritional guidelines also suggest that adults in the United States only need 0.8 gram of protein per kilogram of body weight daily; however, some researchers contend that this value is based primarily on the needs of young adults, not older adults. Based on data which showed that many adults over the age of sixty consume less than 0.8 gram per body weight daily, researchers from the Noll Research Laboratory at Pennsylvania State University suggested that older adults should consume between 1.0 and 1.25 grams of high-quality protein per kilogram of body weight daily. This would potentially help to prevent the compensatory loss in muscle mass resulting from long-term deficits in dietary protein intake. The negative age-related changes in body composition are reflected in decreased muscle, bone density, and water content of the body, with a corresponding increase in body fat. Muscle tissue plays an important role in the regulation of metabolic rate (the burning of calories). It is generally agreed that muscle mass is maintained up to about age forty; however, the gender issue as to who loses muscle mass faster is not resolved. Some reports state that men begin to lose muscle mass between forty and sixty years of age, with women not experiencing similar declines until after age sixty; other reports declare the opposite or find no difference between the genders. Regardless of gender, however, by eighty years of age, the cumulative muscle mass loss is estimated to average 30 percent, with a corresponding decline in muscle strength. Ultrasound estimates of muscle mass loss suggest that older subjects lose between 0.5 and 0.7 percent of muscle annually. Muscle tissue is more metabolically active than fat tissue, meaning that muscle burns
650 ✧ Muscle loss with aging more calories than fat. Beginning in the third decade of life, metabolic rate, or the rate at which calories are burned by the body, decreases 2 to 3 percent per decade. Taken together, the loss in muscle tissue and the decrease in metabolic rate results in a gradual percent body fat increase from the second through the eighth decades of life, resulting in a net percent body fat gain of 20 percent for men and 10 percent for women. Hence, as muscle tissue atrophies, the unused “leftover” space is replaced by fat tissue, which is not used to perform muscular work. Cross-sectional studies comparing athletes to sedentary controls, as well as studies with nonathletes, suggest that large muscle mass is predictive of higher bone mass. Thus, age-related sarcopenia and osteopenia (loss of bone) may be related. Research suggests that age-related changes in the dynamics of muscular contractions might contribute to bone remodeling imbalances, resulting in bone loss. The loss of motor units, activation, and synchronization of these units not only impairs bone integrity but also contributes to the loss of strength that accompanies muscle mass loss. Muscle strength is the ability to generate a maximal force by a muscle group. This strength is determined not only by total muscle mass but also by the individual muscle fibers. When muscle mass atrophies with aging, there is a decrease in fiber size, fiber number, and selective shrinking of type II, or fast-twitch, muscle fibers. Fast-twitch fibers are responsible for anaerobic, power-type strength activities. In addition, the loss of muscle mass may contribute to the reduction in aerobic capacity as the total amount of mitochondria, the powerhouses of cells, is reduced when muscle mass is lost. Prevention and Treatment Research is inconclusive as to whether age-related skeletal muscle wasting is preventable. It appears to be an inevitable part of aging. It may be, however, that the rate of skeletal muscle loss can be slowed down with progressive resistance (strength) training. This type of exercise has been shown to increase muscle size and strength even in the oldest of old. If strength training is to be used as a potential preventive measure, research suggests that high-intensity training (50 to 70 percent of one’s maximal strength) with low repetitions should be implemented no later than fifty years of age; after age sixty, strength training is considered to be therapeutic, compensating for the age-related muscle mass wasting. This is not to say, however, that after age sixty strength training should not been done. This situation is quite the contrary. While sarcopenia may not be preventable after age fifty, it has been proven that the frail elderly as well as community-dwelling healthy elderly can increase muscle mass by as much as 17 percent and maximal strength by as much as 110 percent with an aggressive strength training program. Contrary to the “moderate” exercise guidelines used for improving aerobic fitness, low-level resistance training
Natural childbirth ✧ 651 only yields modest increases in strength and muscle mass. In addition to the use of exercise for maintaining and improving muscle mass and strength, the judicious use of hormone replacement therapy (estrogen, testosterone, growth hormone) may also assist in maintaining muscle protein synthesis, thereby preventing and/or reducing muscle wasting. —Bonita L. Marks See also Aging; Hormone replacement therapy; Exercise and the elderly; Malnutrition among the elderly; Mobility problems in the elderly; Nutrition and aging; Weight changes with aging. For Further Information: Baumgartner, R. N., K. M. Koehler, D. Gallagher, L. Romero, S. B. Heymsfield, R. R. Ross, P. J. Garry, and R. D. Lindeman. “Epidemiology of Sarcopenia Among the Elderly in New Mexico.” American Journal of Epidemiology 147, no. 8 (April 15, 1998): 755-763. Dutta, Chhanda. “Significance of Sarcopenia in the Elderly.” Journal of Nutrition 127, no. 5 supplement (May, 1997): 992S-993S. Evans, William J. “Reversing Sarcopenia: How Weight Training Can Build Strength and Vitality.” Geriatrics 51, no. 5 (May, 1996): 46-47, 51-53. Roubenoff, R. “The Pathophysiology of Wasting in the Elderly.” Journal of Nutrition. 129, 1S supplement (January, 1999): 256S-259S. Shepard, Roy J. Aging, Physical Activity, and Health. Champaign, Ill.: Human Kinetics, 1997.
✧ Natural childbirth Type of issue: Social trends, women’s health Definition: The use of relaxation and breathing exercises rather than painkillers during labor. The basic tenets of natural childbirth education are informing women about the biological aspects of reproduction and childbirth, encouraging physical fitness for pregnant women, and teaching relaxation and breathing exercises. The movement toward natural childbirth has been one of the ways that women have acknowledged the importance of reclaiming their bodies and their experience in order to confront a male-defined medical establishment. The European Roots of Natural Childbirth The concept of dignity in labor was popularized by English obstetrician Grantly Dick-Read, who wrote the book Childbirth Without Fear: The Principles
652 ✧ Natural childbirth and Practice of Natural Childbirth (3d ed., 1942) as a reaction to the alarming rise of anesthetics in childbirth. The increased use of anesthetics required an increased use of forceps, and the incidence of brain damage and birth defects rose. Dick-Read introduced a method of concentrated relaxation during labor based on the concept that fear causes tension and tension causes pain. Thus, by replacing fear of labor with education and exercise, the incidence of a positive labor and birth experience without anesthetics was dramatically increased. Childbirth began to be seen as a healthy human process rather than as a disease. The popularity of these ideas, which stressed the participation and knowledge of the mother about her body and the birthing process, began to grow into the natural childbirth movement. By the 1950’s, organizations such as the National Childbirth Trust in England were formed and helped to sustain these ideas and practices and spread them to the United States and Canada. The French obstetrician Fernand Lamaze visited the Soviet Union in 1951 and brought back the Russian psychoprophylactic method of childbirth, which involves the lessening of pain by psychological and physical means. The Lamaze method taught women the importance of responding actively to labor contractions with a set of prelearned, controlled breathing techniques. These techniques changed women’s posture and attitude toward labor and childbirth from one based on passivity to one of competence and control. Instead of forcing a woman to be an isolated “patient,” the Lamaze method encouraged the use of a team approach surrounding the birth process that included doctor, nurse, the child’s father, and other family members. The Movement’s Spread to America In 1959, Marjorie Karmel introduced the Lamaze method to the United States with her book Thank You, Dr. Lamaze: A Mother’s Experience in Painless Childbirth. Her first baby had been delivered by Lamaze in Paris. On returning to the United States, she met with tremendous opposition when she tried to have her second child by this method. She joined forces with Elisabeth Bing, a physical therapist from Germany, to found the American Society for Psychoprophylaxis in Obstetrics, the purpose of which was to train doctors, nurses, and expectant parents in prepared childbirth techniques. In addition to prepared childbirth techniques, Bing emphasized that giving birth is one of the great crises and peak experiences in a human being’s life. Thus, it can be a bonding force for the family, and the quality of this experience establishes the fundamental starting point for a child’s future development. Grassroots organizational efforts, such as the International Childbirth Education Association (ICEA) founded in 1960, helped to spread and solidify natural childbirth as an important social movement in the United States. The ICEA and other organizations represented a federa-
Natural childbirth ✧ 653 tion of groups, composed of both parents and professionals, who shared an interest in childbirth education and family-centered maternity care. Robert A. Bradley, an American physician who wrote Husband-Coached Childbirth (1965), and Frédéric LeBoyer, a French obstetrician who wrote Pour une naissance sans violence (1974; Birth Without Violence, 1975), also became noted for their approaches to natural childbirth. Bradley stressed the role of the father or “coach” as an active participant in pregnancy, labor, and delivery. LeBoyer was renowned for advocating the modification of delivery rooms to simulate the environment of the womb. He described dim lights, a warm bath, the importance of physical bonding between the baby and mother immediately after the birth, and the advantages of avoiding premature cutting of the umbilical cord as a simple yet effective means for a “gentle” birth. Ina May Gaskin and her partner, Stephen Gaskin, were responsible for taking natural childbirth to a radical social alternative called The Farm, a self-sufficient farming community started in 1971 in Tennessee. All children on the land were delivered by Farm midwives, who also ran the clinic-infirmary. In her book Spiritual Midwifery (1978), Gaskin provided practical information that became a treatise for the effectiveness of natural childbirth and midwifery. Midwifery, although still shunned by most of the medical establishment, has become an active force in women’s health and a viable alternative to hospital births. Other options that have arisen as a result of the natural childbirth movement have been birthing rooms, birthing centers, and home births. The degree of availability of these options to women depends on differing state and county laws and regulations, attitudes, and practices. In 1973, the Boston Women’s Health Collective published Our Bodies, Ourselves as the first comprehensive source on women’s health from a woman’s perspective. The chapter on childbearing, included in a section on prepared childbirth, emphasized the need for pregnant women to educate and prepare their bodies, minds, and lives for the childbirth experience. Whether a woman has a baby at home or in a hospital, a knowledge of natural childbirth and prepared childbirth methods has been seen as essential for a positive birth experience. Subsequent updates of Our Bodies, Ourselves in 1984 and 1992 continued to stress the basic tools taught in natural childbirth of self-education, self-empowerment, and responsibility as important to both women’s health and childbirth. The emphasis was placed on the needs, strengths, and positive experience of the mother, father, and child rather than on the convenience, expertise, and control of the doctor. —Trina Nahm-Mijo See also Childbirth complications; Pregnancy among teenagers; Prenatal care; Women’s health issues.
654 ✧ Necrotizing fasciitis For Further Information: Arms, Suzanne. Immaculate Deception II: A Fresh Look at Childbirth. Berkeley, Calif.: Celestial Arts, 1994. Boston Women’s Health Collective. Our Bodies, Ourselves for the New Century. New York: Simon & Schuster, 1998. Edwards, Margot, and Mary Waldorf. Reclaiming Birth: History and Heroines of American Childbirth Reform. Trumansburg, N.Y.: Crossing Press, 1984. Gaskin, Ina May. Spiritual Midwifery. 3d ed. Summertown, Tenn.: Book, 1990. Wertz, Richard, and Dorothy Wertz. Lying-In: A History of Childbirth in America. Rev. ed. New Haven, Conn.: Yale University Press, 1989.
✧ Necrotizing fasciitis Type of issue: Epidemics, public health Definition: An invasive bacterial infection in the connective tissue between the skin and muscle which cuts off blood flow to the skin. This invasive bacterial infection occurs in the connective tissue between the skin and muscle known as the fascia. It must be urgently treated surgically and, even in the best circumstances, has a high mortality rate. Although it had been identified in the past, in 1994 there were numerous headline newspaper reports describing a new “flesh-eating bacteria.” These articles detailed the devastating effect of seemingly minor wounds infected with streptococcal bacteria. Patients quickly become very sick, with a rapidly progressive downward course, even from trauma resulting in a deep muscle bruise or muscle strain or in “minor” cuts and scrapes. In the former nonpenetrating injuries, it is likely that the bacteria were already present in the blood and then seeded the site of damage. Most of these patients, however, did not recall any prior recent infection that may have made them susceptible. Penetrating injuries, where the normally protective barrier of the skin has been broken, were often minor and not originally treated as contaminated or infected. Other cases of necrotizing fasciitis are caused by surgical infections and bowel contamination. These cases are more rare and often found to have a mixture of bacteria, such as staphylococci or Escherichia coli (E. coli). Symptoms and Treatment Patients with necrotizing fasciitis have fever, inflammation, severe pain, and blistering at the site of infection. If this cellulitis is not recognized and urgently treated, the infection will quickly spread in the layers of connective tissue just under the skin known as the fascia. As the bacteria multiply, they
Necrotizing fasciitis ✧ 655 cause blood vessels supplying the skin to form clots and thus cut off blood flow to the skin. Without nutrients, oxygen, and the ability to remove waste products, the skin dies. Once this occurs, the nerves are destroyed and the patient no longer has the excruciating pain. The skin at this point appears to be “eaten away.” The possibility exists that the underlying muscle adjacent to the fascia will become infected. Thus, the potential for muscle death as well as skin death is of great concern, particularly if the infection begins in the arms, legs, abdomen, or back, as these areas have large muscle groups directly underlying the skin. In necrotizing fasciitis, the extremities and the area around the genitals and anus (perineum) are most commonly and extensively involved. Multiplication and movement of these streptococcal bacteria and their toxins into the bloodstream produces a shocklike state. The patient must quickly be stabilized in an intensive care unit, where fluids can be administered and heart and lung condition can be closely monitored. The only lifesaving treatment available is extensive surgical debridement to remove the necrotic (dead) tissue and slow the spread of the bacteria. Antibiotics including penicillins, clindamycin, and gentamicin are given to help eradicate the pathogen. Because the infection spreads so rapidly, death often results even with heroic surgical and drug therapy unless the condition is diagnosed and treated early. Fortunately, these infections remain relatively rare. —Matthew Berria See also Antibiotic resistance; Epidemics. For Further Information: Finegold, Sydney M., and William J. Martin. Bailey and Scott’s Diagnostic Microbiology. 6th ed. St. Louis: C. V. Mosby, 1998. A well-organized text that is accessible to the general reader. Describes in detail methods for the isolation and identification of microorganisms, in particular diagnostic procedures for the identification of bacterial infectious diseases. Includes many illuminating color plates illustrating diagnostic tests. Roemmele, Jacqueline A., and Donna Batdorff. Surviving the Flesh-Eating Bacteria: Understanding, Preventing, Treating, and Living with the Effects of Necrotizing Fasciitis. Garden City Park, N.Y.: Avery, 2000. A comprehensive book geared to survivors of the disease, their families, and anyone wishing to learn more about necrotizing fasciitis. Written by the cofounders of the National Necrotizing Fasciitis Foundation. Shaw, Michael, ed. Everything You Need to Know About Diseases. Springhouse, Pa.: Springhouse Press, 1996. This well-illustrated consumer reference, compiled by more than one hundred doctors and medical experts, describes five hundred illnesses and conditions, their causes, symptoms, diagnosis, treatment, and prevention. A valuable reference book for everyone interested in health and disease. Of particular interest is chapter 19, “Infection.”
656 ✧ Noise pollution
✧ Noise pollution Type of issue: Environmental health, occupational health, public health Definition: Excessive noise associated with rising population density. Music, speech, and noise are the three basic categories of sound. Noise is simply defined as any unwanted sound. The degree of being unwanted is, however, a psychological question and may range from moderate annoyance to various forms of hearing loss. Furthermore, the interpretation of noise must be subjective, since both music and conversation may be regarded as noise in places such as an office or a library. Noise in the Environment With few exceptions, technological advances in the past few decades have resulted in a steady increase in the amount of unwanted sound. Examples may include jet airplanes, automobiles, and ventilation fans. It was thought at one time that noise should be tolerated in order to gain the benefits of industrial advances. Yet problems associated with exposure to noise have manifested themselves often enough that there is now serious concern about noise pollution in the environment. Noise from airplanes poses a major problem in urban areas. Airplanes produce noise through the efflux of the jet engine and the high-pitched whine of the engine fan. It is anticipated that the number of takeoffs and landings near major cities will continue to grow in the early decades of the twenty-first century. Furthermore, as land prices rise, residential dwellings will encroach on noise buffer zones near airports in greater numbers. The control of aircraft noise will certainly become more pressing in the future. Social surveys in cities consistently rank road traffic noise as one of the primary sources of annoyance. Traffic noise may be controlled by rerouting heavy traffic and smoothing the flow of traffic to avoid unnecessary starts, stops, and acceleration. Construction of sound-barrier walls near highways is an effective but passive means of noise reduction. Traffic noise can also be reduced if motor vehicles are properly maintained. At low speeds, most of the noise from a vehicle is radiated from the exhaust system, and a good muffler is very effective in controlling the acoustical emission. The Environmental Protection Agency (EPA) has made several recommendations for reducing noise from motor vehicles. Any future legislative control of traffic noise must be carefully planned, since there are more than 100 million cars in the United States alone.
Noise pollution ✧ 657 Indoor Noise A high proportion of the workforce is employed in interior environments in which the workers are subject to long periods of exposure to noise. Indoor noise also affects people living in apartments and homes of relatively light construction. Pollution by indoor noise may be reduced by lining walls and ceilings with acoustic panels and absorbing materials. In addition, the operation of most home appliances and factory machinery produces noise. Noise from washing machines, drills, and air-conditioning systems arises from friction, unbalanced rotating parts, and air turbulence created by fans. Such noise can be substantially reduced through proper lubrication, balance of rotating parts, and acoustic insulation. The American National Standards Institute has published guidelines for manufacturers to rate noise emission in their products. Nevertheless, these guidelines are not always adhered to, and they have not served to encourage the design of quiet products. Perhaps this will change if consumers and employers express a willingness to pay higher prices for quieter appliances and machinery. Some sources of noise pollution cannot even be heard. Ultrasonic and infrasonic noise possesses frequencies above and below the audible range, respectively. Such noise is emitted, for instance, through the background hum of high-voltage transmission cables. Although not heard, ultrasonic and infrasonic noise affects people in ways similar to audible noise. The adverse physiological and psychological effects of noise on people have been the subject of considerable study in recent years. Noise interferes with work, sleep, and recreation. It also causes strain, fatigue, loss of appetite, indigestion, irritation, and headaches. High-intensity noise has adverse cumulative effects on the human hearing mechanism that may produce temporary or permanent deafness. In fact, noise-induced hearing loss has been identified as a major health hazard by the Occupational Safety and Health Administration (OSHA). Noise decreases the efficiency of workers and increases their liability to error. —Fai Ma See also Headaches; Hearing aids; Hearing loss; Occupational health; Stress. For Further Information: Beranek, Leo L. Noise and Vibration Control. New York: McGraw-Hill, 1971. Advanced treatment of noise control. Berg, Richard E., and David G. Stork. The Physics of Sound. 2d ed. Englewood Cliffs, N.J.: Prentice Hall, 1995. A lucid discussion of noise and hearing. Kinsler, Lawrence E., et al. Fundamentals of Acoustics. 4th ed. New York: John Wiley & Sons, 2000. Technical exposition. Rossing, Thomas D. The Science of Sound. 2d ed. Reading, Mass.: AddisonWesley, 1990. A readable account of the principles of sound and noise reduction.
658 ✧ Nursing and convalescent homes
✧ Nursing and convalescent homes Type of issue: Elder health, social trends, treatment Definition: Facilities intended to provide long- or short-term nursing supervision for people with chronic medical problems. In 1999, only about 5 percent of the elderly people in the United States resided in the nation’s 20,000 nursing homes. Although 80 to 85 percent of people over sixty-five are in relatively stable health, as many as 30 to 40 percent of them will spend some time in a nursing home for short-term care at least once in their lifetime. About 50 percent of those admitted to nursing homes stay fewer than six months, 20 percent stay one year or longer, and 10 percent stay three or more years. The terms “nursing home” and “convalescent home” are widely misused and misunderstood. They have been used to describe everything from shelter care to acute care hospitals. However, nursing homes are primarily designed to meet the needs of people convalescing from illness or to provide long-term nursing supervision for people with chronic medical problems. The goal of a nursing home is to provide care and treatment to restore or maintain the patient’s highest level of physical, mental, and social wellbeing. This goal is ensured by strict federal legislation called the Omnibus Reconciliation Act (OBRA), which was implemented in October, 1990. The OBRA set minimum requirements for registered nurse staffing, training for nursing assistants, limited use of restraints (both physical and chemical), physical layout of the building, services, and patient rights. Skilled Nursing Facilities A skilled nursing facility (SNF) is required to provide twenty-four-hour nursing supervision by registered or licensed practical nurses. Commonly referred to as “nursing homes” or “convalescent hospitals,” these facilities normally care for the incapacitated person in need of long- or short-term care and assistance with many aspects of daily living, such as walking, bathing, dressing, and eating. At a minimum, SNFs provide medical, nursing, dietary, pharmacy, and activity services. Most SNFs have a certified distinct part (CDP) or transitional care/subacute unit that provides Medicare part A rehabilitative services by occupational therapists, speech-language pathologists, and physical therapists. Examples might include rehabilitation for a fractured hip, tube feedings, and ostomy care. The cost is nearly one-half of what would be charged in an acute care hospital, but the intensive, multidisciplinary approach to rehabilitation is excellent. Nursing homes are designed to help people recover strength and return to the activities of daily living with the goal of going back
Nursing and convalescent homes ✧ 659 home; they are not, as is popularly believed, “warehouses” for infirm and dying elderly people. Three areas have had a significant impact on the evolution of care in nursing homes: economics, attitudes, and education. Trends in nursing home care include short-stay rehabilitation, outpatient rehabilitation, managed care, and subacute care (which includes ventilator patients, wound management, postsurgical care, coronary care, enhanced rehabilitation, and the medically complex patient). Such trends have allowed the image of nursing homes to change rapidly to that of highly specialized health care centers. The difference this transformation has made in care and outcomes has been significant. The exchange of skills and information not only has expanded the practice of the clinicians involved but also has benefitted residents. The inclusion of occupational therapists who work on resident positioning offers new approaches and facilitates the reduction of the use of physical restraints. Recreational therapists and occupational therapists may collaborate to provide special classes using adaptive equipment for residents with residual disabilities from stroke. Feeding and swallowing problems in the nursing home are now addressed by a team consisting of specialists in speechlanguage pathology, diet, nursing, and occupational therapy if necessary. Most of all, residents are involved in care decisions and choices about their daily activities, which enhances resident self-esteem and independence. Special Disability Units and Intermediate Care Facilities Skilled nursing facilities for special disabilities provide a protective or secure environment for people with mental disabilities, such as Alzheimer’s disease. Residents in head injury units tend to be young and middle-aged adults. Many states reimburse the nursing home at a higher rate for these residents, who are sicker or require more complex care. Facilities are challenged not only to provide protection for these demented residents and others in the facility but also to devise prostheses and programs to enable these individuals to maintain their independent self-care abilities for as long as possible with a minimum of psychotropic drugs. Mind-altering medications are considered chemical restraints that can immobilize an individual. The advantage of this type of unit is that care can be specifically tailored to meet the special needs of these residents. For instance, activities for demented residents must be structured differently from those for residents who are not demented. The staff ratio may need to be higher than in the traditional nursing home unit because, depending upon the stage of the disease, more intense supervision may be needed. The unit must be safe, comfortable, and not overstimulating. These units usually have their own admission and discharge criteria. An intermediate care facility (ICF) is required to provide eight hours of
660 ✧ Nursing and convalescent homes nursing supervision per day. Because of their physical appearance, these facilities are often confused with the SNFs. Intermediate care, however, is less extensive than skilled nursing care and generally serves clients who are ambulatory and need less supervision and care. Licensed nurses are not always immediately available in an ICF. At a minimum, ICFs provide medical, intermittent nursing, dietary, pharmacy, and activity services. Some states, such as Texas and Nebraska, have a large number of ICFs, while others, such as California, have very few. Approximately one-third of all nursing homes are certified to provide intermediate care, with most services performed by unlicensed staff members. Licensing and Certification Most nursing homes are certified to participate in both the federal Medicare and Medicaid programs, which pay certain funds for a “spell of illness.” Some facilities, such as Mount St. Vincent’s in Seattle, Washington, and the Mary Conrad Center in Anchorage, Alaska, have also emphasized the social aspects of care. Instead of meals being served on trays in the individual’s room or in the dining room, the food is presented buffet style, with the residents choosing what appeals to them. “Pods” or “neighborhoods” are formed with clusters of residents to encourage friendships and bonding. All state governments require that nursing homes be licensed. The licensing requirements establish acceptable practices for care and services. State inspectors visit nursing homes at least once each year to determine their compliance with state standards and their qualifications to receive Medicare and Medicaid reimbursement. This survey report of the facility’s deficiencies is available for public scrutiny in the lobby of the facility, on the Internet, and upon written request from the state department of health. Some licensed nursing homes may also be certified to designate what level of care they provide and how they may be reimbursed for that level of care. Depending upon the state, residents may be classified as light care, moderate care, heavy care, or heavy special care. Light care residents require less assistance with the activities of daily living (dressing, bathing, and feeding) than residents in other classifications. Ownership and Management of Nursing Homes Some nursing homes are operated as nonprofit corporations. They are sponsored by religious, charitable, fraternal, and other groups or are run by government agencies at the federal, state, or local levels. However, about 80 percent of nursing homes are proprietary, meaning they are businesses that aim to make a profit. They may be privately owned by small companies or individuals, or corporately owned by large chains, such as Beverly Enterprises.
Nursing and convalescent homes ✧ 661 Final responsibility for the operation of a nursing home lies with its governing body, which acts as the legal entity licensed by the state to operate the facility. The governing body sets policies, adopts rules, and enforces them for the health care and safety of the residents. The person in charge of the financial and day-to-day management is called the administrator. The nursing home administrator reports to the owner, board of directors, or corporate officer. Within the nursing home are many departments that either provide direct care, such as nursing, or provide such support services as dietary and laundry. The largest department is the nursing department, which provides twenty-four-hour resident care. A person in a nursing home must be under the care of a physician. If the person’s personal physician will not continue to provide care, a new physician must be chosen who will evaluate the person’s needs and prescribe a program of medical care. A nursing home is not free to initiate any form of medical treatment, medication, restraint, special diet, or therapy without the consent of a physician. Prior to being admitted to a nursing home, most people undergo a complete physical examination to determine whether skilled nursing care or intermediate care is required, the person’s diagnosis, the duration of the illness or need for nursing home care, what treatments are indicated, and the person’s rehabilitation potential. Since physicians are slow to make nursing home rounds, more and more facilities have geriatric nurse practitioners on staff who relieve the physicians and provide on-site visits on a daily basis. Financing and Admission In 1999, the basic charge for a double-bed room in a typical nursing home was in the range of $20,000 to $60,000 per year. Homes in rural areas tend to be slightly less expensive than those in the cities. The costs of medications and physician’s visits are not included in the basic charge. Also, special treatments, such as physical, occupational, and speech therapy, often add to the cost. There are also possible additional charges for drugs, personal laundry, haircuts, and extra services. Three out of four residents are dependent upon government assistance through Medicare (including supplementary Medicare insurance called Medigap) or Medicaid. Other financial aid might be available from private health insurance sources. Medicare part A will pay the entire bill for the first twenty days, then partially pay for the rest of the first one hundred days of skilled nursing home care in the CDP; however, Medicare pays nothing for care in an ICF. Medigap policies typically pay only a portion of the daily costs, and then only for a limited number of days. Long-term or catastrophic care insurance is designed to provide benefits for this type of care. Financial assets accumulated by the resident and spouse could be exhausted through
662 ✧ Nursing and convalescent homes prolonged care in a skilled nursing facility. Therefore, it is extremely important to plan ahead by determining all the benefits available under Medicare and Medicaid. A staff social worker can usually guide the resident and family through the maze of red tape and paperwork needed to qualify for available programs. Patients are routinely advised to contact the local state Medicaid agency for eligibility and program information as early in the placement process as possible. Advance planning is one of the best ways to ease the stress that accompanies choosing a nursing home. Many good nursing homes have waiting lists, and the chances of getting placed in the home of choice will be greatly enhanced if placement is made on a waiting list prior to the actual time of need. Selecting a home is an important decision—one that deserves foresight and careful, clear-headed consideration rather than a crisis atmosphere. Professionals in the long-term care field may provide referrals to particular nursing homes. In addition, state inspection reports on nursing facilities will detail any code violations and provide information on how the facility treats its residents. The home’s contract or financial agreement is a legal contract, so it is advisable to have a lawyer review the agreement before signing it. Free legal assistance is usually available to senior citizens. The admission papers should include the following items: an agreement stating the terms and conditions, the daily room rate, and what services are covered by it; a list of optional services and the charges for them; a copy of each patient’s bill of rights; a statement about eligibility for Medicaid; and a statement that the nursing home is or is not Medicare and Medicaid certified. —Maxine M. McCue See also Aging; Alzheimer’s disease; Dementia; Hospitalization of the elderly; Medications and the elderly. For Further Information: Allender, Judith A., and Cherie L. Rector. Readings in Gerontological Nursing. Philadelphia: Lippincott-Raven, 1998. This book is written for the professional assisting the elderly in decision making. Guide to Choosing a Nursing Home. Rev. ed. Baltimore: U.S. Department of Health and Human Services, Health Care Financing Administration, 1996. A step-by-step guide to choosing the right nursing home. Ignatavicius, Donna D. Introduction to Long Term Care Nursing: Principles and Practice. Philadelphia: F. A. Davis, 1998. Written for student nurses, this book provides practical and accessible information in every chapter. McConnell, John. “Reflections on the Evolution of Care in Nursing Homes.” Journal of Gerontological Nursing 20, no. 6 (June, 1994). McConnell describes the changes in nursing homes made during the late 1980’s and early 1990’s.
Nutrition and aging ✧ 663 “Nursing Homes: A Special Investigative Report.” Consumer Reports 60, no. 8 (August, 1995). This series of articles on long-term care examines public policy on the financing of nursing homes and offers suggestions for families facing the cost of long-term care.
✧ Nutrition and aging Type of issue: Elder health, prevention, public health Definition: The role of diet in maintaining health. Certain functions of the body change as a natural result of the aging process. Many organs are not as efficient as they once were. As these normal physiological changes occur, the requirements for certain nutrients also change. Some changes in the older body are pathological and represent chronic diseases of old age, such as hypertension, diabetes, cardiovascular disease, pulmonary disease, and cancer. Programs designed to prevent or delay the onset of these chronic conditions always include a nutritional component. Even after a disease is established, nutrition maintains a significant role in its treatment. Changing Nutrient Requirements Requirements for calories usually decline with age. This decline in caloric need is tied to the frequent decline in lean body mass and increase in adipose tissue that occurs with aging. This may be because of a decline in energy metabolism. Although some researchers feel that this is associated with an aging body alone, others believe that physical activity also plays a large role in determining what the basal energy metabolism will be. In fact, some experts believe that most of these negative effects can be overcome by a vigorous exercise program. Changes in protein requirements with age are more controversial because recommendations for both decreased and increased dietary protein intakes have been advocated by different experts. Many believe that dietary protein requirements decrease with age and that this decline is secondary to the decline in lean body mass. Less muscle tissue would require less dietary protein to sustain it. The lower dietary protein recommendation is also congruent with kidney function, which declines somewhat with age as well. The opposing argument claims that higher dietary protein intakes diminish the loss in lean body mass that occurs with aging and that these higher dietary protein intakes are not detrimental to renal function. Of the vitamins for which there seems to be increased requirements during normal aging, vitamin B12, vitamin D, and vitamin B6 are most
664 ✧ Nutrition and aging
Some people suffer from poor nutrition in their later years as the senses of taste and smell decline, food preparation becomes more difficult, income decreases, and social opportunities for meals are limited. Restaurant specials and communal dining can encourage proper eating habits. (PhotoDisc)
prominent. During aging, the amount of hydrochloric acid secreted by the stomach gradually decreases. For many people, this results in achlorhydria (lack of hydrochloric acid in gastric juice) or hypochlorhydria (low levels of hydrochloric acid in gastric juice). The reduction in hydrochloric acid secretion results in less intrinsic factor being secreted. Intrinsic factor is required for efficient absorption of vitamin B12. Therefore, the decrease in intrinsic factor leads to a decrease in the absorption of vitamin B12. This can partially be overcome by ingesting larger amounts of vitamin B12, which will saturate the intrinsic factor carrier system and allow for some free diffusion of vitamin B12. Some of the manifestations of vitamin B12 deficiency are mental changes and dementia. Indeed, many elderly with dementia have subtle vitamin B12 deficiencies. Although the major dietary source of vitamin D is fortified milk, most vitamin D is synthesized by the skin after exposure to sunshine. The synthesis of vitamin D occurs primarily in the epidermis layer of the skin, where a precursor of vitamin D is metabolized to vitamin D. There is less of this precursor in the epidermis of older people; therefore, less vitamin D is synthesized. Both dietary vitamin D and vitamin D synthesized in the skin must undergo an activation reaction in the kidney. It is also believed that this activation process might be reduced in older people because of the decline in renal function that occurs in aging. Although specific recommendations for older people have not been set concerning vitamin D, additional dietary sources or sunlight exposure are being considered by experts. This is
Nutrition and aging ✧ 665 especially important for housebound elders who would benefit by sun exposure on their face and hands for fifteen minutes several times per week. Many elderly have indicators of poor vitamin B6 status, although the cause for this marginal status is not clear. Vitamin B6 requirements are linked to protein intake, so some of the variability may be because of a range of protein intake across many ages and body compositions. Vitamin A is the only vitamin for which lower requirements have been discussed for the elderly. Preformed vitamin A is found in organ meats, eggs, some fish, and dairy products. Carotenoids found in vegetables and some fruits can be converted to vitamin A. Vitamin A is a fat-soluble vitamin, and excess is stored in the liver. However, vitamin A toxicity can occur when either the liver’s capacity to store vitamin A is exceeded or the dose is so large that normal carrying and storage processes are overwhelmed. With a normal, varied diet, sufficient vitamin A will be stored in the liver. The quantity of vitamin A stored will increase as the person ages. Because of the probability of having enough vitamin A stored to cover vitamin A requirements and the possibility that the liver’s storage capacity could be exceeded because of long years of vitamin A deposition, experts are considering lowering the recommended intakes of vitamin A for the elderly. However, since carotenoids pose no health risk or threat of toxicity, no recommendation concerning carotenoids has been forthcoming. Changing Mineral Needs Of the minerals, calcium is discussed most often in terms of recommending increased requirements during normal aging. The consensus statement from the National Institutes of Health (NIH) concerning optimal intake of calcium recommends almost twice the current recommended dietary allowance for those over sixty-five years. The reason for the increased calcium intake is based upon a lower intestinal absorption of calcium in the elderly and a decreased conversion of vitamin D to its active form by the older kidney. Vitamin D is necessary for calcium utilization. Higher intakes of calcium are thought to diminish the calcium losses from bone that result in osteoporosis. Although intestinal absorption of other minerals, such as zinc and iron, may decrease during aging, studies do not suggest a need for an overall increase in dietary intake of these two minerals in general. Furthermore, despite considerable mythology, neither fatigue nor lack of energy seems related to iron status in the elderly. Changes in smell and taste that are common during aging do not seem related to zinc status. However, elderly people with very poor diets, or those who are malnourished, may develop a zinc or iron deficiency that would require dietary modifications. —Karen Chapman-Novakofski
666 ✧ Nutrition and children See also Aging; Breast cancer; Cancer; Cholesterol; Dementia; Diabetes mellitus; Heart disease; Heart disease and women; Malnutrition among the elderly; Nutrition and children; Nutrition and women; Obesity; Obesity and aging; Osteoporosis; Prostate cancer; Vitamin supplements; Weight changes with aging. For Further Information: Morley, John E., Zvi Glick, and Laurence Rubenstein. Geriatric Nutrition: A Comprehensive Review. 2d ed. New York: Raven Press, 1995. Contributors offer reviews on nutritional deficiencies and diseases affected by nutrition in the elderly. Munro, Hamish, and Gunter Schlierf, eds. Nutrition of the Elderly. New York: Raven Press, 1992. Examines the relationship between diet and disease in the elderly, especially osteoporosis and Alzheimer’s disease. Schlenker, Eleanor D. Nutrition in Aging. 3d ed. Boston: WCB/McGraw-Hill, 1998. Includes discussions on the theories of aging, nutritional needs of the elderly, and food habits of ethnic groups. Vellas, Bruno J., Paul Sachet, and R. J. Baumgartner, eds. Nutrition Intervention in the Elderly. Paris: Serdi/Springer, 1995. Contributors present nutrition studies of elderly people around the world and provide information about nutrient intake, nutrition status, and nutrition-related risk factors for disease. Ziegler, Ekhard, and L. J. Filer, Jr., eds. Present Knowledge in Nutrition. 7th ed. Washington, D.C.: ILSI Press, 1996. A comprehensive overview of vitamins, minerals, and nutrition with reference to the elderly in several sections.
✧ Nutrition and children Type of issue: Children’s health, prevention, public health Definition: The requirements of a proper diet, which supplies all the essential nutrients to carry out normal tissue growth, repair, and maintenance. It also must supply enough substrates to produce the energy necessary for work, physical activity, and relaxation. Good nutrition also includes the right amounts of any nutrient (not too little or too much) to prevent serious health problems. The ideal composition of the diet throughout life remains fairly stable, but nutritional requirements vary with age. Prior to birth, the fetus is receiving what it needs from the mother through the placenta. This is why obstetricians focus on the nutrition of the mother. Once the baby is born, the required nutrition either continues to come from the mother, through breast-feeding, or the baby starts on formula.
Nutrition and children ✧ 667 Breast milk is tailor-made to meet the nutritional needs of the developing infant. It contains the carbohydrate lactose, and breast milk fat provides the omega-6 fatty acid, linoleic acid, and its products. The proteins in breast milk are largely alpha-lactalbumin for tissue growth and lactoferrin for iron. In addition, all the essential vitamins and minerals that the baby needs are included. The only vitamin that is not passed easily is vitamin D, but even very small amounts of sun exposure allow babies to produce this vitamin for themselves. If sun exposure is not possible, some physicians may recommend a supplement for breast-fed infants. Other substances in breast milk that are not nutrients are enzymes, hormones, and antiviral and antibacterial agents, all of which benefit the infant. The interesting thing about breast milk is that its composition changes along with the growth and development of the infant. Therefore, the composition of breast milk for a newborn is different from that for a six-month-old. Sometimes, the nutrition of the mother is not sufficient to supply both herself and the infant with required nutrients. As during pregnancy, the infant generally receives what he or she needs, to the detriment of the mother; over time, the mother may become sick, which could affect the baby. Generally, poor maternal nutrition will cause a decrease in the quantity of milk formed even if the quality is the same, meaning that growth could be influenced. Formula-fed infants will probably receive the same nutrients as breast-fed ones. Manufacturers have spent much time and money developing formulas that are scientifically formulated to meet a baby’s needs. The options are cow’s milk-based or soy-based, but the nutrient requirements for each have been formulated to resemble the nutrients in breast milk. It is important to note that infants up to one year of age should not be fed whole cow’s milk. Cow’s milk is higher in protein, calcium, and phosphorous to support the calf’s faster growth rate and can be harmful to human babies. The U.S. government report Healthy People 2000 (1991) set a goal of 75 percent of new mothers breast-feeding upon discharge from the hospital and 50 percent of new mothers breast-feeding for five to six months. The actual number in 1990 was barely above 50 percent upon discharge and did not change much during the decade, partially because of government-sponsored programs to provide free formula to low-income mothers. Because breast milk formation is a positive feedback system, it is virtually impossible to return to breast-feeding once milk production has stopped. Consequently, many mothers who only learn of the benefits of breast-feeding several weeks after delivery must continue with formula. Baby Food Foods are introduced into a baby’s diet as the baby becomes physically ready to handle them, which develops in stages. A newborn can swallow liquids
668 ✧ Nutrition and children only when they are well back in the throat. By four months of age, the baby’s tongue can move against the palate to swallow semisolid food. Between six and twelve months, the baby develops teeth, but it is about another year before the infant can handle very chewy foods. At birth, the stomach and intestines are immature and can digest milk sugar (lactose) but not other starches. At about four months of age, the enzymes necessary to digest starch are in the baby’s stomach, so that starchy foods become possible. Semisolid food is introduced to the infant at four to six months of age and the recommended first food is iron-fortified rice cereal. Fortification is beneficial because the iron stores that the baby had at birth are usually depleted by the time that birth weight doubles. The chewing and swallowing reflex takes some time to develop, and prior to about four months of age, the gag reflex prevents the swallowing of most things except those far back in the mouth. The criteria for when to start solid foods is developmental: That the baby can sit up, can handle finger foods, and is teething are good bases. Parents should start with hard foods such as crackers or cookies that soften with saliva; this helps the chewing reflex but decreases the risk of choking. No food should be given to an infant unless the caregiver is able to observe the process to watch for choking. New foods should be introduced one at a time to detect allergies or food sensitivities. One recommendation for cereals is to start with rice, which is less likely to cause a negative reaction, and end with wheat, which is more likely to cause a reaction. Several days should be sufficient to detect a problem. The symptoms of food allergies may vary from slight digestive discomfort to skin rashes to respiratory distress, depending on the severity of the reaction. Several months should pass before the food causing the reaction is introduced again, as sensitivities often disappear with maturity. Vegetables should be introduced before fruits because the sweet taste sensation is dominant and the infant may not like the less sweet taste of vegetables if fruits are eaten first. Soft protein foods such as yogurt, cheese, tofu, or cooked egg white can be introduced at six to eight months of age. The chewing process is new to the infant, and often the tongue is used rather than the teeth to mash food in the mouth. By about eight to ten months of age, the infant should be chewing and have some baby teeth present, which is the marker for introducing finely chopped meats and soft table (finger) foods. The decision about whether to use prepared baby food or to fix it at home is an issue of personal choice. The prepared product meets all the quality standards for healthy, safe food and is very convenient. Home-prepared food should be bland and therefore needs to be fixed separately from the food for the rest of the family. It should also be prepared fresh or in small quantities and frozen for storage because the infant’s immune system is still developing and may be at higher risk for botulism. Liquids are still very important and should deliver necessary nutrients, not simply calories.
Nutrition and children ✧ 669 Water, breast milk or formula, or juice should be given to maintain adequate hydration. By the end of the first year, the baby should have been introduced to a wide variety of foods and should be receiving about 1,000 Calories (kilocalories) a day in a well-balanced manner to ensure the intake of all the required nutrients in the proper amounts. Nutrition needs after the first year are more standard because all children by age one should be eating solid food and have been exposed to a wide variety of foods. They are no longer dependent only on breast milk or formula for their nutrients. Growth also slows down from the rapid rate experienced during the first year. Because of increased activity, especially walking, the body composition is changing from the storage of large amounts of fat for energy to the building of muscle and bone for mobility. From age one forward, appetite should be the controlling factor for calories needed. It will fluctuate as growth speeds up and slows down during the lifetime. What is extremely important is the establishment of healthy eating patterns that include all the necessary nutrients, with total calories increased or decreased as demanded. Eating patterns are developed during early childhood, and it is up to the parents to provide guidance so that adequate nourishment for healthy growth without obesity is ensured. The Food Guide Pyramid The Food Guide Pyramid was designed to show visually how much of the diet should provide the quantity and quality necessary to supply the macronutrients of carbohydrates, fats, and proteins and the micronutrients of vitamins and minerals necessary for optimum nutrition, with an emphasis on fruits, vegetables, and whole grains. Water is the only nutrient not included in the pyramid; the requirement is 64 ounces per day—eight 8-ounce glasses spread over the day. A very active person or a person in a hot environment needs even more. The pyramid base is bread, cereal, rice, and pasta, with a daily goal of six to eleven servings. The next level is vegetables and fruits. The split is slightly in favor of vegetables, with the goal of three to five servings, over fruits, with two to four servings a day. Moving up the pyramid, the next level consists of the milk, yogurt, and cheese group on one side, with two to three servings as the goal, and the meat, poultry, fish, dry beans, eggs, and nuts group on the other, which also has two to three servings as the daily goal. The top of the pyramid is for the nutrients that add calories but not much else, including fats, oils, and sweets; the recommendation is to use them sparingly. Serving Sizes The determination of how many servings to eat from the ranges is based mostly on the caloric requirement. A child with a lower caloric requirement
670 ✧ Nutrition and children would select the lower end of the serving number, and a teenager with a higher requirement would select the higher end. This makes it easy to keep the proper proportion of macronutrients. It is also recommended that daily choices be from as wide a variety as possible in each section. An example is eating as many colors as possible in fruits and vegetables. The quantities of the macronutrients required daily are based on multiple factors concerning their function in the body. The requirement for carbohydrates is based on the amount of glucose needed by the central nervous system, the muscles, and any other tissue that uses glucose for its energy source. Because the stores of glucose are very small, it is needed in the largest quantity. Figures of 55 percent to 70 percent of daily calories for carbohydrates have been used, depending on growth and energy requirements at the time. For optimum daily function of the brain and central nervous system, the percent of total carbohydrate calories should never go below 55 percent. The makeup of the carbohydrates should be complex because the body attains things other than glucose, such as fiber, that are essential to good health. Eating from the bottom two tiers of the Food Guide Pyramid should make that possible. The amount of fat required is partly based on its function as an energy source. In addition, fat in the diet is required for the absorption of the fat-soluble vitamins. Essential fatty acids (ones that the body cannot produce) present in dietary fat are used for cell membrane repair and the formation of certain hormones. The dietary requirement for fats is between 20 and 30 percent of daily calories, with the decision between the high and low ends based on energy needs and health risks. Fats can be saturated or unsaturated. The form eaten may have some impact on health. Of the total fat, no more than 10 percent should be saturated, which is the form associated with heart disease. The rest of the fat can be split between polyunsaturated and monounsaturated fats, which both come from plant sources of fat that are usually an oil at room temperature. Not much research has focused on low-fat intake, since the problem for Americans in the latter half of the twentieth century became too high an intake (greater than 30 percent). For some parents, the media campaign of the 1980’s and 1990’s on the evils of fat may have set the pendulum swinging the other way, with children not getting enough fat in their diet. During the first two years especially, fat is essential for the development of the myelin sheath that surrounds the larger nerves and the brain. Poor development of this sheath may lead to problems with learning and memory throughout life. Protein requirements are based on tissue growth and repair, which means that the requirement goes up during a growth spurt, illness, or physical activity. The requirement by percent of calories is between 10 percent and 20 percent. Another way to figure protein requirement is based on 0.9 gram per kilogram of body weight in children. The requirement for children is higher than for adults because growth is going on all the time, even though
Nutrition and children ✧ 671 it is faster and slower at different times. Protein has other functions as well, such as formation of hormones, enzymes, and antibodies and the maintenance of fluid, electrolyte, and acid-base balances. It is also a back-up energy source when the body cannot use or does not have enough glucose. Proteins are made up of amino acids; there are nine essential amino acids. Animal sources usually have the amino acids in about the same complement as humans use to make protein. Because plant sources often do not, a vegetarian receiving all protein from plant sources needs to eat complementary proteins. A common example is combining rice and beans, which have complementary essential amino acids. The complements closest to human protein are found in egg whites and milk; some vegetarians add these two animal products to their diet to help ensure adequate protein. Whole Foods for Whole Nutrition Eating from the Food Guide Pyramid helps to guarantee the proper intake of vitamins and minerals, the micronutrients. Vitamins are organic substances found in foods that are essential for many body functions. They come in two forms, water-soluble and fat-soluble. The differences are how the body absorbs them and how the body stores them. Water-soluble vitamins require only water to be absorbed and so are readily absorbed in the intestine. Because water is constantly moving around in the body, into and out of cells, water-soluble vitamins are not stored anywhere for very long. Any excess is excreted regularly by the kidneys. Fat-soluble vitamins are only absorbed in the presence of fat in the intestine. Once they enter the body, they can be stored for long periods of time in fat cells. The water-soluble vitamins are the B vitamins—thiamin, riboflavin, niacin, B6, folate, pantothenic acid, biotin, and B12—and vitamin C. The fat-soluble vitamins are vitamins A, D, E, and K. Minerals are naturally occurring inorganic chemical elements. The designation of either major or trace minerals has to do with the amount naturally found in the body. The amount of major minerals is greater than 5 grams, or one teaspoon. The major minerals required from the diet include calcium, chloride phosphorus, potassium, magnesium, sulfur, and sodium. Trace minerals include copper, iodine, iron, manganese, selenium, and zinc. Vitamins and minerals are involved in most body functions, and if they are not present or consumed in the diet, diseases result. Research on the value of substances other than nutrients found in foods has presented some very interesting results on compounds variously called phytonutrients, phytofactors, or phytochemicals. These compounds are part of the benefit of eating the natural source of a food, rather than a processed form or a supplement. Many of these substances have been determined to have antioxidant properties against various cancers and heart disease, two of the leading lifestyle-related diseases faced today. For example, blueberries have gone from being something eaten occasionally in muffins or pancakes
672 ✧ Nutrition and children to a highly recommended fruit for their very high concentration and variety of phytofactors. The Roots of Eating Disorders Because the early feeding of an infant lays the foundation for lifelong eating habits, parents should discourage the development of behaviors and attitudes associated with unhealthy eating. The psychology of eating disorders of both extremes, undereating or overeating, can actually begin to develop in infancy if food is used as either a punishment or a reward. Eating and mealtime should never be a negative experience for toddlers. Research on growth and development has shown better growth in height and weight in children fed in an emotionally positive environment, along with better brain development because the formation of nerve-to-nerve connections in the brain relies on both nutrients and environmental stimulation. The goal of parents should be to help the child develop a healthy relationship with food. Dieting should not be encouraged at any time during the growth years and should not be necessary if healthy eating patterns and activities are encouraged and no psychological pressure has been applied concerning food. —Wendy E. S. Repovich See also Anorexia nervosa; Breast-feeding; Children’s health issues; Eating disorders; Failure to thrive; Food poisoning; Lactose intolerance; Malnutrition among children; Obesity; Obesity and children; Phenylketonuria (PKU); Vitamin supplements; Weight loss medications. For Further Information: Foods That Harm, Foods That Heal: The A-Z Guide to Safe and Healthy Eating. Pleasantville, N.Y.: Reader’s Digest, 1997. This source provides a practical listing of how to use nutritional choices to benefit one’s health, as well as how to avoid common mistakes that can lead to illness. Haas, Elson M. Staying Healthy with Nutrition: The Complete Guide to Diet and Nutritional Medicine. Berkeley, Calif.: Celestial Arts, 1992. A complete guide to diet and nutritional medicine, with a chapter focusing on nutritional applications at different life stages, from infancy to old age. Krummel, Debra A., and Penny M. Kris-Etherton, eds. Nutrition in Women’s Health. Gaithersburg, Md.: Aspen, 1996. A nutrition book specifically for women, with chapters for children, adolescents, athletes, pregnant teenagers, and people with eating disorders. Sharkey, Brian. Fitness and Health. 4th ed. Champaign, Ill.: Human Kinetics, 1997. A textbook written for the layperson that includes information about nutrition as it relates to activity in the growing child. Sizer, Frances Sienkiewicz, and Eleanor Noss Whitney. Nutrition Concepts and Controversies. 7th ed. Belmont, Calif.: West/Wadsworth, 1997. An in-depth
Nutrition and women ✧ 673 book on nutrition dealing with all the essential nutrients and some of the non-nutritive elements of food that relate to good health.
✧ Nutrition and women Type of issue: Prevention, women’s health Definition: The proper intake of nutrients, which plays a major role in women’s health and may prevent or delay the onset of degenerative diseases such as heart disease and osteoporosis. The primary nutritional problem for women of the United States and Canada is not one of undernutrition but rather one of poor nutrition: too many high-fat calories and too few fruits and vegetables. This type of diet contributes to the high prevalence of obesity, defined as a body weight more than 20 percent higher than recommended for a given height or a percentage of body fat that exceeds 30 percent. Using these guidelines, some experts estimate that one-third of all American women and one-half of all teenage girls are obese. The eating behaviors that result in excess body fat may be attributable to cultural traditions or ill-informed notions about proper nutrition. The rate of obesity decreases among women with higher levels of education and economic status. Concurrent with the excess nutritional intake are jobs and recreational activities that require little expenditure of energy. While there is a genetic component to obesity, more than 70 percent of these cases can be attributed to lifestyle: food that is unhealthy and easily accessible combined with the sedentary nature of work and recreation found in most of North America. Obesity is associated with many degenerative diseases such as coronary artery disease, diabetes mellitus, hypertension, and cancer. In addition to the risk of disease, women can also suffer from a lack of self-esteem as a result of excess body fat. The Health Effects of Excessive Fat Intake Cardiovascular disease, including coronary artery disease, hypertension, and stroke, has a well-established relationship with dietary fat, especially saturated fats. Saturated fats are found in animal products such as meat and dairy products and in tropical oils used in commercial baking. A diet high in fat can alter the levels of circulating blood (or serum) lipids: The total serum cholesterol and the level of low-density lipoprotein cholesterol (often called “bad” cholesterol) increase, while the level of high-density lipoprotein cholesterol (“good” cholesterol) decreases. The risk of cardiovascular disease also increases after the menopause, when the body decreases its pro-
674 ✧ Nutrition and women duction of estrogen. Combined with a typical American diet, the result is an undesirable serum lipid profile. There is good evidence that women who are given hormone replacement therapy have a substantially lowered risk of cardiovascular disease. The relationship between dietary fat and cancer is less clear. Some nutritionists believe that up to 70 percent of cancers can be prevented by nutritional modifications depending on the type of cancer. For example, the rates of both breast and colon cancer are thought to be reduced by a lower fat intake. The association between breast cancer and dietary fat is the result of examining other countries who have a lower fat intake and a lower rate of breast cancer. Yet, it may not be only dietary fat that is the major factor. Women in developing countries eat less total calories, experience menarche (first menstruation) later, have their first child earlier, and have more children—all factors thought to protect women from breast cancer. Immigrants to North America do not experience an increase in the rate of breast cancer after living in North America, but their children have the same rate of breast cancer as Americans and Canadians. Therefore, it may be that a combination of dietary factors and other Western lifestyle behaviors increases the risk of breast cancer. In any case, a reduction in dietary fat is certainly warranted because of the other benefits of a lower fat intake. Osteoporosis The loss of mineral from bones is called osteoporosis. In the United States and Canada, more than 25 million women are afflicted with this degenerative disease that can leave a woman susceptible to bone fractures. While it may be possible to prevent the disease or delay its onset, osteoporosis cannot be cured once it has begun. The key is to build strong bones during growth by eating a diet that includes plenty of calcium-rich foods, such as dairy products and green, leafy vegetables. The recommended dietary (or daily) allowance (RDA) for calcium is 1,200 to 1,500 milligrams per day. Young women who are too conscious of body weight often find it difficult to obtain enough calcium from foods because of the total calories that must be eaten to achieve the RDA guidelines. Calcium supplementation does provide women with an alternative. The recommended amount of calcium supplements per day is 500 milligrams. While nutrition is important, young women must also have regular menstrual cycles and exercise regularly to ensure maximal bone density. Postmenopausal women should consider hormone replacement therapy if there is a genetic tendency for osteoporosis. Other factors important to healthy bones are limited intakes of caffeine, alcohol, and sodium; the moderate intake of protein; and the avoidance of cigarette smoking because such substances and activities interfere with calcium absorption.
Obesity ✧ 675 Pregnancy and Lactation If a woman follows the nutritional guidelines of the Food Guide Pyramid, she should have enough energy nutrients, vitamins, and minerals during pregnancy and breast-feeding with only two additions. First, during pregnancy, the RDA recommendations are for an additional 30 grams of protein per day. This amount is thought to be necessary for normal growth and development of the fetus. Second, all women should take a low-dose iron supplement equivalent to 30 milligrams of iron per day. Physicians may recommend additional dietary supplements depending on a women’s other habits, such as vegetarianism or levels of alcohol consumption and tobacco use. —Chester J. Zelasko See also Aging; Anorexia nervosa; Arteriosclerosis; Breast cancer; Breastfeeding; Cholestrol; Diabetes mellitus; Eating disorders; Heart disease and women; Hypertension; Malnutrition among children; Malnutrition among the elderly; Nutrition and aging; Nutrition and children; Obesity; Obesity and aging; Osteoporosis; Strokes; Vitamin supplements; Weight changes with aging; Weight loss medications. For Further Information: Clark, Nancy. Nancy Clark’s Sports Nutrition Guidebook. Champaigne, Ill.: Leisure Press, 1990. Foods That Harm, Foods That Heal: The A-Z Guide to Safe and Healthy Eating. Pleasantville, N.Y.: Reader’s Digest, 1997. Ornish, Dean. Eat More, Weigh Less. New York: HarperCollins, 1993. Thaul, Susan, and Dana Hotra. An Assessment of the NIH Women’s Health Initiative. Washington, D.C.: National Academy Press, 1993. Willet, Walter. “Diet and Health: What Should We Eat?” Science 264, no. 5158 (April 22, 1994): 532-537.
✧ Obesity Type of issue: Public health, social trends Definition: A condition in which an individual weighs in excess of 20 percent more than his or her ideal weight. Obesity is a condition in which the body accumulates an abnormally large amount of adipose tissue. Fat normally makes up about 15 to 18 percent of body weight in young men, 20 to 25 percent in young women, and 30 to 40 percent in older adults. Because it is not practical to measure body fat content directly but it is easy to measure weight and height, the body mass
676 ✧ Obesity index (BMI), which correlates closely with body fat, is often used to identify and quantify obesity. Statistics compiled by life insurance companies have revealed the body weight (depending on a given individual’s height, sex, and frame size) that is associated with the lowest mortality rate; this figure is assumed to be the individual’s ideal weight. Because health problems associated with obesity have been observed to increase significantly when body weight is more than 20 percent higher than ideal weight, or when the BMI exceeds 27, obesity is often defined by these limits. If these criteria are used, it is estimated that about 23 percent of men and 30 percent of women in the United States are obese. Factors Involved in Obesity Genetic factors appear to be very important in determining the presence or absence of obesity. Body weight tends to be similar in close relatives, especially in identical twins, who share the same genetic makeup. The extent to which genetic factors affect food intake, activity level, or metabolic processes is not known. One theory holds that each individual has a set point that determines body weight. When food intake is decreased, experiments show less weight loss than predicted by the caloric deficit, suggesting that the body has slowed its metabolic rate to minimize deviation from the original weight. Many believe that physiologic regulation of body weight, which tends to maintain a preferred weight for each individual, explains some of the difficulty in treating obesity. In addition, producing lesions in the hypothalamus, a part of the brain, can make animals eat excessively and become obese, and rare cases of obesity in humans are attributable to disease of the hypothalamus. In hypothyroidism, a condition in which the thyroid gland produces too little thyroid hormone, the metabolic rate is slowed, which may cause a mild gain in weight. In Cushing’s syndrome, which is caused by excessive amounts of the adrenal hormone cortisol or by drugs that act like cortisol, there is an accumulation of excessive fat in the face and trunk, which disappears when the disease is cured or the drug is stopped. Weight gain has also occurred with the use of antidepressants and tranquilizers. While most physicians and the public assume that the main factor causing obesity is excessive food intake in relation to physical activity, it has not been possible to prove that overweight people eat more than slender people. Some experts believe, however, that differences in metabolic efficiency and the physiologic set point for body weight are the principal causes of obesity in some people, rather than excessive food intake. The basal metabolic rate (BMR) varies fairly widely among persons of the same age, sex, and body size, and studies have shown large differences in the daily caloric intake
Obesity ✧ 677 needed to maintain a constant body weight in normal people; these observations support the possibility that metabolic differences could contribute to obesity. Obesity and Health Problems Many health problems are associated with obesity. The majority of people who develop non-insulin-dependent, or type II, diabetes mellitus are overweight. Manifestations of the disease commonly improve or disappear if the individual succeeds in losing weight. Hypertension (high blood pressure) is more common with obesity, and weight loss may lower the blood pressure enough to lessen or avoid the need for medication. Arteriosclerosis is more prevalent in obese persons and causes an increased risk for heart attacks and strokes. Certain forms of cancer are more prevalent with obesity: cancer of the colon, rectum, and prostate in men and cancer of the uterus, gallbladder, ovary, and breast in women. Severe obesity can cause difficulties in breathing, with sleepiness resulting from inadequate oxygen delivery to the tissues and sometimes from interruption of sleep at night. In addition, conditions such as arthritis may be worsened by the additional strain that obesity places on weight-bearing parts of the body. The distribution of excess adipose tissue differs among individuals. Two main patterns have been described: android obesity (more commonly affecting men), in which fat accumulates mainly in the abdomen and upper body; and gynoid obesity (more common in women), in which fat accumulates mainly in the hips, thighs, and lower body. Persons with android obesity are more likely to suffer from diabetes, hypertension, and cardiovascular disease. The closest association with these diseases is seen when sensitive measurements of abdominal visceral fat mass are made with computed tomography (CT) scanning, a special X-ray technique. A simple measurement of the waist circumference compared with the hip circumference—the waist-to-hip ratio—can also be used to identify those obese individuals at greater risk. Reducing Caloric Intake The basis for any long-term weight reduction program is a low-calorie diet. The average daily calorie intake in the United States is approximately 1,600 calories for women and 2,300 calories for men; decreasing an individual’s intake, usually to between 800 and 1,500 calories, will result in weight loss, provided that energy expenditure does not decrease. A balanced diet, with 20 percent to 30 percent of calories derived from fat (considerably less than found in the typical American diet) is usually recommended. Many unbalanced diets, or “fad diets,” have enjoyed periods of popularity. Rice diets, low carbohydrate diets, vegetable diets, and other special diets may produce
678 ✧ Obesity rapid weight loss, but long-term persistence with an unbalanced diet is rare and the lost weight is often regained. Many patients fail to lose weight with low-calorie diets. More severe calorie restriction can be achieved with very-low-calorie diets that provide only 400 to 800 calories daily. This level of caloric restriction is unsafe unless a very high proportion of the diet consists of high-quality protein, with correct amounts of other nutrients such as vitamins and minerals. These requirements can be met with special formula diets under careful medical supervision. Such a program is recommended for severely obese patients who are otherwise healthy enough to tolerate this degree of caloric restriction. The “diet merry-go-round” which many mildly obese individuals experience—restricting their caloric intake until a weight goal is achieved, ending the diet only to resume overeating and regain the weight lost—often results in higher weight. Over time, such a pattern can “cycle” the individual to a dangerously high weight. Such individuals tend to experience more success if they can adjust their long-range eating behavior to moderate, rather than restrictive, intake of food. Many physicians would prefer to see their obese patients remain relatively stable in weight, reducing slowly over time, to avoid physical stress and ensure success. Drugs that decrease appetite are occasionally used to help people comply with a low-calorie diet. Some appetite suppressants act like adrenaline and may cause such side effects as nervousness, irritability, and increased heart rate and blood pressure. Other drugs may stimulate serotonin, a chemical transmitter in the central nervous system that decreases appetite, and may cause drowsiness as a side effect. The use of these drugs is controversial because of their side effects and their limited effectiveness in promoting weight loss. Increasing Energy Expenditure Another approach to weight loss is to increase energy utilization by increasing physical activity. Some studies show that overweight individuals are less active than their nonobese counterparts. This fact could contribute to their obesity, since less energy utilization results in more energy available for storage as fat. Decreased activity could also be a result of obesity, since a heavier person must do more work, by carrying more pounds, than a nonobese person who walks or climbs the same distance. Each pound of fat contains energy equal to about 4,000 calories. If an obese person expends 400 extra calories each day by walking briskly for one hour, it will take ten days for this activity to result in the loss of one pound. In a year, this increased calorie expenditure would result in a thirty-sixpound weight loss. More vigorous exercise, such as running, swimming, or calisthenics, would lead to more rapid weight loss, but might not be advis-
Obesity ✧ 679 able for every person because of the increased prevalence of certain health problems in obese individuals. Any exercise program that involves vigorous physical activity should be undertaken with medical supervision. Exercise as part of a weight-loss program has additional benefits. The function of the cardiovascular system may be improved, and muscles may be strengthened. Exercise will lead to loss of adipose tissue and gain in lean body mass as weight is lost, a change in body composition that is beneficial to overall health. Although some fear that physical activity will lead to an increase in appetite, studies show that any increase in food intake that occurs after exercise is usually not great enough to match the calories expended by the exercise. Surgical Treatment Several surgical procedures have been used to treat severe obesity that has impaired the patient’s health and has resisted other treatment. Operations that decrease the absorption of food by bypassing a section of the small bowel have largely been abandoned because of long-term complications of diarrhea and liver disease. The operation now most commonly performed is gastroplasty, which creates a small pouch in the stomach with a narrow outlet through which all food must pass. This procedure decreases the effective volume of the stomach, causing fullness and nausea if more than small amounts of solid food are eaten. Patients have lost about half of their excess weight after one and one-half to two years, but some weight may be regained after this period. Gastroplasty has produced fewer serious complications than intestinal bypass operations. Care must be taken to avoid certain foods that might cause blockage of the narrowed opening from the surgically created stomach pouch, and the benefit of the operation can be overcome by eating soft or liquid foods, which can be consumed in large quantities. The long-term benefit of this procedure is being evaluated. The Treatment Dilemma Obesisty is an important public health problem in the United States because it increases the risk of diabetes, hypertension, cardiovascular disease, and other illnesses. Also, many overweight men and women are distressed by the effects of their weight on their social interactions and self-image. Therefore, many obese individuals desire to lose weight. Unfortunately, the results of weight-loss programs and countless individual efforts at dieting to achieve this goal have often been disappointing. Short-term weight loss can often be achieved; programs utilizing low-calorie diets, behavior modification, exercise, and sometimes appetite-suppressing drugs usually lead to a weight loss of ten to thirty pounds or more over a
680 ✧ Obesity period of several weeks or months. After a year or more, however, the majority of these dieters have regained the lost weight. It appears that the maintenance of a low-calorie diet and an increase in physical activity require a degree of commitment and willingness to endure inconvenience, self-deprivation, and physical discomfort that most people can accept for short periods but not indefinitely. Dieters commonly return to or surpass their original weight. It is as if the body’s set point can be overcome temporarily by intense effort, but not permanently. Because of the poor prognosis for long-term weight loss, some experts question the extent to which efforts should be devoted to the treatment of obesity. —E. Victor Adlin, M.D.; updated by Karen E. Kalumuck See also Anorexia nervosa; Arteriosclerosis; Cholesterol; Diabetes mellitus; Eating disorders; Exercise; Exercise and children; Exercise and the elderly; Heart disease; Heart disease and women; Hypertension; Malnutrition among children; Malnutrition among the elderly; Mobility problems in the elderly; Nutrition and aging; Nutrition and children; Nutrition and women; Obesity and aging; Obesity and children; Weight changes with aging; Weight loss medications. For Further Information: Bennett, J. Claude, et al., eds. Cecil Textbook of Medicine. 21st ed. Philadelphia: W. B. Saunders, 2000. This textbook offers a brief review of all aspects of the problem of obesity by a recognized authority in the field. Bjorntorp, Per, and Bernard N. Brodoff, eds. Obesity. Philadelphia: J. B. Lippincott, 1992. A very comprehensive, multiauthor book on all aspects of obesity, from basic considerations of metabolism, body composition, and etiology, to practical questions of the psychologic and medical consequences and the various methods of treatment. Bray, G. A., ed. “Obesity: Basic Considerations and Clinical Approaches.” Disease-a-Month 35 (July, 1989): 449-537. This volume contains a series of review articles by leading experts in many areas of obesity, including the causes and basic physiology, diagnosis and prevalence, complications, and treatment with diet, behavioral management, drugs, and surgery. An authoritative review of the entire topic. Hirsch, J., and R. L. Leibel. “Clinical Review 28: Biological Basis for Human Obesity.” The Journal of Clinical Endocrinology and Metabolism 73 (December 1, 1991): 1153-1157. Reviews the long-term results of the treatment of obesity by all available methods, and emphasizes the fact that effective treatment for most patients is not yet available. The authors examine the genetic and metabolic factors that affect body weight and stress the need for research that will increase the understanding of obesity and perhaps lead to more satisfactory treatment. Rink, Timothy J. “In Search of a Satiety Factor.” Nature 372 (December 1,
Obesity and aging ✧ 681 1994): 372-373. A history of the research into weight regulation and how leptin supports prior theories is presented in a general news format. References are provided for further reading.
✧ Obesity and aging Type of issue: Elder health, public health, social trends Definition: An abnormally high percentage of body fat. The prevalence of obesity has been increasing in most industrialized nations. The prevalence is higher in certain population groups such as African American women and Latinas. The factors that contribute to obesity are numerous, but the key factor is energy imbalance, which means that calories eaten are greater than calories used. By definition, obesity is an abnormally high percentage of body fat; however, assessing the precise value of this measurement is subject to debate. Measurements of Body Fat Body composition can be measured by several techniques, each with varying degrees of accuracy and cost. One of the best methods is underwater weighing. A technique that uses the electrical conductivity of body tissues to estimate fat is based on the premise that lean tissue and fat tissue have differences in the ability to conduct electromagnetic waves. Methods such as computed tomography (CT) scanning and nuclear magnetic resonance imaging (MRI) scanning give an accurate picture of regional fat such as intra-abdominal and extra-abdominal fat. Ultrasonic waves can also give a measure of regional fat. A simple technique is the measurement of skinfold thicknesses and circumferences. A practical technique is measuring height and weight. Measures can be compared to tables of acceptable weights for heights or converted into the body mass index (BMI), also called the Quetelet index. BMI gives a measure of weight relative to height. It is calculated as weight in kilograms divided by height in meters squared or as weight in pounds divided by height in inches squared, multiplied by 703. In addition to knowing an individual’s BMI, it is important to measure where that body fat is distributed. Abdominal fat, or central adiposity, is a more potent risk factor for obesity-related diseases than BMI alone. Central adiposity can be measured using a variety of techniques, from sophisticated and expensive techniques such as CT scans to a simple circumference ascertained with a tape measure. Waist circumference provides an estimate of central adiposity that is inexpensive and easy to do. Some experts measure
682 ✧ Obesity and aging both waist and hip circumference and calculate a waist-hip ratio (WHR). A desirable WHR is under .90 for a man and under .80 for a woman. Waist circumference alone is a useful measure of central adiposity that can be used by health professionals to assess an individual’s risk for obesity-related diseases. Thus, two simple parameters, BMI and waist circumference, can be used to define obesity with reasonable accuracy, especially among the older population. Healthy weight ranges reflect statistically derived values that appear to provide maximal protection against the development of chronic disease. A BMI of 19.0 to 25.0 seems to reflect a healthy weight. Overweight is defined as a BMI between 25.0 and 29.9, and obesity is defined as a BMI of 30.0 or greater. Extreme obesity is defined as a BMI of 40 or greater. For waist circumference, the cutoffs identifying increased disease risk for adults are greater than 40 inches (102 centimeters) for men and greater than 35 inches (88 centimeters) for women. High waist circumference coupled with a high BMI escalates the risk potential for disease. Body fat composition increases with age. As men age, their fat content almost doubles, while women experience a 50 percent increase but their weight rises only about 10 to 15 percent, reflecting a reduction in lean body mass. When older people become obese, this change of proportion of fat to lean is further exaggerated. Contributing to the problem of obesity in the older population is that energy requirements also decrease with age. For example, basal metabolism, the energy required to rest, declines about 2 percent per decade in adults. Causes and Health Risks of Obesity Although physiological changes in body composition might explain the tendency to gain weight with age, there are aspects of lifestyle that can accelerate or retard body composition changes. Numerous labor-saving devices have fostered a reduction in energy output. The physical activity patterns of older people tend to decline as well, further facilitating caloric output deficits. Many changes in the food supply foster obesity. Numerous snack and convenience foods make it easy to procure and consume excess calories. Eating in restaurants and fast-food establishments is associated with consumption of larger portions of high-calorie, high-fat foods. For elderly on fixed incomes, inexpensive food choices are often necessary and are higher in fat and calories. Combining the reduction in energy expended and the increased variety of high-calorie food choices for energy consumed, it is understandable why obesity rates have risen. Obesity is a risk factor for several diseases such as cardiovascular disease, hypertension, diabetes mellitus type II, arthritis, gallbladder disease, gout, and certain cancers. Aging itself is also a risk factor for these diseases. The
Obesity and aging ✧ 683 lowest cardiovascular disease mortality is among those who remain lean throughout life. Obesity increases the risk of high blood cholesterol levels and is estimated to cause 40 to 50 percent of hypertension (high blood pressure). Obese people are five to six times more likely to develop hypertension than lean people. Weight reduction of as little as 10 to 15 pounds in many individuals, however, can reduce the dosage or eliminate the need for drugs to control blood pressure in many individuals. The rate of type II diabetes rises as BMI increases, with the highest prevalence seen in those with a BMI greater than 28. This type of diabetes, characterized by the inability of body cells to use insulin, can be corrected with weight reduction. Many elderly with diabetes suffer from related complications, such as kidney disease, blindness, heart disease, and the destruction of sensory function. Obesity is associated with some cancers. There is a consistent positive relationship between body weight and endometrial cancer, with risk starting at a BMI of 28 to 30 or greater. Postmenopausal women with a BMI of 27 or greater have an increased risk for breast cancer. Research has estimated that a reduction in BMI of about two units can reduce later onset of knee osteoarthritis and decrease the rate of symptomatic occurrences. Obesity also increases the risk for gallbladder disease, especially among women. Obesity is a risk factor for the development of gout and sleep apnea (episodes of breath cessation during sleep), which is common among those with upper-body obesity. Treating Obesity People need to reject the notion that increasing weight is a normal phenomenon of aging and begin to make lifestyle changes to prevent weight gain. Dieting alone is not an effective long-term solution because the failure rate is high. Restrictive dieting can also result in inadequate intake of nutrients. Drug therapy is not recommended unless the person has a BMI of 30 or greater or a BMI of 27 or greater with concomitant risk factors or diseases. Weight loss surgery is reserved for those with severe obesity or a BMI greater than 35 who also suffer from related disease conditions, but only when all other medical therapies have failed. Lifelong healthy weight maintenance requires a lifestyle that includes regular daily physical activity and consumption of a healthful diet that is calorically matched with energy output. Nothing else has been shown to work as effectively. Weight loss of as little as 10 percent is sufficient to reduce disease risks associated with being overweight. A loss of 5 to 10 pounds helps to lower blood pressure and can improve both blood cholesterol and blood sugar levels. For many elderly, this modest goal is attainable and could provide health benefits. Weight reduction among elderly must be monitored carefully, however, to prevent mistaking disease-related weight loss as
684 ✧ Obesity and children the result of voluntary weight loss. With proper guidance, healthful eating patterns coupled with regular physical activity could afford the elderly with marked health benefits that are sustainable and substantial. —Wendy L. Stuhldreher, R.D. See also Aging; Arthritis; Cancer; Diabetes mellitus; Eating disorders; Exercise and the elderly; Heart disease; Heart disease and women; Hypertension; Malnutrition among the elderly; Nutrition and aging; Obesity; Obesity and children; Weight changes with aging. For Further Information: Bray, George A., Claude Bouchard, and W. P. T. James, eds. Handbook of Obesity. New York: Marcel Dekker, 1998. Cassell, Dana K., and Felix E. F. Larocca. The Encyclopedia of Obesity and Eating Disorders. New York: Facts on File, 1994. The Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report. Bethesda, Md.: National Institutes of Health, National Heart, Lung, and Blood Institute, 1998. Jensen, Gordon L., and Joanne Rogers. “Obesity in Older Persons.” Journal of the American Dietetic Association 98, no. 11 (November, 1998): 1308. “Recommendations from the American Health Foundation’s Expert Panel on Healthy Weight.” American Journal of Clinical Nutrition 63, supplement (1996).
✧ Obesity and children Type of issue: Children’s health, public health Definition: In children, a complex medical condition with genetic, metabolic, and behavioral components that results in excessive fat weight gain and is strongly influenced by an imbalance between caloric intake and expenditure. Obesity, the most prevalent nutritional disease of children and adolescents in the United States, manifests complex genetic, metabolic, and behavioral components that result in the excessive gain of fat weight. The composition of the human body can be divided into fat-free weight and fat weight. Fat-free weight consists of the weight of the body’s lean tissues, with the remainder of body weight existing as either essential fat or storage fat. Essential fat is required for normal physiological functioning, whereas storage fat accumulates in the adipose tissue, with the cells shrinking or swelling like sponges depending on the amount of fat deposited within them. Obesity is often defined as a body mass index of 130 percent or greater
Obesity and children ✧ 685 than ideal, or the 95th percentile or greater using skinfold measurements, which are usually taken in the subscapular region of the back. Adolescent girls generally carry more essential fat than boys, while the percentage of storage fat remains similar across sexes. The extra essential fat in girls is found in the hip, thigh, and abdominal regions and is attributable to hormonal differences related to childbearing capacity. Depending on how obesity is defined, as of 1998 between 11 percent and 25 percent of American children (six to eleven years old) and adolescents (twelve to seventeen years old) were obese, with percentages exceeding 30 percent reported for population subgroups such as non-Hispanic blacks and Mexican Americans in certain areas of the country. It was estimated that severe obesity affected about 12 percent of the pediatric population and that the rate of increase of pediatric obesity had fluctuated between 39 percent and 54 percent during the previous twenty years. The Snowball Effect While childhood problems contributing to being overweight are complex and individually determined, researchers have identified several factors, such as genetics, lifestyle, emotional factors, and other medical issues. Genetics certainly exerts a strong regulatory influence, as shown by a child with two overweight parents having an 80 percent chance of being overweight, but environmental factors that influence caloric input and output may play a stronger role in pediatric obesity. This is evidenced by data that show the average daily caloric intake of children as higher at the beginning of the twentieth century than in the 1990’s but the percentage of children with weight gain problems as much greater. The culprit is decreased energy expenditure. Once a child begins to gain weight, difficulties that contribute to further weight gain develop, such as peer problems, social isolation, self-esteem issues, psychological stress, physical limitations, health problems, and skill deficits that limit participation in sports and other physical activities. The strongest environmental factors affecting childhood weight gain appear to be the amount of time spent watching television or playing computer video games, in addition to parental eating styles and attitudes toward diet. American children spend an average of twenty-four hours per week in sedentary activities such as watching television, with research indicating that for each additional hour of viewing, the prevalence of obesity rises by 2 percent. Likely contributions to this statistic include the amount and quality of snack food consumed during sedentary activities, the supplanting of more physical activities, and a possible decline in overall metabolic rate. Increasing the amount of physical exercise has consistently been shown to be the best predictor of long-term success in pediatric weight management programs.
686 ✧ Obesity and children Diet and Exercise Methods that have exhibited the best success in treating pediatric obesity include diet, exercise, and the combination of the two. Alternative means such as medications, surgery, and external methods have also been utilized in children with whom obesity presents a severe disability or is life-threatening. Dietary suggestions for weight loss are diverse and ever-changing. Americans spend billions of dollars annually on diets and weight-reducing remedies. Regardless of the method, when weight is lost by diet alone, a majority of the short-term weight loss comes from lean tissue and not fat tissue. This is attributable primarily to water losses that occur with the depletion of the body’s carbohydrate stores. For every 1 gram of glycogen used for energy and not replenished through the diet, there is a concomitant loss of nearly 3 grams of water. Many semistarvation diets recommend a low carbohydrate intake to reduce weight quickly, leaving the body in a relative state of dehydration and possibly disrupting electrolyte balance. It is commonly recommended not to lose more than 2 pounds per week without physician supervision. Dieting alone does not cause everyone to lose fat weight. Some researchers explain this fact with the set point theory, which suggests that the brain’s appetite control center in the hypothalamus attempts to maintain body fat at a predetermined level. This “thermostat” may attempt to conserve storage fat by forcing the body to burn carbohydrate and protein stores instead of fat during dieting. Exercise alone is also not a highly effective way to lose fat weight. A caloric expenditure of 3,500 calories is required to burn 1 pound of fat from the body. Considering that the caloric cost of running a 26.2 mile marathon is only about 2,600 calories, completing a marathon would theoretically expend less than one-quarter of a pound of fat, with a majority of the energy burn coming from carbohydrates. Research has shown swimming to be an even worse way to shed fat, with regular swimming programs actually causing some children to gain weight. Exercise in the water is not associated with as dramatic a rise in body temperature as that during land exercise, which stimulates an important increase in metabolism within the muscles that enables them to burn more calories. Additionally, after a strenuous workout on land, body temperature may stay elevated for up to six hours, causing a significant “afterburn” of calories that does not occur after swimming. Many children comment that they are not overly hungry after a vigorous land workout but are starving following swimming. This may be because the hypothalamus is the brain’s temperature control center in addition to its appetite regulator. Apparently, when the hypothalamus is needed to control body temperature during physical exertion, it suppresses appetite for a time following the activity. When it is not needed to regulate temperature during exercise, as during swimming, and a significant amount of carbohydrate is burned, appetite increases.
Obesity and children ✧ 687 The American College of Sports Medicine recommends that exercise sessions be conducted three to five times per week for fifteen to sixty continuous minutes at 60 percent to 90 percent of maximum heart rate (HR) reserve. Regular aerobic exercise that uses large muscle groups, that can be maintained continuously, and that is rhythmical in nature is most effective at burning calories. A combination diet and exercise program with the goal of reducing approximately 1 pound of body fat per week is the most flexible and effective way to reduce fat percentage and overall body weight while still maintaining muscle mass and fluid and electrolyte balance. When energy input is equally compensated by energy output, the body is said to be in equal caloric balance. When input exceeds output, the body will gain weight (positive caloric balance); when output exceeds input, the body will lose weight (negative caloric balance). To lose 1 pound of fat per week, the body needs to be in a negative caloric balance of 500 calories per day. A diet and exercise program allows considerable flexibility in accomplishing this goal—for example, eliminating a 300-calorie milk shake and adding a 200-calorie halfhour workout in a day will achieve a 500-calorie deficit. In seven days, this will burn the 3,500 calories that are stored in 1 pound of fat. A nutritionally sound diet with a mild calorie restriction combined with regular exercise has been shown to reduce fat weight in children safely and effectively. Pills and Procedures Medications that have been given to children to reduce fat weight include thyroid hormone, which elevates resting metabolic rate, thus burning more calories during everyday activities. Unfortunately, thyroid hormone also causes an undesirable reduction in lean body weight and occasionally produces abnormal heartbeats. Certain types of amphetamines have been given to patients as appetite suppressants, but weight is often regained after the medication is withdrawn. There is also considerable potential for drug abuse and addiction with these medications. Surgical methods to curtail extreme pediatric obesity include lipectomy, the surgical removal of adipose tissue. Lipectomy is seldom successful, however, because the body tends to compensate by packing more fat into the remaining adipose cells. Intestinal bypass surgery has been performed to reduce the absorption of foodstuffs from the digestive tract into the bloodstream. Ingested nutrients are rerouted from the stomach to the large intestine, preventing them from entering the small intestine, where the absorption of most food occurs. While this procedure has proven mildly successful, it is often accompanied by diarrhea, kidney stones, and liver damage. Stomach stapling has been conducted to divide the stomach’s storage area into functional and nonfunctional segments. Balloons have also
688 ✧ Obesity and children been inserted into the stomach to limit further the amount of food that it can hold. These techniques have produced marked weight losses in cases of life-threatening obesity, but complications have included infections, nausea, and kidney failure. External methods to achieve fat weight loss, such as wearing rubber suits and sauna belts, have been experimented with through the years. These tight-fitting garments cause a temporary reshaping and a loss of body circumference as a result of dehydration of the cells underneath, but normal fluid balance is quickly restored after their removal. Jaw wiring has been conducted to prevent the ingestion of solid foods but has been shown to be another transitory way to lose weight, with poundage being quickly regained after removal. The ancient art of acupuncture has also been used for weight loss; this method involves the painless insertion of a sharp needle into a part of the ear that contains vagus nerve fibers, potentially causing inhibition of the nerves that stop stomach pangs and suppress appetite. High Stakes Obesity presents one of the most serious health problems facing children, and in the late 1990’s, all indications implied that the current pediatric generation would grow into the most obese generation of adults in U.S. history. Research has indicated that while obesity in infancy does not predict obesity later in life, being overweight at later stages of childhood becomes an increasingly more accurate predictor of adult obesity and its related problems. Approximately 40 percent of overweight seven-year-olds will grow up to be overweight adults, while 70 percent of overweight ten- to thirteenyear-olds will become overweight adults. Prevention rather than treatment will continue to be the most effective method to combat pediatric obesity, with the development of effective scholastic instructional methods and materials to encourage appropriate behavioral modification changes being very important. The presence of “fat genes” that apparently prevent communication to the brain when the body has eaten enough and the effects of slow energy metabolism have recently been described, but the implications of these discoveries on the incidence and severity of pediatric obesity remain uncertain. —Daniel G. Graetzer See also Children’s health issues; Diabetes mellitus; Eating disorders; Exercise and children; Malnutrition among children; Nutrition and children; Physical fitness tests for children. For Further Information: American Heart Association. “ARA Report on Obesity in Youth.” American Family Physician 55, no. 5 (April, 1997): 1982-1983. The American Heart
Occupational health ✧ 689 Association issued this childhood obesity statement for health care professionals, which is organized into sections that cover the epidemiology, morbidity, etiology, and prevention and treatment. Bennett, J. Claude, et al., eds. Cecil Textbook of Medicine. 21st ed. Philadelphia: W. B. Saunders, 2000. This textbook offers a brief review of all aspects of the problem of obesity by a recognized authority in the field. Christoffel, Katherine K. “The Epidemiology of Overweight in Children: Relevance for Clinical Care.” Pediatrics 101, no. 1 (1998): 103-105. This manuscript highlights the efforts needed to reverse the trend toward higher rates of childhood obesity. Hill, James O., and Frederick L. Trowbridge. “Childhood Obesity: Future Directions and Research Priorities.” Pediatrics 101, no. 3 (1998): 570-574. This excellent article discusses the treatment of pediatric obesity in the United States and numerous reasons why immediate preventive action needs to be taken by the joint action of health care professionals and educators.
✧ Occupational health Type of issue: Occupational health, public health Definition: The diagnosis, treatment, and prevention of diseases and injuries that can occur in the workplace or that result from a person’s employment. The discovery that eighteenth century chimney sweeps were prone to developing testicular cancer is often cited as the first example of an acknowledged occupational illness. In fact, physicians and other health care professionals had been aware for many centuries that certain jobs were linked to particular medical disorders: Millers developed coughs, and hatmakers became mentally unbalanced. Textbooks urged physicians to consider a patient’s occupation both in diagnosing and in treating illness. The emergence of occupational health as a distinct specialty within the medical professions is, however, a relatively recent phenomenon. The Industrial Revolution brought with it not only the separation of one’s home life from one’s work life but also increased risks of injury from factory machinery. Spinning jennies, power looms, mill wheels and belts, and early assembly line processes all carried the risk of accidental amputations, mangled limbs, and other permanently crippling injuries. Not surprisingly, much of the early emphasis of occupational health focused on safety. While company doctors treated the injured workers, engineers sought ways to reduce the job hazards. By the twentieth century, several different but related specialties had
690 ✧ Occupational health evolved that focused on different aspects of occupational health. Industrial hygienists combine training in engineering and public health and attempt to improve safety in the workplace by providing education and training for workers and by redesigning the work area to eliminate hazards. Doctors of occupational medicine are employed by both government and industry to diagnose and to treat occupational illnesses and work-related disabilities. Public awareness of occupational health issues has led to the passage of legislation creating such agencies as the United States Occupational Safety and Health Administration (OSHA). All occupational health specialists in the United States must work within guidelines established by OSHA. There is a high cost to society from such disabilities as the black lung disease suffered by coal miners and the toxic or radioactive exposure experienced by workers ranging from hospital laboratory technicians to pipefitters and welders. As a result, occupational health has become an ever-expanding, complex, and important medical specialty. Diagnostic Techniques Occupational health problems can affect any part of the human anatomy. If a worker is injured on the job or suffers from an easily recognizable problem, such as a repetitive motion disorder, diagnosis and treatment can be quite straightforward. In the case of repetitive motion, problems such as carpal tunnel syndrome, which is sometimes experienced by word processing operators, might be treated by advising patients to change their work posture, providing them with splints to align the wrists and hands properly, employing corrective surgery to alleviate pain, and redesigning the work site to prevent future problems. The treatment for many on-the-job injuries will also include an extensive course of physical and rehabilitative therapy to allow the worker to return to work eventually, either at the old job or at a new one. Many occupational health problems, however, are not as readily diagnosed as carpal tunnel syndrome. The industrial hygienist and the doctor of occupational medicine often must rely on the expertise of epidemiologists and toxicologists to determine which occupational exposures, if any, may be responsible for a worker’s ill health. In cases where workers complain of vague symptoms such as chronic fatigue, nausea, or neuropathy (loss of nerve functions), an accurate diagnosis can prove elusive. The medical literature contains numerous examples of occupational illnesses that mimicked other common disorders. For example, doctors misdiagnosed a cosmetologist as suffering from multiple sclerosis when she was actually experiencing nerve damage caused by many years of exposure to the chemical solvents used to apply and remove artificial fingernails. Because many occupational illnesses can take years or even decades to appear, in some cases an accurate diagnosis may never be achieved. Once a diagnosis is
Occupational health ✧ 691 made, treatment for an occupational illness caused by exposure to chemicals, for example, can be as simple as assigning the worker to tasks that eliminate exposure or as technologically sophisticated as using dialysis or chemical chelation to remove toxins from a patient’s blood. Changing Patterns of Workplace Health Workplace safety remains a concern in occupational health, but obvious hazards such as poorly lit work areas or exposed moving parts on machines have been joined by a host of subtler threats to workers’ well-being. Epidemiologists and toxicologists have linked on-the-job exposure to dust, heavy metals, radiation, solvents and other chemicals, and even blood-borne pathogens to a host of cancers, disabling diseases, reproductive problems, and other concerns. Yet, not only must the industrial hygienist and doctor of occupational medicine worry about protecting workers from these physical hazards but the modern occupational health specialist must also be concerned with the long-term effects of repetitive motions, noise exposures, and even emotional stress as well. As the influence of workers’ jobs on those workers’ health and on the health of their families is recognized as a major factor in a family’s overall well-being, the importance of the occupational health specialist becomes increasingly obvious within modern society. Occupational health specialists employed in government, industry, and private practice, each approaching the question of worker wellness from a slightly different perspective, all fill a vital and expanding niche in modern medical practice. —Nancy Farm Mannikko See also Asbestos; Burns and scalds; Cancer; Carpal tunnel syndrome; Electrical shock; Environmental diseases; Frostbite; Hazardous waste; Health insurance; Hearing loss; Heat exhaustion and heat stroke; Infertility in men; Infertility in women; Law and medicine; Lead poisoning; Lung cancer; Mercury poisoning; Multiple chemical sensitivity syndrome; Noise pollution; Pesticides; Preventive medicine; Radiation; Secondhand smoke; Sick building syndrome; Smoking; Stress. For Further Information: Caplan, Robert D., et al. Job Demands and Worker Health: Main Effects and Occupational Differences. Ann Arbor: University of Michigan, 1980. Cohen, Murray L. Occupational Health in Health Service Areas. Cincinnati: National Institute for Occupational Safety and Health, 1978. Durbin, Paul T., ed. A Guide to the Culture of Science, Technology, and Medicine. New York: Free Press, 1980. Koren, Herman. Illustrated Dictionary of Environmental Health and Occupational Safety. Boca Raton, Fla.: Lewis, 1996.
692 ✧ Osteoporosis Sadhra, Steven, and Krishna Rampal, eds. Occupational Health Risk Assessment and Management. Malden, Mass.: Blackwell Science, 1999.
✧ Osteoporosis Type of issue: Elder health, public health, women’s health Definition: A condition resulting from reduced bone mass; fractures are the major complications and are associated with significantly increased risks of morbidity and mortality, especially in older women. Bone is constantly being remodeled by cells: Old bone is reabsorbed by the osteoclasts, and new bone is formed by the osteoblasts. In children, formation exceeds resorption, and the bone mass increases. In old age, however, bone resorption exceeds bone formation and bone mass is lost. The bone becomes mechanically weak and vulnerable to fractures. This condition of reduced bone mass is known as osteoporosis and is part of the aging process. At this time, there is no known cure for osteoporosis, which emphasizes that prevention is the only strategy for combating bone mineral loss and the development of osteoporosis. Type I osteoporosis is related to aging. It has two forms: postmenopausal (occurring in women between the ages of fifty-one and sixty-five, with fractures of the vertebrae and wrist) and senile (occurring in both men and women past the age of seventy, with fractures of the hip and vertebrae). Type II osteoporosis is associated with an underlying disease such as hyperparathyroidism or multiple myeloma and may occur in younger as well as older individuals. A third type has been found in young women who are amenorrheic (having no menstrual cycles) in association with eating disorders. Osteoporotic fractures are occurring in women in their twenties and thirties who have been amenorrheic for several years. Because it was found in athletic women, the link between eating disorders, amenorrhea, and osteoporosis was named the Female Athlete Triad. Risk Factors A number of factors predisposing an individual to osteoporosis have been identified. Some of these factors cannot be changed. For example, the older patients are, the more likely they are to develop osteoporosis. Furthermore, women tend to be more vulnerable because, in addition to the accelerated rate of bone loss occurring at the menopause, they tend to have smaller skeletons and are likely to reach the threshold at which bone fragility is increased much sooner. People with large body frames are less likely to develop osteoporosis than those with small body frames, probably because
Osteoporosis ✧ 693 their bone reserve allows them to lose bone for a longer period before reaching the threshold at which the bone fragility is significantly increased. Genetic research has also determined that variations in the gene for the vitamin D receptor may contribute to 7 to 10 percent of the difference in bone mass density because of its influence on calcium intake. For those with a family history of osteoporosis, this factor could lead to identification of an individual’s risk factor and enable early intervention. A number of risk factors that can be reversed have also been identified. A low dietary calcium intake is associated with a reduced bone mass and an increased fracture rate. Conversely, an elevated calcium intake, particularly before puberty, is associated with an increased mass. In 1997, the National Academy of Sciences’ Dietary Reference Intake (DRI), formerly the Recommended Dietary Allowance (RDA), increased from 800 milligrams per day to 1,300 milligrams at age nine up to age eighteen. Some researchers are recommending a daily intake of 1,300 to 1,500 milligrams for all young people during puberty and up to at least age thirty to obtain optimal peak bone mass. Women during pregnancy and lactation also need a higher amount, up to 1,300 milligrams. Men from age thirty to sixty-four should take in 1,000 milligrams, increasing to 1,200 milligrams at age sixty-five. Women from age nineteen to the menopause should take in 1,000 milligrams, increasing to 1,200 milligrams when they are no longer producing estrogen. Women on hormone replacement therapy (HRT) may only need 1,000 milligrams. Amenorrheic women should be taking in 1,300 to 1,500 milligrams. The maximum allowable intake has been increased from 2,000 to 2,500 milligrams. Physical inactivity is associated with a reduced bone mass and therefore an increased predisposition to developing osteoporosis. There is also evidence that people who have a sedentary lifestyle are more susceptible to osteoporosis than those who are physically active. During the formative years, exercise is imperative to develop the highest bone density possible. Then throughout the rest of life, exercise is essential to slow the rate of bone loss. In the elderly, exercise may have a secondary benefit. Often, a fracture is precipitated by a fall, and the cause of the fall may be a loss of balance or coordination. Studies in the elderly have demonstrated that general exercise such as walking is not enough to maintain gains in bone density for long. Exercise studies of one or two years duration show a decline begins after about one year. A regular strength training regimen targeting the most common fracture sites, done two or three times a week for twenty minutes, should be added. Cigarette smoking is associated with osteoporosis; however, the underlying mechanism is not clearly understood. It is possible that cigarette smokers are more likely to lead a sedentary life and have a reduced dietary calcium intake than nonsmokers. Cigarette smoking may have a direct effect on the bone cells, or it may have an indirect effect by modulating the release of
694 ✧ Osteoporosis substances which may affect the activity of these cells, such as the parathyroid hormone or calcitonin secretion. A number of drugs may induce osteoporosis. Among them, cortisone preparations are particularly notorious. Therefore, the long-term administration of these drugs should be avoided. If cortisone must be administered, then the lowest effective dose should be chosen. Studies are underway on a drug, etidronate (Didronel), which, when given along with corticosteroid drugs, may act as a bone-sparing therapy and lower the chance of fractures in people who must take the corticosteroids. The long-term administration of potent diuretics induces a negative calcium balance by increasing renal urinary calcium excretion. Milder diuretics, on the other hand, may actually induce a positive calcium balance by reducing renal calcium excretion. Other drugs that have been added to the list include anticonvulsive drugs, antacids containing aluminum, some forms of chemotherapy, and heparin, which is used to prevent blood clots. Treating Osteoporosis Several drugs are currently being used or investigated for treating osteoporosis; the most commonly prescribed is HRT. HRT is effective in arresting the bone loss that occurs after the menopause, and even increasing the bone mass, particularly if started within the first five years and combined with calcium and exercise. The main drawback is that estrogens increase the risk of uterine cancer. If they are combined with progesterone, however, the risk is eliminated as the latter hormone exerts a protective effect on the uterus. Such therapy also reduces the risk of developing cardiovascular diseases. The effect of HRT on the incidence of breast cancer is controversial, and it is recommended that a mammogram be done beforehand and at yearly intervals thereafter. If HRT is administered on a cyclical pattern, then menstrual periods are likely to resume. They can be avoided if the hormones are administered continuously, in the form of either tablets or patches placed over the skin and replaced twice a week. Subcutaneous implants, which can be left in the skin for much longer periods, are being evaluated. Calcitonin, a hormone produced by the thyroid gland, specifically inhibits osteoclasts, the bone resorbing cells. As a result, there is a relative increase in the rate of bone formation, and bone mass increases. After the initial increase, however, bone mass tends to stabilize, and the continued administration of calcitonin beyond this point may be associated with an actual decline in bone mass. Many physicians, therefore, administer calcitonin in cycles of six to twelve months. One of the main advantages of calcitonin is that, unlike HRT, it is effective in both sexes and in patients of all ages, including the very old. Calcitonin also appears to have an analgesic effect, which may be quite useful following a vertebral collapse. A synthetic form administered as a nasal spray has received Food and Drug Administration
Osteoporosis ✧ 695 (FDA) approval, which is a relief to patients who had to give themselves a daily injection. The only disadvantage is that the drug does not appear to be as effective in thickening bones as other drugs being studied. Another drug that has received FDA approval for use in women is alendronate, the first nonhormonal osteoporosis drug. In very large studies, dramatic increases in bone density have been seen, along with less fractures. The cost is about the same as calcitonin, but considerably more than HRT. The cost, coupled with the lack of long-term use studies to determine side effects, suggests that alendronate should be the drug of choice for the elderly with severe bone loss rather than a preventive measure for a newly postmenopausal woman, unless her risk is very high. Several other drugs are showing promise in controlled studies, including slow-release sodium fluoride, calcitriol, and raloxifene. Sodium fluoride causes significant increases in bone densities, as much as 5 percent a year for four years. The side effects, however, include peptic ulcers, and, unfortunately, the bone that is built is sometimes brittle. Also, fluoride can be toxic, so the levels must be monitored carefully. The slow-release form seems to avoid some of the side effects, but larger studies need to be completed before the drug can be approved. Calcitriol is used in many countries as a treatment for osteoporosis. Currently, it is only used in the United States to treat a bone disorder that can result from kidney dialysis. Calcitriol helps in the absorption of calcium and stimulates osteoblasts. Raloxifene is a compound that attaches to estrogen receptors in the body. It is thought that the drug might mimic the estrogen effect on the bones, but it will take several more years of testing before raloxifene could be available. Calcium supplements are useful if the patient’s dietary calcium intake is less than required. There is no evidence to support any beneficial effect of supplements if the daily dietary intake of calcium exceeds the DRI. Similarly, if the daily vitamin D intake is below the recommended level of 400 milligrams in the elderly population, supplementation is recommended. Vitamin D supplements may also be necessary in patients who are taking a medication that interferes with vitamin D metabolism, such as anticonvulsant drugs which increase the rate of vitamin D breakdown in the liver. The determination of proper dosage is based on some vitamin D formation from sunlight; if a person is not exposed to a minimum of twenty minutes of sunlight a day, the requirement increases by 200 milligrams. Considerable research has been conducted on the use of different preparations, such as growth hormone, testosterone, and anabolic steroids, in the treatment of osteoporosis, particularly in men. Some experts are recommending that in men with low testosterone, a biweekly injection or the daily application of a testosterone patch may be needed. More research is needed on men with the new drugs that have been approved for use for women. Also, studies of heart disease risk or prostate problems in men using testosterone need to be conducted.
696 ✧ Osteoporosis Public Education and Preventive Measures Osteoporosis is a major public health problem, affecting at least 25 million Americans, with about 1.5 million fractures occurring each year. It is often silent until a fracture occurs. Up to one of every five older patients sustaining a hip fracture dies within six months of the fracture. One-half of the survivors need some help with their daily living activities, and as many as 25 percent of these patients need care in a nursing home. The 1995 estimated cost for treating osteoporotic fractures was nearly $14 billion. It is recommended that all women approaching the menopause be checked to determine a base-line density reading and to help with prevention and possible treatment options. Working with young people may be the best way to combat osteoporosis. For many, making the right choices early in life may have great influence in preventing this debilitating disease later in life. Attempts are being made to develop “risk profiles” for older adults, which can be used to estimate an individual patient’s fracture risk. —Ronald C. Hamdy, M.D., Larry Hudgins, M.D., and Sharon Moore, M.D.; updated by Wendy E. S. Repovich See also Aging; Anorexia nervosa; Broken bones in the elderly; Eating disorders; Exercise; Exercise and the elderly; Hormone replacement therapy; Malnutrition among the elderly; Nutrition and aging; Nutrition and women; Menopause; Preventive medicine; Vitamin supplements. For Further Information: Bilger, Burkhard. “Bone Medicine.” In Health 10, no. 3 (1996). This article summarizes the new drugs approved by the FDA for the treatment of osteoporosis in women, as well as other drugs that are being researched for approval. Heaney, Robert P. “Osteoporosis.” In Nutrition in Women’s Health, edited by Debra A. Krummel and Penny M. Kris-Etherton. Gaithersburg, Md.: Aspen, 1996. This chapter highlights the role of nutrition in the prevention and treatment of osteoporosis in the postmenopausal woman. Isselbacher, Kurt J., et al., eds. Harrison’s Principles of Internal Medicine. 14th ed. New York: McGraw-Hill, 1998. This text contains a chapter outlining the physiology and pathophysiology, diagnosis, and treatment of bone metabolism. Rosen, Clifford J., Julie Glowacki, and John P. Bilezikian, eds. The Aging Skeleton. San Diego, Calif.: Academic Press, 1999. Divided into forty-nine chapters that range widely across such topics as the biology of aging, determinants of peak bone mass, the biology of age-related bone loss, assessment of bone loss, the epidemiology of osteoporotic fractures, and the therapeutics of osteoporosis. Van Horn, Linda, and Annie O. Wong. “Preventive Nutrition in Adolescent Girls.” In Nutrition in Women’s Health, edited by Debra A. Krummel and
Overmedication ✧ 697 Penny M. Kris-Etherton. Gaithersburg, Md.: Aspen, 1996. Discusses the role that nutrition in the adolescent may play in the prevention of osteoporosis later in life.
✧ Overmedication Type of issue: Elder health, ethics, mental health, treatment Definition: Use of too many or too potent pharmacological agents, often by the elderly, which causes great harm to individuals and results in unnecessary health care expenditures. The overmedication of older Americans is a serious problem with many dimensions—cultural, economic, political, and medical. In the late 1990’s, Americans spent eighty billion dollars a year on prescription drugs. People over sixty-five constituted 13 percent of the population but consumed 34 percent of the prescription drugs (as high as 45 percent, according to some estimates). Approximately 70 percent of men over sixty-five used drugs, compared to 75 percent of women in this age group. The number of old persons taking more than six drugs a day was not known, but geriatricians (specialists in the diseases of old age) believed the number to be large. Adverse Drug Reactions Each year, 100,000 Americans die of adverse drug reactions. The old are the most vulnerable, especially those who take several drugs daily. They are twice as likely to suffer ill effects from medications as persons in their thirties and forties, and their adverse reactions are more likely to be severe. An estimated nine million older Americans suffer adverse drug reactions each year. Approximately 17 percent of hospital admissions of people over seventy are caused by this problem. Not all adverse reactions are caused by overmedication, but gerontologists (those who study aging) surmise that among the elderly, overmedication is the most common cause. About 40 percent of respondents to a survey by the American Association of Retired Persons (AARP) reported side effects from the medications they were taking. Some of the side effects were presumably mild and acceptable, given the benefits of the drugs. Because the metabolism of older people slows down and organs tend to function less efficiently, drugs can have a very strong impact on aging bodies. With age, less blood flows into the liver, which becomes smaller and less efficient in metabolizing some drugs. Drug clearance from the body declines with age. For example, reduced kidney function results in drug accumulation. Because the stomach empties more slowly with age, drugs
698 ✧ Overmedication remain there longer. Age-related changes in hormones mean that drugs have a stronger impact on the old than on younger people. For example, the elderly are more likely to develop drug-induced hypoglycemia. With age, the brain becomes more sensitive to the sedative effects of drugs, so that oversedation is often found among the elderly. For example, excess sedation or confusion from too much Valium (diazepam) or Dalmane (flurazepam) may not occur until several weeks after well-tolerated doses were begun. Consequently, some geriatricians recommend that Valium not be given to old patients. According to physician Margaret W. Winker, fat-soluble drugs, including those that affect the brain, are retained longer in the body with age, so that drugs prescribed for problems in the elderly such as anxiety or insomnia must be given in smaller doses and less frequently than they would be given to younger patients. Some narcotic medicines may cause serious side effects in older patients. Winker believes that medications commonly used in the past for insomnia, such as barbiturates, should now be avoided in old persons because they interact with many other drugs, slow respiration, and cause confusion. She also notes that prednisone should not be prescribed for osteoarthritis, the most common form of arthritis, because of its harmful effect on the endocrine system. In addition, the monoamine oxidase (MAO) inhibitors used to treat depression, a common complaint of the elderly, may interact with food to cause high blood pressure. Over-the-counter medicines such as cold remedies and nasal decongestants also interact with MAO inhibitors. Other common reactions to overmedication include impaired movements, memory loss, anxiety, constipation, palpitations, depression, restlessness, insomnia, blocked thyroid function, mood swings or other emotional imbalances, blurred vision, urine retention, potassium depletion, and lessening capacity to smell and taste. In addition, overuse of drugs can cause nutritional depletion, resulting in such problems as hearing loss, anemia, breathlessness, and weakness. Among nutrients lost are vitamins A and C and beta carotene, all thought likely to help the immune system ward off cancer. Prescription Drug Interactions with Other Substances Alcohol and tobacco interact with prescription drugs, increasing risk factors for the old who take multiple drugs. Some arthritis medicines, for example, interact with coffee and alcohol to damage the lining of the stomach. When sleeping pills mix with alcohol, breathing can be impaired to a dangerous degree. Nonbiological factors related to overmedication are drug swapping by the old, poor doctor-patient communication, and noncompliance on the part of patients. Sometimes an elderly patient will obtain prescriptions from various doctors or pharmacies, so that no one doctor or pharmacist sees the complete picture of the individual’s drug consumption. Patients may not tell
Overmedication ✧ 699 doctors what over-the-counter medicines they take. They may not understand, for example, that long-term use of laxatives for constipation can damage their intestines. Others may neglect to mention herbal medications that they take, anticipating the doctor’s disapproval. Doctors may not have time for a thorough review of drug use history, current symptoms, and potentially harmful side effects. Limited knowledge of English, hearing loss, extreme deference to doctors, and a sense of powerlessness on the part of the patient may also be factors in incomplete drug assessment. Although overmedication of the old affects those who live independently or with families as well as those who are institutionalized, overmedicating is especially serious among nursing home residents. Since this population is largely female, the problem of overmedicating nursing home residents is considered a women’s issue. Over one-half of all nursing home residents are prescribed psychotropic drugs (those having an effect on the mind). Geriatricians are concerned that in many cases, no precise diagnosis indicates a need for these powerful drugs. They also believe that nursing home residents are often overdosed with medications marked “as needed.” Another problem is that some drugs have very similar names, resulting in mix-ups. Many falls in nursing homes result from overmedication. Sedating is a chemical restraint necessary for unruly or out-of-control patients but often unnecessary for the majority of nursing home residents. Cultural devaluing of the frail and dependent elderly and the convenience of often-underpaid staff may play a larger role in medicating decisions than the particular health needs of individual residents. While the precise extent of overmedication remains uncertain, pharmacologists who specialize in aging believe that as much as 25 percent of the prescriptions given to the elderly are unnecessary. Other researchers estimate that approximately one-fourth of the elderly are given drugs inappropriate for their complaints. Prescription drugs are most effective for acute, short-term illnesses, but the health problems of the old tend to be chronic. Related Social and Cultural Issues Often when drugs cause the old to become confused or disoriented, these behaviors are attributed to dementia. When reactions to drugs are mistaken for normal signs of aging, elderly persons are unlikely to have their drug use evaluated carefully and adjusted for their individual needs. Perhaps much of what is called “aging” in the United States is actually a cumulative reaction to multiple prescription drugs taken over a long period. Those who live and work with the elderly and the elderly themselves may well believe that the problems they experience result from a slowing down natural to their age and not from overmedication. The more frequently the old see mainstream doctors, the more often they get prescriptions for drugs and the more likely they are to get sick from side
700 ✧ Pain management effects if they take several drugs. Thus, high consumption of medical services on the part of the old perpetuates itself. Typically, gerontologists say, if an old person leaves a doctor’s office without a prescription, he or she feels neglected or believes that a health problem has not been taken seriously. The prescription represents a doctor’s caring. Heavy medication of the old is a fairly recent phenomenon, one more characteristic of aging in the United States than in other societies. In the United States, where drug companies are among the most profitable businesses, the use of many drugs by the old is repeatedly presented as a normal part of aging for all people, not only for those who are sick. Thus, overmedication of the old is both a health and medical problem and a sign of the American tendency to equate aging with illness. Potential dangers of multiple drug use need further study and public discussion. One solution to overmedication is to increase the number of geriatricians trained to meet the needs of an increasingly elderly population, especially those over eighty. Periodic reevaluation of drug use can help prevent overmedication. —Margaret Cruikshank See also Alcoholism among the elderly; Antibiotic resistance; Depression in the elderly; Elder abuse; Health insurance; Medications and the elderly; Memory loss; Nursing and convalescent homes; Nutrition and aging; Safety issues for the elderly; Sleep changes with aging; Vision problems with aging. For Further Information: Gomberg, Edith S. “Alcohol and Drugs.” In Encyclopedia of Gerontology: Age, Aging, and the Aged, edited by James E. Birren. New York: Academic Press, 1996. Hearing on Adverse Drug Reactions in the Elderly. Special Committee on Aging. U.S. Senate, 104th Congress, 2d session. Washington, D.C.: U.S. Government Printing Office, 1996. Knight, Eric, and Jerry Avorn. “Older Adults’ Misuse of Alcohol, Medicines, and Other Drugs.” The Gerontologist 39, no. 1 (February, 1999): 109-111. Roberts, Jay. “Drug Interactions” and “Drug Reactions.” In The Encyclopedia of Aging, edited by George L. Maddox. New York: Springer, 1995. Winker, Margaret. “Managing Medicine.” In The Practical Guide to Aging, edited by Christine Cassel. New York: New York University Press, 1999.
✧ Pain management Type of issue: Elder health, medical procedures, mental health, treatment Definition: Any treatment or management technique to lessen, eliminate, or make pain more tolerable.
Pain management ✧ 701 Pain is described by most people by its intensity. Recent onset of pain is termed acute pain. Long-standing pain or pain that returns periodically is termed chronic pain. Pain is not easily treated because doctors cannot measure it directly. The patient must be able to communicate the pain’s intensity, location, pattern (such as throbbing, steady, or comes-and-goes), and type (such as crushing, burning, sharp, or dull). In addition, factors that make the pain better or worse must be known. Types of Treatment Generally, the best way to treat pain is to prevent its occurrence. Failing that, a number of different interventions should be used together. The therapy must be tailored both to the patient and to the nature and severity of the pain. When medications are used, review of some important principles is essential, such as the pharmacology, duration of effectiveness, and optimal dose of a certain medication. Even the route of administration must be considered in every case. Treatment may include combinations of simple analgesics, narcotics, and other treatments. Combinations take advantage of the additive pain relief while sparing the patient potential side effects. When choosing pain medications, a step-wise approach is often used. It starts with the simple analgesics: aspirin, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs). These medications are generally well tolerated, although aspirin and NSAIDs can produce gastrointestinal distress ranging from mild heartburn to bleeding ulcers. For more severe pain, the second step often includes a narcotic analgesic with or without the simple analgesics. Narcotics are very potent and have a potential for addiction. Furthermore, they may produce problems such as confusion, nausea and vomiting, constipation, and drowsiness. The third step in pain control involves alternative methods of pain control. Treatments here include physical therapy, nerve-blocking injections, transcutaneous electrical nerve stimulation (TENS), or behavioral approaches. The latter method seeks to identify the causes of preventable pain (physical or mental) and takes steps to minimize pain. —Charles C. Marsh, Pharm.D. See also Acupuncture; Addiction; Alternative medicine; Biofeedback; Headaches; Hospice; Hypnosis; Medications and the elderly; Meditation; Overmedication; Stress. For Further Information: Cousins, Michael J., and P. O. Bridenbaugh, eds. Neural Blockade in Clinical Anesthesia and Management of Pain. 3d ed. Philadelphia: J. B. Lippincott, 1998.
702 ✧ Pap smears Ferrari, Lynne R., ed. Anesthesia and Pain Management for the Pediatrician. Baltimore: The Johns Hopkins University Press, 1999. Ferrer-Brechner, Theresa. Common Problems in Pain Management. Chicago: Year Book Medical, 1990. Loeser, John D., ed. Bonica’s Management of Pain. 3d ed. Philadelphia: Lippincott, Williams & Wilkins, 2001.
✧ Pap smears Type of issue: Medical procedures, prevention, women’s health Definition: A laboratory test that is the best method of mass screening for cervical and uterine cancers. Named after George N. Papanicolaou, the originator of the test, the Pap smear is a screening test for abnormal cells on the cervix. The test looks for precancerous cell changes but also may identify cells showing infection and other noncancerous or precancerous irritations, such as human papilloma virus. The procedure is not painful but may be uncomfortable for the patient. A speculum is placed in the vagina to expose the cervix. Cells are collected from the endocervical canal using a small, narrow brush (or a cotton swab if the patient is pregnant); this part of the procedure may cause the patient to feel a slight uterine cramping. Cells are collected from the squamocolumnar junction with a flat, small spatula. These cell samples are then sent for cytological examination to a laboratory equipped for this study. Within one or two weeks, a written report is made regarding the cells studied. The Bethesda classification system, a precise method that describes exactly how the cells appeared to the cytologist, is used. When the report cites abnormal or atypical cells, then further study, possibly including a biopsy of an actual tissue sample, is required. All women who are over eighteen and/or who are sexually active should have Pap smears. The frequency of such tests varies and depends on a woman’s past sexual history, past and present Pap smear results, and age. With a normal Pap smear history, the test should be done yearly after the age of eighteen and until the age of sixty, after which time every other year is sufficient. Should abnormalities occur, follow-up is decided on by the patient and her health care provider. The Pap smear is usually performed by a nurse practitioner, a nursemidwife, or a physician in an office or clinical setting. —Kris Riddlesperger See also Cancer; Cervical, ovarian, and uterine cancers; Screening; Women’s health issues.
Parasites ✧ 703 For Further Information: Clayman, Charles B., ed. The American Medical Association Encyclopedia of Medicine. New York: Random House, 1989. This encyclopedia lists in alphabetical order medical terms, diseases, and medical procedures. It does an excellent job of explaining the different types of cancer and their treatments. Epps, R., and the American Medical Women’s Association, eds. The Women’s Complete Healthbook. New York: Dell Books, 1995. This book by the oldest organization of female physicians in the United States is an invaluable guide for the layperson on female-specific diseases.
✧ Parasites Type of issue: Environmental health, epidemics, public health Definition: Diseases borne by parasites, or organisms that live within other, “host” organisms; parasites travel to their hosts via vectors which may include fleas, mosquitoes, rats, and other animals. Parasites are organisms that take up residence, temporarily or permanently, on or within other living organisms for the purpose of procuring food. They include plants such as bacteria and fungi; animals such as protozoa, helminths (worms), and arthropods; and forms such as spirochetes and microscopic viruses. The study of parasitism is a study of symbiosis. Symbiosis occurs when two organisms, known as symbionts, live in close association with each other, usually with one organism living in or on the body of the other. Such a living arrangement is called a symbiotic relationship. In a symbiotic relationship, the symbionts are usually, but not always, of different species, and the relationship need not be beneficial or damaging to either organism. When one member of a symbiotic relationship actually harms its host or in some way lives at the expense of the host, it is then a parasite. The word “parasite” is derived from the Greek parasitos, which means “one who eats at another’s table” or “one who lives at another’s expense.” A parasite may harm its host by causing a mechanical injury, such as boring a hole into it; by eating, digesting, or absorbing portions of the host’s tissue; by poisoning the host with toxic metabolic products; or by robbing the host of nutrition. It has been found that most parasites inflict a combination of these conditions. Parasites and Disease Medical parasitology is the study of human diseases caused by parasitic infection. It is commonly limited to the study of parasitic worms (helminths)
704 ✧ Parasites and protozoa. The science places nonprotozoan parasites in separate disciplines, such as virology, rickettsiology, and bacteriology. The branches of parasitology known as medical entomology and medical arthropodology deal with insects and noninsect arthropods that serve as hosts and transport agents for parasites, as well as with the noxious effects of these pests. The medical study of parasitic fungi (molds and yeasts) that cause human disease is called mycology. Throughout history, human welfare has suffered greatly because of parasites. Fleas and bacteria killed one-third of the human population of Europe during the seventeenth century, and malaria, schistosomiasis, and African sleeping sickness have killed additional countless millions. Despite successful medical campaigns against yellow fever, malaria, and hookworm infections worldwide, parasitic diseases in combination with nutritional deficiencies are the primary killers of humans. Medical research suggests that parasitic infections are so widespread that if all the known varieties were evenly distributed among the human population, each living person would have at least one. Most serious parasitic infections occur in tropical, less modernized regions of the world, and because most of the planet’s industrially developed and affluent populations live in temperate regions, many people are unaware of the magnitude of the problem. On an annual basis, 60 million deaths occur worldwide from all causes; of these deaths, half are children under five years of age. Fifty percent of these, 15 million child deaths per year, are directly attributable to a combination of malnutrition and intestinal parasitic infection. It must be noted that less than 15 percent of the world’s present population is served by adequate clean water supplies and sewage disposal programs, and that almost all intestinal parasitic infections are the result of ingesting food or water contaminated with human feces. The transmission of parasitic diseases involves three factors: the source of the infection, the mode of transmission, and the presence of a susceptible host. The combined effect of these factors determines the dispersibility and prevalence of a parasite at a given time and place, thus regulating the incidence of a parasitic disease in a population. Because of host specificity, other humans are the chief source of most human parasitic diseases. The various manifestations of any human parasitic disease are a result of the particular species of parasite involved, its mode of transport, the immunological status of the host, the presence or absence of hosts, and the pattern of exposure. Humans transmit parasitic diseases to one another through the intestinal tract, nose and mouth, skin and tissue, genitourinary tract, and blood. It is fecal discharge, however, that offers the most convenient and common means for a parasite or its ova and larvae to leave its host, since the majority of parasites inhabit the gastrointestinal tract. For this reason, the proper disposal of fecal material becomes the most important method of prevent-
Parasites ✧ 705 ing the spread of parasitic disease. Since most parasites inhabit the intestinal tract, food and water are also important means of transmitting parasitic infections. The infective organism may be present in contaminated drinking water, in animal and fish flesh used as food, in human feces used as fertilizer, or on the hands of food handlers. Arthropods are one of the main sources of parasitic diseases in humans. Arthropods act as both mechanical carriers of and intermediate hosts to many diseases—bacterial, viral, rickettsial, and parasitic—which they transmit to humans. In most tropical countries, basic preventive medicine for many devastating parasitic diseases depends on the control or eradication of insects and arachnids.
Any organism that, temporarily or permanently, lives on or in another organism for the purpose of procuring food is considered a parasite; these parasites may cause infection in their human hosts. (Hans & Cassidy, Inc.)
The Common Parasites There are four major groups of parasites that most often invade human hosts: nematodes, trematodes, cestodes, and protozoa. Most nematodes, or roundworms, are free-living, and nematodes are found in almost every terrestrial and aquatic environment. Most are harmless to humans, but some parasitic nematodes invade the human intestinal tract and cause widespread debilitating diseases. The most prevalent intestinal nematodes are Ascaris lumbricoides, which infects the small intestine and affects more than a billion people; the whipworm Trichuris trichiura, which infects the colon and is carried by an estimated 500 million individuals; the human hookworms Necator americanus and Ancylostoma duodenale, which suck blood from the human small intestine and cause major debilitation among undernourished people; and Enterobius vermicularis, the human pinworm, which infects the large intestine and is common among millions of urban dwellers because it is easily transmitted from perianal tissue to hand to mouth. Nonintestinal, tissue-infecting nematodes are spread most often by hyperparasitic bloodsucking insects such as mosquitoes, biting flies, and midges.
706 ✧ Parasites The most common tissue-infecting nematode is Trichinella spiralis, the pork or trichina worm, which is the agent of trichinosis. Other important parasitic nematodes include Onchocerca volvulus, which is transmitted by blackflies in tropical regions and causes blindness, and the mosquito-transmitted filarial worms that are responsible for elephantiasis. Trematodes, or flatworms, are commonly called flukes. Flukes vary greatly in size, form, and host living location, but all of them initially develop in freshwater snails. The human intestinal fluke, the oriental liver fluke, and the human lung fluke are all transmitted to humans by the ingestion of raw or undercooked aquatic vegetables, fish, or crustaceans. An important group of trematodes consists of the blood flukes of the genus Schistosoma, which enter the body through skin/water contact and are responsible for schistosomiasis. Cestodes, commonly called tapeworms, are parasitic flatworms that parasitize almost all vertebrates, and as many as eight species are found in humans. The two most common cestodes—Taenia saginata, the beef tapeworm, and Taenia solium, the pork tapeworm—are transmitted to humans by infected beef or pork products obtained from livestock that grazed in fields contaminated by human feces, or by contaminated water. The resulting disease, cysticercosis, which is potentially lethal, develops mostly in the brain, eye, and muscle tissue. Another animal-transmitted cestode is the dog tapeworm, Echinococcus granulosus, which dogs ingest by eating contaminated sheep viscera and then pass on to humans, who ingest the parasite’s eggs after petting or handling an infected dog. The human infestation of E. granulosus results in hydatid disease. Probably the most dramatic of the cestode parasites is the gigantic tapeworm Diphyllobothrium latum, which may reach lengths of 10 meters and a width of 2 centimeters. This tapeworm is transmitted to humans by the ingestion of raw or undercooked fish. This tapeworm, like most cestodes, can be effectively treated and killed by drugs, but if the worm merely breaks, leaving the head and anterior segments attached, it can regenerate its original body length in less than four months. Protozoa that can infect human hosts are found in the intestinal tract, various tissues and organs, and the bloodstream. Of the many varieties of protozoa that can live in the human intestinal tract, only Entamoeba histolytica causes serious disease. This parasite, which is ingested in water contaminated by human feces, is responsible for the disease amebiasis, also known as amebic dysentery. A less serious, though common, waterborne intestinal protozoan is Giardia lamblia, which causes giardiasis, a common diarrheal infection among children in day care and campers who ingest water fouled by animal waste. Another group of protozoa parasites specializes in infecting the human skin, bloodstream, brain, and viscera. Trypanosoma brucei, carried by the African tsetse fly, causes the blood disease trypanosomiasis (African sleeping sickness). In Latin America, infection by the protozoa Trypanosoma cruzi
Parasites ✧ 707 results when the liquid feces of the reduviid (assassin) bug is rubbed or scratched into the skin; it causes Chagas’ disease, which produces often fatal lesions of the heart and brain. Members of the protozoan genus Leishmania are transmitted by midges and sandflies, and their parasitic infestation manifests in long-lasting dermal lesions and ulcers; the destruction of nasal mucous, cartilage, and pharyngeal tissues; or in the disease kala-azar, resulting in the destruction of bone marrow, lymph nodes, and liver and spleen tissue. Two other types of protozoa are parasitic to humans. The first is the ciliate protozoa, which are mostly free-living, and of which only a single species, Balantidium coli, is parasitic in humans. This species is responsible for balantidiasis, an ulcerative disease. The second is the sporozoans, all of which are parasitic. Many species of sporozoans are harmful to humans, the most important being Plasmodium, the agent of malaria. The sporozoan parasite Toxoplasma gondii, the agent of toxoplasmosis, is responsible for encephalomyelitis and chorioretinitis in infants and children and is thought to infect as much as 20 percent of the world’s population. Pneumocystis, a major cause of death among persons with acquired immunodeficiency syndrome (AIDS), was formerly considered a result of sporozoan infection but is now thought to be fungal. —Randall L. Milstein See also Environmental diseases; Epidemics; Food poisoning; Lice, mites, and ticks; Lyme disease; Plague; Worms; Zoonoses. For Further Information: Despommier, Dickson D., Robert W. Gwadz, and Peter J. Hotex. Parasitic Diseases. 4th ed. New York: Springer-Verlag, 2000. This source provides a list of parasitic diseases of current concern to public health professionals. It also describes the assessment of and treatment options for a variety of these diseases. Klein, Aaron E. The Parasites We Humans Harbor. New York: Elsevier/Nelson Books, 1981. An overview of common human-infecting parasites written for the general reader. The text is nontechnical, easy to follow, and presents numerous examples. Noble, Elmer R., and Glenn A. Noble. Parasitology: The Biology of Animal Parasites. 5th ed. Philadelphia: Lea & Febiger, 1982. A graduate-level textbook on parasites that infect animals. The comprehensive and highly technical text deals with the biological, environmental, and pathological aspects of parasites. Well illustrated with anatomical drawings and photographs. Roberts, Larry S., and John Janovy, Jr. Gerald D. Schmidt and Larry S. Roberts’ Foundations of Parasitology. Rev. 6th ed. Dubuque, Iowa: Wm. C. Brown, 2000. A graduate-level textbook covering all aspects of parasitology. The
708 ✧ Parkinson’s disease text is highly technical and intended for the informed reader. The book is well illustrated, but sensitive readers may be disturbed by many of the case study photographs.
✧ Parkinson’s disease Type of issue: Elder health, public health Definition: A progressive neural degeneration that leads to the death of specific cells deep within the brain. As the average life span has steadily increased, Parkinson’s disease has become a growing problem; in 1999, there were approximately 500,000 patients with this disease in the United States alone. In fact, the number of people affected is higher than all patients of multiple sclerosis (MS), muscular dystrophy, and amyotrophic lateral sclerosis (Lou Gehrig’s disease) combined. Most patients are above forty years old, although the disease has been found to affect younger people. A rare form of Parkinson’s disease appears to also affect teenagers. Statistically, men have a higher incidence of the disease, and Caucasians are more affected than any other race. Symptoms and Diagnosis A human is born with all the brain cells (also known as neurons) he or she will ever have. This means that if, during lifetime, some of those neurons die, they will never be replaced. Extensive research has shown that people with Parkinson’s disease have lost most of the neurons that produce dopamine, an important neurotransmitter that delivers messages within the brain. As the available dopamine is decreased, an imbalance of dopamine and acetylcholine occurs in the brain, leading to a lack of movement coordination. Parkinson’s disease is not diagnosed easily because various patients do not show the same symptoms and because there are no proven, specific tests for its identification. Moreover, Parkinson-like symptoms can often arise from head trauma or the use of tranquilizing drugs, such as phenothiazines and butyrophenones. Even carbon monoxide poisoning or Reglan, a common antidote against stomach upset, may provide these symptoms. The general diagnosis involves a neurological examination, which evaluates the symptoms and their severity. If the symptoms are judged as serious, a trial test of anti-Parkinson’s drugs (such as primary levodopa) may be administered to establish the existence of the disease. If the patient fails to gain ground, other brain evaluations using such technology as computed tomography (CT) or magnetic resonance imaging (MRI) are used to rule out other diseases rather than certify the presence of Parkinson’s disease.
Parkinson’s disease ✧ 709 Type A patients display an extensive degree of tremor, often on either the left or right side only, together with a muscle rigidity. Type B patients may not exhibit tremors at all but may show a great disturbance in balance and gait, as well as an inability to move easily. A more severe class involves the “Parkinson’s plus” patients, whose cases are accompanied by six different types of neurological disorder, such as Shy-Drager syndrome, substantia nigra degeneration (SND), progressive supranuclear palsy (PSP), olivopontocerebellar atrophy (OPCA), or multisystem atrophy. Despite the scientific breakthroughs in understanding various brain mechanisms, the cause of the disease is still unknown. In some cases, viral infections appear to have triggered the symptoms, such as in the worldwide encephalitis epidemic that took place between 1918 and 1922, in which the mortality rate reached 40 percent. Parkinson’s disease has also been found among people whose pyramidal nervous system was damaged by the use of illegal drugs related to the narcotic painkiller meperidine (Demerol). Comparisons of healthy and Parkinson’s patients’ brains have shown considerable differences in the substantia nigra and the striatum parts. Many of the substantia nigra’s pigmented cells are damaged in the patients; instead of the normal black spots, they contain pink-staining spheres called Lewy bodies. It is estimated that loss of approximately 80 percent of the substantia nigra’s pigmented cells and 80 percent of the striatum’s dopamine content results in the appearance of Parkinson’s disease symptoms. History Parkinson’s disease took its name from nineteenth century British physician James Parkinson, who described the classic symptoms of resting tremor, propulsion, and stooped posture for the first time in a monograph entitled “An Essay on the Shaking Palsy” in 1817. In 1939, neurosurgeon Russell Meyers removed a brain tumor from a patient who also had Parkinson’s disease. Further experimental surgery on the same patient involved a lesion in a neurosignal fiber bundle, called the ansa lenticularis, which reduced the patient’s Parkinson’s symptoms to a considerable degree. The same complex surgical procedure was later applied to about one hundred more people, thirty-nine of which showed improvement, while seventeen died. In the early 1950’s, Swedish neurosurgeon Lets Leksel applied a procedure called posterolateral pallidotomy to patients, with mixed results. In this approach, a small-diameter metal probe was inserted into the skull along the front hairline, deep into the globus pallidus part of the brain. However, missing the target by the smallest margin led to blindness or permanent impairment of other functions. Thirty years later, several other Swedish neurosurgeons attempted to implant surgically in the brain parts of the patient’s adrenal gland that produces dopamine. Success, however, remained elusive. In 1985, Lauri Laitenen proposed a modified procedure of
710 ✧ Parkinson’s disease Leksel’s original pallidotomy, called PVP pallidotomy. The process involved attaching a calibrated metal halo to the patient’s head. The use of CT or MRI pictures with the calibration of the halo allowed the identification of the exact target spot during the surgery. Transplanting small parts of live tissue from aborted fetuses into the brains of Parkinson’s disease patients appeared to gain ground in the war against the disease in the late 1980’s. This process, also called fetal tissue transplant, first involved fetal adrenal gland tissue and later fetal brain tissue and served as an attempt to enhance the production of more dopamine in the patient’s brain. Pioneering neurosurgeons who used this procedure included Laitenen in Sweden, Z. S. Tang in China, and Robert Iacono in the United States. A fetal bank was established in Hua Shan Hospital in Shanghai, China, where the fetal brain tissue was held under cryogenic conditions. The actual transplants took place in China, since a long-standing ban on fetal tissue research made this kind of surgery practically impossible in the United States. Treatment Apart from surgery, type A and B patients can be helped by medication prescription or neurosurgery. The primary medications are classified as anticholinergics, antihistamines, dopaminergics, and dopamine agonists. Unfortunately, all drugs used have side effects that may create a serious impact on the quality of life. Drug therapy attempts to maintain the patient on conservative levels of medication while maintaining mobility. Side effects include dry mouth, constipation, blurred vision, visual hallucinations, lethargy, confusion, and nausea. Levodopa is the drug of choice for treatment of Parkinson’s disease and is marketed as a mixture with carbidopa. Carbidopa is used as a blocker of the breakdown of levodopa in the peripheral organs in order to allow more levodopa to cross the blood-brain barrier. Through a series of complex enzymatic reactions, levodopa is converted to dopamine. As the disease progresses, however, the patients need much larger quantities of levodopa. During the administration of the medicine, patients appear to have a surge of energy, which quickly wears off as time elapses. Interestingly, symptoms on the left side of the patient are relieved with an operation on the right part of the brain, and vice versa. Moreover, a brain whose problems arise from the death of some of the neurons can show signs of improvement by deadening some more of those cells in the critically overstimulated pathways. Thus, the activity that would result if all of the brain’s circuits carried action commands appears to be controlled. During the overall surgical procedure, the patient is awake and only lightly anesthetized, responding to the surgeon’s commands to move various parts of the body, such as hands, fingers, eyes, toes, and tongue. With
Pesticides ✧ 711 the help of the MRI pictures, the surgeon can pinpoint the cells that are to be neutralized. A probe is slowly entered into the brain, and its tip sends an electric signal back to the control panel, indicating the overall geography of the brain map. Once it reaches the target spot, an electrical shock is applied at the probe tip that kills the overreacting cells. The patient has absolutely no feeling, and the electrical “cauterization” has no effect on the nearby capillaries and the blood flowing in them. The probe is then removed, and the penetrated skin is stitched up. After the surgery, the patient displays much less muscle tightening, as well as dramatic decreases in tremors. In most cases, the patient stays one night in the hospital for observation, then walks with no help out of the hospital the next day. —Soraya Ghayourmanesh See also Illnesses among the elderly; Mobility problems among the elderly; Muscle loss with aging. For Further Information: Bunting, L. K., and B. Fitzsimmons. “Depression in Parkinson’s Disease.” Journal of Neuroscience Nursing 23, no. 3 (June, 1991). Cram, David L. Understanding Parkinson’s Disease: A Self-Help Guide. Omaha, Nebr.: Addicus Books, 1999. Duvoisin, Roger C., and Jacob Sage. Parkinson’s Disease: A Guide for Patient and Family. 4th ed. Philadelphia: Lippincott-Raven, 1996. Giovannini, P., et al. “Early Onset Parkinson’s Disease.” Movement Disorders 6, no. 1 (1991). Jahanshahi, Marjan, and C. David Marsden. Parkinson’s Disease: A Self-Help Guide for Patients and Their Careers. London: Souvenir Press, 1998.
✧ Pesticides Type of issue: Environmental health, industrial practices, public health Definition: Chemicals designed to kill unwanted organisms that interfere with human activities. The major types of pesticides in common use are insecticides (to kill insects), nematocides (to kill nematodes), fungicides (to kill fungi), herbicides (to kill weeds), and rodenticides (to kill rodents). Herbicides and insecticides make up the majority of the pesticides applied in the environment. While the use of pesticides has mushroomed since the introduction of monocultures (the agricultural practice of growing only one crop on a large amount of acreage), the application of chemicals to control pests is by no
712 ✧ Pesticides means new. The use of sulfur as an insecticide dates back before 500 b.c.e. Salts from heavy metals such as arsenic, lead, and mercury were used as insecticides from the fifteenth century until the early part of the twentieth century, and residues of these toxic compounds are still being accumulated in plants that are grown on soil where these materials were used. In the seventeenth and eighteenth centuries, natural plant extracts such as nicotine sulfate from tobacco leaves and rotenone from tropical legumes were used as insecticides. Other natural products, such as pyrethrum from the chrysanthemum flower, garlic oil, lemon oil, and red pepper, have long been used to control insects. In 1939 the discovery of dichloro-diphenyl-trichlorethane (DDT) as a strong insecticide opened the door for the synthesis of a wide array of synthetic organic compounds to be used as pesticides. Chlorinated hydrocarbons such as DDT were the first group of synthetic pesticides. Other commonly used chlorinated hydrocarbons include aldrin, endrin, lindane, chlordane, and mirex. Because of their low biodegradability and long persistence in the environment, the use of these compounds was banned or severely restricted in the United States after years of use. Organophosphates such as malathion, parathion, and methamidophos have replaced the chlorinated hydrocarbons. These compounds biodegrade in a fairly short time but are generally much more toxic to humans and other animals than the compounds they replaced. In addition, they are water soluble and, therefore, more likely to contaminate water supplies. Carbamates such as carbaryl, maneb, and aldicarb have also been used in place of chlorinated hydrocarbons. These compounds rapidly biodegrade and are less toxic to humans than organophosphates, but they are also less effective in killing insects. Herbicides are classified according to their method of killing rather than their chemical composition. As their name suggests, contact herbicides such as atrazine and paraquat kill when they come in contact with the leaf surface. Contact herbicides generally disrupt the photosynthetic mechanism. Systemic herbicides such as diuron and fenuron circulate throughout the plant after being absorbed. They generally mimic the plant hormones and cause abnormal growth to the extent that the plant can no longer supply sufficient nutrients to support growth. Soil sterilants such as triflurain, diphenamid, and daiapon kill microorganisms necessary for plant growth and also act as systemic herbicides. Pesticide Use In the United States, approximately 55,000 different pesticide formulations are available, and Americans apply about 500 million kilograms (1.1 billion pounds) of pesticides each year. Fungicides account for 12 percent of all pesticides used by farmers, insecticides account for 19 percent, and herbi-
Pesticides ✧ 713 cides account for 69 percent. These pesticides have primarily been used on four crops: soybeans, wheat, cotton, and corn. Approximately $5 billion are spent each year on pesticides in the United States, and about 20 percent of this is for nonfarm use. On a per unit of land basis, homeowners apply approximately five times as much pesticide as do farmers. On a worldwide basis, approximately 2.5 tons (2,270 kilograms) of pesticides are applied each year. Most of these chemicals are applied in developed countries, but the amount of pesticide used in underdeveloped countries is rapidly increasing. Approximately US$20 billion are spent worldwide each year, and this expenditure is expected to increase in the future, particularly in the underdeveloped countries. The use of pesticides has had a beneficial impact on the lives of humans by increasing food production and reducing food costs. Even with pesticides, pests reduce the world’s potential food supply by as much as 55 percent. Without pesticides, this loss would be much higher, resulting in increased starvation and higher food costs. Pesticides also increase the profit margin for farmers. It has been estimated that for every dollar spent on pesticides, farmers experience an increase in yield worth three to five dollars. Pesticides appear to work better and faster than alternative methods of controlling pests. These chemicals can rapidly control most pests, are cost effective, can be easily shipped and applied, and have a long shelf life as compared to alternative methods. In addition, farmers can quickly switch to another pesticide if genetic resistance to a given pesticide develops. Perhaps the most compelling argument for the use of pesticides is the fact that pesticides have saved lives. It has been suggested that since the introduction of DDT, the use of pesticides has prevented approximately seven million premature human deaths from insect-transmitted diseases such as sleeping sickness, bubonic plague, typhus, and malaria. Perhaps even more lives have been saved from starvation because of the increased food production resulting from the use of pesticides. It has been argued that this one benefit far outweighs the potential health risks of pesticides. In addition, new pesticides are continually being developed, and safer and more effective pest control may be available in the future. In spite of all the advantages of using pesticides, their benefit must be balanced against the potential environmental damage they may cause. Environmental Concerns An ideal pesticide should have the following characteristics: It should not kill any organism other than the target pest; it should in no way affect the health of nontarget organisms; it should degrade into nontoxic chemicals in a relatively short time; it should prevent the development of resistance in the organism it is designed to kill; and it should be cost effective. Since no currently available pesticides meet all of these criteria, a number of environ-
714 ✧ Pesticides mental problems have developed, one of which is broad-spectrum poisoning. Most, if not all, chemical pesticides are not selective. In other words, they kill a wide range of organisms rather than just the target pest. Killing beneficial insects, such as bees, lady bird beetles, and wasps, may result in a range of problems. For example, reduced pollination and explosions in the populations of unaffected insects can occur. When DDT was first used as an insecticide, many people believed that it was the final solution for controlling many insect pests. Initially, DDT dramatically reduced the number of problem insects; within a few years, however, a number of species had developed genetic resistance to the chemical and could no longer be controlled with it. By the 1990’s there were approximately two hundred insect species with genetic resistance to DDT. Other chemicals were designed to replace DDT, but many insects also developed resistance to these newer insecticides. As a result, although many synthetic chemicals have been introduced to the environment, the pest problem is still as great as it ever was. Depending on the type of chemical used, pesticides remain in the environment for varying lengths of time. Chlorinated hydrocarbons, for example, can persist in the environment for up to fifteen years. From an economic standpoint, this can be beneficial because the pesticide has to be applied less frequently, but from an environmental standpoint, it can be detrimental. In addition, when many pesticides are degraded, their breakdown products, which may also persist in the environment for long periods of time, are often toxic to other organisms. Pesticides may concentrate as they move up the food chain. All organisms are integral components of at least one food pyramid. While a given pesticide may not be toxic to species at the base, it may have detrimental effects on organisms that feed at the apex because the concentration increases at each higher level of the pyramid, a phenomenon known as biomagnification. With DDT, for example, some birds can be sprayed with the chemical without any apparent effect, but if these same birds eat fish that have eaten insects that contain DDT, they lose the ability to properly metabolize calcium. As a result, they lay soft-shelled eggs, which causes the death of most of the offspring. Pesticides can also be hazardous to human health. Many pesticides, particularly insecticides, are toxic to humans, and thousands of people have been killed by direct exposure to high concentrations of these chemicals. Many of these deaths have been children who were accidentally exposed to toxic pesticides because of careless packaging and storage. Numerous agricultural laborers, particularly in Third World countries where there are no stringent guidelines for the handling of pesticides, have also been killed as a result of direct exposure to these chemicals. Workers in pesticide factories are also a high-risk group, and many of them have been poisoned through job-related contact with the chemicals. Pesticides have been suspected of
Phenylketonuria (PKU) ✧ 715 causing long-term health problems such as cancer. Some of the pesticides have been shown to cause cancer in laboratory animals, but there is currently no direct evidence to show a cause-and-effect relationship between pesticides and cancer in humans. —D. R. Gossett See also Environmental diseases; Food poisoning; Mercury poisoning; Occupational health; Poisoning. For Further Information: Carson, Rachel. Silent Spring. Boston: Houghton Mifflin, 1962. Even though it is somewhat outdated, an excellent dramatization of the potential dangers of pesticides and served as a major catalyst for bringing the hazards of using pesticides to the attention of the general public. Mannion, Antionette M., and Sophia R. Bowlby, eds. Environmental Issues in the 1990’s. New York: John Wiley & Sons, 1992. A good discussion of some of the environmental issues associated with the use of pesticides. Miller, G. Tyler, Jr. Living in the Environment: An Introduction to Environmental Science. 7th ed. Belmont, Calif.: Wadsworth, 1992. An excellent discussion of the environmental issues associated with the use of pesticides. Nadakavukaren, Anne. Man and Environment: A Health Perspective. Prospect Heights, Ill.: Waveland Press, 1990. A good discussion on human health issues associated with the use of pesticides. Pierce, Christine, and Donald VanDeVeer. People, Penguins, and Plastic Trees. 2d ed. Belmont, Calif.: Wadsworth, 1995. Good discussions of environmental ethics, including the ethics of using agricultural chemicals.
✧ Phenylketonuria (PKU) Type of issue: Children’s health, public health Definition: A genetic disorder caused by a deficiency of the liver enzyme phenylalanine hydroxylase. Phenylketonuria (PKU) is a genetic disorder, occurring in about 1 in 10,000 births, that disrupts the metabolism of the amino acid phenylalanine. The disorder is caused by a deficiency of phenylalanine hydroxylase, a liver enzyme that catalyzes the conversion of phenylalanine to tyrosine. Since normal phenylalanine metabolism is blocked, the amino acid accumulates in blood and tissues, resulting in progressive, irreversible mental retardation and neurological abnormalities. Most forms of PKU are caused by a mutation—more than two hundred mutations are now characterized—in the gene for phenylalanine hydroxylase.
716 ✧ Phenylketonuria (PKU) A small percentage of infants with PKU have a variant form of the condition, known as malignant PKU. This disorder is caused by a defect in the synthesis or metabolism of tetrahydrobiopterin, a cofactor for the conversion of phenylalanine to tyrosine, or in other enzymes along the pathway. Without treatment, malignant PKU causes a progressive, lethal deterioration of the central nervous system. The Importance of Screening Infants with classic and malignant PKU appear normal; however, if untreated, the condition severely impairs normal brain development and growth after a few months of age, causing mental retardation, seizures, eczema, and neurological and behavioral problems. Affected infants have plasma phenylalanine levels ten to sixty times above normal, along with normal or reduced tyrosine levels and high concentrations of the metabolite phenylpyruvic acid in their urine. Routine screening of newborns for PKU before three weeks of age, usually by using whole blood obtained from a heel prick, is mandated in all fifty U.S. states. Elevated phenylpyruvic acid levels also can be detected in urine of infants with PKU after adding a few drops of 10 percent ferric chloride, resulting in a deep green color. Newborns often have transient PKU—elevated phenylalanine and phenylpyruvic acid levels in the first few weeks of life that normalizes—so classic PKU should be distinguished from transient conditions. Elevated phenylalanine levels that persist beyond a few weeks of life, accompanied by normal or low tyrosine levels, usually indicate an inborn error of metabolism. Malignant PKU is usually diagnosed by detecting biopterin metabolites in urine or showing that tetrahydrobiopterin supplementation restores normal phenylalanine and tyrosine levels. Babies of mothers with PKU are at high risk of brain damage, impaired growth, and malformations of the heart and other organs. Managing maternal phenylalanine levels at near normal concentrations appears to be crucial to preventing these cognitive and neurological defects. Treating PKU The detrimental effects of PKU can largely be controlled by maintaining phenylalanine levels in the normal range through a strict low-phenylalanine diet. This complex diet, often supplemented with tyrosine, prevents the buildup of phenylalanine and its metabolites in body tissues. Children whose phenylalanine levels are regularly monitored and managed can achieve normal intelligence and development. In infants with malignant PKU, tetrahydrobiopterin or cofactor supplements are required to control phenylalanine levels successfully. The successful treatment of PKU depends on managing phenylalanine
Phenylketonuria (PKU) ✧ 717 levels. However, the diet is complex and challenging to sustain over many years. Since phenylalanine is an essential amino acid, found in virtually all proteins, maintaining adequate nutrition is nearly impossible on a lowphenylalanine diet. The treatment requires rigorous protein restriction and the substitution of most natural proteins in meat, fish, eggs, and dairy products. Phenylalanine intake must not be too restricted, however, or else phenylalanine deficiency can occur. Treatment for PKU must begin at a very early age, before the first three months of life, and usually continue through adulthood, or else some degree of mental retardation or neurological abnormalities is expected. In some cases, dietary treatment for PKU can be discontinued or made less restrictive as children age, without causing severe effects. In many cases, however, the ill effects of the disorder carry into adulthood unless dietary management is continued over the long term. Untreated adolescents and adults may exhibit behavioral or neurological problems, difficulty concentrating, poor visual-motor coordination, and a low intelligence quotient (IQ). Strict control of phenylalanine levels also is indicated for pregnant women with PKU because their babies are at high risk for severe brain damage. In the 1980’s, clinical trials examined the use of dialysis-like procedures that allowed the rapid breakdown of phenylalanine in the blood. The treatment applies to pregnant women with PKU or those with severely elevated phenylalanine levels resulting from stress or illness. In the 1990’s, PKU became the focus of gene therapy research. Animal models of PKU have been successfully treated by introducing normal phenylalanine hydroxylase deoxyribonucleic acid (DNA) into the liver cells of mice. Since the underlying genetic defects are known in most cases of PKU, gene therapy appears a likely research focus for long-term treatment. —Linda Hart See also Children’s health issues; Genetic diseases; Mental retardation; Nutrition and children; Screening. For Further Information: Behrman, Richard E., and Robert M. Kliegman. Nelson Essentials of Pediatrics. Philadelphia: W. B. Saunders, 1998. Dworkin, Paul H., ed. Pediatrics. 4th ed. Baltimore: Williams & Wilkins, 2000. Lloyd, June K., and Charles R. Scriver. Genetic and Metabolic Disease in Pediatrics. London: Butterworths, 1985.
718 ✧ Physical fitness tests for children
✧ Physical fitness tests for children Type of issue: Children’s health, medical procedures, prevention, public health Definition: An assessment procedure that measures a child’s performance in one or more of the components of fitness. Physical fitness tests are used with children to determine baseline performance and to track progress over time. A battery of tests is developed to evaluate one or more of the components of fitness. They may include flexibility, cardiovascular endurance, muscular endurance, speed, strength, power, and agility. Each component of fitness has several methods of assessment. Some are simple, use basic equipment, and provide minimal information. Others are complicated, involve sophisticated equipment, and provide very accurate information. There is always a trade-off between the quality of the information obtained and the cost and complexity of the test. Basic Tests Flexibility is most frequently measured by the sit-and-reach test. This simple test requires a box with a ruler on top. The individual sits with his or her feet against the box and then leans forward as far as possible; the tester measures how far past or short of the toes the person reaches. The score is recorded in inches or centimeters. The problem with the sit-and-reach test is that it measures only the flexibility of the hamstring muscles. This measure may not be indicative of other joints in the body. Cardiovascular endurance is typically measured by having the individual complete a walking or running test. Many variations of this type of test exist, such as the one-mile run and the nine-minute run. In the one-mile run, the individual is timed in how long it takes to run or walk a mile. In the nine-minute run, the participant runs or walks for nine minutes. Performance is determined by how far the child goes. These types of cardiovascular tests are easy to complete on a typical running track. Muscular endurance tests are among the simpler evaluations from which to gain accurate information. These tests involve the number of repetitions of a specific activity, such as push-ups, pull-ups, or sit-ups. The activity is performed to exhaustion. The number of repetitions is recorded and used as the score. One limitation of such tests is that they measure only one muscle group; other muscle groups may have better or worse endurance. Speed is perhaps the simplest test. The runner is timed in either a 40-, 50or 60-yard dash. The time is recorded in seconds. The shorter the time, the better the individual’s speed.
Physical fitness tests for children ✧ 719 Strength tests are one of the most difficult to do. To measure strength, it is necessary to obtain the measurement at the strongest contraction of which the person is capable. Trial and error to find the maximum by trying several different weights does not work because the subject becomes fatigued. Therefore, instruments that measure a maximum contraction, called ergometers, are used. One of the most common, and the simplest to use, is the hand ergometer. the individual squeezes this handheld instrument with a maximum effort. The ergometer displays the force generated in pounds or kilograms. The biggest limitation of this test is that it measures only the strength of the forearm, which may not necessarily be indicative of the strength of other parts of the body. Power is another simple test. Since power is weight divided by time, it is a measure of how strong and fast the muscles contract. A good test for power is the vertical jump. Standing reach is measured against a wall. Then, the individual jumps as high as possible without taking any steps. The difference between the two measures is taken to determine how high the person jumped. The higher the jump, the greater the power. Another power test used less often is the standing long jump. The distance that the person jumps from a standing position is recorded. The common factor between these two tests is that the subject tries to contract the leg and trunk muscles forcefully and quickly. Agility tests measure the ability of the individual to run, stop, and turn on command. To conduct this test, a small course is set up. The courses vary but typically include cones directing the participant to stop or turn. The subject starts on the go command and runs the course while the tester times the runner in seconds. The quicker the course is completed, the better the agility score. Keeping Track Fitness tests that are intended for children have few risks of complications. People can be injured in any form of physical activity, but these tests are designed to minimize the risk. The primary purposes for these tests are to evaluate the physical abilities of children and to develop programs to help them improve in specific areas. In addition, these data are useful for tracking the progress of the individual over time. Fitness trends can also be evaluated for age groups over time to determine the changes in fitness levels of groups of children. Fitness testing probably dates back to ancient Greece. The development of most of the protocols that are used today started in the early twentieth century. In the United States, interest in testing children in schools increased in the late 1950’s, when physical fitness was promoted to combat the declining fitness levels of young Americans. Fitness tests have been under continuous evaluation for accuracy and
720 ✧ Physical rehabilitation improvement. This scrutiny will continue in the future as new tests that are easier, cheaper and more accurate are pursued. —Bradley R. A. Wilson See also Children’s health issues; Exercise; Exercise and children; Obesity; Obesity and children; Sports injuries among children. For Further Information: American Alliance for Health, Physical Education, Recreation, and Dance. Physical Best: A Physical Fitness Education and Assessment Program. Reston, Va.: Author, 1988. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. Philadelphia: Williams & Wilkins, 1995. Ratman, Jeffrey, ed. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 3d ed. Baltimore: Williams & Wilkins, 1998.
✧ Physical rehabilitation Type of issue: Medical procedures, treatment Definition: The discipline devoted to the restoration of normal bodily function, primarily of the muscles and skeleton. Physical rehabilitation has been defined as a scientific discipline that uses physical agents such as light, heat, water, electricity, and mechanical agents in the management and rehabilitation of pathophysiological conditions resulting from disease or injury. Rehabilitation involves the treatment and training of patients with the goal of maximizing their potential for normal living physically, psychologically, socially, and vocationally. Physical rehabilitation is known for its work in restoring function to traumatized limbs. Practitioners in the field work with persons of all ages: with children to overcome birth defects, with adults to restore muscular function lost from strokes, with the elderly to maintain as much of normal functioning as possible in the face of advancing age, and with postoperative patients to accelerate healing and a return to normal activities. In addition, emphasis is placed on preventing and treating athletic injuries—prevention through the teaching of exercises to strengthen specific body parts and treatment through the restoration of normal bodily movements. Four main therapeutic modalities are used in physical rehabilitation: heat, diathermy, cold, and hydrotherapy.
Physical rehabilitation ✧ 721 Heat and Cold Therapy The primary reason for using heat is to raise the temperature in a specific area, usually the site of a wound. Heat increases the rate of cellular metabolism, thus increasing blood flow. Heat also has a sedative effect, relaxing the body part. Tissue repair occurs more rapidly with increased metabolism and circulation. Stress on the injured area is reduced, allowing tissue repair to proceed unimpeded. The net effect is to speed healing. Heat is supplied by several methods. Compresses of cloth immersed in heated water have been used for centuries. Confining the heated water in a container provides heat in a dry form. Electric heating pads are more convenient because they can supply dry heat at a constant temperature for an unlimited length of time. Melted paraffin is occasionally used to concentrate heat in a specific location; this substance must be applied by a professional under controlled conditions. These modalities supply heat to the surface of skin; it penetrates passively, diminishing in intensity with increasing distance from the surface. Infrared lamps provide heat that can penetrate to greater depths than heat sources applied to the surface of skin. Additional advantages include dryness and being able to position the body to be heated in any position. Because of its ability to penetrate, infrared light must be limited in exposure to avoid burns. It can also cause excessive drying of skin surfaces. Heat can also be supplied convectively, most often by immersion in warmed water. The stream of water can be directed at particular body parts, providing both heat and stimulation. Diathermy is defined as deep heating. Deep tissues are heated because superficial heating produces only a few mild physiologic reactions. The problem is to avoid burning superficial tissues while heating deep structures. Three main methods are used to achieve this desired effect: shortwave, ultrasound, and microwave. In all three methods, energy is transferred and finally converted into heat when it reaches deep tissues. With shortwave, energy is transferred into deeper tissues by high-frequency current. Ultrasound uses high-frequency acoustic vibrations that penetrate into deep tissues. Microwave uses electromagnetic radiation to heat deeper tissues. Diathermy is most useful in treating relatively deep muscular injuries. It cannot be used safely with sensory impairment because burning can occur, nor can it be used in joints that have been replaced with prostheses. Cold creates physiological effects that are opposite to those of heat. Cooling decreases tissue metabolism. The application of cold slows blood circulation, which, in turn, tends to reduce tissue swelling caused by edema. Cold is more penetrating than heat. Too much cold, however, can become a problem. Cooling a large surface area of skin or lowering the core temperature of a body induces shivering, which causes the production of heat. Local cooling is used to reduce the unrestricted flow of fluid and blood
722 ✧ Physical rehabilitation into tissues after they have been traumatized. Cold reduces pain, both superficial and deep, and reduces reflex spasticity of muscles. Cold tends to preserve and extend the viability of tissues that have inadequate circulation, thus retarding the development of gangrene in an ischemic body part, which is most commonly seen in limbs. Common methods for achieving therapeutic cooling are immersion, cold packs, cryokinetics, and a combination of local cooling and remote heating. Immersion is usually begun in cold water to which ice is steadily added. Total immersion is usually limited to ten or twenty minutes. The affected portion of the body is submerged in the chilled water. Cooling to a temperature above that of ice water may reduce muscular spasticity. Cold packs are often made by wrapping ice in a wet towel or plastic bag and applying it to the skin. Frozen cold packs should not be applied directly to the skin because they can cause locally severe tissue damage. Cryokinetics is a procedure that combines cooling and exercise. Cooling is first accomplished by means of immersion or rubbing the skin over the affected part of the body with ice for five to seven minutes, so-called ice massage. The cooling produces a mild anesthesia which allows the individual to exercise the cooled body portion actively without pain. This method is considered to be particularly effective in recent acute muscle strains. The simultaneous application of heat and cold is sometimes effective. Heating an uninvolved portion of the body maintains the core temperature, which inhibits shivering, while cold applied to the injured portion of the body reduces pain. In theory, this arrangement allows cold to be applied for longer periods of time than would otherwise be possible. Because it is difficult to control heating and cooling simultaneously, however, this technique is not frequently used. Hydrotherapy and Massage Hydrotherapy is the external application of water for therapeutic purposes. The water temperature can range from cold to hot. With immersion, water provides buoyancy, which relieves pressure on weight-bearing portions of the body. Water also provides resistance that is used in treating patients with motor weakness. Buoyancy alters the effect of exercises done in water by allowing a severely injured person to move; this provides psychological benefit and hope that the motion can eventually be done out of water. Brief application of cold has a tonic or stimulating effect, increasing blood pressure and the respiratory rate and stimulating shivering. Mild hot water provides sedation to irritated sensory and motor nerves, thus relieving pain caused by cramps and spasms in muscles. It also reduces stress, calming agitated or excited persons. The most common method of hydrotherapy is a whirlpool bath, which combines buoyancy, heat, and mechanical stimulation to the affected body part.
Physical rehabilitation ✧ 723 Massage and movement are key components of applied physical rehabilitation. Massage is the systematic and scientific manipulation of body tissues; massage is best performed by the hands. Massage has a sedative effect when constantly and steadily applied, and it leads to a decrease in muscular tension. Combined with heat or cold, the resulting relaxation facilitates the movement of injured body parts. Mechanically, massage stimulates the circulatory system, enhancing blood flow. The applied force of massage is effective in stretching muscle groups and breaking the adhesions between individual muscle fibers which limit motion. This same action mobilizes fluid and promotes its elimination. Massage does not develop muscle strength, however, and should not be used as a substitute for active exercise. Therapeutic exercise is defined as the performance of movement to correct an impairment, improve musculoskeletal function, or maintain a state of well-being. The energy to accomplish movement can be supplied passively by a therapist or actively by a patient. Muscles are stretched with passive movement or contracted during the process of active flexion or contraction. Individuals with injuries that involve the nervous system may lose the function of any muscles supplied by the injured nerves. These muscles must be moved passively in order to avoid loss of muscle mass and function as a result of disuse atrophy. Muscles respond to stimulation. Thus, exercises are designed to strengthen injured muscles. Prolonged moderate stretching is more beneficial than momentary vigorous stretching. Movements and stretching should be within the pain tolerance of the patient in order to avoid injury to blood vessels. The Growing Understanding of Physical Rehabilitation Physical rehabilitation operates within a larger context of health care provision. The need for primary prevention is addressed by teaching correct methods for strengthening muscle groups to athletes and recreational fitness practitioners. Classes on first aid measures for treating common musculoskeletal injuries are taught by rehabilitation specialists such as physicians, therapists, and nurses. These classes are offered in schools and communities throughout the year. Physicians practicing occupational medicine also advocate primary prevention of musculoskeletal injuries associated with the work site. These professionals analyze working environments and recommend ways to restructure particular job tasks in order to reduce the chances of injury. Secondary prevention is provided in office and hospital settings by professionals who treat injuries such as sprains, strains, and fractures. Care for acute injuries is usually accompanied by instruction in prevention in the hope that patients will avoid similar problems in the future. In the working environment, injured workers are provided with appropriate treatment and therapy and returned to work in an expeditious manner that is consistent
724 ✧ Physical rehabilitation with standards of proper care. This approach is usually best for all concerned, especially the injured worker. Normal physical functioning is returned with conventional therapy. Economically, the employer also benefits by having a trained and experienced worker on the job rather than having a skilled individual on disability and a less capable replacement worker on the job, both receiving payment. Tertiary prevention involves the traditional rehabilitation activities that begin after treatment for a massive injury or chronic disease process. Frequently, such rehabilitation only returns a portion of lost functions, but it improves self-esteem and the quality of life for an injured person. —L. Fleming Fallon, Jr., M.D., M.P.H. See also Aging; Birth defects; Cardiac rehabilitation; Exercise; Exercise and children; Exercise and the elderly; Falls among the elderly; Heart attacks; Mobility problems in the elderly; Muscle loss with aging; Occupational health; Physical fitness tests for children; Sports injuries among children; Strokes; Yoga. For Further Information: Braddom, Randall L., ed. Physical Medicine and Rehabilitation. Philadelphia: W. B. Saunders, 1996. Discusses physical therapy and medical rehabilitation. Includes a bibliography and an index. DeLisa, Joel A., ed. Rehabilitation Medicine: Principles and Practice. 3d ed. Philadelphia: J. B. Lippincott, 1998. This standard textbook provides a comprehensive overview of rehabilitation. It is written for professionals but is accessible to laypeople. The subject entries are written by experts in their fields. Fletcher, Gerald F., ed. Rehabilitation Medicine. Philadelphia: Lea & Febiger, 1992. An introduction to the subject of rehabilitation written for professional audiences. The writing is consistent and of high quality. The illustrations are unusually good. Garrison, Susan J. Handbook of Physical Medicine and Rehabilitation Basics. Philadelphia: J. B. Lippincott, 1993. This text provides a good overview of the subject. Because it is written for students, it should be understandable to most readers. As an introduction to rehabilitation, it is well written. Sinaki, Mehrsheed, ed. Basic Clinical Rehabilitation Medicine. 2d ed. St. Louis: C. V. Mosby, 1993. An introductory textbook for students in the field. Well written, has good illustrations, and should be readily understood by laypeople.
Plague ✧ 725
✧ Plague Type of issue: Environmental health, epidemics, public health Definition: An infection transmitted by fleas, which may prove fatal if left untreated. Plague is caused by infection with a bacterium called Yersinia pestis (formerly Pasteurella pestis), which predominantly infects rodents, with humans being accidental hosts. The disease is transmitted by the bite of a flea which has become infected after a blood meal from another animal with the bacterium in its bloodstream or by the ingestion of contaminated animal tissues. Types of Plague Sylvatic or wild plague is maintained in the wild rodent population, such as ground squirrels, rock squirrels, and prairie dogs. Urban rat plague occurs in developing countries, especially seaports, and is maintained by the infection of urban and domestic rats, which during epidemics may be as high as 10 percent of the rat population. Pneumonic plague, a form limited to humans, directly transmits the infection via infected aerosol droplets from a person with a lung infection. The most common plague illness in humans is called bubonic plague. After an incubation period of two to eight days following the bite of an infected flea, there is a sudden onset of fever, chills, weakness, and headache. Within hours, extremely tender oval swellings 1 to 10 centimeters in length appear in one anatomic area of lymph nodes, usually the groin, axilla (armpit), or neck. These buboes presumably result when the bacteria inoculated into the skin by the infected flea migrate to the regional lymph nodes. Many of these patients will have bacteria intermittently present in the bloodstream during the acute stage of the illness. Less common, but more severe, forms of the illness include septicemic and pneumonic plague. Septicemic plague occurs when the inoculated bacteria proliferate rapidly in the blood, overwhelming the patient before producing a bubo. Pneumonic plague may occur as a secondary pneumonia in bubonic plague, when the lung becomes infected by bacteria carried in the bloodstream, or as a primary pneumonia, through direct inhalation following exposure to a coughing plague patient. Septicemic and pneumonic plague are often fatal, especially if antibiotic therapy is delayed. Rarely, plague can be manifested as a pharyngitis resembling acute tonsillitis or meningitis.
726 ✧ Plague Diagnosing and Treating Plague A diagnosis of plague is suspected in febrile patients who have been exposed to rodents in areas of the world known to harbor the disease. The causative bacteria are usually identified by microscopic examination and culture of material obtained from aspiration of a bubo. Blood, sputum, throat swabs, or spinal fluid can be processed in a similar manner. Quarantine, rat control, and insecticides to kill fleas have successfully controlled urban plague in many cities around the globe. Sylvatic plague has been more difficult to control because of the range and diversity of the world rodent reservoirs. A vaccine is available for selected high-risk individuals. Untreated plague has a mortality of more than 50 percent, but this high risk of death can be reduced by the early institution of antibiotic treatment with either streptomycin or tetracycline and the use of modern medical supportive care. Historical Plagues The first pandemic of plague began in Egypt or Ethiopia in 540 c.e. and continued for sixty years, killing about one hundred million people. The second pandemic, called the Black Death, began in the fourteenth century in central Asia and then spread to Europe, where a quarter of the total population died. The world is currently in the third pandemic, which began in China during the 1890’s when infected rats were inadvertently transported on ships to other countries in the Americas, Asia, and Africa. Currently, about one thousand cases are reported each year to the World Health Organization, with Tanzania and Vietnam leading the list in numbers of cases. The United States reports twenty to twenty-five cases per year, mostly from Arizona and New Mexico. American Indians seem especially susceptible to this disease. —H. Bradford Hawley, M.D. See also Epidemics; Lice, mites, and ticks; Parasites; Zoonoses. For Further Information: Altman, Linda Jacobs. Plagues and Pestilence: A History of Infectious Disease. Springfield, N.J.: Enslow, 1998. Designed for students in grades six through twelve, this book examines well-known plagues and epidemics in world history, past and present, through the social and historical context of the times. Biddle, Wayne. Field Guide to Germs. New York: Henry Holt, 1995. This comprehensive book is easily accessible to the nonspecialist and includes a discussion of nearly every virus, bacterium, and fungus known to cause human and nonhuman animal disease. The history of the microbe and the treatment of diseases are included.
Poisoning ✧ 727 Cook, G. C., ed. Manson’s Tropical Diseases. 20th ed. London: W. B. Saunders, 1996. Offers an extensive discussion of plague, including a complete list of rodent reservoirs by country. Mandell, Gerald L., R. Gordon Douglas, Jr., and John E. Bennett, eds. Principles and Practice of Infectious Diseases. 3d ed. New York: Churchill Livingstone, 1990. A standard reference textbook of infectious diseases with a chapter on plague including maps and illustrations. Woods, Gail L., et al. Diagnostic Pathology of Infectious Diseases. Philadelphia: Lea & Febiger, 1993. A pathology reference textbook with a description of host-pathogen interactions and laboratory diagnostic methods.
✧ Poisoning Type of issue: Children’s health, environmental health, public health Definition: Exposure to any substance in sufficient quantity to cause adverse health effects, from severe to fatal. Incidents can be grouped into intentional poisonings, accidental poisonings, occupational and environmental poisonings, social poisonings, and iatrogenic poisonings. One source has reported that as many as eight million people are accidentally or intentionally poisoned each year. It has been stated further that 10 percent of all ambulance calls and 10 to 20 percent of all admissions to medical facilities involve poisonings. Many incidents of poisoning go unreported because a poison control center is not consulted or the effects are not severe enough to require extensive medical treatment. In other cases where exposure to the toxic agent involves constant contact to low but toxic levels of industrial chemicals, such as occupational or environmental exposures, symptoms may be subtle or confused with diseases that are associated with the normal aging process. The degree of illness and/or the number of premature deaths resulting from environmental exposure to naturally occurring or artificial toxic substances—radiation, chemical waste, and other toxins in the air, water, and food supply—is simply not known. Accidental and Intentional Poisoning While poison control centers receive some calls related to intentional or iatrogenic poisonings, 88 percent of the calls are considered accidental exposures. About 92 percent of exposures occur in the home, almost two-thirds involve children under six, and three-fourths involve ingestion. The great predominance of young children in the accidental poisoning category reflects the inquisitive behavior of that age group. For children
728 ✧ Poisoning under one, inappropriate administration of medications by parents is the dominant cause of poisonings. Intentional poisonings are mostly suicide-related. Various studies have placed the number of attempts per year in the United States at between 200,000 and 4,000,000, indicating the difficulty of collecting accurate statistics. A government report states that 30,000 attempts result in death every year, but at least one source has suggested that the figure is probably 50 percent lower than the actual number that could be attributed to suicide. Although carbon monoxide (as in motor vehicle exhaust) is one of the most common agents used, intentional dosing with large quantities of drugs is also frequently involved. Approximately 90 percent of cases involve only about twenty products in nine drug groups. Most of these are addictive or abused drugs, including stimulants, antidepressants, tranquilizers, narcotics, sedatives or hypnotics, and antipsychotics. Alcohol alone is seldom lethal, but it is often consumed along with the more deadly drugs and may make the lethal effects possible. Intentional poisoning of children also occurs as a well-planned act of a psychiatrically disturbed parent. Although many of these incidents are clearly homicidal and abusive by design, some have received medical notoriety as cases of Münchausen syndrome by proxy, in which the psychiatric needs of an adult are fulfilled through an induced medical disorder in the child. For example, one parent surreptitiously administered syrup of ipecac to her child, inducing unexplained vomiting and gastrointestinal disorders that required extended hospital care. The phenomenon is rare but well documented in the medical literature and is classified as a form of child abuse. Drug Overdoses Common pain relievers found in virtually every home medicine cabinet constitute a large number of both adult and pediatric poisoning incidents. Preparations containing aspirin, as well as nonaspirin analgesics containing acetaminophen (such as Tylenol), are possibly life-threatening when consumed in excess. Acetaminophen poisoning is particularly insidious since death from total and irreversible destruction of the liver will occur unless the antidote, a chemical called Mucomyst, is administered within six hours of ingestion of a lethal dose. Since a specific antidote exists, most hospitals with emergency service will offer around-the-clock testing for acetaminophen levels in the blood. Aspirin, although not as lethal as acetaminophen, can be fatal if a sufficient amount is consumed. Its universal availability and common usage make aspirin a significant poisoning agent encountered in all localities. The symptoms of toxicity are related to aspirin’s effects on temperature regulation, rate of breathing, and the body’s ability to influence the acidity of the
Poisoning ✧ 729 blood. Treatment involves monitoring the patient’s vital signs, calculating the severity of the dose taken. Vomiting may be introduced with syrup of ipecac, or charcoal (a very active adsorption agent) may be given orally to limit gastric absorption. Intravenous fluids may also be given to counteract the blood acidity changes. Prescription drugs that are commonly overused or abused (antiepileptic medication, sedatives and tranquilizers, and antipsychotic or antidepressant drugs) are often routinely assayed in the hospital laboratory as part of the treatment process for patients receiving these medications. The levels in the blood can be monitored to determine the toxicity status of the patient. Usually, supportive care is sufficient for treatment until the drug clears the system. For certain tranquilizers and antidepressants, an antidote called flumazenil can be administered, but it must be used with caution. Poisoning from an overdose of opiates or morphinelike drugs is a special treatment case. A specific antidote called naloxone can be administered if the patient is treated before irreversible respiratory depression occurs. Recovery is virtually instantaneous and dramatic, with a comatose patient becoming alert within seconds of naloxone administration. For this reason, the routine treatment of comatose patients includes the administration of opiate antidote even when the cause of the unconscious state is unknown. Alcohol and Lead Poisoning Alcohol is not usually life-threatening unless it is consumed in quantities sufficient to cause a coma. Death most commonly results from respiratory depression and related complications. Methanol (wood alcohol) is a common industrial solvent found in materials around the home or work site; consumption can cause blindness and death. Isopropyl alcohol (rubbing alcohol), although not as toxic as methanol, can also cause severe illness and death when consumed in sufficient quantities. Ethylene glycol, a common ingredient in antifreeze, is highly toxic and is especially attractive to small children and pets because of its sweet taste. It may also be consumed by alcoholics as an ethanol substitute. When not treated, its consumption can result in kidney failure. Ironically, the treatment for both methanol and ethylene glycol poisoning is administration of high doses of ethanol, which prevents the formation of toxic metabolites by the liver. In the United States, lead poisoning is a major medical problem for children living in older, substandard housing; they can become exposed to large amounts of lead from the consumption of lead-based paint. Another major source of exposure is inhalation of leaded gas fumes and exhaust. Other less common sources include consumption of food stored in leaded crystal or pottery and moonshine whiskey distilled in automobile radiators. Intentional gasoline sniffing by adolescents can also be a problem. Lead exposure is extremely hazardous because its effects are both severe and
730 ✧ Poisoning cumulative. Children are especially susceptible to lead poisoning because they absorb and retain more of this substance and have less capacity for excretion than adults. Treatment Options for Poisoning Emergency medical treatment of the poisoned patient is most often based on the relief of symptoms and the provision of life support. If the patient is awake and alert, a medical history is taken and a clinical examination is performed, both of which can help determine substance exposure. The medical staff must never assume that the patient is providing truthful information, especially if clinical impressions conflict with the patient account. If the patient is comatose, then stabilization and life support takes immediate priority over determination of the specific toxic substance involved. The attending physician will want to prevent airway blockage and to maintain respiration and circulation, which may require mechanical aids for breathing assistance. Treatment of cardiac and blood pressure problems can be accomplished with drugs, fluid, or oxygen administration. If the patient is unconscious, the depth of central nervous system depression can be evaluated using a standard test of reactivity to light, sound, pain, and the presence or absence of normal body processes. If the patient is suffering from seizures, drugs that counteract these symptoms can be administered. Although many hospitals offer in-house toxicology testing in a clinical laboratory, treatment usually must begin before results are available. For this and several other reasons, a comprehensive toxicology testing laboratory is not as useful an asset in the emergency treatment of poisoning as might be believed. It would be impossible for any analytical laboratory to provide timely or cost-effective emergency identification of all potentially toxic substances. Instead, a more efficient strategy concentrates on analyzing those substances for which a specific antidote exists or for which specific medical procedures are required in a critical period of time. A very high percentage of drug overdose cases involve one of a group of six or eight drugs that will vary depending on locality. Pesticide poisoning, for example, is a more prevalent medical problem for rural than urban hospitals. Drug abuse is a problem in all localities, but the frequency and type of drugs abused varies. Regional preferences exist for PCP, cocaine, amphetamines, and opiates. Even prescription drug abuse depends on locality and the patient population. —David J. Wells, Jr. See also Addiction; Alcoholism; Alcoholism among teenagers; Alcoholism among the elderly; Allergies; Asbestos; Child abuse; Children’s health issues; Chlorination; Domestic violence; Elder abuse; Environmental diseases; First aid; Fluoridation of water sources; Food poisoning; Hazardous
Poisonous plants ✧ 731 waste; Iatrogenic disorders; Lead poisoning; Mad cow disease; Mercury poisoning; Multiple chemical sensitivity syndrome; Occupational health; Overmedication; Poisonous plants; Safety issues for children; Safety issues for the elderly; Suicide; Suicide among children and teenagers; Suicide among the elderly; Water quality. For Further Information: Baselt, Randall C., and Robert H. Cravey. Disposition of Toxic Drugs and Chemicals in Man. 5th ed. Chicago: Year Book Medical Publishers, 2000. A condensed toxic substances reference book. All toxics are listed alphabetically rather than by class or mechanism of action. The commonly encountered drugs and chemicals are listed with information on toxicokinetics, treatment, analytical techniques, and references for further information. Ellenhorn, Matthew J., et al. Ellenhorn’s Medical Toxicology: Diagnosis and Treatment of Human Poisoning. Rev. 2d ed. Baltimore: Williams & Wilkins, 1997. A classic medical reference book on toxic substances. Drugs, industrial chemicals, animal and plant toxins, household products, and pesticides are discussed in depth, with an emphasis on medical symptoms and treatment. Presents poisoning statistics data and sources of information in the first chapter. Garriott, James C., ed. Medicolegal Aspects of Alcohol Determination in Biological Specimens. Littleton, Mass.: PSG, 1988. This book concentrates on ethanol. Chapters are devoted to discussions of alcoholic beverages and their chemical constituents, the metabolism and disposition of alcohol, methods of analysis, state and federal regulations on drinking and driving in the United States, and the reliability of breath and blood-alcohol testing. Pesce, John, and Amadeo J. Pesce. The Lead Paint Primer. Melrose, Mass.: Star Industries, 1991. An easily understood source of information about lead poisoning. Written for the layperson.
✧ Poisonous plants Type of issue: Environmental health, public health Definition: Plants that cause gastrointestinal or dermatological reactions in humans. Some plants manufacture substances to assist them in survival. These chemicals can cause irritation or allergic reactions in organisms which contact them. Among human beings, the most common reaction is an allergy. The specifics of an allergic reaction can vary widely and range from no apparent reaction to shock. Allergic reactions to contact with most plants are uncom-
732 ✧ Poisonous plants mon and classified on an individual basis. Some plants, however, cause reactions in virtually everyone with whom they come into contact. As a result, they are termed poisonous plants. Many commonly encountered poisonous plants cause reactions in the skin, while some can cause adverse systemic reactions when ingested. The reaction of skin to plant toxins is termed dermatitis. These reactions are rarely fatal but have widespread morbidity. Poison Oak, Poison Ivy, and Poison Sumac Poison ivy is widely distributed throughout the United States. This is a vine with groups of three shiny green leaves. Poison oak is a low shrub with leaves that also come in groups of three to a stem; it is found in dry areas. Poison sumac is a taller plant with slender leaves arranged in pairs along a stem and a single leaf at the end of the stem. It grows in damp or swampy areas. Contact with these plants leads to a reaction in the skin at the site of contact. An individual’s first contact causes no apparent reaction. In the days (usually between five and twenty) following the initial exposure, the immune system causes the entire body to become sensitive to the chemical. If the plant is touched on another occasion, a reaction will occur. The second reaction commonly causes itching, redness, and swelling at the site of contact. Vesicles filled with a clear fluid may develop. Proper treatment consists of washing the area of contact as soon as possible, then keeping the area dry until the vesicles become crusty and disappear. This process normally requires up to ten days. Sometimes corticosteroids are used to manage serious cases. (Hans & Cassidy, Inc.) Scratching to relieve urti-
Poisonous plants ✧ 733 caria may break the surface of the skin and introduce infection to the affected area. This may prolong the healing time and lead to scarring. The clear, watery fluid found in vesicles does not contain plant material and cannot spread the rash to other parts of one’s own body or to other individuals, but a thicker, cloudy material (pus) may be found in vesicles that have become infected by scratching. Pus can transmit the infection, but not the rash, to other individuals. Sensitivity to poison ivy and poison oak is usually lifelong. Sensitivity to other plants is more individual in nature and is dependent on factors such as the magnitude of the initial exposure, the number of subsequent exposures, and an individual’s body chemistry and immune status. Mushrooms Although mushrooms appear harmless, they can cause a variety of reactions when ingested: gastrointestinal discomfort with nausea, vomiting, and diarrhea; sweating; inebriation or hallucination without sleep; delirium with sleep or coma; and vomiting only when associated with alcohol. Some mushrooms produce reactions only after delays of six hours to three days, including headaches, extreme thirst, nausea, and vomiting. The gastrointestinal symptoms associated with mushroom intoxication usually appear within three hours of ingestion. The resulting discomfort is transient. Sweating is caused by the presence of a chemical which is not inactivated by cooking. The symptoms usually subside within two hours. Psilocybin, a chemical which causes hallucinations, is found in some mushroom species. The effect usually lasts approximately two hours, although the extent of a reaction is determined by the amount ingested, the setting, and the mood and personality of the individual. Delirium associated with sleep or coma is encountered with ingestion of Amanita muscaria and Amanita pantheria species. Within approximately thirty minutes of ingestion, an individual becomes drowsy. This may be followed by elation and extreme activity, again followed by a period of drowsiness. This alternating cycle may continue for up to twelve hours. Coprinus atramentarius is an edible mushroom but temporally sensitizes the body to alcohol. For three days after ingestion, a chemical contained in the mushroom reacts with alcohol to cause vomiting. All mushroom species contain some amount of mycotoxins that may or may not be affected by cooking. The best guideline is to avoid eating any mushroom unless it is either purchased in a store or positively identified by an expert. Other Common Poisonous Plants Contact with nettles can cause intense reactions. Contact with plants of the carrot family such as caraway, dill, parsley, and parsnip can cause a brief
734 ✧ Poisonous plants sensitivity of the skin to ultraviolet light for six to twenty-four hours. Citrus plants of the rue family can also cause this skin photosensitivity. It can be prevented by thoroughly washing the skin after contact. Inflammation after exposure can be treated with aspirin. Inquiries concerning the ingestion of plant materials account for about 10 percent of all calls to poison control centers. The plant species involved in the greatest number of adverse reactions is Dieffenbachia, which causes immediate burning pain and swelling in the mouth upon ingestion. Other house plants, such as philodendron, poinsettia, holly, honeysuckle, jade plant, and yew, may accidentally be ingested by children. Individual reactions to ingested house plants vary; specifics are dependent on the species and amount ingested, the specific plant part ingested, the body size of the individual, and how quickly the plant material is removed from the body. Once in the body, most plants cause vomiting and diarrhea. Leaves of several plants in the Solanum family, such as nightshade, jessamine (jasmine), and the immature fruit of some ground cherries and European bittersweet, contain a chemical that can cause intense gastroenteritis. These plants are especially toxic to small children. If ingested, jimsonweed may cause delirium. Common flowers such as lily of the valley, foxglove, and oleander contain chemical substances that can cause the heart to malfunction. —L. Fleming Fallon, Jr., M.D., M.P.H. See also Allergies; Children’s health issues; First aid; Food poisoning; Poisoning. For Further Information: Ammirati, J. F., J. A. Traquair, and P. A. Horgen. Poisonous Mushrooms of the Northern United States and Canada. Minneapolis: University of Minnesota Press, 1985. Foster, Steven, and Roger A. Caras. A Field Guide to Venomous Animals and Poisonous Plants: North America, North of Mexico. Boston: Houghton Mifflin, 1994. Frohne, Dietrich, and H. J. Pfander. A Colour Atlas of Poisonous Plants: A Handbook for Pharmacists, Doctors, Toxicologists, Biologists, and Veterinarians. London: Manson, 2000. Lampe, Kenneth F. Common Poisonous and Injurious Plants. Washington, D.C.: U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, Bureau of Drugs, Division of Poison Control, 1981. Turner, Nancy J., and Adam F. Szczawinski. Common Poisonous Plants and Mushrooms of North America. Portland, Oreg.: Timber Press, 1991.
Postpartum depression ✧ 735
✧ Postpartum depression Type of issue: Mental health, women’s health Definition: Depression in a woman following the birth of her child. While many women suffer a few days of “baby blues” following childbirth, 10 to 15 percent develop serious postpartum depression and 0.1 to 0.2 percent become psychotic. Between 26 and 85 percent of women experience “baby blues,” also known as “maternity blues” or “new-mother blues.” For one to ten days after giving birth, new mothers may cry easily, feel agitated, or experience exhaustion. They may also have difficulty sleeping, experience loss of appetite, feel sad, or undergo mood swings. This is considered a normal reaction to the stress of giving birth. At least one woman in ten develops a more serious and long-lasting depression during the first year after the birth of a baby. Health care providers may not recognize this as postpartum depression, dismissing women’s concerns as “the blues” or attributing symptoms to the stresses of being a new parent. Depression may occur when women begin menstruating again or when they stop breast-feeding. Women with postpartum depression may have feelings of despair and inadequacy, be unable to cope with the demands of mothering, or suffer from guilt. Some lose interest in normal activities, feel agitated, or have thoughts of suicide. They may hide their depression for fear of being labeled “bad mothers.” A very small number of women experience psychosis, usually beginning on the second or third day after childbirth. This usually comes on suddenly, with patients showing excessive energy, extreme confusion, hallucinations or delusions, paranoia, and incoherence. Women experiencing postpartum psychosis rarely commit suicide or kill their infants. Researchers have not been able to determine the cause of either postpartum depression or postpartum psychosis. Theories accounting for postpartum depression include hormonal imbalance, thyroid problems, and stress. No scientific evidence clearly links hormone changes to postpartum depression, although some women respond well to hormone treatment. Some women experiencing symptoms of postpartum depression have slowed or sluggish thyroid glands. Neither of these theories explains the fact that new fathers and adoptive parents may also experience postpartum depression. Women under significant stress are more likely to experience postpartum depression than women who are not under significant stress. Women more at risk of postpartum depression include those who have a history of depression or bipolar disorder (manic-depression), those who did not want to have a child, those who have experienced a personal loss within the previous two years, those who are divorced or separated, those who were
736 ✧ Pregnancy among teenagers abused or neglected as children, those who lack family support, those who suffer from a traumatic birth experience, or those who have high birth or parental expectations. Some women who experience postpartum psychosis have a family history of manic-depressive illness (bipolar disorder). Women experiencing “baby blues” usually require no treatment other than rest and support from loved ones. Postpartum depression is treated with antidepressant medications, counseling, supportive care, or hospitalization. Several antidepressant drugs are compatible with continued breastfeeding. If women suffering from postpartum depression must be hospitalized, infants should remain with their mothers if at all possible in order to maintain the mother-infant relationship. Postpartum psychosis requires immediate hospitalization, antipsychotic medications, antidepressants, and possibly electroconvulsive therapy. —Rebecca Lovell Scott See also Child abuse; Childbirth complications; Depression; Suicide; Women’s health issues. For Further Information: Dalton, Katharina. Depression After Childbirth: How to Recognize and Treat Postnatal Illness. 2d ed. New York: Oxford University Press, 1989. Dix, Carol. The New Mother Syndrome: Coping with Postpartum Stress and Depression. Garden City, N.Y.: Doubleday, 1985. O’Hara, Michael W. Postpartum Depression: Causes and Consequences. New York: Springer-Verlag, 1995. Sebastian, Linda. Overcoming Postpartum Depression and Anxiety. Omaha, Nebr.: Addicus Books, 1998.
✧ Pregnancy among teenagers Type of issue: Children’s health, public health, social trends, women’s health Definition: When a female adolescent has conceived and is carrying the product of that conception as it develops toward birth (approximately 280 days). With the age of menarche having declined three to four months each decade for at least the last hundred years, the potential for adolescent females of all ages to become pregnant has increased significantly. Similarly, with improved nutrition and greater control over the diseases of childhood and youth, teenage conception is not only more likely to occur but also more likely to produce a viable fetus. Social and psychological factors, however,
Pregnancy among teenagers ✧ 737 are at least as important as physical ones in predicting teenage pregnancy as well as that which makes it possible—adolescent sexual activity. The Psychology of Teenage Pregnancy Indications exist that those who engage in sexual activity at earlier ages are more impulsive and feel less in control of their lives than teenagers who defer such activity. Earlier sexual activity is associated with increased risk of pregnancy because those who enter into sexual relationships earlier tend to be less likely to use contraception than those who wait. Thus, one sees the influence of age on maturity in decision making. In addition, the use of mind-altering substances such as drugs and/or alcohol tends to be associated with impaired decision making and therefore greater rates of adolescent intercourse and pregnancy as a result of lower contraceptive use. Teenagers from more conservative families or with more traditional values—especially those who attend church regularly—are more likely to defer intercourse and thus are less likely to become pregnant. Also, teenagers who value education more highly and who may be involved in extracurricular school activities are less likely to engage in early intercourse and to become pregnant. Other family influences include the quality of the relationship between the female adolescent and her parents. Those relationships that might be considered dysfunctional in some sense are more likely to be a risk factor contributing to adolescent pregnancy. Specifically, the poorer the communication—especially about sex—and the less the parental support, the more likely a teenager is to engage in early and unprotected sex. This situation tends to be negatively magnified in families where the birth father is absent and there is no substitute, such as a stepfather or a mother’s boyfriend. This result is likely to be influenced by the lower levels of adult supervision that might be expected in such families. Research indicates that the lower the amount of such supervision, whether or not the family is intact, the greater the likelihood of premature sexual activity and adolescent pregnancy. Lower levels of adult supervision may also account for the fact that such undesirable outcomes are more likely in larger families, especially if one of the older daughters had previously become pregnant. Finally, the socioeconomic status of the family seems to influence these outcomes such that families who are poorer and less well educated run a greater risk of having premature parenthood among their female offspring. The Risks of Early Pregnancy Pregnancy and parenthood during the teenage years are associated with a variety of physical, psychological and social difficulties. Some of these affect the mother, while others affect the offspring.
738 ✧ Pregnancy among teenagers Early intercourse is associated with an elevated risk of cervical cancer. Anemia, which often accompanies the rapid growth of the early adolescent years, is negatively magnified by pregnancy and childbirth during this period. In addition, pregnant teenagers are more likely to experience toxemia than are more mature mothers-to-be. Furthermore, pregnant teenagers less than seventeen years of age have three times the rate of eclampsia during pregnancy than do more mature women. They are more likely to experience premature labor, spontaneous abortion, stillbirth, and postpartum hemorrhaging. The youngest expectant teenagers have a maternal mortality rate that is two and a half times that of young adult women. Many of these difficulties facing expectant teenagers are magnified by the fact that they are less likely to start prenatal care as early as more mature women. This care, which benefits both the girl and her developing fetus, usually includes enhanced nutrition (especially involving supplementation with folic acid) that can moderate many of the potential physical problems associated with premature pregnancy. Teenage mothers are more likely to experience psychological stress than their older counterparts. They tend to have lower self-esteem, resulting in more feelings of failure, depression, and helplessness and leading to more suicides and suicide attempts than among older mothers-to-be. Socially, teenage mothers are hampered as well. Compared to teenagers from similar social and educational backgrounds, teenage mothers have lower levels of educational and occupational attainment, increasing the likelihood that they will live in poverty. They tend to have higher levels of overall fertility, closer spacing between births, and more unplanned pregnancies than women who do not bear children during their teenage years. They are less likely to marry than their nonmaternal counterparts, and when they do, they are more likely to experience a marital dissolution. The offspring of adolescents are also at considerably greater risk of physical, psychological, and social problems. Infants of teenage mothers are more likely to be premature and to have a low birth weight. This statistic may be partly attributable to the overconcern of many adolescents with body image, which may deter them from gaining the necessary amount of weight during pregnancy. This problem may be even more pronounced for teenagers less than fifteen years of age, who need to gain amounts at the top end of the recommended range in order to ensure healthy fetal development. Low birth weight contributes to rates of infant mortality that are as many as three times higher in the first month for babies whose mothers are less than fifteen years old. The newborns of teenage mothers tend to have lower Apgar scores, meaning they are in poorer condition than those of more mature mothers. They are also likely to have elevated rates of epilepsy, blindness, deafness, nervous disorders, and spinal and brain deficiencies. The toxemia more characteristic of pregnant teenagers both affects and reflects a condition known as utero placental insufficiency—also more
Pregnancy among teenagers ✧ 739 characteristic of premature pregnancy—that can contribute to both acidosis and fetal hypoxia. The elevated morbidity of the offspring of teenagers may be partly attributable to the fact that these mothers are less likely to breastfeed because of overconcern with body image. Babies fed breast milk are healthier than those who consume formula. The children of adolescent mothers tend to have lower cognitive skills than their counterparts. They also show more signs of maladjustment and social impairment. These findings may account for the fact that they tend to follow their mother’s lack of more optimal educational attainment, with the corresponding occupational and economic deficits. They are also more likely to become adolescent parents themselves. How much these psychological and social outcomes are the result of the physical problems of the child or the problems passed on by the teenage mother, neither of which are universal and inevitable, is yet to be determined. The Societal Consequences of Teenage Pregnancy Approximately one million American teenagers become pregnant each year. About half of these pregnancies result in live births, although that figure is only one in three for the youngest teenagers. While their rate of miscarriage is higher than that of older teenagers, so is their rate of abortion, a procedure that troubles many people. The incidence of adolescent pregnancy and childbearing is much greater in the United States than in other nations of the industrialized world, even though teenagers in these nations seem to engage in as much premarital sexual activity as do American teenagers. Not only is the United States highest in such incidences, but its rate is twice that of the next highest nation (Great Britain) as well. The overall ranking and thus the magnitude of the problem are amplified by the fact that those of lower socioeconomic status (often racial and ethnic minorities) are overrepresented among those engaging in premature parenthood in the United States. Furthermore, while the vast majority of the children born to American adolescents have mothers who are members of the dominant racial group, an absolute majority of the children born to the youngest teenagers have mothers who are members of minority groups. Children born to the youngest teenagers, whatever their mother’s race or ethnicity, tend to be at the very greatest risk for all the potential problems associated with adolescent childbearing. The variety of problems associated with teenage pregnancy is strongly influenced by related social trends in the United States over the past few decades. While some of these difficulties are inherently (although not inevitably) based on the age of the adolescent, many are the result of lifestyle issues, which vary by such factors as race, ethnicity, and class. Overall, the birth rate for all teenagers in the late 1990’s was down dramatically from what it had been thirty years before. Indeed, for the oldest teenagers, it was
740 ✧ Pregnancy among teenagers almost half the rate in 1960. While it did rise from the early to late 1980’s, it declined steadily after 1991. Two profound social changes, however, magnified the problematic potential of adolescent childbearing. The first was that the marriage rate of teenagers was also down dramatically. Thus, most of the products of teenage sexual activity were being born to never-married, single mothers. A variety of risks are associated with this group even if the mother is not an adolescent. Furthermore, of those children in previous decades who were born to single, never-married adolescents, most of them were given up for adoption and placed in two-parent homes with adoptive parents who were considerably more socially and emotionally mature than the birth mother. In the late 1990’s, a majority of the children born to teenage mothers were kept and reared by these unwed adolescents—thus, the often-cited problem of “children having children.” While a significant minority (between 13 and 27 percent) of unwed teenage pregnancies are planned—with the mother perhaps thinking “I wanted a baby to love me” or “I thought my boyfriend would stay with me if I had a child”—the vast majority are not. There seems to be evidence that condom use is growing, if only as a response to concerns about sexually transmitted diseases. This may be helping to reduce adolescent pregnancies in the United States. In addition, the welfare reform enacted at federal and state levels is quite likely to reduce such premature parenthood. Previous welfare policies were an incentive for teenage girls to have babies in order to be guaranteed the money for a place of their own until the baby was grown. The revised policies are far more restrictive and thus less likely to encourage premature parenthood as a route to economic independence from what may be an unsatisfactory parental home life. These same restrictions, however, may magnify the problems associated with teenage pregnancy and childbearing in the short run if the limited time frame for assistance proves inadequate for existing teenage mothers to become economically self-sufficient before they become ineligible for benefits. Estimates in 1998 were that the annual cost of adolescent parenthood, for both the mother and her children—with a small but significant minority having multiple births in the teenage years—ran from thirteen to nineteen billion dollars. —Scott Magnuson-Martinson See also Abortion among teenagers; Childbirth complications; Children’s health issues; Drug abuse by teenagers; Premature birth; Prenatal care; Sexually transmitted diseases (STDs); Women’s health issues. For Further Information: Humenick, Sharron S., Norma N. Wilkerson, and Natalie W. Paul. Adolescent Pregnancy: Nursing Perspectives on Prevention. White Plains, N.Y.: March of
Premature birth ✧ 741 Dimes Birth Defects Foundation, 1991. This book represents a public health approach to virtually all facets the problem, with a special focus on the medical model in treatment and prevention. Lock, Sharon E. “Adolescent Sexuality, Pregnancy, and Parenthood.” In Maternity and Women’s Health Care, edited by Deitra Leonard Lowdermilk, Shannon E. Perry, and Irene M. Bobak. 6th ed. St. Louis: C. V. Mosby, 1997. A fine section on adolescent aspects of the topic in a general compendium. Meschke, Laurie L., and Suzanne Bartholomae. “Examining Adolescent Pregnancy.” Human Development and Family Life Bulletin 3, no. 4 (Winter, 1998): 1-3. This article outlines teenage pregnancy risks in a special issue devoted to this problem. Evaluates some programs designed to prevent teenage pregnancy. Schlitt, John, J. Primary Prevention of Adolescent Pregnancy Among High-Risk Youth. Washington, D.C.: Southern Center on Adolescent Pregnancy Prevention, Southern Regional Project on Infant Mortality, 1992. A brief report on policies and programs intended to prevent this problem. Thompson, Sharon. Going All the Way: Teenage Girls’ Tales of Sex, Romance, and Pregnancy. New York: Hill & Wang, 1995. An easy-to-read book of casestudy interviews that sheds light on the range of motivations for premature sex, pregnancy, and childbearing.
✧ Premature birth Type of issue: Children’s health, women’s health Definition: Childbirth occurring before the thirty-eighth week of pregnancy; premature infants are those babies born before this time and/or those that are severely underweight. Babies born later than the thirty-eighth week of pregnancy and before the forty-second are known as term or full-term infants, and birth anywhere during this month is within the window of normal gestation. By definition, babies born before the thirty-eighth week are called preterm or premature infants. It is common practice to call newborns weighing under 5.5 pounds premature as well. While it is possible for a newborn to be both full-term and under 5.5 pounds, both measures, time and weight, are indices of risk. Preterm and premature infants are at high risk. They have both a lower survival rate and more medical complications with potential lifelong effects than term babies. In the United States, there are 250,000 preterm births per year. These infants make up the majority of the 300,000 to 350,000 lowweight births that occur annually.
742 ✧ Premature birth Development and Survival Prior to twenty-four weeks of gestation, fetuses are not considered to have developed sufficiently to live outside the womb. Somewhere between twentyfour and twenty-eight weeks of gestation, however, the fetus does become viable, although any baby born between twenty-four and thirty weeks is called very premature. Very premature babies comprise about 1 percent of all live births in the United States (between 35,000 and 39,000 per year). The length of these infants ranges from 11 inches to 18 inches, and weight can range from 1 pound, 5 ounces to almost 4 pounds. At this stage of development, a few ounces more or less make a big difference in the baby’s ability to survive. Neonates at 2 pounds have little better than a one in two chance of survival; infants at 3.5 pounds have better than a nine in ten chance. Babies born between thirty-one and thirty-six weeks of gestation are moderately premature and make up between 4 and 6 percent (150,000 to 200,000) of live births in the United States each year. These babies do well, with a 90 to 98 percent survival rate, and weigh from a little more than 3 to almost 4.5 pounds. Typical lengths range from 16 to 19 inches. Parents who expect their very premature baby who reaches five to nine weeks of age to resemble a moderately premature baby born at thirty-five weeks will be disappointed. The very premature still appear much less like babies, are significantly lighter, and remain behind developmentally. They are often unready to be bottle-fed or breast-fed or to sleep in an open crib, and they are always less alert and have less behavioral control than the moderately premature. Simply reaching the same number of chronological weeks as moderately premature babies does not negate the substantial differences in their developmental beginnings. Borderline premature infants are born during weeks thirty-seven or thirty-eight and constitute 16 to 20 percent (600,000 to 700,000) of all live births in the United States. These babies are much like full-term newborns: They have almost the identical survival rate (98 percent) and approach average weights. Nevertheless, they are still at greater risk for respiratory distress syndromes, jaundice, unstable body temperatures, and a variety of problems associated with feeding. The Causes of Prematurity and Preterm Births Although many conditions result in premature birth, not all causes are known. Some well-known causes include toxemia in the mother (a multistage disease which begins with high blood pressure and rapid fluid retention and may progress to brain hemorrhage, seizure, and coma), placenta previa (when the placenta implants in the lower uterus), placenta abruptio (when a normally positioned placenta detaches from the uterus), premature membrane rupture (when the tissue containing the amniotic fluid tears or leaks before labor begins), incompetent cervix (when the cervix opens
Premature birth ✧ 743 mid-pregnancy), and multiple births (twins, triplets, and so on). Some mothers blame themselves for the premature births of their infants. While it is natural to look for a cause and a target to vent the often-powerful feelings associated with prematurity, it is the rare mother who deliberately causes her baby to be born earlier than necessary. While some factors in the mother—such as high blood pressure, diabetes mellitus, sickle-cell disease, and kidney diseases—can contribute to prematurity, these are not volitional conditions and the mother is not at moral fault in any way. Some causes do not involve the mothers at all, but the babies themselves, including congenital defects, intrauterine illnesses, and defective placentas. The vast majority of women will never deliver prematurely. Those who do, however, run a 25 to 50 percent chance of having a second premature birth. It is important not to overinvest in probability statistics and comparative risk factor data which include race (for example, African Americans have a higher prematurity rate than whites), paternity (for example, a few individual males seem to father premature babies with different mothers without risk factors themselves), the mother’s age, and even her mother’s exposure to biochemicals (such as diethylstilbestrol, or DES). It is extremely important to realize that many women who are formally classified as high-risk mothers have normal deliveries of full-term babies and that others, who are healthy and without known risk factors, deliver premature, preterm babies. The Psychological Impact Few events in a parent’s life equal the impact of seeing one’s tiny, struggling, helpless, and high-risk baby. It is common for parents to have been forewarned of the baby’s chances, especially if the infant is very premature. They may, in fact, have begun to prepare themselves psychologically for the death of their baby even as the baby clings to life outside the womb. They may try to protect themselves from bonding to one whose death may be imminent. Parents who expected a bundle of joy can fear that even if their baby lives, he or she will be handicapped, sickly, malformed, and never able to live a life as an independent, functioning, and happy adult. Parents sometimes confess not knowing whether they want their baby to live or die, and they feel guilt for not knowing. Their distress, confusion, and contradictory feelings can overwhelm them. Their babies may not look much like the babies they had pictured or prepared for, and they may not feel much like parents. Nearly all parents of premature infants experience various forms of shock, denial, anger, guilt, and depression. Researchers who study and compare parents who cope better and worse have learned that those parents who accept and express their whole range of emotions (versus only the emotions that they believe they are supposed to have), who seek further information, who accept help in their caring for the babies, and who begin
744 ✧ Prenatal care to develop an early relationship with their babies adapt to the crisis well and successfully. Premature infants were thought, at one time, to be inactive, unaware, and inert. Research and anecdotal observation strongly support the view that these infants are acutely sensitive to their environment, though they usually respond in ways too subtle to be perceived casually. When parents are present, even on the outside of the incubator wall, their babies behave differently, tolerate feedings better, and heal more quickly and completely. —Paul Moglia See also Birth defects; Childbirth complications; Children’s health issues; Euthanasia; Mental retardation; Multiple births; Pregnancy among teenagers; Prenatal care; Postpartum depression. For Further Information: Avery, Mary E., and Georgia Litwack. Born Early. Boston: Little, Brown, 1983. Curtis, Glade B. Your Pregnancy Week-by-Week. Tucson, Ariz.: Fisher Books, 1997. Harrison, Helen, and Ann Kositsky. The Premature Baby Book: A Parents’ Guide to Coping and Caring in the First Years. New York: St. Martin’s Press, 1983. Hotchner, Tracie. Pregnancy and Childbirth. Rev. ed. New York: Avon Books, 1997. Hynan, Michael. The Pain of Premature Parents: A Psychological Guide for Coping. Lanham, Md.: University Press of America, 1987.
✧ Prenatal care Type of issue: Children’s health, prevention, women’s health Definition: Regular medical care during pregnancy to identify or avoid harmful conditions for both mother and child; numerous studies have found a connection between poor prenatal care and low birth weight or birth defects. The idea that women should seek regular medical care during normal pregnancies was first widely recommended at the beginning of the twentieth century. The recommendation was so strong that social reformers and nurses introduced organized programs of prenatal care, which significantly reduced neonatal and maternal mortality. While it is necessary for an expectant mother to seek professional medical assistance in her care, there is now increased recognition that a physician is simply monitoring the care that a woman gives herself. Thus, the expectant mother is seen as the most important player in prenatal care.
Prenatal care ✧ 745 Care Before Pregnancy Ideally, a woman should begin prenatal care and see a health practitioner before becoming pregnant. Being in good health before pregnancy increases the chances of having a healthy baby. Some prepregnancy concerns may be the woman’s weight (either underweight or overweight), detrimental lifestyle habits such as drinking or smoking, medical history, and general health. Genetic counseling is available and may sometimes be important. Couples who may be advised to seek genetic counseling include those who have had a malformed infant in the past, those with a family history of inherited diseases, women who have had recurrent miscarriages, and women who will be age thirty-five or older at the time that they give birth. Studies have shown that pregnancy in women over thirty-five carries increased risks of Down syndrome and placental separation for the fetus, high blood pressure and bleeding in the mother, and multiple births or the need for a cesarean section. Despite these risks, the number of older women giving birth to healthy babies rose steadily during the twentieth century as a result of advances in medical technology and better education about pregnancy. Nutrition and Health Good prenatal care begins with nutrition. While good nutrition is always part of a healthy lifestyle, it is vital that a woman eat well during her pregnancy to meet the needs of her expanding blood volume, as well as the needs of the developing fetus. Women need to eat from all food groups, paying special attention to consuming extra amounts of folic acid, iron, and calcium. A woman’s fluid intake must increase during pregnancy as well. Health care providers suggest that a pregnant woman consume at least eight glasses of liquid per day, generally avoiding those that contain sugar or caffeine, such as coffee, tea, and soda. Sugar and excessive sodium should be limited. Theories about the proper weight gain during pregnancy have changed over the years. Health care providers recommend a gradual total weight gain of approximately thirty pounds during a healthy pregnancy. This figure varies given a number of considerations, including the woman’s weight before pregnancy. Underweight women should gain more, about thirty-four pounds, while obese women can gain about twenty pounds. Since everything that an expectant mother consumes crosses the placenta to the developing fetus, women should take care to avoid certain substances that can be harmful. Smoking has consistently been shown to have detrimental effects on a fetus. Studies are inconclusive about the effects of caffeine, but most health care professionals recommend limiting it. Even commonplace drugs such as aspirin and allergy remedies should never be taken without consulting a doctor first. A number of studies have been done on women who drank heavily during their pregnancies. Many of the infants
746 ✧ Prenatal care were born with what is called fetal alcohol syndrome, which is characterized by physical, mental, and behavioral problems. There is no clear safe level of alcohol consumption for expectant mothers. Some health care providers advocate no alcohol consumption for pregnant women, while others believe that drinking in moderation or occasionally does no harm. Many women experience a number of unpleasant side effects at some time during their pregnancy, including nausea, heartburn, fatigue, shortness of breath, mood swings, frequent urination, tender breasts, and food aversions or cravings. Yet, some women report few or no unpleasant symptoms and actually feel euphoric and physically healthy throughout the pregnancy. Proper prenatal care and good nutrition can help alleviate some of the unpleasant symptoms. Exercise While during a pregnancy is not the time to begin new or strenuous activities, regular exercise certainly has many benefits for pregnant women. Moderate exercise during pregnancy can help overall appearance and posture, as well as help reduce some unpleasant side effects that a woman may be feeling. Gentle stretching and reaching exercises can be beneficial, as can mild aerobic activities such as walking or swimming. After the fourth month, women should not exercise while lying on their backs because this position can cut off circulation to the placenta and uterus. Exercise should always begin with a warmup and end with a period of cooling down. Most physicians recommend that a pregnant woman’s heart rate not exceed 140 beats per minute. Women who did not exercise before pregnancy should begin any physical program very slowly, with the advice of a doctor. The goal of exercise during pregnancy should be to achieve or maintain a safe level of fitness. Some experts also recommend that women perform Kegel exercises, which involve contracting the pelvic floor muscles, in order to prepare for childbirth. —Bonnie Flaig See also Addiction; AIDS and women; Alcoholism; Amniocentesis; Birth control and family planning; Birth defects; Breast-feeding; Childbirth complications; Cleft lip and palate; Down syndrome; Drug abuse by teenagers; Fetal alcohol syndrome; Genetic counseling; Genetic diseases; Hydrocephalus; Natural childbirth; Nutrition and women; Pregnancy among teenagers; Premature birth; Screening; Sexually transmitted diseases (STDs); Smoking; Spina bifida; Tobacco use by teenagers; Well-baby examinations; Zoonoses. For Further Information: Boston Women’s Health Book Collective. Our Bodies, Ourselves for the New Century. New York: Simon & Schuster, 1998.
Preventive medicine ✧ 747 Curtis, Glade B. Your Pregnancy Week-by-Week. Tucson, Ariz.: Fisher Books, 1997. Eisenberg, Arlene, Heidi E. Murkoff, and Sandee E. Hathaway. What to Expect When You’re Expecting. Rev. ed. New York: Workman, 1996. Hotchner, Tracie. Pregnancy and Childbirth. Rev. ed. New York: Avon Books, 1997. Kogan, Michael D., Greg R. Alexander, Milton Kotelchuck, and David A. Nagey. “Relation of the Content of Prenatal Care to the Risk of Low Birth Weight.” Journal of the American Medical Association 271, no. 17 (May 4, 1994): 1340-1345.
✧ Preventive medicine Type of issue: Prevention Definition: The medical field that seeks to protect, promote, and maintain the health and well-being of individuals and defined populations and to prevent disease, disability, and premature death. Modern preventive medicine is considered to exist at three levels within the health care community. The initial level, primary prevention, has as its purpose to maintain health by removing the causes of or by protecting the community or individual from agents of disease and injury. These activities are no longer limited to the prevention of infection; they now include improvement in the environment and behavioral changes to reduce risk factors that contribute to chronic disease and injury. An example of primary prevention is immunization programs for children. To reduce the risk of heart attack, one should refrain from smoking, be active, and reduce fat intake—all wise primary prevention actions. Halting the loss of atmospheric ozone, reducing air and water pollution, and developing environmentally friendly technologies form another class of prevention actions. Secondary prevention seeks to detect and correct adverse health conditions before they become manifest as disease, by reversing, halting, or retarding the disease process. A frequently used secondary prevention technique is health screening. Examples include hypertension, diabetes, prostate cancer, and glaucoma screening services. In industry, a hearing test is used as a tool to prevent noise-induced hearing loss among the workforce. Once a potential health problem is identified, clinical preventive medicine techniques can be instituted to reverse the condition or prevent further progression. Tertiary prevention attempts to minimize the adverse effects of disease and disability. Coronary bypass surgery, vocational rehabilitation, and treatment of an incapacitating mental illness are examples.
748 ✧ Preventive medicine Specialists and General Practitioners Most physicians provide some degree of preventive medicine services. Pediatricians are practicing preventive medicine when they conduct well-baby examinations and ensure that immunization programs are current. Family medicine specialists are providing such services when they perform Pap smears or order mammograms. When the cessation of smoking is discussed and internists prescribe nicotine patch regimens, that too is preventive medicine. In the United States, approximately one thousand physicians specialize in general preventive medicine. Some use epidemiological methods to design and develop prevention programs that may feature a single intervention or may constitute a strategy which includes a multitude or matrix of screening technologies and interventions. Other preventive medicine specialists provide services in a clinical setting by ordering a history and physical examination, which may include age- and gender-specific screening tests. The clinical preventive medicine specialist then can counsel the patient on lifestyle alterations recommended to preserve or improve health. Within the United States, another field of the specialty of preventive medicine is occupational medicine. Practicing in industry or private clinic settings, these specialists are concerned about preventing injury and illness as a result of the physical, biological, and chemical hazards that are present in the workplace. Should workers be injured or made ill as a result of their employment, the occupational medicine physician manages their treatment, rehabilitation, and return to work. Applying Preventive Measures During the twentieth century, there was a major shift from deaths attributable to infectious disease to deaths attributable to chronic diseases that are often a reflection of individual lifestyle. Preventive medicine has clearly proven itself effective in altering both the cause of death and the age at which death occurs. Accompanying this increased shift to chronic diseases such as cancer and heart disease, however, is a significant increase in the life expectancy of the population during the same nine decades. The focus of preventive medicine is now on reducing morbidity and mortality from chronic diseases and accidents, particularly those in which an individual’s lifestyle increases the risk for illness and death. Disease prevention and health promotion are the two pillars supporting the discipline of preventive medicine. Beginning in 1987, a consortium was convened to begin to address a preventive medicine strategy to improve the health of Americans. The Institute of Medicine of the National Academy of Sciences worked with the United States Public Health Service and numerous organizations to formulate health objective goals that could be attainable by the beginning of the twenty-first century. Once goals and objectives were
Preventive medicine ✧ 749 established, the next task was to devise methods, technologies, and strategies to achieve the objectives, with the goal being the year 2000. The resulting report was entitled Healthy People 2000: National Health Promotion and Disease Prevention Objectives (1991). Promoting Good Health Good health is the result of reducing needless disease, injury, and suffering, resulting in an improved quality of life. A strategy of Healthy People 2000 was to combine scientific knowledge, professional skills, community support, individual commitment, and the public will to achieve good health. This plan required reducing premature death, preventing disability, preserving the physical environment, and enabling Americans to develop healthy lifestyles. Three broad goals were detailed in the report: increase the healthy life span, reduce health disparity, and achieve access to preventive services. Achieving these objectives would require the dedicated commitment of preventive medicine specialists and the broader medical community. Enhanced effectiveness and efficiency of clinical preventive services, screening procedures, immunizations, consultation, and counseling can be achieved only through a close relationship between the physician and both the community and the individual. In the decade leading to 1988, there was a 33 percent reduction in the death rate from heart attacks when adjusted for the difference in the age of population. One might think that this decrease is attributable to improvements in coronary bypass surgery or to the development of new cardiovascular medications. The true explanation, however, lies with the adoption of more healthful living habits as a result of health education and preventive medicine interventions. Coronary artery disease and its resultant heart attacks are preventable. A large national clinical trial of preventive medicine procedures known as MRFIT (multiple risk factor intervention trial) not only demonstrated the value of risk factor reduction in preventing disease but also demonstrated that the impact of established disease could be reversed. A subgroup of the MRFIT population made up of those who had established coronary artery disease at the start of the study had 55 percent fewer fatalities than did the control group when both were followed over seven years. Preventive medicine interventions are not only cost-effective but relatively inexpensive as well. For example, coronary artery bypass surgery or a heart transplant cost many times more than preventive medicine rehabilitation and lifestyle modification programs. The same advantages also accrue for the prevention of strokes. Reducing salt intake, controlling high blood pressure, correcting obesity, performing regular exercise, and quitting smoking reduce the risk factors for stroke. The evidence clearly shows that preventive medicine reduces the death rate for heart attack and stroke and enhances quality of life.
750 ✧ Preventive medicine Clinical preventive services have been designed based on the best available scientific evidence to promote the health of the individual while remaining practical and cost-effective. The publication of the Guide to Clinical Preventive Services (1989), by the U.S. Preventive Services Task Force, was a major milestone on the road toward reducing premature death and disability. It has been well established that the majority of deaths among Americans under the age of sixty-five are preventable. The guide is the culmination of more than four years of literature review, debate, and synthesis and provides a listing of the clinical preventive services that clinicians should provide their patients. More than one hundred interventions are proposed to prevent sixty different illnesses and medical conditions. The guide is intended to be used by preventive medical specialists and other primary care clinicians. The recommendations are based on a standardized review of current scientific evidence and include a summary of published clinical research regarding the clinical effectiveness of each preventive service. The Importance of Personal Responsibility The periodic health examination was once frequently referred to as an annual examination. The Guide to Clinical Preventive Services tailors this examination to the individual needs of the patient and considers factors such as age, gender, and risk. Consequently, a uniform health examination is not recommended. The examination for those between forty and sixtyfour years of age is scheduled on a one- to three-year basis, with the more frequent examinations scheduled for those in high-risk groups. Although the examination is not comprehensive, it is focused on identifying the leading causes of illness and disability among people in this age group. During the physical examination, particular attention would be paid to the skin of those individuals at high risk for excessive exposure to sunlight or with a family or personal history of skin cancer. A complete oral cavity examination would be appropriate for individuals abusing tobacco or consuming excessive amounts of alcohol. Counseling would be provided on such items as diet and exercise, substance abuse, sexual practices, and injury prevention. For some women, discussion is recommended regarding estrogen replacement therapy. In discussing patient education and counseling it is wise to remember a comment made by bacteriologist René DuBos: “To ward off disease or recover health, men as a rule find it easier to depend on the healers than to attempt the more difficult task of living wisely.” —Roy L. DeHart, M.D., M.P.H. See also Acupuncture; Aging; Alternative medicine; Amniocentesis; Biofeedback; Cardiac rehabilitation; Chlorination; Cholesterol; Environmental diseases; Exercise; Exercise and children; Exercise and the elderly; Fluorida-
Prostate cancer ✧ 751 tion of water sources; Fluoride treatments in dentistry; Genetic counseling; Holistic medicine; Homeopathy; Immunizations for children; Immunizations for the elderly; Mammograms; Meditation; Nutrition and aging; Nutrition and children; Nutrition and women; Occupational health; Pap smears; Safety issues for children; Safety issues for the elderly; Screening; Stress; Vitamin supplements; Well-baby examinations; Yoga. For Further Information: Greenberg, Raymond S., et al. Medical Epidemiology. 2d ed. Norwalk, Conn.: Appleton and Lange, 1996. This small study guide will assist the reader in understanding the key concepts of epidemiology. The overview and specific topics create a firm foundation for understanding this important discipline. Halperin, William, and Edward L. Baker. Public Health Surveillance. New York: Van Nostrand Reinhold, 1992. This compact text addresses health surveillance in a wide variety of settings, from the community to the physician’s office to the work setting. Provides the medical rationale for establishing and performing health surveillance programs. Last, John M., and Robert B. Wallace, eds. Maxcy-Rosenau-Last Public Health and Preventive Medicine. 13th ed. Norwalk, Conn.: Appleton and Lange, 1992. This textbook enjoys wide use by most preventive medicine training programs in the United States. Provides excellent coverage of all the principals and most of the related topics of preventive medicine. The layperson will find many chapters accessible, although some require attention and study. U.S. Department of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, D.C.: Government Printing Office, 1991. Documents the goals, objectives, and strategies for national health promotion and disease prevention. An excellent source of data and material related to the United States’ health status. Many of the objectives for a healthy nation require public participation. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. Baltimore: William & Wilkins, 1989. A reference list of more than one hundred of the most common clinical preventive medicine initiatives, documenting their importance as a required health care evaluation tool.
✧ Prostate cancer Type of issue: Elder health, men’s health, public health Definition: Cancer of the prostate gland, directly correlated with aging.
752 ✧ Prostate cancer With the exception of skin cancer, prostate cancer is the most frequently occurring cancer in men; in the United States, it accounts for one out of every three cancers in men. Between 1987 and 1997, the estimated number of identified cases of prostate cancer grew from about 90,000 to 209,000 annually. The direct correlation with aging is shown by the fact that only 7 percent of these cases were discovered in men below the age of sixty. The average age at which prostate cancer was diagnosed was seventy-two. There are some obvious ethnic factors in the incidence of prostate cancer. Black men have the highest incidence in the world, approximately one-third higher than Caucasian men, and their death rate is double that of Caucasians. Asian immigrants to the United States, on the other hand, have a much lower incidence. Researchers continue to look for explanations for these differences. Another risk factor involves having relatives with the disease. When a father or brother has the disease, the risk doubles; some studies have shown that when a man has three relatives with prostate cancer, he is more than ten times as likely to get the disease. Environmental factors also seem to raise the risk of prostate cancer. Some studies have shown links between farmers and workers exposed to cadmium through welding, electroplating, and making batteries and an increase in incidence of prostate cancer. Workers in the rubber industry may also be a higher risk group. Diagnosis and Prevention Preliminary tools for diagnosing prostate cancer are the digital rectal examination (DRE), the prostate-specific antigen (PSA) test, and the prostate acid phosphatase (PAP) test. The DRE consists of a doctor inserting a gloved and lubricated finger into the rectum and physically feeling for abnormal growths. The PSA test checks the blood for the level of a specific protein produced by the prostate gland, while the PAP test checks the level of prostatic acid phosphatase. Elevated PSA or PAP levels do not necessarily indicate cancer but do suggest the need for further testing. None of the tests is foolproof. While the PSA test is the most accurate of the tests, it still misses about one-third of cancers that have not spread outside the prostate gland. In addition to these tests, some doctors may perform a urine test to check for blood or infection. An intravenous pyelogram—a series of X rays of the organs of the urinary tract—may also be used. In another procedure, called a cystoscopy, the doctor looks through a thin, lighted tube into the urethra and bladder. If any of these tests suggests the possibility of a malignancy, the doctor may combine a transrectal ultrasonography (a procedure in which sound waves are sent out by a probe inserted into the rectum, allowing a computer to create a picture called a sonogram) with a biopsy. If an abnormal area is found by the DRE, tissue will be removed from the abnormal area by
Prostate cancer ✧ 753 insertion of a hollow needle through a tube inserted into the rectum. If an elevated PSA is the indicator, random sections from the entire prostate gland may be taken. The only certain way to detect cancer is to observe the tissue under a microscope. Perhaps the most important part of the diagnosis is determining the stage of the cancer when a biopsy reveals it to be present. One system is to rank the malignancy from 2 through 10, with the higher numbers being the more advanced stage. The more common system uses a grading of 1 through 4. Stage 1 means the cancer has not spread beyond the prostate gland, is causing no symptoms, and cannot be detected by the DRE. Stage 2 tumors may be felt by the DRE or detected by blood tests but have not spread beyond the prostate. Stage 3 means the cancer has spread to nearby tissues outside the prostate. Stage 4 means cancer cells have spread to lymph nodes or other parts of the body. While research is ongoing in attempts to find ways of preventing prostate cancer, results have not been notable. High-fat diets have long been recognized as a risk factor; daily consumption of green and yellow vegetables, and especially tomato-based foods, has been shown by some studies to reduce the risk of several types of cancer, including prostate. The validity of such studies has not been universally acknowledged, however, and a strong question has been raised as to whether switching to a low-fat diet after years of ingesting high levels of fat can be effective. Regular amounts of raisins and other dried fruits in the diet have also been suggested as a preventive measure. Exercise is yet another factor. Several studies have suggested that exercise reduces testosterone levels and hence the odds of getting prostate cancer. Treatment Primary methods of treatment include surgery, hormones, radiation, chemotherapy, and cryosurgery. The stage of the malignancy is a primary determinant of treatment methods to be used. Two types of surgery that are used are radical prostatectomy (surgical removal of the entire prostate gland) and radical orchiectomy (surgical removal of the testicles so that the prostate gland is deprived of testosterone needed for malignant cells to reduplicate and grow). The latter has shown dramatic results in the short term; in the long term, however, the cancers returned, usually with fatal results. Surgery is often accompanied by undesirable side effects, such as impotence and inability to control urination. Radiation therapy is often combined with surgery or may be used independently. A machine may be used to direct radiation to the area of the malignancy (external radiation), or radioactive material may be placed directly in or near the infected areas (internal radiation). External radiation is administered on an outpatient basis, whereas internal radiation usually
754 ✧ Prostate cancer involves a brief stay in the hospital. For stage 3 tumors, radiation is the more common treatment. Like surgery, radiation therapy may have undesirable side effects, such as impotence, diarrhea, or frequent and painful urination. The preferred treatment for stage 4 cancer is hormone treatment. One form consists of introducing luteinizing hormone-releasing hormone (LHRH) into the body, which prevents the testicles from producing testosterone. Another form is to introduce estrogen, a female hormone that stops the testicles from producing testosterone. These treatments are often accompanied by a drug called an antiandrogen, which blocks small amounts of male hormones produced by the adrenal glands. Researchers have also tested chemotherapy. Although a variety of drugs have been administered, no consensus has developed as to their effectiveness. Also, such drugs usually cause undesirable side effects. The effectiveness of cryosurgery—the application of extreme cold directly to the tumor to freeze it and destroy the cancer cells—also remains questionable. Sometimes the best treatment for prostate cancer is simply “watchful waiting.” Prostate cancer cells are notoriously slow growing and are sometimes best left alone. About seven out of ten men diagnosed with prostate cancer will die of other causes. Medical experts advise aging males to have a DRE and PSA test annually after age fifty. In the case of high-risk people, these tests should probably begin around age forty. Early detection is a key factor in effective treatment. —Joe E. Lunceford See also Aging; Cancer; Chemotherapy; Illnesses among the elderly; Prostate enlargement; Sexual dysfunction. For Further Information: Aigotti, Ronald E. The People’s Cancer Guide Book. South Bend, Ind.: Belletrist, 1996. Klein, Eric A. “Hormone Therapy for Prostate Cancer: A Topical Perspective.” Urology 47, Supplement 1A (January, 1996). McKinnell, Robert G., et al. The Biological Basis of Cancer. Cambridge, England: Cambridge University Press, 1998. Phillips, Pat. “Reports at European Urology Congress Reflect Issues of Interest to Aging Men.” Journal of the American Medical Association, May 6, 1998. Watson, Ronald R., and Siraj I. Mufti. Nutrition and Cancer Prevention. New York: CRC Press, 1996.
Prostate enlargement ✧ 755
✧ Prostate enlargement Type of issue: Elder health, men’s health, public health Definition: Enlargement of the prostate gland associated with aging, which causes problems with urination. The prostate gland is a walnut-sized organ of the male reproductive system located just below the bladder. It consists of two halves (lobes) surrounded by an outer layer, or capsule. The prostate gland surrounds the urethra (the tube that carries urine from the bladder out through the penis) just as it leaves the bladder. The primary function of the prostate gland is to produce a milky fluid, which, along with other fluids, makes up semen. Semen carries and nourishes sperm cells and is expelled during ejaculation. There are three main problems that can affect the prostate gland and cause problems for men: benign prostatic hyperplasia, prostatitis, and prostate cancer. The prostate gland goes through two main periods of growth. During puberty and young adulthood, the prostate grows rapidly, doubling in size. Around age forty to forty-five, the prostate begins to grow again, a condition called benign prostatic hyperplasia (BPH), and continues growing slowly until death. As the name implies, BPH is not cancer and does not turn into cancer. However, it is possible to have BPH and prostate cancer at the same time. The prostate enlarges from within and is kept from expanding by its surrounding capsule. This causes the gland to press against the urethra passing through it, much like a kink in a garden hose. This pressure on the urethra is responsible for the most common symptoms of BPH: difficulty starting or maintaining a stream of urine, the urge to urinate suddenly, the need to urinate more frequently (especially at night), and leaking or dribbling urine. BPH develops slowly over many years, and the symptoms usually develop slowly as well. This is why symptoms of prostate enlargement caused by BPH are more common among older men. When severe, BPH can cause serious health problems, such as bladder or kidney damage. Prostatitis is inflammation of the prostate gland usually caused by a bacterial infection of the urinary tract. Prostatitis occurs in middle-aged men and is associated with BPH in older men. Symptoms of prostatitis may be similar to those of BPH and may also include fever and burning or pain with urination. Prostatitis is generally treated with a course of antibiotics lasting several weeks or several months. Several treatment options for BPH are available. Surgery generally involves removal of all or part of the gland. Other medical treatments involve the use of drugs to shrink the prostate gland or reduce symptoms, though these drugs are not effective in all cases. Prostate enlargement is extremely common among older men. The symptoms of an enlarged prostate are not a necessary part of getting older,
756 ✧ Radiation and men need not suffer from such symptoms. Medical experts advise all men over fifty to have an annual examination, including a digital rectal exam to screen for prostate problems. —William J. Ryan See also Aging; Illnesses among the elderly; Prostate cancer; Sexual dysfunction. For Further Information: Fox, Arnold, and Barry Fox. The Healthy Prostate: A Doctor’s Comprehensive Program for Preventing and Treating Common Problems. New York: John Wiley & Sons, 1996. Gilbaugh, James H. Men’s Private Parts: An Owner’s Manual. Updated ed. New York: Crown, 1993. Marieb, Elaine N. Essentials of Human Anatomy and Physiology. 6th ed. Redwood City, Calif.: Benjamin/Cummings, 2000.
✧ Radiation Type of issue: Occupational health, public health Definition: The exposure of the body to nuclear radiation or X rays. Radiation is sometimes used for diagnosis or treatment, but acute illness can occur if an individual is exposed to a sudden, large dose. Typical symptoms of radiation sickness are nausea, diarrhea, skin burns, internal bleeding, and severe anemia. The production of blood corpuscles in the bone marrow is inhibited, and the ability of the body to fight infection is reduced. The severity of radiation sickness depends on the dose, which is commonly measured in units called rads (an acronym for radiation absorbed dose). For humans, a whole-body dose greater than 600 rads is usually fatal. At 450 rads, there is a 50 percent survival rate. Below 50 rads, no symptoms of radiation sickness are observable, although the risk of cancer is somewhat higher than normal. Radiation therapy for cancer patients typically prescribes doses of about 5,000 rads. Such large doses are not fatal for two reasons: First, only a small region of the body (the actual cancer site) is irradiated; and second, the therapy is given over a period of several weeks, so that the body has time to recover between treatments. Once radiation damage occurs, however, little can be done to repair it directly. Treatment focuses on helping the body’s natural processes of recovery. Vomiting and diarrhea can be controlled with drugs, while bacterial infections and wounds are treated with antibiotics. In extreme cases, bone marrow transplants can be performed to reestablish the formation of
Radon ✧ 757
Some people view nuclear power plants as a public health threat because of the potential for reactor accidents and the dangers of the radioactive waste produced. (PhotoDisc)
new blood cells. Donor cells are not likely to be rejected because the body’s immune system has been inactivated temporarily by the radiation. —Hans G. Graetzer See also Breast cancer; Burns and scalds; Cancer; Cervical, ovarian, and uterine cancers; Chemotherapy; Colon cancer; Environmental diseases; Food irradiation; Lung cancer; Occupational health; Prostate cancer; Screening; Skin cancer. For Further Information: Frigerio, Norman. Your Body and Radiation. Washington, D.C.: U.S. Atomic Energy Commission, 1967. Hall, Eric J. Radiation and Life. 2d ed. New York: Pergamon Press, 1984. Prasad, Kedar N. Handbook of Radiobiology. Rev. 2d ed. Boca Raton, Fla.: CRC Press, 1995.
✧ Radon Type of issue: Environmental health, public health Definition: A radioactive gas that naturally occurs in rocks; although it accounts for approximately 50 percent of the normal background radioactivity in the environment, radon gas can pose a health hazard if it accumulates in houses and buildings.
758 ✧ Radon Unsafe levels of radon gas have been detected in structures built over soils and rock formations containing uranium. One of the radioactive products of uranium is radium, which decays directly to radon. Every 3 square kilometers (1.2 square miles) of soil to a depth of 15 centimeters (6 inches) contain about 1 gram (0.035 ounces) of radon-emitting radium. Three forms of radon are generated in the decay of uranium in rocks and soils. The potential health risks are posed by the radon isotope with an atomic mass of 222 (radon 222), which has a 3.8-day half-life. Radon 220 and radon 219 also form in rocks and soils, but these isotopes have half-lives of fifty-six seconds and four seconds, respectively. The shorter half-lives of these isotopes compared to radon 222 give them a much greater chance to decay within the rocks and soils before becoming airborne. Thus they are of lesser radiological significance. Certain regions, such as the Reading Prong stretching from southeastern Pennsylvania to northern New Jersey and portions of New York, contain higher concentrations of radium in their rocks and soils. Similar regions occur across the nation and around the world. Radon gas is chemically inert, and within its 3.8-day half-life, the gas can become airborne and enter a building through small fissures in its foundation. Indoor radon levels are typically four or five times more concentrated than outdoor levels where air dilution occurs. Contributions to indoor radon levels also come from building materials, well water, and natural gas. Airborne radon itself poses little hazard to health. As an inert gas, inhaled radon is not retained in significant quantities by the body. The potential health risk arises when radon in the air decays, producing nongaseous radioactive products. These products can attach themselves to dust particles or aerosols. When inhaled, these particles can be trapped in the respiratory system, causing irradiation of sensitive lung tissue. Sustained exposure may result in lung cancer. The U.S. Environmental Protection Agency (EPA) has estimated that between 5,000 and 20,000 lung cancer deaths each year are attributable to radon products. The EPA recommends remediation measures if radon levels in a building exceed four picocuries per liter of air. Remediation techniques to relieve indoor radon pollution usually involve ventilating basements and foundation spaces to outside air. —Anthony J. Nicastro See also Cancer; Environmental diseases; Lung cancer; Radiation. For Further Information: Committee on the Biological Effects of Ionizing Radiation. National Research Council Beir IV Committee. Health Effects of Exposure to Radon. Washington, D.C.: National Academy Press, 1999. Committee on the Risk Assessment of Exposure to Radon in Drinking Water. Board on Radiation Effects Research. Commission on Life Sci-
Reaction time and aging ✧ 759 ences. National Research Council. Risk Assessment of Radon in Drinking Water. Washington, D.C.: National Academy Press, 1999. Kladder, Douglas L., James F. Burkhart, and Steven R. Jelinek. Protecting Your Home from Radon: A Step-by-Step Manual for Radon Reduction. Colorado Springs: Colorado Vintage Companies, 1995.
✧ Reaction time and aging Type of issue: Elder health, mental health Definition: Increase in the time between stimulus and response. Reaction time refers to the amount of time that passes between the occurrence of a stimulus and the execution of a response to that stimulus. Factors that influence reaction time include the need to accurately perceive the stimulus, to decide what action needs to be taken, and to coordinate the actions of the relevant muscular systems involved in the execution of the response. There is little doubt that humans experience a gradual slowing in reaction time as part of the aging process. However, the significance of this finding for performance in everyday life and its relevance to issues such as driving safety is far less clear. Reaction time remains relatively stable until the age of forty, at which point a gradual pattern of slowing begins. Comparisons between healthy younger and older adults typically show that the responses of older adults take approximately 30 percent longer to execute than those of younger adults. Estimates regarding the rate of slowing indicate that reaction times decrease by approximately 2 percent for every five years of age. The size of age differences in reaction time varies widely from study to study. Larger age differences are found in studies in which there is greater difficulty in detecting the stimulus, less opportunity to prepare a response in advance, and a change in the rules that indicate the correct response to a given stimulus. In addition, the difficulty of the task has a large influence on the size of age differences in reaction time. More complex or difficult tasks are associated with larger age differences in reaction time. This result is usually thought to reflect a slower speed of information processing in the brains of older adults. While older adults almost always display slower responses than younger adults, declines in the speed of cognitive operations may not provide a complete explanation of age differences in cognitive performance. For example, there is evidence that older adults make fewer errors on reaction time tasks than younger adults. This indicates that at least a portion of reaction time slowing in older adults may be explained by a style of performance that places more emphasis on accuracy than on speed. This stylistic
760 ✧ Recovery programs difference may manifest itself in everyday life through more cautious driving habits. Two other lines of research indicate that age differences in reaction time are not as absolute as once thought. First, age differences in reaction time are reduced with extensive practice in a particular task. Second, data suggest that physically fit older adults may not experience slowed reaction times to the same degree as less physically fit older adults. —Thomas W. Pierce See also Aging; Alzheimer’s disease; Exercise and the elderly; Memory loss; Muscle loss with aging; Safety issues for the elderly. For Further Information: Arking, Robert. Biology of Aging: Observations and Principles. 2d ed. Sunderland, Mass.: Sinauer Associates, 1998. Burkhardt, Jon E., Arlene Berger, Michael Creedon, and Adam McGavock. Mobility and Independence: Changes and Challenges for Older Drivers. Bethesda, Md.: Ecosometrics, 1998. Ferrandez, Anne-Marie, and Normand Teasdale. Changes in Sensory Motor Behavior in Aging. New York: Elsevier, 1996. Kotulak, Ronald. “Keeping the Brain Sharp as We Age.” Saturday Evening Post 268, no. 6 (November/December, 1996). Schmall, Vicki L. Sensory Changes in Later Life. Rev. ed. Washington, D.C.: U.S. Department of Agriculture, 1991.
✧ Recovery programs Type of issue: Mental health, public health, social trends, treatment Definition: Organizations based on the concept that individuals can recover from addictive compulsions. Recovery programs originated with the founding of Alcoholics Anonymous (AA), which promotes a twelve-step recovery program. AA, founded in 1935 by Robert Smith and William G. “Bill” Wilson, has helped millions of people overcome the destructive effects of alcoholism. By the 1990’s, the organization included more than 93,000 groups in 131 countries, with an estimated membership of more than two million. Drug users are among those who have been helped by attending meetings of Alcoholics Anonymous and its offshoot, Narcotics Anonymous. Other recovery programs, such as Overeaters Anonymous (O-Anon), Gamblers Anonymous (Gam-Anon), and Sex Addicts Anonymous, have adopted
Recovery programs ✧ 761 the twelve-step spiritual philosophy developed by AA. Adjunct groups such as Al-Anon, Alateen, Adult Children of Alcoholics, and Codependents Anonymous (CoDA) have sprung up to aid those affected by the addictions and behaviors of relatives and loved ones. The Growing Recovery Movement The growth of these organizations—all based on the concept that individuals can recover from addictive compulsions—and their accompanying twelvestep program of spirituality constitute the social phenomenon known as the recovery movement. These programs have no dues or fees; the only requirement for membership is that an individual desires to become free of addictions and compulsions. Alcoholics, substance abusers, and others whose lives have become unmanageable because of addictive and compulsive behaviors attend meetings in which they share their experiences and hopes with others who have been in similar situations. This sharing of stories and life experiences is one of the cornerstones of the twelve-step recovery process. The first recovery step involves an admission of powerlessness over a substance or behavior, whether it is alcohol, drugs, sex, gambling, food, or work. Next, individuals in recovery are encouraged to examine their past experiences closely in an effort to take responsibility for and accept the consequences of past actions. Other steps encourage personal spiritual growth and a policy of reaching out to assist others who have similar troubles. As members work through the necessary steps of the program (not necessarily in a particular chronological order), they are said to be “recovering” from, rather than “cured” of, addictive compulsions. Alcoholism (considered to be the primary addiction) and substance abuse affect more families than do other addictions. More than ten million Americans are estimated to be alcoholics. An estimated 75 percent of alcoholics are male. Alcoholism is found among people of all ages and cultural and socioeconomic backgrounds. Twelve-Step Recovery Programs In addition to AA and Narcotics Anonymous, which are designed to assist recovering alcoholics and drug addicts, there are a variety of recovery programs tailored to the needs of family members. Al-Anon and Alateen, for example, provide support to the families and teenage children of alcoholics. In Al-Anon, spouses and other family members are welcomed by people who have experienced similar problems in living with individuals suffering from alcoholism. Such contact alleviates the feeling of isolation and separation from the community that is common among families of alcoholics. New members of Al-Anon are encouraged to elect sponsors, someone who is
762 ✧ Recovery programs available any hour of the day to help the newcomer over immediate hurdles. In Alateen, teenagers come together to share their experiences. The intense shame associated with having an addicted parent is something all members have experienced. In this support group, teenagers are free to talk and express emotions that may have been suppressed for years. Overeaters Anonymous welcomes people with various eating disorders, undereaters and bulimics as well as overeaters. Although participants are not placed on diets, they are encouraged to share nutritional information and reach appropriate weight goals by sponsors who have had success. O-Anon is for individuals, particularly family members, who have been affected by others’ eating disorders. Such individuals may become compulsive themselves in their efforts to control the behavior of another person who has an eating disorder. Types of Recovery Programs Narcotics Anonymous helps people recover from chemical dependency, and Families Anonymous is available to assist people concerned about chemical dependency in relatives or friends. Members of Smokers Anonymous meet to support each other through the process of quitting cigarettes. Gamblers Anonymous works with people who want to stop compulsive gambling, and Gam-Anon is available for people affected by the behavior of gamblers. Sex Addicts Anonymous deals with compulsive sexual behavior, and Co-Dependents of Sex Addicts (COSA) supports people affected by the sexual conduct of such addicts. Parents Anonymous is open to parents who are abusive or are afraid of becoming abusive toward their children. The organization also works with teenagers who have been or are current victims of parental abuse. Other twelve-step programs include Sexual Abusers Anonymous, Depressives Anonymous, Emotions Anonymous, Cocaine Anonymous, Overachievers Anonymous, Native American Children of Alcoholics, Shoplifters Anonymous, Agoraphobics Anonymous, Schizophrenics Anonymous, and Prostitutes Anonymous. Some chapters of Alcoholics Anonymous have established special programs for gays, lesbians, and nonsmokers. All twelve-step recovery programs follow the basic tenets and spiritual philosophy underlying Alcoholics Anonymous. At meetings, people use only their first names to extend an atmosphere of trust for those who prefer anonymity. As their common goal, these programs attempt to teach people how to live. They attempt to bring peace and happiness to the lives of addicts and their families, and they promote healing. Codependency In her best-selling work Codependent No More, Melody Beattie developed the recovery concept of codependency. Beattie illustrated how people who are
Recovery programs ✧ 763 personally involved with individuals who are chemically dependent or have addictive personalities become compulsively disordered themselves. Such people may take on characteristics of hostile control and manipulation, constantly giving to others but not knowing how to receive. In Beattie’s estimation, the conditions that make such individuals feel victimized make them more disordered than their addicted significant others. She strongly advocates that such people seek recovery through the twelve-step program known as Codependents Anonymous (CoDA). Adult Children of Alcoholics (ACoA) This twelve-step program assists adult children of alcoholics who find themselves playing out roles and behaviors that became ingrained when they were children growing up in alcoholic homes. Sharon Wegscheider-Cruse describes the following rigid roles adopted by adult children of alcoholics: the enabler, the hero, the scapegoat, the lost child, and the mascot. The enabler takes on responsibilities that allow compulsive or addicted individuals to continue in their detrimental behavior. For example, by calling in sick for a family member suffering from a hangover, an enabler may inadvertently contribute to an alcoholic’s continued pattern of excessive drinking. A deep sense of shame and the desire to cover up for another’s mistakes leads to a process popularly referred to as denial. The hero, who is usually the oldest child and a high achiever, is predisposed to workaholism in adult life. The job of such children is to “cure” the family, often at the price of their own health. The scapegoat, who is commonly the next child in line chronologically, is the family member who receives the blame for all family problems. By focusing on this child, the family overlooks the behavior of the addicted individual. The scapegoat often internalizes this blame-taking role, becoming the so-called black sheep of the family in adulthood. The lost child role falls upon younger middle children who become lost in the crowd in an alcoholic home. Such children receive very little, if any, attention and suffer extreme loneliness, pain, and isolation later in life. These lost children find it almost impossible to enter into long-lasting relationships. Individuals who act as mascots in the family serve as a catalyst for comic relief through their irresponsible behavior. Behind this comic mask, however, lies sadness and pain. As adults, mascots find it difficult to be taken seriously. Although they were cut-ups in class as children, mascots have difficulty focusing on and completing tasks as adults. Through intervention, counseling, and participation in twelve-step groups such as ACoA, these painful family roles can be recognized and discarded. Information regarding twelve-step groups is available in public libraries and on the Internet. Many such programs are listed in local
764 ✧ Reproductive technologies telephone directories, and some of these programs have toll-free hotlines that provide information and advice twenty-four hours a day. —M. Casey Diana See also Addiction; Alcoholism; Alcoholism among teenagers; Alcoholism among the elderly; Anorexia nervosa; Child abuse; Depression; Depression in children; Depression in the elderly; Drug abuse by teenagers; Domestic violence; Eating disorders; Elder abuse; Obesity; Obesity and aging; Obesity and children; Sexual dysfunction; Smoking; Speech disorders; Steroid abuse; Suicide; Suicide among children and teenagers; Suicide among the elderly; Tobacco use by teenagers; Weight loss medications. For Further Information: Beattie, Melody. Codependent No More. New York: Harper & Row, 1987. This best-selling classic of the recovery movement discusses options for people who exhibit compulsive behavior themselves as a result of their relationships with addicted people. Casey, Karen. If Only I Could Quit: Becoming a Non-Smoker. Center City, Minn.: Hazelden Educational Materials, 1987. Adapts the twelve-step approach for those wishing to recover from an addiction to tobacco smoking. Durse, Joseph. Painful Affairs: Looking for Love Through Addiction and Co-Dependency. Deerfield Beach, Fla.: Health Communications, 1989. Discusses how some individuals turn to destructive relationships for comfort and prescribes a program of treatment and recovery. Maxwell, Milton. The A.A. Experience. New York: McGraw-Hill, 1984. Although this book was written for professionals in the recovery movement, it is easily read and provides in-depth information regarding Alcoholics Anonymous and its twelve-step program. Satir, Virginia. Conjoint Family Therapy. 3d ed. Palo Alto, Calif.: Science and Behavior Books, 1983. Written by a renowned behavioral scientist, this work provides a scientific explanation for much of the recovery movement’s impetus.
✧ Reproductive technologies Type of issue: Ethics, social trends, treatment, women’s health Definition: Medical technologies and procedures relating to fertility and conception; they challenge the biological limitation that human reproduction is related to sex and that children are related to their mothers. Research beginning in the 1950’s, primarily centered on hormonal controls of the menstrual cycle and ovulation, led to effective oral drugs for birth
Reproductive technologies ✧ 765 control. The birth control pill provided an effective female contraceptive that separated sex from pregnancy and is generally recognized as a major contributor to the 1970’s era of sexual freedom. While the advent of acquired immunodeficiency syndrome (AIDS) in the 1980’s dampened this freedom for individuals who were sexually active outside the framework of monogamous relationships, advances in drug implants and “morning-after pills,” including RU-486, continued to make birth control increasingly reliable. Reproductive technology accelerated as equipment and techniques were developed to treat the one in seven women who are infertile. While artificial insemination had been in use for decades, the first test-tube baby was born in the United States in December 1981. First developed in Australia, in vitro fertilization uses a laparoscope to retrieve eggs from women who are unable to conceive directly. The eggs fertilized in glassware are either reimplanted or frozen using protective cryoprotectant chemicals. This technique became effective with the development of drugs that stimulate the ovulation of many eggs. A surrogate mother can receive the fertilized embryo and carry the pregnancy to term on behalf of the donor. Reversing this procedure, it is possible to artificially inseminate egg donors and then flush out the embryos five days later and implant them into mothers who have intact uteruses but defective ovaries. Derived from established agricultural practices, the first case of human embryo transfer in the United States occurred in 1984. This increases the potential number of “parents” to five: the donor father and mother, the surrogate mother, and the adoptive father and mother. As with earlier artificial insemination, human embryo transfer separates reproduction from sex. Following implantation, additional technologies allow parents to make decisions on the status of fetuses. Amniocentesis is a traditional diagnostic technique whereby amniotic fluid is withdrawn from the uterus and cells sloughed from fetuses are tested for genetic defects, including Down syndrome. Newer techniques can sift fetal cells from a mother’s bloodstream, eliminating the risk of miscarriage associated with amniocentesis. While amniocentesis is only effective after the end of the fourth month of pregnancy, chorionic villus sampling (CVS) can be used by the eighth week. A small sample is drawn from the chorionic membrane, which the embryo contributes to the placenta, and the cells are analyzed. Original CVS research was conducted in China until it was evident that this was being used for sex selection. Meanwhile, Landrum Shettles and colleagues promoted techniques that allowed couples to heighten their chances of having boys or girls on demand. While science has been effective in producing technologies that allow couples to prevent, produce, or select children, society has found it far more difficult to decide the extent to which these technologies should be commercialized, to determine the status of embryos, and to define motherhood and family. —John Richard Schrock
766 ✧ Resuscitation See also Abortion; Birth control and family planning; Birth defects; Childbirth complications; Ethics; Genetic counseling; Genetic engineering; Infertility in men; Infertility in women; In vitro fertilization; Morning-after pill; Multiple births; Premature birth; Prenatal care; Sterilization. For Further Information: Bonnicksen, Andrea L. In Vitro Fertilization: Building Policy from Laboratories to Legislature. New York: Columbia University Press, 1989. An excellent discussion of the history of in vitro fertilization and the ethical questions raised. An appendix includes a detailed but concise description of the technique. Harkness, Carla. The Infertility Book: A Comprehensive Medical and Emotional Guide. Berkeley, Calif.: Celestial Arts, 1992. Written as a guide for the infertile couple, this book offers emotional support as well as medical information. The text is augmented by firsthand accounts of individuals’ reactions to their infertility and the treatments. Weschler, Toni. Taking Charge of Your Infertility. New York: HarperPerennial, 1995. This book encourages women to become responsible consumers of their own reproductive health. Includes excellent discussions of infertility, natural birth control, and achieving pregnancy. Wisot, Arthur, and David Meldrum. Conceptions and Misconceptions. Vancouver: Harley and Marks, 1997. Written by two leading fertility experts, this book is an excellent guide through the maze of in vitro fertilization and other assisted reproductive techniques. Includes an excellent discussion of the basic physiology of conception and reproduction. Yeh, John, and Molly Uline Yeh. Legal Aspects of Infertility. Boston: Blackwell Scientific Publications, 1991. The authors, a practicing physician and a lawyer, wrote this text as a guide for doctors, but it makes fascinating reading for anyone interested in the governmental regulation of infertility treatments. Also includes medical information on the use and success of various treatments.
✧ Resuscitation Type of issue: Medical procedures, treatment Definition: The physical act of reviving a person in cardiac or respiratory arrest, which involves such techniques as artificial respiration, chest compressions, and defibrillation. Every cell in the human body needs a constant and steady supply of oxygen. The delivery of oxygen is only possible through a continuous movement of oxygen-rich blood, with the heart and lungs working efficiently together. In
Resuscitation ✧ 767 order to survive, the body must have a functioning heart and lungs, or an outside force that makes both organs function artificially. Two major lifethreatening conditions include respiratory arrest (cessation of breathing) and cardiac arrest (cessation of heartbeat). When either the circulatory or the respiratory system is not able to perform properly, the entire body suffers quickly. Without oxygen, brain damage begins within four minutes. While sitting, the human heart pumps sixty to one hundred times each minute, moving about 5.5 liters of blood throughout the body every minute. The heart acts like a pump because it is a special muscle with its own electrical system. Much the same way as a light switch turns on a light bulb, the heart pumps because an electrical message at the top of the heart, in the sinoatrial (S-A) node, makes the entire heart muscle contract. This natural pacemaker keeps the heart beating when all things are in proper working order. If the heart stops beating correctly or the lungs do not work, however, the person will die unless resuscitation is started. Resuscitation Techniques Resuscitation means making the heart pump and getting oxygen into and out of the lungs. In an example of the most severe case, a person is found not breathing and without a pulse. Cardiopulmonary resuscitation (CPR) courses teach that the first step is to open the airway and be sure that nothing is blocking the flow of air in and out of the lungs. If a blockage is found, it must be removed immediately. If the person is not breathing, the rescuer must breathe for him or her. Artificial respiration, in which one individual breathes air into another’s mouth, will force air into the lungs so that it can be picked up in the bloodstream and transported to body cells. Pinching the patient’s nose and blowing into the mouth forces air into the lungs in much the same way as taking a deep breath. Yet this artificial breathing alone is not enough. The oxygen put into the lungs must be moved around the body, which can only be done through circulating blood. In order to move the blood through the circulatory system, something must be done to make the heart pump. This can be accomplished through chest compressions. Since the heart lies between the breastbone (sternum) and the spine, it is surrounded by hard, bony structures. By pressing in the correct position, with sufficient pressure and depth, the heart muscle can be squeezed. This squeezing action will result in blood being forced out of the heart and onto its path around the body. The oxygen blown into the lungs will be picked up by the passing blood and moved out to necessary areas of the body. Even with the use of proper techniques, however, cardiopulmonary resuscitation should only be a temporary measure for a person who has no pulse and who is not breathing. CPR is only a momentary first-aid measure. Yet
768 ✧ Resuscitation this procedure is a vital one: Until further medical assistance can be given, it is extremely important that oxygen circulate in the patient’s body. CPR is usually done by the first responder who finds the victim and is known as basic life support (BLS). The administration of BLS is the step just before advanced life support (ALS), which offers additional treatment measures given by medically trained personnel. ALS is given by emergency medical technicians (EMTs) or paramedics responding in ambulances. While continuing CPR, the medical team will start advanced care before or during the drive to a hospital emergency room. In order to provide the proper treatment, paramedics must determine the electrical activity of the heart. The heart’s rhythm is recorded on an electrocardiograph (ECG or EKG) machine, which helps the medical team find the cause of the problem. The portable ECG machine, which is commonly called a cardiac monitor, displays the electrical activity in the heart. When the electrical impulses are not producing a rhythmic beating pattern, various treatment procedures may follow, depending on how the heart is pumping or if it is working at all. It is possible to correct a heart that has an irregular beat caused by abnormal electrical activity. A total lack of electrical activity in the heart is called asystole and is recorded on the monitor as a flat line. The ALS team can attempt to adjust the abnormal electrical signal but cannot mechanically restart a heart that has no electrical impulses. Other heart problems produce other types of tracings on the monitor. In one type of arrhythmia called ventricular fibrillation, the heart has a rapid, chaotic beating rhythm that will not keep the person alive for an extended period of time: The heart will become exhausted and cease electrical activity. In this case, CPR is performed while paramedics begin advanced life support. Different Protocols Many different protocols exist on how ALS treatment should progress, and the following is merely one example. The medics may use an electrical machine known as a defibrillator to deliver electrical shocks through the chest and toward the heart in the hope of correcting the rhythm. Three electrical shocks, given at increasing strengths, are followed by continued CPR. A needle and special catheter are placed in a vein to allow for the starting of an intravenous (IV) drip in which medications can travel to the heart through the circulatory system. A high concentration of oxygen is delivered through a tube inserted through the mouth or nose and passed into the upper part of the lung so that artificial ventilation can aid in the movement of concentrated oxygen. Next, adrenaline (also known as epinephrine) is given through the IV; this drug will increase the blood flow to the heart and brain by narrowing other vessels and will also increase the heart rate and blood pressure. After this drug is given, another electrical shock is administered. The next drug
Resuscitation ✧ 769 given is lidocaine, which helps to calm a heart that is beating too fast or erratically. Another electrical shock is given, followed by a third drug called bretylium tosylate. This drugs works through interactions with the nervous system to increase the output of blood from the heart. If the irregular rhythm has still not been corrected, then sodium bicarbonate will be given to reduce the acids produced in the body because of the lack of oxygen. Another electrical shock is given, followed by a repeat dose of either bretylium tosylate or lidocaine. This entire scenario is repeated until the heart is beating in a manner which will sustain life. Other drugs that are used for specific heart problems include atropine, procainamide, verapamil, dopamine, and adenosine. All these drugs target specific problems during a cardiac episode. When the heart slows or weakens to the point that it is barely beating, life can be artificially maintained in a few cases by using a cardiac pacing unit to create an artificial heartbeat electrically, a procedure called cardiac pacing. This artificial heartbeat may be sufficient until a mechanical pacemaker can be implanted. Advances in Resuscitation Procedures Over the years, huge advances have been made in resuscitation measures. More lives have been saved by the training of medical personnel to administer advanced life support before a patient reaches the hospital. Lifesaving drugs and defibrillation have greatly decreased the death rate for heart attack victims and cardiac patients. With the continued training of emergency medical technicians, the survival rate can improve as a result of earlier and more aggressive medical treatment. Medical treatment could be avoided entirely, however, if more preventive health measures were implemented. With continued research identifying risk factors, the public can be educated about how to prevent conditions that lead to heart attacks. Among the known risk factors are cigarette smoking, hypertension (high blood pressure), high cholesterol and triglycerides, lack of exercise, excess weight and improper nutrition, stress, and diabetes mellitus. Three risk factors cannot be changed: predisposing heredity, gender (men are more likely to have heart attacks), and increasing age. With further research, the first group of risk factors may be addressed in society through extensive education, but heart attack rates cannot be curbed unless people change their lifestyles. An understanding of heredity, gender, and age risk factors can only bring changes in these rates through further research into their relationship to heart attacks. Until people are willing to change their lifestyles, early recognition of the warning signs of a heart attack may be the easiest method of increasing survival rates. These warning signals include a squeezing tightness in the chest, sweating, nausea, weakness, and shortness of breath. Too often,
770 ✧ Resuscitation people deny that they could be suffering a heart attack, with many believing that the pain is heartburn or indigestion. If medical attention is sought immediately, however, severe damage can often be reduced or stopped. Special drugs such as streptokinase or tissue plasminogen activator (TPA) can dissolve clots that interfere with blood flow, while surgical techniques can open clogged arteries. Heart transplants offer a solution for patients with extensive heart damage. Research continues to decrease the rejection rates for heart transplants. Medications are being developed to decrease the buildup of plaque in arteries. The fields of genetics and gene therapy hold many keys to the prevention and treatment of heart disease. It is important to note that all medically trained personnel, from the EMT to the emergency room physician, must perform life support measures. Unless patients have given appropriate “do not resuscitate” orders, they will receive some form of the above-mentioned procedures. A living will is a legal document that stops CPR or advanced life support from being given. Future resuscitation measures will be influenced by ethical questions regarding when to sustain life. —Maxine Urton See also Drowning; Electrical shock; Ethics; First aid; Heart attacks; Living wills; Malpractice. For Further Information: Bledsoe, Bryan E., Robert S. Porter, and Bruce R. Shade. Brady Paramedic Emergency Care. 3d ed. Upper Saddle River, N.J.: Brady Prentice Hall Education, Career & Technology, 1997. A book used to train emergency medical technicians at the paramedic level. Some of the text is technical, but the anatomy and physiology of the body are covered in an understandable format. Extensive drawings and photographs explain the anatomy of the heart and lungs, CPR, and defibrillation. Crosby, Lynn A., and David G. Lewallen, eds. Emergency Care and Transportation of the Sick and Injured. 6th rev. ed. Rosemont, Ill.: American Academy of Orthopaedic Surgeons, 1997. This book is often used in the training of emergency medical technicians, yet its chapters are easily understood by nonmedical lay readers. The information given goes a step beyond basic first aid. Handal, Kathleen A. The American Red Cross First Aid and Safety Handbook. Boston: Little, Brown, 1992. A comprehensive, fully illustrated guide outlining basic first aid and emergency care procedures to be given by the first responder until medical assistance arrives. Updated materials can also be obtained directly from local Red Cross Association chapters listed in telephone books. Heartsaver Manual: A Student Handbook for Cardiopulmonary Resuscitation and First Aid for Choking. Dallas: American Heart Association, 1987. This
Reye’s syndrome ✧ 771 handbook is used when teaching the CPR courses offered by the American Heart Association. Offers easy-to-understand descriptions of anatomy and physiology, and lists health risk factors. Intended to be read during formal classes. Thygerson, Alton L. First Aid and Emergency Care Workbook. Boston: Jones and Bartlett, 1987. Concise information packed into a workbook format, produced in cooperation with the National Safety Council. Charts, drawings, photographs, and tables outline common emergency care and cover a wide range of topics for the general public. Designed to be used as a textbook in a first aid course.
✧ Reye’s syndrome Type of issue: Children’s health, public health Definition: A somewhat rare, noncontagious disease of the liver and central nervous system that strikes individuals under the age of eighteen. The exact cause of Reye’s syndrome has not been determined, but the majority of patients develop the disease while recovering from a mild viral illness, such as chickenpox, influenza, or a minor respiratory illness. It is theorized that the virus combines with another unknown substance (or substances) in the body to produce a damaging poison. The first symptom of the disease is a sudden onset of vomiting, then high fever, headache, and drowsiness. As the disease progresses, alternating states of excitation and confused sleepiness may occur, as well as convulsions and a loss of consciousness. In the final stages of the disease, damage occurs to the liver, kidneys, and brain. The brain cells swell and pressure builds in the skull, followed by a coma, permanent brain damage, and, in some cases, death. Treatment There is no known cure for Reye’s syndrome. Early recognition and specialized care may be lifesaving. Treatment consists of helping the victim survive the first few days of the illness through intake of fluids, glucose, and other nutrients. If the patient survives the first three or four days, the symptoms usually subside and recovery follows. Medication, such as mannitol, or surgery will reduce the pressure within the skull if it reaches dangerous levels. Although it has not been proven that aspirin causes or promotes Reye’s syndrome, based on a variety of medical studies, it is recommended that aspirin not be given to children with viral infections, especially chickenpox and influenza. With few exceptions, acetaminophen or ibuprofen are safe alternatives.
772 ✧ Safety issues for children Reye’s syndrome was first described by an Australian pathologist, R. D. K. Reye, in 1963. In the early 1980’s, approximately 50 percent of the cases were fatal, but improved diagnosis and treatment of the disease had reduced that number to about 10 percent by the 1990’s. —Alvin K. Benson See also Children’s health issues; Influenza; Pain management. For Further Information: Crocker, John F. S., ed. Reye’s Syndrome II. New York: Grune and Stratton, 1979. Hoekelman, Robert, ed. The New American Encyclopedia of Children’s Health. New York: New American Library/ Dutton, 1991. Pollack, J. D., ed. Reye’s Syndrome. New York: Grune and Stratton, 1975. Taubman, Bruce. Your Child’s Symptoms. New York: Simon & Schuster, 1992.
✧ Safety issues for children Type of issue: Children’s health, prevention, public health Definition: Measures taken to prevent accidents among children. Each year in the United States, approximately 1 million children receive medical care as a result of unintentional injury. Of these, 40,000 to 50,000 suffer permanent damage and 4,000 die. The first years of a child’s life are the most dangerous: Unintentional injuries are the primary cause of death in children up to the age of five. Foresight, common sense, and vigilance are required to prevent injuries to children, particularly those under the age of two. Basic information in case an emergency occurs should be accessible in all homes with children. The phone number of the family physician, the nearest hospital and emergency service, and the local poison control center should be posted adjacent to the phone. When caregivers are employed, they should be given car fare, a copy of children’s medical card, the doctor’s phone number, and the phone number of the parents. For optimum communication, parents should travel with a cellular phone. The number of a relative to contact in the event of an emergency occurring to the parents should be included as well. Safety in the Home All parents should develop a childproofing plan before a newborn arrives and modify it when the baby begins to crawl and walk. Hazards change with
Safety issues for children ✧ 773 age. The Consumer Product Safety Commission urges families to do a room-by-room check of their house. The best way to do this is to put oneself in the place of the child, getting down on one’s hands and knees and imagining what would be interesting or constitute an obstacle. Surprisingly, almost as many children are injured or die from using objects designed for their use as from automobile accidents. In the United States, accidents related to playing with toys send 120,000 children to the emergency room annually. Most standards for baby equipment went into effect in the early 1970’s, so extra caution must be exercised with equipment manufactured prior to that date. Baby walkers are involved in more than 28,000 injuries annually. Tipping is the most common cause of injury; it can be prevented by using a walker with at least six wheels and a base wider than the seat height. Walkers can also fall down stairs. Falls from high chairs sent another 7,000 infants to the hospital. High chairs should have a safety strap and a wide base to prevent tipping. Cantilevered high chairs that hook to a table are more unstable. They should lock to the table and be attached only if the table is strong enough to support them. Despite standards to ensure safe cribs, up to 30 million potentially dangerous cribs are in use in the United States, and approximately fifty babies suffocate or strangle in cribs annually. Cribs more than twenty-five years old are the most hazardous because the slats are too wide. Moreover, they may have lead-based paint. Even newer cribs with decorative cutouts can trap a baby’s head. In addition, corner posts can catch clothing, resulting in strangulation. The first safety measure is to ensure that crib slats are spaced no more than 2 3/8 inches apart and that corner posts extend no more than 1/16 of an inch above the railing. Cribs should never be placed next to a wall lamp, electrical outlet, window, radiator, or vent. To prevent the possibility of suffocation, puffy gear such as large stuffed animals, adult pillows, or comforters should not be used in cribs until a child reaches one year of age. Securely fastened bumpers, however, may be used until the baby is able to stand (and thus able to climb on them to exit the crib). Portable playpens may have faulty latches that can cause the enclosure to collapse, trapping a child’s head in the top rails. Latches on a playpen should click audibly, signifying that they are securely locked. Also, the side of a mesh playpen should never be left lowered, as an infant can be trapped in the slack mesh. Windows, Electrical Outlets, Furniture, and Stairs Children aged five and younger are most likely to fall from windows because they are mobile but do not comprehend the danger of an open window. In the United States, about 15,000 children aged ten and younger are injured annually from window falls. The majority of falls occur when children play
774 ✧ Safety issues for children on furniture adjacent to an open window and topple out as a result of losing their balance. All windows from the second floor up should have window guards. Each guard should have a quick-release mechanism for swift exit in case of a fire. Screens do not support a child’s weight, so windows should be opened at the top rather than the bottom; if they are opened on the bottom, they should not be wide enough to allow a child to fit through them. Above all, furniture should not be placed under a window. Drapery and blind cords should be secured so that a child is unable to play with them. The most important safety procedure is to cover unused electrical outlets with a safety plug. In wet areas, such as the kitchen or the bathroom, a ground-fault circuit interrupter can be installed in outlets to prevent electrocution if an appliance comes in contact with the water. Tempting electrical appliances such as hair dryers should be unplugged and stored out of reach of a child when not in use. If toddlers are in the house, any standing object such as bookcases, dressers, desks, or a television stand may tip onto a child, who may be tempted to climb on it and any open drawers. To diminish the hazard of household furniture, angle braces or anchors should be used to secure any potentially unstable item, such as bookcases or china hutches, to a wall. Heavy furniture must rest flat on the floor; gliders should be removed. Television sets should be mounted above a child’s reach or set far back from the edge on a very low piece of furniture. Rugs on slippery areas, such as linoleum tile or the bathroom floor, should be stabilized with nonskid backing. Any edge that could cut a child, such as on a table, should be covered with padding; heat-resistant padding is available for hearths. Glass tables should not be used. All breakable items should be kept on high shelves. Safety gates should be installed at both the top and bottom of the stairs. Stair gates should have a straight top edge and be filled with a rigid mesh screen containing slats less than 4.25 inches apart. Accordion gates made before February, 1985, are unacceptable, as the openings are wide enough to trap a child’s head. The V-shaped openings at the gate’s top edge should be no more than 1.5 inches wide. All gates should be at least 32 inches high. Hardware-mounted gates securely attached to a solid structure, such as a stair post or wall, should be used at the top of the stairs rather than an expanding-pressure gate, which can be dislodged by the weight of a toddler. Gates should be removed as soon as a child attempts to climb over them. Outdoor Safety Measures More than 200,000 injuries occur annually on playgrounds to children fourteen years old or younger in the United States. More than half of playground injuries result from a fall onto a hard surface, including asphalt,
Safety issues for children ✧ 775 concrete, and even grass and dirt. A significantly higher risk for serious injury is associated with a fall of more than 4 feet for preschoolers or more than 8 feet for school-age children. Playground equipment is specifically designed for one of two age groups: two to five years old or five to twelve years old. To address this issue, equipment made after 1994 is supposed to be marked with a sign indicating its intended age group. To optimize safety on playgrounds, children should use a playground covered with pea gravel, sand, chips, rubber, or a soft synthetic surface. This protective surface should extend at least 6 feet around slides and twice the height of the swings in front and back to create a safety fall zone. Playgrounds should be checked for sharp edges, loose joints, and protruding hardware, such as unclosed “S” hooks. Swings that are not at least 2 feet apart and 2.5 feet lower than the swing support should be avoided. Platforms and ramps are usable only if they have guardrails. Above all, a toddler should play on equipment lower than 4 feet high, while a school-age child should be restricted to structures 8 feet high or lower. Drowning is known as the “silent death” since young children do not scream or splash while drowning. Each year in the United States, 1,000 children aged fourteen and younger drown, while 4,000 more are treated for near-drowning injuries. Of these, 20 percent end up with permanent neurological damage. More than 300 children aged four and under drown in residential pools annually. Accidents in children five and older tend to occur in lakes or the ocean as well as in pools. A pool should be enclosed with a four-sided fence at least 5 feet high that is filled with vertical bars 3.5 inches apart or less. The gate should be self-locking and self-closing, with the latch out of reach of children. Toys and floats that attract young children should be kept away from the pool when not in use, and furniture that enables climbing over a pool fence should be moved to a different location. Parents and caregivers should know cardiopulmonary resuscitation (CPR), and the CPR instructions should be posted near the pool. Basic life-saving equipment, including a pole, rope, and flotation device, should be next to the pool. Many parents also keep a phone near the pool. In addition, children who cannot swim should wear an approved flotation device that has a collar to keep the head upright and the face out of the water. Children should never have access to the pool while unsupervised, which includes exiting the back door while a parent is on the phone. A toddler should be taught repeatedly not to go near the pool without a parent. Many parents install a motion-sensing device that sounds an alarm if something has fallen into the water. Hot tubs are dangerous for young children; children under the age of four years should not be allowed in them. Most parents are unaware that hot tubs and spas manufactured prior to 1987 have strong suction that could injure a child; children should be cautioned to keep their head above water and their hair tied up and to sit away from a drain. The water temperature should not exceed 104 degrees Fahrenheit.
776 ✧ Safety issues for children Burns The kitchen is considered the most dangerous room in the home for children by experts. A burn may occur when a hot pan or liquid falls on a child or when a child presses hands against an oven door or pulls a pan off the stove. The insulation on oven doors may wear out and cause second-degree and third-degree burns, even when the oven is at a relatively low temperature. Hot pans placed on a counter should be far enough from the edge to prevent them from falling. Pots should be placed on the back burners, with handles turned toward the rear, so a child cannot reach them. In addition, stove knobs may be removed or covered when the stove is not in use if they are especially accessible or tempting to a child. Several working fire extinguishers should be readily available, and smoke detectors should be installed outside sleeping areas and tested regularly. To prevent scald burns from hot water, the temperature on hot water heaters should be set to a maximum of 120 degrees Fahrenheit. A parent should always test the water before putting a child in the bathtub. If a child is burned, the immediate goal is to prevent heat from penetrating deeper into the skin. Clothing must be removed from the burned area immediately. If fabric is stuck to the skin, it should not be pulled away, as this can tear the skin, but cut away as best as possible. Cold water should be applied to the burn at once until the pain subsides and the skin is no longer hot to the touch, usually at least five minutes. Nothing else should be applied to the area, including ice cubes, which may cause frostbite, and butter, grease, or ointment, which may impel the heat deeper into the skin. If the burn is not oozing, a sterile gauze dressing should be applied, taking care not to break blisters or remove any skin. Medical attention should be sought immediately if the burn is on a child six months or younger or if the burn affects a child’s eyes, face, mouth, hands, feet, or genitals. In addition, blisters, oozing, severe pain, dizziness, breathing problems are all reasons to seek medical attention. Choking Choking is the most common cause of accidental death in children under age one. Choking is life-threatening if a child swallows an object that blocks the flow of air to the lungs. The child will be unable to talk, and his or her face will turn blue. A child who is coughing should not be interrupted, as this strong natural reflex may dislodge the object. The Heimlich maneuver is not recommended for infants; rather, they are to be turned face down on the forearm or lap and administered rapid blows between the shoulder blades. If this fails, the infant is turned on the back and four rapid chest thrusts over the breastbone are given with only two fingers. If all else fails, mouth-to-mouth or mouth-to-nose respiration should be performed.
Safety issues for children ✧ 777 Items that can be swallowed should be kept away from babies, including marbles, coins, safety pins, and small refrigerator magnets. Particular caution must be exercised with toys. Hazards include rattles less than 1 5/8 inches across, eyes or ribbons that come off stuffed animals, balloons, and small parts of toys that break off. Toys labeled for ages three and under must meet federal guidelines requiring they have no small parts. Young children can choke on peanuts, candy, whole grapes, or any hard, smooth food that must be chewed with a grinding motion. Drawstrings in clothing can strangle a child if caught on a slide, school bus door, or handrail. Drawstrings should not be worn at the neck. If they are at the waist of a garment, then knots should be untied, as they may catch on objects. A child should not use playground equipment while wearing clothing with drawstrings. In 1994, the Consumer Product Safety Commission asked clothing manufacturers to remove drawstrings from the hoods of children’s garments; hand-knit or second-hand clothing still poses a risk. Poisoning Ironically, although most parents are aware of the poisonous hazard posed by cleaning products, they do not consider the toxicity of household plants. For example, ivy, geraniums, and philodendrons are poisonous if ingested. In addition, many plants in the yard are toxic. A poison control center can provide names of hazardous plants in a particular region. A poison control center should be called immediately if a child ingests a toxic substance. The number of the regional center is listed on the inside cover of the telephone book and should be posted next to the phone. The parent should report what was ingested, how much, and, if it is a plant, the common and botanical name. Syrup of ipecac to induce vomiting should be readily available, but it should not be administered until instructions are received from the poison control center, since in some cases vomiting causes more harm. If a child gets poison in the eyes or on the skin, the area should be flushed immediately with lukewarm water for a period of fifteen minutes as the poison control center is being called. To prevent the ingestion of poisons, safety locks should be installed on low-level cabinets containing cleaning products and on the medicine chest. Over-the-counter and prescription medicines, soaps, cosmetics, and shampoos are all potentially toxic if ingested by a child. Many people are unaware that vitamins consumed in a sufficient quantity can cause an overdose reaction. Shampoo and soap in the tub should be kept out of a child’s reach. Many parents opt to keep medicines and vitamins, as well as sharp items such as razors, in a separate, high, and locked place. Many automobile and building products are poisonous as well as flammable; they should be kept in locked metal cabinets away from children. In addition, lawn products, such as fertilizer and weed killer, should be kept in a locked area away from toddlers.
778 ✧ Safety issues for children In the late 1990’s, about 1 million children in the United States had elevated blood lead levels. Any building constructed before 1978, the year that lead paint was banned, probably has lead in the paint. This puts a child at risk, especially if the paint is chipped or sanded or renovations are being done. Lead is also found in pipes, made entirely of lead in the United States until the 1950’s; lead was used to fuse copper pipes until 1986. Repainting a home built prior to 1977 is recommended. Even if an area has been covered with nonleaded paint, precautions should be taken when children are not in the house. Chipped and peeling paint should be removed with a wet cloth. If extensive peeled has occurred, the area should be sanded and painted over. Tap water should be run for ninety seconds before using it, as water that as been standing in the pipes has a higher concentration of lead. Cold water should be used for drinking and cooking, as it is less likely to leach lead. High-phosphate detergents are recommended for cleaning. All infants should be tested for lead, no matter how safe the home is. The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) recommend that babies be tested at ages one and two, the ages when they are most likely to put objects that may be covered with lead dust into their mouths. Risk factors for lead exposure in children include living in cities; being poor, African American, or Hispanic; or living in areas where houses were built prior to 1950. Parents should remain alert to any possible exposure, if even their children are not considered at risk. —Lee Williams See also Allergies; Asthma; Burns and scalds; Children’s health issues; Choking; Drowning; Electrical shock; Falls among children; First aid; Food poisoning; Frostbite; Heat exhaustion and heat stroke; Lead poisoning; Lice, mites, and ticks; Parasites; Pesticides; Poisoning; Poisonous plants; Snakebites; Sports injuries among children; Sunburns; Well-baby examinations; Worms; Zoonoses. For Further Information: American Academy of Pediatrics. Baby Alive. Elk Grove Village, Ill.: Author, 1994. Describes procedures for dealing with a medical emergency. For copies of this book or video, write to the following address: AAP, Dept C-“Baby Alive,” 141 Northwest Point Blvd., P.O. Box 927, Elk Grove Village, IL 60009. The phone number of the AAP is (800) 433-9016. _______. Choking Prevention and First Aid for Infants and Children. Elk Grove Village, Ill.: Author, 1994. Free samples of this brochure are available upon request with a self-addressed, stamped #10 envelope to the address listed above, Dept C-“Choking Prevention and First Aid for Infants and Children.” _______. Playground Safety. Elk Grove Village, Ill.: Author, 1994. This bro-
Safety issues for the elderly ✧ 779 chure reviews the safety hazards of playgrounds and offers prevention measures. Free samples of this brochure are available upon request with a self-addressed, stamped envelope to the address listed above, Dept C-“Playground Safety.” Shelov, Steven P., et al., eds. Caring for Your Baby and Young Child: Birth to Age Five. Rev. ed. New York: Bantam Books, 1998. Offers a comprehensive discussion of the accidents that commonly occur with young children, accident-prevention techniques for the home and outdoors, and emergency measures to enact if an accident does take place.
✧ Safety issues for the elderly Type of issue: Elder health, prevention Definition: Physical changes related to aging that put elderly people at higher risk of injury from accidents. The age-related changes that elderly people experience often alter what constitutes a risk to their safety. The family home environment can be dangerous for an elderly person, not because the aspects of the house have changed, but because of the change in the physical abilities of the elderly person. Elderly people with intact cognitive abilities may choose to take the risk of staying in their familiar home environments with full knowledge of the increased risk. The dilemma for others, especially health providers, is defining what constitutes an acceptable level of risk for the elderly. Unintentional injuries (accidents) are the sixth leading cause of death in people over sixty-five years of age. The death rate is 51 per 100,000 people for those sixty-five to seventy-four years of age, rises to 104 per 100,000 for those aged seventy-five to eighty-four, and reaches a high of 256 per 100,000 for those who are eighty-five years of age or older. In the over-eighty-five age group, accidental injury is the fifth leading cause of death. Injuries cost the United States between 75 and 100 billion each year. Accidents are usually viewed as random events over which individuals have little or no control. Many other types of injuries are preventable, and safety enhancement may decrease the number of serious outcomes. Falls Falls account for a considerable number of deaths and injuries among elderly people. They are the second leading cause of death related to unintentional injury, after motor vehicle deaths. Falls are not an uncommon event for elderly people; approximately 30 percent of noninstitutionalized elders report a fall each year. One-half of the people who report falls
780 ✧ Safety issues for the elderly experience multiple falls. Although falls are a common occurrence, they are not always dangerous: Only 11 percent result in a serious injury, and an estimated 1 percent result in hip fractures. The number of hip fractures yearly in the United States (200,000) is substantial and serious. They lead to death in 12 percent to 20 percent of cases and account for 2 percent of the mortality rate in the United States. More than 40 percent of deaths from falls occur in the home. Stairs account for a large proportion of falls, many occurring because the elderly individual misses the last step. Falling injuries account for 40 percent of nursing home admissions; however, more than 20 percent of all fatal falls occur in the nursing home setting. Falls may cause bruises, abrasions, pain, swelling, or fractures. Changes in cognitive function related to pressure from edema or blood clots within the brain may also be evidenced. Psychological damage resulting from falls is more subtle. An older person who sustains little or no injury in a fall may delay or avoid discussing it in order to avoid embarrassment or risk of being viewed as less competent. Falls may also prompt changes in behavior, such as decreased thoroughness in housekeeping tasks or discussion of fears of living alone. Changes in grooming, dress, and personal appearance may also be observed. Increased fear of venturing out into the neighborhood may lead to a decreased ability to meet the daily requirements of shopping and food preparation. Falls are better prevented than treated. Many falls occur in the bathroom. Nonslip bath mats and adhesive-backed, nonskid strips in the bathtub or shower are important safety measures. Grab bars may be placed at critical locations near the bathtub and toilet to lend support. Railings may be installed on stairways for support. A piece of fabric, a knob, or some other marker can be attached to the rail to indicate the level of the top and bottom steps. Traffic Injuries Elderly people with impaired physical capabilities must make a choice between continuing to drive, and therefore maintaining their independence, or taking measures to increase safety for themselves and others on the road. Traffic injuries in the elderly population are divided into two categories: pedestrian injuries and vehicle-related injuries. Elderly people are more at risk for injury at street intersections than anywhere else, both as pedestrians and as drivers or passengers in an automobile. As pedestrians, many elderly people are at risk because of an inability to cross the street in the time allotted between changes in the traffic lights. Factors that may influence pedestrian injuries are curb height, driver error, and physical and cognitive impairment of the elderly pedestrian. A major problem for older drivers is the multivehicle accident, and the
Safety issues for the elderly ✧ 781 risk for injury in these crashes increases dramatically with age. The majority of such accidents take place in daylight, on good roads, and with no alcohol involvement. Elderly people experience a higher mortality rate with less severe injuries in vehicle crashes; the risk of death is three times greater for a seventy-year-old person than for a twenty-year-old person. The major factor that influences the high susceptibility of involvement in traffic injuries may be the decreased skill of the elderly person in operating an automobile. This change in skill level may be caused by age-related changes, such as decreased visual acuity or a slower neurological response time. Citations for traffic violations, such as failure to yield right-of-way and failure to obey traffic signs, increase after the age of sixty. Although older adults have lower accident rates and fewer traffic violation citations than those under twenty-five years of age, elderly people have an increased risk of fatality in traffic accidents. One group of elders at increased risk for vehiclerelated injury are those who are experiencing the early signs and symptoms of dementia. The American Association for Retired Persons (AARP) operates special classes in driver education to help older adults cope with age-related changes that affect their driving abilities. Safety Considerations Safety is a major concern when assessing living conditions. Many older adults live in unsafe housing. Relatively minor nuisances—such as excessive clutter, loose flooring or floor coverings, poor lighting, and unstable stairs—can pose safety risks for the older adult. Financial constraints may prompt older adults to settle for living in less desirable areas. Other safety concerns are related to the older adult’s physical or mental functioning. People who have trouble walking or climbing stairs are prime examples of those at risk as the result of impaired physical functioning. People who are forgetful or who wander off and get lost pose a significant risk to themselves and others as the result of impaired mental function. It may be necessary to observe the elderly actually moving about in their environment to locate any potential problems. If the elderly person uses an assistive device, such as a cane, walker, or wheelchair, the environment may require further modifications. Ramps may need to be installed, or living arrangements may need to be changed to accommodate these ramps. —Jane Cross Norman See also Aging; Alzheimer’s disease; Broken bones in the elderly; Burns and scalds; Canes and walkers; Death and dying; Dementia; Disabilities; Exercise and the elderly; Falls among the elderly; First aid; Foot disorders; Injuries among the elderly; Memory loss; Mobility problems in the elderly; Osteoporosis; Overmedication; Wheelchair use among the elderly.
782 ✧ Schizophrenia For Further Information: Abramson, Alexis. Home Safety for Seniors. Atlanta: Mature Mart Press, 1997. Gill, T. M., C. S. Williams, J. T. Robison, and M. E. Tinetti. “A PopulationBased Study of Environmental Hazards in the Homes of Older Persons.” American Journal of Public Health 89, no. 4 (1999): 553-556. Kannus, P., et al. “Fall-Induced Injuries and Deaths Among Older Adults.” JAMA 281, no. 20 (May 5, 1999): 1895-1899. Lachs, Mark S. “Caring for Mom and Dad: Can Your Parent Live Alone?” Prevention 50, no. 10 (October, 1998): 155-157. Lisak, Janet M., and Marlene Morgan. The Safe Home Checkout: A Professional Guide to Safe Independent Living. 2d ed. Chicago: Geriatric Environments for Living and Learning, 1997.
✧ Schizophrenia Type of issue: Mental health Definition: A disease of the brain characterized by withdrawal from the world, delusions, hallucinations, and other disorders in thinking. The symptoms of schizophrenia include a break with reality, hallucinations, delusions, or evidence of thought disorder; these are referred to as positive symptoms. Negative symptoms include withdrawal from society, the inability to show emotion or to feel pleasure or pain, total apathy, and the lack of a facial expression. The patient simply sits and stares blankly at the world, no matter what is happening. Forms of Schizophrenia Schizophrenia can take many forms. Among the most frequent are those that display acute symptoms under the following labels. Melancholia includes depression and hypochondriacal delusions, with the patient claiming to be extremely physically ill but having no appropriate symptoms. Mania is characterized by withdrawal and a mood of complete disinterest in the affairs of life. Schizophrenia can also be catatonic, in which patients become immobile and seem fixed in one rigid position for long periods of time. Delusional states accompanied by hallucinations frequently involve hearing voices, which often scream and shout abusive and derogatory language at the patient or make outrageous demands. The delusions are often visual and involve frightening monsters or aliens sent to do harm to the afflicted person. The preceding symptoms can often be accompanied by disconnected speech patterns, broken sentences, and excessive body movement and
Schizophrenia ✧ 783 purposeless activity. Victims of the disease also suffer through states of extreme anger and hostility. Cursing and outbursts of uncontrolled rage can result from relatively insignificant causes, such as being looked at “in the wrong way.” Many times, anniversaries of important life experiences, such as the death of a parent or the birthday of a parent or of the patient, can set off positive and negative symptoms. Hallucinations and mania can also follow traumatic events such as childbirth or combat experiences during war. The paranoid form of schizophrenia is the only one that usually develops later in life, usually between the ages of thirty and thirty-five. It is a chronic form, meaning that patients suffering from it usually become worse. Paranoid schizophrenia is characterized by a feeling of suspiciousness of everyone and everything, hallucinations, and delusions of persecution or grandiosity. This form becomes so bad that many victims, perhaps one out of three, eventually commit suicide simply to escape their tormentors. Others turn on their alleged tormentors and kill them, or at least someone who seems to be responsible for their terrible condition. Other chronic forms of the disease include hebephrenic schizophrenia. In this case, patients suffer disorders of thinking and frequent episodes of incoherent uttering of incomprehensible sounds or words. The victims move quickly from periods of great excitement to equally exhausting periods of desperate depression. They frequently have absurd, bizarre delusions such as sex changes, identification with and as godlike creatures, or experiences of being born again and again. Those suffering from “simple” schizophrenia exhibit constant feelings of dissatisfaction with everything in their lives or a complete feeling of indifference to anything that happens. They are usually isolated and estranged from their families or any other human beings. Patients with these symptoms tend to live as recluses with barely any interest in society, in work, or even in eating or in talking to anyone else. The Development of the Disease The various types of schizophrenia start at different times in different people. Generally, however, except for the paranoid form, the disease develops during late adolescence. Men show signs of schizophrenia earlier than women, usually by age eighteen or nineteen. It is unusual for signs of the disorder to appear in males after age twenty. In women, symptoms may not appear until the early twenties and sometimes are not evident until age thirty. Sometimes, there are signs in childhood. People who later develop schizophrenia tended to be withdrawn and isolated as children and were often made fun of by others. Not all withdrawn children develop the disease, however, and there is no way to predict who will get it and who will not. Schizophrenia is a genetic disease. Individuals with the disease are very likely to have relatives—mothers, fathers, brothers, sisters, cousins, grand-
784 ✧ Schizophrenia mothers, or grandfathers—with the disorder. Surveys indicate that 1 percent of all people have the disease. A person with one parent who has the disease is ten times more likely to develop schizophrenia than a member of the general public. Thirty-nine percent of people who have both parents afflicted with the disease also develop schizophrenia. Schizophrenia operates by disrupting the way in which brain cells communicate with each other. The neurotransmitters that carry signals from one brain cell to another might be abnormal. Malfunction in one of the transmitters, dopamine, seems to be a source of the problem. This seems likely because the major medicines that are successful in the treatment of schizophrenia limit the production or carrying power of dopamine. Another likely suspect is serotonin, a transmitter whose presence or absence has important influences on behavior. Treatment and Therapy Since the 1950’s, many medications have been developed that are very effective in treating the symptoms of schizophrenia. Psychotherapy can also be effective and beneficial to many patients. Drugs can be used to treat both positive and negative symptoms. Some such as Haldol, Mellaril, Prolixin, Navane, Stelazine, and Thorazine are used to treat positive symptoms. Clozapine and Risperidone can be used for both positive and negative symptoms. These medications work by blocking the production of excess dopamine, which may cause the positive symptoms, or by stimulating the production of the neurotransmitter, which reduces negative symptoms. Clozapine blocks both dopamine and serotonin, which apparently makes it more effective than any of the other drugs. The chief problem resulting from the use of such drugs are the terrible side effects that they can produce. The most dreaded side effect, from the point of view of the patient, is tardive dyskinesia (TD). This problem emerges only after many years of use. TD is characterized by involuntary movement of muscles, frequent lip-smacking, facial grimaces, and constant rocking back and forth of the arms and the body. It is completely uncontrollable. Dystonias are another side effect. Symptoms include the abrupt stiffening of muscles, such as the sudden contraction of muscles in the arms, neck, and face. Most of these effects can be controlled or reversed with antihistamines. Some patients receiving medication are afflicted with effects similar to those movements associated with Parkinson’s disease. They suffer from the slowing of movements in their arms and legs, tremors, muscle spasms. Their faces seem frozen into a sad, masklike expression. These effects can be treated with medication. Another problem is akathisia, a feeling developed by many patients that they cannot sit still. Their jumpiness can be treated with Valium or Xanax. Some of these side effects are so severe or embarrass-
Schizophrenia ✧ 785 ing that patients cite them as the major reason that they do not take their medicine. Many patients report great value in family or rehabilitation therapy. These therapies are not intended to cure the disease or to “fix” the family. Instead, they are aimed at helping families learn how to live with mentally ill family members. Family support is important for victims of schizophrenia because they usually are unable to live on their own. Therapy can also help family members understand and deal with their frustration and the constant pain that results from knowing that a family member is very ill and probably will not improve much. Rehabilitation therapy is an attempt to teach patients the social skills that they need to survive in society. —Leslie V. Tischauser See also Dementia; Depression; Depression in children; Depression in the elderly; Domestic violence; Genetic diseases; Health problems and families; Suicide; Suicide among children and teenagers; Suicide among the elderly. For Further Information: Gorman, Jack M. The New Psychiatry: The Essential Guide to State-of-the-Art Therapy, Medication, and Emotional Health. New York: St. Martin’s Press, 1996. A well-written, easy-to-understand book by a doctor and researcher that provides the latest information concerning the development of new medications, treatments, and therapies. Valuable information on the new antipsychotic drugs, how they work, and what their possible side effects are. Johnstone, Eve C., et al. Schizophrenia: Concepts and Clinical Management. New York: Cambridge University Press, 1999. Written in conjunction with colleagues from Edinburgh, Eve Johnstone’s book is a useful summary of current knowledge. The suggestion that psychosis can be thought of as occurring along three dimensions—positive, negative, and disorganized— with distinct pathological mechanisms, is well argued but probably still falls short of being an accepted theory. Marsh, Diane T. Families and Mental Illness: New Directions on Professional Practice. New York: Praeger, 1992. A good book on the role of families in the care and treatment of the mentally ill. Written for professionals but very useful for anyone who must learn to deal with schizophrenia. Torrey, E. Fuller. Surviving Schizophrenia: A Manual for Families, Consumers, and Providers. 3d ed. New York: Harper & Row, 1995. Perhaps the best single book on the topic, by a leading medical researcher and advocate of more humane care for the mentally ill. Describes the latest research into the origins of the illness and provides useful information and evaluations of the newest drugs and best forms of treatment. Woolis, Rebecca. When Someone You Love Has a Mental Illness: A Handbook for
786 ✧ Scoliosis Family, Friends, and Caregivers. New York: Jeremy P. Tarcher/Perigree Books, 1992. A brief, practical guide that gives useful tips on handling the anger, hostility, and bizarre behavior exhibited by people with the disease. Also describes how to help patients to live at home and what to do if suicide is threatened. A very valuable sourcebook.
✧ Scoliosis Type of issue: Children’s health, public health Definition: Abnormal curvature of the spine, often progressive, which can result in severe deformity and associated medical problems. The normal spine takes the form of four separate curves. If one looks at a person with good posture from the side, however, the gently S-shaped curve of the spine is clearly visible. Deformities involving abnormal spinal curvature toward the front or back are well known, but they are not called scoliosis. The side-to-side curvature of scoliosis is referred to as a lateral curve. Types of Scoliosis Scoliosis can result from a number of different causes. While a birth defect, an accident, poliomyelitis, or muscular dystrophy can all result in lateral curvature, the cause is unknown in the majority of cases. Some authorities believe that 80 percent of all scoliosis has no known cause. The technical term for this important class of malady is “idiopathic scoliosis.” Within this general subdivision, three separate forms are recognized, based on the age of the patient at the onset of the curvature. The adolescent form of scoliosis, which is usually recognized between ten and thirteen years of age, is by far the most common form. It is also occurs as infantile (birth to three years) and juvenile (four to ten years) scoliosis. When the scoliosis is recognized in the youngest range, it is more common in males, with one study giving a 3:2 ratio. By contrast, in the far more common adolescent condition one finds a striking shift to females, who are three times more likely to be affected. While it is often observed that infantile idiopathic scoliosis corrects itself, this natural remission is rarely observed when the diagnosis is made later. The juvenile condition is likely to be related closely to adolescent scoliosis. As before, there is marked evidence of hereditary influence. In this age range, males and females share equally in the likelihood of being diagnosed. The chance of significant progression of the curvature is so variable that close watching of the patient is the single point of common
Scoliosis ✧ 787 agreement among specialists. There is concern among parents, patients, and practitioners alike over the excessive use of X rays for diagnosis. Major Classes of Curvature A dozen different types of curves associated with scoliosis have been identified, but four major classes are of greatest frequency and concern. In the chest area, one finds the most common of all curve patterns, the right thoracic curve. It is possible for this condition to progress rapidly. Early treatment is essential. As the curve develops, the ribs on the right side shift and create a deformity which not only is unattractive but also can squeeze the heart and lungs; this so-called rib hump can result in serious cardiopulmonary difficulties. A similar, but gentler, curve is the thoracolumbar curve. It begins in the same region of the thoracic vertebrae and ends further down the back, in the lumbar region. The twist may be either right or left and is generally less deforming in its appearance. A lumbar curve is found far down in that region of the back, producing a twist in the hips. In pregnant women and other adults, this twist often causes severe back pain. The three curves described thus far are single, or C-shaped, curves. The double major curve is an S-shaped curve and is the most common of that type. Curvature begins in the thoracic or chest area and is complimented by a second curve in the opposite direction found in the lumbar region. To some extent, the two curves offset each other and the scoliosis is less deforming. The double major curve can progress and become the source of a rib hump. Diagnosing Scoliosis A diagnostic examination for scoliosis demands specific attention to accurate family his-
(Hans & Cassidy, Inc.)
788 ✧ Scoliosis tory. Particularly important is information concerning the first recognition and previous treatment of the condition. Then a detailed evaluation of the nature and extent of the curvature must be made. The examining physician should make certain that the patient is standing straight with the knees unflexed. A simple plumbline is used to examine the patient’s back to determine any curvature in the spine. Then the forward bending test is conducted. This observation is considered one of the most reliable diagnostic tools. Various forms of curvature, including scoliosis, can be seen by the trained observer. When viewed, at eye level from both front and back, one side of the thoracic or lumbar regions is higher. An accurate measurement of the degree of difference can be made with a level. The use of X-ray photographs also forms a vital part of the diagnostic data. Even with the best diagnostic skill, training, and experience, the decision concerning the treatment of scoliosis is hardly straightforward. One important consideration is the patient’s bone age. Because people grow and mature at such different rates, chronological age may not correspond well to the degree of maturity of that person’s skeleton. Many clues are used to determine the bone age, including the degree of fusion observed in the individual vertebra or the bony pelvic girdle. A catalog of X rays of hands is available and provides a useful measure of the bone age. The central concern is that curvature is more likely to progress if the growth and development of the patient’s skeleton is still incomplete. Braces, Casts, and Surgery The treatment of scoliosis varies from none at all to extensive surgical procedures. In general, treatment is undertaken for the prevention of further curvature or for the correction of the curvature already present. Some treatments, such as exercise, are of benefit to the patient in general but are seen as having no prospect of arresting or correcting the spinal curvature. The use of braces and casts is certainly the oldest and the most common treatment. The many modifications of design and material used in braces over the centuries have had the central purpose of forcing the spine to become straight. The evolution of the brace has reached the point of an active or kinetic apparatus called the Milwaukee brace. It is a carefully designed assembly of a molded plastic pelvic girdle, three metal bars which keep the wearer erect and allow a neck ring to be attached. The neck ring and its associated axillary sling keep the torso balanced and prevent listing to the right or left. In order for the Milwaukee brace (or any modified versions of it) to be effective, it must be worn day and night and until the growth period of the patient has been completed. It is also imperative that exercise be carried out on a daily basis. There are many advantages of the modern brace over older systems. For example, it can be removed for showering and swimming, and much greater activity is allowed. The one serious drawback is that a patient
Scoliosis ✧ 789 must not expect correction of the scoliosis. The value of the brace is that it can, with good use and exercise, maintain the already present curvature and prevent further progression. With curves of 40 or 50 degrees, pain that does not respond to treatment, or the failure of the brace to stop the curve’s progression, surgery is the most reasonable approach. Surgery can offer some degree of correction, but it is important to recognize that only a partial correction is possible. Even with the safest techniques, pressure must be applied to the spine, creating a serious risk of damage to the spinal cord. Most authorities estimate reasonable correction to be about 60 percent. A wide range of methods are available. The most common, and generally considered the safest, method is the Harrington rod technique. The incision is from the back (as opposed to front or side entries), and metal hooks are inserted at the highest and lowest points in the curve. These hooks hold metal rods used to straighten the spine and then to hold it in place. Small chips of bone are then taken from the hip or ribs and inserted between especially prepared vertebrae. In a period of six to eight months, solid bone will grow and fuse the vertebrae, giving a solid bone mass of a single elongated vertebra. After the surgery, the patient is usually placed in a brace or cast for four to six months. The success of the Harrington rod technique has inspired several modifications, such as using two rods to achieve more balance and greater correction. With a patient who has unusually soft bones, a system of wires is used to hold the rods in place. This method is considered superior because the normal hooks might break off. Several variants of the wire technique are also available. Some surgeons thread the wires through the neural canal, and others drill small holes to avoid coming near to the spinal cord. Another technique which is growing in popularity uses many small wires attached through the neural canal and twisted around two thin rods, one on either side of the curvature. This Luque method provides greater stability, and usually there is no need to wear a cast after surgery. These advantages must be balanced, however, against a significantly greater risk of paralysis and a smaller amount of room for new bone growth in fusion. Another modern technique which is showing some success involves placing small electrodes near the spine and transmitting tiny electrical impulses to nerve endings periodically during sleep. This electronic bracing, or electrosurface stimulation, appears to stop scoliosis curves from progressing in about 80 percent of the cases studied. The application of these devices has about the same limitations as conventional braces—that is, curves of greater than 40 degrees, curves treated after the end of bone growth, and certain types of lumbar curves will fail to benefit from this treatment. —K. Thomas Finley See also Birth defects; Children’s health issues; Screening.
790 ✧ Screening For Further Information: Cailliet, Rene. Scoliosis: Diagnosis and Management. Philadelphia: F. A. Davis, 1975. A well-written description of the entire range of scoliosis, along with a good bibliography and many diagrams. Eisenpreis, Bettijane. Coping with Scoliosis. New York: Rosen, 1998. Designed for students in grades seven to ten, this clearly written and well-organized book looks at the patterns of spinal curvature, treatment options, and emotional effects of this condition. Provides helpful, factual information while offering reassurance and hope. Neuwirth, Michael, with Kevin Osborn. The Scoliosis Handbook. New York: Henry Holt, 1996. This popular work, subtitled A Consultation with a Specialist, educates the general reader about scoliosis. Includes a bibliography and an index. Sachs, Elizabeth-Ann. Just Like Always. New York: Atheneum, 1981. A beautifully written story of two young ladies who share so much more than their hospitalization for surgery. Dated technical information is nevertheless skillfully woven into this essential book for anyone suffering from scoliosis. Schommer, Nancy. Stopping Scoliosis: The Complete Guide to Diagnosis and Treatment. New York: Doubleday, 1987. One of the best books written for the layperson that is devoted to the discussion of a medical problem. Includes many references to other information, specialists, and organizations concerned with the study and treatment of scoliosis. An important text.
✧ Screening Type of issue: Medical procedures, prevention, public health Definition: A strategy used by physicians and public health professionals to diagnose disease or the potential for disease at an early stage, when it may be treatable or preventable; may be a mandatory procedure for a specific population or a voluntary activity requested by individuals. Screening is an activity that is intended to identify a condition or a disease before symptoms develop in a person, at which time the condition becomes apparent to a clinician or has a negative impact on the individual or society. From a clinical perspective, screening and early detection are intended to prevent disease in or provide early treatment for an asymptomatic, apparently healthy person. Detection and treatment of high cholesterol and abnormal lipids, for example, will prevent heart attacks, strokes, and other cardiovascular problems. Early detection of a cancer may mean the difference between survival and death. Screening is distinguished from testing persons who have developed symptoms of a disease or condition. Screening
Screening ✧ 791 programs for infectious diseases also serve the public’s health by identifying infected persons and directing them to appropriate health care, thereby limiting disease transmission. Screening techniques vary in the sophistication of the technology used and the cost to the consumer. They may be quick, simple, and inexpensive, such as a total blood lipid profile obtained from a booth in a shopping mall: about five minutes, from the finger prick for a blood sample to a printed profile, and usually available at no cost. They may be time-intensive, technologically advanced, and costly, as in the case of a mammogram for the detection of breast masses indicative of breast cancer: two to three hours from the time of the appointment to the completion of the procedure, with potential adverse effects from radiation and at a high cost to the patient. In the United States, the costs associated with screening for the presence of a disease are often not reimbursable from standard, commercial health insurance policies; however, insurers are increasingly encouraging periodic screening for individuals associated with defined populations and reimbursing providers for much of the costs associated with the procedures involved. Health maintenance organizations (HMOs) routinely offer patients comprehensive periodic screenings to afford diagnosis and treatment at a stage when the disease or condition is relatively easy and inexpensive to treat. The appropriateness of screening for a disease or condition rests primarily upon the disease or condition in question and the screening technique chosen. The Practicality of Screening The natural process of the disease studied is an important determinant for whether and when a screening procedure may be practical. There is a time lag associated with every condition, from initial exposure to the onset of infection or development of a cancer or other disorder and the point at which early diagnosis is possible. Screening is ineffective if it occurs during this time interval, called the biologic onset of disease. For some diseases, biologic onset occurs immediately or within days upon the initial interaction with the causal agent. There is an eight-to-thirteen-day period between exposure to the measles virus and onset of fever. For other conditions, early diagnosis becomes possible after a more prolonged period as in the case of tuberculosis, in which the onset of infection occurs about four to twelve weeks after exposure. Screening protocols can be organized as unlinked, anonymous, or confidential. Unlinked screening occurs when a blood, fluid, or tissue specimen is examined without the possibility of identifying its source. In anonymous screening, samples are identified by a code that is known only to the person tested and the results of the test are made known to the person tested. Confidential screening occurs when a health care provider orders a test and receives the test results.
792 ✧ Screening Screening Participation Participation in screening programs may be voluntary, routine, or mandatory. The nature of the condition examined, its significance for the public’s health, and the situation in which a potentially infected person is identified all pose guidelines for the means of structuring participation in a screening program. Mandatory screening occurs when the individual has no choice but to undergo the screening procedure. For example, a government may require all military recruits to be screened for a variety of infectious diseases to prevent epidemics from occurring within the military. In the United States, some federal and state statutes call for screening newly incarcerated prisoners, the mentally ill, and other institutionalized groups to avoid transmission of infection among the larger group. Some states require that all marriage certificate applicants undergo screening for syphilis to protect potential unborn children from the consequences of congenital infection. From the individual’s perspective, there is little to differentiate mandatory screening from routine screening. The difference lies in whether enabling legislation exists requiring an individual to undergo the screening procedure. Blood banks routinely screen donated blood for hepatitis B and antigens to HIV. Many hospitals routinely screen surgery patients for the presence of HIV antigens to protect health care workers. Commercial life insurance applicants are almost always required to undergo a physical examination and to provide samples of blood, urine, and even feces for screening tests. The rationale for routine screening is sometimes disputed. For example, health care professionals are expected to maintain vigilance regarding virus transmission by avoiding direct contact with blood and body fluids of all patients in accord with universal precautions, which were developed by the Centers for Disease Control (CDC). Presumably, knowledge of a patient’s infection status should not justify altering the way in which a health care provider encounters the patient, nor should it justify altering patient care. Hospitals and surgeons reason that alternative methods may be employed for some surgical procedures that may potentially reduce the chances of the physician receiving an injury from a needle or a bone fragment while suturing a wound or manipulating organs within the body. Routine screening for blood-borne diseases is also recommended by some hospitals and law enforcement agencies for employees who come into contact with blood or body fluids through needle pricks or human bites. Mandatory screening is most effective and scientifically useful in cases where testing is anonymous or unlinked (such as blood banks or research protocols for the purpose of surveying the epidemiology of an infection). Routine screening may be justified when implemented within a defined group of people who, by nature of their living or working situations, are at greater risk for infection than the general public (soldiers, prisoners, the institutionalized, hemophiliacs, health care workers, law enforcement officers) or who fall into a high-risk group for other disorders such as cancer.
Screening ✧ 793 Routine hospital screening for preoperative patients is considered justified by the CDC only when the institution can document a high prevalence of HIV within the population likely to access its services. Mandatory and routine screening for most conditions, however, are usually too costly and inefficient to justify. Voluntary screening occurs when individuals avail themselves of a screening procedure for no other reason than personal knowledge of infection or disease status. In some cases, when a condition may be engendered through lifestyle choices rather than by airborne transmission or casual contact, and may be more predominant in specific subpopulations or minority groups, mandatory screening is probably counterproductive. Human immunodeficiency virus (HIV) is an example of an infection for which screening individuals on a voluntary basis is expected to yield more positive results than a mandatory program. Transmission of the acquired immunodeficiency syndrome (AIDS) virus occurs only through intimate contact, not casual contact. Although a required mass screening program may appease public anxiety about widespread infection, it may also have the unintended result of causing infected individuals to be secretive about their disease status. Pulmonary tuberculosis, on the other hand, is an example of a disease that is highly transmissible through casual contact and for which well-structured screening programs for specific populations are likely to benefit the public’s health. Although the epidemiology of tuberculosis is such that the antibiotic-resistant strain, the cause of the disease’s resurgence in the 1990’s, is most prevalent among intravenous drug users and their sexual partners, the benefits of restraining infection through screening far outweigh the potential dangers of a mass-screening program. Risks and Benefits Screening should never occur without a full disclosure by the health care professional regarding the concomitant risks and benefits and without the individual’s consent. The concept of informed consent is a hallmark of the scientific and medical code of ethics in the United States. The recognition that informed consent is a crucial part of any medical study or screening program grew out of several striking and severe abuses of medical power that occurred during the twentieth century. The ideal screening tool is one that is noninvasive, quick, inexpensive, and always accurate. Although these characteristics may appear simple to evaluate, the scientific and medical communities apply rigorous criteria to screening techniques to assess the extent to which they conform to the ideal. A screening technique should be valid; that is, it should appropriately do what it intends to do by categorizing persons accurately who have a preclinical disease as test-positive and those who do not have a preclinical disease as test-negative. Validity consists of two components: sensitivity and specificity.
794 ✧ Screening Sensitivity is defined as the ability of a test to identify correctly those who have the disease, while specificity is the ability to identify those who do not. Sensitivity and specificity are complements of each other; therefore, a single test cannot be both highly sensitive and highly specific. The best screening tests sacrifice a small degree of sensitivity to gain specificity, and vice versa. In some cases, these thresholds are arbitrarily set. For example, if in a hypertensive screening program the threshold for positivity for diastolic blood pressure, indicating hypertension, were set low, most people who actually have the disease would be identified. Many people who are not hypertensive, however, those whose diastolic blood pressures are greater than the threshold, would be falsely diagnosed with hypertension. Falsepositive and false-negative results can have significant consequences when they lead to subsequent treatment for the incorrectly diagnosed condition or lack of treatment for the undiagnosed condition. A screening technique must be reliable to be considered useful. A highly reliable, or precise, screening technique is one that provides consistent results when the technique is performed more than once on the same individual under the same conditions. The reliability of a technique can be increased by minimizing the variability of interpreting its results and by defining and quantifying its end points. Finally, a screening technique must be beneficial; it must do more good than harm. It must provide adequate results (both reliable and valid) by identifying presymptomatic individuals at a cost that is less than what would be spent on potential morbidity and mortality from the disease or condition if it went undetected. Expenses incurred by both the individual and the society should be considered when estimating the economy and benefits of a screening tool. Individual expense would include specific medical costs, transportation costs, and the less tangible costs of submitting to potentially unpleasant medical care. Societal costs would include such issues as a measure of resources used to benefit one individual and the loss of productivity for a period of time. Rigorous scientific evidence has not yet been developed to determine the effectiveness of some screening techniques that society has come to accept as beneficial. Rather, as in the case of screening for cervical cancer, the evidence for its benefit lies mainly in the comparison of trends of deaths from cervical cancer among countries that have wellorganized screening and those that do not. Ethical Considerations Complex ethical and practical issues arise with this increased ability to screen for genetic disorders. In the first place, not every person with a genetic predisposition to a given disorder will develop that disorder. Understanding of the other, nongenetic, factors that allow one person with a given gene or set of genes to remain healthy throughout life and those factors that
Screening ✧ 795 cause another person with the same genes to fall ill is still limited. Questions arise about how to treat people with a genetic predisposition to a disorder. Some worry that people with certain gene patterns will be unable to obtain health or life insurance. Others worry about the mental health of a person shown by genetic screening to be at risk for a serious disease. Genetic manipulation for the treatment or prevention of disease is yet another controversial issue that society as a whole must address. —John G. Ryan, Dr.P.H.; updated by Rebecca Lovell Scott See also AIDS; AIDS and children; AIDS and women; Amniocentesis; Breast cancer; Cancer; Cervical, ovarian, and uterine cancers; Childhood infectious diseases; Colon cancer; Diabetes mellitus; Down syndrome; Epidemics; Genetic counseling; Genetic diseases; Heart disease; Heart disease and women; Herpes; Hypertension; Immunizations for children; Immunizations for the elderly; Lung cancer; Mammograms; Phenylketonuria (PKU); Preventive medicine; Prostate cancer; Scoliosis; Sexually transmitted diseases (STDs); Skin cancer; Spina bifida; Tuberculosis. For Further Information: Bennett, Rebecca, and Charles A. Erin. HIV and AIDS: Testing, Screening, and Confidentiality. New York: Oxford University Press, 1999. This book sets out the different points of view that have been gathered by the University of Manchester under the direction of John Harris. It is based on research financed by the European Commission of Bio-medicine. Dawson, Deborah A. Breast Cancer Risk Factors and Screening: United States, 1987. Hyattsville, Md.: U.S. Department of Health and Human Services, Public Health Center, Centers for Disease Control, and National Center for Health Statistics, 1990. Examines data from the National Health Interview Survey (NHIS), a periodic survey of a sample of the U.S. population to identify health status. Addresses cancer epidemiology and control. McBride, David. From TB to AIDS: Epidemics Among Urban Blacks Since 1900. Albany: State University of New York Press, 1991. Infectious diseases capitalize on social situations that facilitate their transmission: poverty and immune systems compromised by other infectious diseases or drugs. These factors are common among the minority populations, causing infectious diseases to affect them disproportionately. McBride’s review of infectious diseases that have affected urban-dwelling African Americans is a well-written review of this aspect of public health. Miller, Anthony B., ed. Screening for Cancer. Orlando, Fla.: Academic Press, 1985. This book focuses on the principles of screening and of its evaluation, the available tests for specific types of cancer, and the issues associated with specific cancer sites (such as the breast).
796 ✧ Seasonal affective disorder (SAD)
✧ Seasonal affective disorder (SAD) Type of issue: Mental health Definition: A variant of depression that may be related to premenstrual syndrome, carbohydrate-craving obesity, and bulimia; it responds to a form of treatment known as phototherapy. Seasonal affective disorder (SAD) became the focus of systematic scientific research in the early 1980’s. Research originally focused on seasonal changes in mood that coincided with the onset of winter and became known as winter depression. Symptoms consistently identified by Norman Rosenthal and others as indicative of winter depression included hypersomnia, overeating, carbohydrate craving, and weight gain. Michael Garvey and others found the same primary symptoms and the following secondary ones: decreased libido, irritability, fatigue, anxiety, problems concentrating, and premenstrual sadness. Several researchers have found that winter depression is more of a problem at higher latitudes. Thomas Wehr and Norman Rosenthal report on a description of winter depression by Frederick Cook during an expedition to Antarctica in 1898. While winter depression is the form of seasonal affective disorder receiving the most initial attention, there is another variation that changes with the seasons. Summer depression affects some people in the same way that winter depression affects others. Both are examples of seasonal affective disorder. According to Wehr and Rosenthal, symptoms of summer depression included agitation, loss of appetite, insomnia, and loss of weight. Many people with summer depressions also have histories of chronic anxiety. As can be seen, the person with a summer depression experiences symptoms which are almost the opposite of the primary symptoms of winter depression. In order to diagnose a seasonal affective disorder, there must be evidence that the symptoms vary according to a seasonal pattern. If seasonality is not present, the diagnosis of SAD cannot be made. The seasonal pattern for winter depression is for it to begin in November and continue unabated through March. Summer depression usually begins in May and continues through September. Siegfried Kasper and others reported that people suffering from winter depression outnumber those suffering from summer depression by 4.5 to 1. Wehr and Rosenthal reported that as people come out of their seasonal depression they experience feelings of euphoria, increased energy, less depression, hypomania, and possibly mania. Philip Boyce and Gordon Parker investigated seasonal affective disorder in Australia. Their interest was in determining whether seasonal affective disorder occurs in the Southern Hemisphere and, if so, whether it manifests the same symptoms and temporal relationships with seasons as noted in the Northern Hemisphere. Their results confirmed the existence of seasonal
Seasonal affective disorder (SAD) ✧ 797 affective disorder with an onset coinciding with winter and remission coinciding with summer. Their study also provided evidence that seasonal affective disorder occurs independently of important holidays and celebrations, such as Christmas. There is also a subsyndromal form of seasonal affective disorder. This is usually seen in winter depression and represents a milder form of the disorder. It interferes with the person’s life, although to a lesser degree than the full syndrome, and it is responsive to the primary treatment of seasonal affective disorder. Possible Causes Three hypotheses are being tested to explain seasonal affective disorder. The first is the melatonin hypothesis; the second is the circadian rhythm phase shift hypothesis; and the third is the circadian rhythm amplitude hypothesis. The melatonin hypothesis is based upon animal studies and focuses on a chemical signal for darkness. Studies show that during darkness, the hormone melatonin is produced in greater quantities; during periods of light, it is produced in lesser quantities. Increases in melatonin level occur at the onset of seasonal affective disorder (winter depression) and are thought to be causally related to the development of the depression. A second hypothesis is the circadian rhythm phase shift hypothesis. This hypothesis contends that the delay in the arrival of dawn disrupts the person’s circadian rhythm by postponing it for a few hours. This disruption of the circadian rhythm is thought to be integral in the development of winter depression. Disruptions in the circadian rhythm are also related to secretion of melatonin. The third hypothesis receiving much interest is the circadian rhythm amplitude hypothesis. A major tenet of this hypothesis is that the amplitude of the circadian rhythm is directly related to winter depression. Lower amplitudes are associated with depression, and higher ones with normal mood states. The presence or absence of light has been an important determinant in the amplitude of circadian rhythms. While each of these hypotheses has data to support it, the melatonin hypothesis is falling out of favor. Rosenthal and others administered to volunteers in a double-blind study a drug known to suppress melatonin secretion and a placebo. Despite melatonin suppression, there was no difference in the degree of depression experienced by the two groups (drug and placebo). Both the circadian rhythm phase shift hypothesis and the circadian rhythm amplitude hypothesis continue to have significant research interest and support.
798 ✧ Seasonal affective disorder (SAD) Diagnosing SAD Seasonal affective disorder was officially recognized in 1987 in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, (rev. 3d ed., DSM-III-R). It was included in the manual as a variant of major depression. In order to diagnose the seasonal variant, the depressed person must experience the beginning and ending of the depression during sixtyday windows of time at the beginning and ending of the season and must meet the criteria for the diagnosis of major depression. Additionally, that person must have had more than three episodes of seasonal affective disorder, and two episodes must have occurred consecutively. Finally, the ratio of 3 to 1 seasonal to nonseasonal episodes must exist in the absence of any seasonally related psychosocial stressors (such as Christmas). Including the diagnosis in the DSM-III-R not only validates individuals who report feeling better or worse at different times of year but also encourages researchers to study the causes, variations, and treatments of this form of depression. Prevalence studies have found that the female-male ratio for seasonal affective disorder is approximately 4 to 1. The age of onset is about twentytwo. The primary symptoms of seasonal affective disorder overlap with other diagnoses which have a relatively high female-to-male ratio. For example, people diagnosed with winter depression frequently crave carbohydrateloaded foods. In addition to carbohydrate-craving obesity, another serious disorder, bulimia nervosa, involves binging on high-carbohydrate foods and has a depressive component. Bulimia nervosa is much more common in females than it is in males. While most of the research has focused on seasonal affective disorder in adults, it has also been found in children. Children affected with seasonal affective disorder seem to experience a significant decrease in their energy level as their primary symptom rather than the symptoms seen in adults. This is not unusual; in many disorders, children and adults experience different symptoms. The winter variant of seasonal affective disorder is much more common than the summer variant. It appears that winter depression is precipitated by the reduction in light that accompanies the onset of winter. As a result, it is also quite responsive to phototherapy. Summer depression, the summer variant of seasonal affective disorder, is precipitated by increases in humidity and temperature associated with the summer months. This suggests a different (and currently unknown) mechanism of action for the two variations of seasonal affective disorder. Treatment Options The importance of light in the development and treatment of the winter variant of seasonal affective disorder has been demonstrated in a variety of studies worldwide. The general finding is that people living in the higher
Seasonal affective disorder (SAD) ✧ 799 latitudes are increasingly susceptible to seasonal affective disorder in the winter. While the mechanism of seasonal affective disorder is still unknown, an important rediscovery has been the use of light to treat it. Phototherapy has been found to be a very important and effective nonpharmacological treatment of the winter form of seasonal affective disorder. Studies have repeatedly shown that bright light, at least 2,500 lux, is more effective than dim light (300 lux). While most studies have compared 2,500-lux light to 300-lux light or other treatments, some researchers have investigated the effect of 10,000-lux light on seasonal affective disorder. Phototherapy treatments using 2,500-lux sources require between two and four hours per day of exposure to reap antidepressant benefits. When 10,000-lux sources of light are employed, the exposure time decreases to approximately thirty minutes a day. Certainly, most people suffering from seasonal affective disorder would prefer to take thirty minutes for their phototherapy treatments than the two to four hours required for 2,500-lux treatments. Thomas Wehr and others investigated the differences in treatment efficacy when light was applied to the eyes rather than to the skin. They found that the antidepressant benefits were greater when the light was applied to the eyes. This suggests that the eye plays an important role in the effectiveness of phototherapy. A study by Frederick Jacobsen and others investigated the timing of the phototherapy. The results suggest that the antidepressant effect of phototherapy does not depend upon the timing of the treatment: Both morning and midday treatments were effective in lifting the depression of seasonal affective disorder. One of the major advantages of phototherapy is that it is a nonpharmacologic approach to treating depression. The fact that no medications are involved allows the patient to avoid the unpleasant and potentially dangerous side effects of medications. However, many researchers are concerned about the possible effect of ultraviolet light on the health of the patient. —James T. Trent See also Depression; Depression in children; Depression in the elderly; Light therapy; Sleep disorders. For Further Information: Kasper, Siegfried, Thomas A. Wehr, John J. Bartko, Paul A. Gaist, and Norman E. Rosenthal. “Epidemiological Findings of Seasonal Changes in Mood and Behavior.” Archives of General Psychiatry 46, no. 9 (1989): 823833. A thorough description of the major prevalence study on seasonal affective disorder. The statistics are fairly advanced, but the authors’ use of figures and tables makes the results understandable. An extensive reference list is provided.
800 ✧ Secondhand smoke Lam, Raymond W., ed. Seasonal Affective Disorder and beyond: Light Treatment for SAD and Non-SAD Conditions. Washington, D.C.: American Psychiatric Press, 1998. Leading clinicians discuss the impact of light and light therapy on conditions such as SAD, premenstrual depression, circadian phase sleep disorders, jet lag, shift-work disorders, insomnia, and behavioral disturbances. Lam, Raymond W., and Anthony J. Levitt, eds. Canadian Consensus Guidelines for the Treatment of Seasonal Affective Disorder. Vancouver, British Columbia: Clinical and Academic Publishing, 1999. A summary of the report of the Canadian Consensus Group on SAD. The first comprehensive clinical guide for the diagnosis and treatment of seasonal affective disorder, which affects between 2 percent and 3 percent of the Canadian population. Rosenthal, Norman E. Winter Blues: Seasonal Affective Disorder—What It Is and How to Overcome It. New York: Guilford Press, 1998. A revised and updated edition of Seasons of the Mind (1989). An exceptionally clear and wellwritten presentation of seasonal affective disorder by one of the pioneering investigators in the field. Discusses the risks and benefits of various treatments, including psychotherapy, antidepressant medication, and light therapy. An excellent book for nonprofessional readers. Rosenthal, Norman E., and Mary C. Blehar. Seasonal Affective Disorders and Phototherapy. New York: Guilford Press, 1997. The authors discuss issues related to the diagnosis and prevalence of the syndrome. In addition, they present mechanisms of action for phototherapy as a treatment and the use of animal models to study seasonal affective disorder. A good summary that avoids being overly technical.
✧ Secondhand smoke Type of issue: Children’s health, environmental health, ethics, occupational health, public health, social trends Definition: A mixture of smoke that has been exhaled by smokers and the smoke produced by the burning end of a cigarette, cigar, or pipe. Containing more than four thousand substances, forty of which are known carcinogens (cancer-causing agents), secondhand smoke is a strong respiratory irritant. When concentrated indoors, secondhand smoke becomes a significant pollutant that greatly reduces air quality. It has been known since the early 1960’s that tobacco smoke posed serious health risks to smokers. Numerous U.S. Public Health Service reports cited cigarette smoking as the largest single preventable cause of premature death in the United States. Research examining the effects of
Secondhand smoke ✧ 801 secondhand smoke, also termed environmental tobacco smoke (ETS) and passive smoke, followed later. In 1986 the surgeon general of the United States reviewed the work of more than sixty physicians and scientists from the United States and elsewhere relating to secondhand smoke. A report published by the U.S. Department of Health and Human Services called The Health Consequences of Involuntary Smoking: A Report of the Surgeon General (1986) listed three conclusions: Involuntary smoking causes disease in nonsmokers; children exposed to secondhand smoke have an increased frequency of respiratory infections and respiratory symptoms, as well as a reduced rate of lung function capacity as the lung matures; and separating smokers from nonsmokers sharing the same airspace may reduce the exposure of nonsmokers to secondhand smoke but does not eliminate their exposure. An examination of the contents of secondhand smoke reveals a selection of very strong chemicals. These chemicals are present in two forms: gases and particles. The major gaseous toxins in secondhand smoke include carbon monoxide, carbonyl sulfide, benzene, formaldehyde, hydrogen cyanide, and nitrogen oxides. The presence of carbon monoxide, which is also present in automobile exhaust, is a cause for particular concern. When inhaled, carbon monoxide interferes with the blood’s ability to carry oxygen to the cells of the body. Red blood cells normally carry oxygen from the lungs to the cells. When carbon monoxide is present, it binds to red blood cells and makes them incapable of taking on the oxygen. The brain, heart, and other tissues do not get the oxygen they need. The chemicals in secondhand smoke that are in particle form include tar, nicotine, and phenol. Tar is considered to be carcinogenic. Nicotine is toxic, and phenol promotes tumor growth. At least twelve other particulate chemicals in secondhand smoke are carcinogenic, including catechol, benz(a)anthracene, quinoline, cadmium, nickel, and polonium 210. So many cancercausing agents are found in secondhand smoke that the U.S. Environmental Protection Agency (EPA) has classified it as a Group A carcinogen, which means that strong evidence of a cause-and-effect relationship in humans exists. In others words, there is strong evidence that secondhand smoke causes cancer in humans. Consequences of Secondhand Smoke Being in the presence of secondhand smoke produces immediate consequences. Burning sensations in the eyes, nose, and throat; increased phlegm, heart rate, and blood pressure; and headaches and stomachaches are common reactions. When exposed to secondhand smoke over time, the risk of contracting the following problems increases: lung problems, cancer, heart attacks, and brain attacks (also known as strokes). Secondhand smoke is responsible for approximately three thousand lung cancer deaths annu-
802 ✧ Secondhand smoke ally in nonsmokers in the United States and thirty-two thousand to forty thousand deaths from heart disease. Infants and young children are especially susceptible to the dangers of secondhand smoke. Children whose parents smoke in the home experience a significantly higher risk of contracting lower respiratory tract infections and asthma. Bronchitis, tracheitis, and laryngitis are three acute respiratory illnesses that children of smokers suffer more frequently that do the children of nonsmokers. Children whose parents smoke also have more difficulty with chronic (persistent and ongoing) coughs and increased phlegm than do the children of nonsmokers. Children who suffer from asthma and are exposed to secondhand smoke show an increase in the severity of their symptoms and the frequency of their attacks. The human and economic consequences of secondhand smoke are far-reaching. Exposure to secondhand smoke has led to increases in human illness, suffering, and medical expenses. Lost wages caused by secondhandsmoke-related illnesses also contribute to the economic costs. The overwhelming body of evidence pointing to the dangers of secondhand smoke for nonsmokers has led to a flurry of public outcry and new regulatory laws. As of August, 1997, 80 percent of U.S. employees worked for companies that had a smoking policy, and the Occupational Safety and Health Administration (OSHA) was in the process of reviewing a proposed rule that would ban smoking in the workplace except in specially ventilated, separate areas. At the beginning of the twenty-first century, communities across the United States continued to struggle with the issue of smoke-free restaurants and community buildings. —Louise Magoon See also Cancer; Children’s health issues; Lung cancer; Occupational health; Smog; Smoking; Tobacco use by teenagers. For Further Information: Browner, Carol M. Environmental Tobacco Smoke: EPA’s Report. Washington, D.C.: Government Printing Office, 1993. http://www.epa.gov/docs/ epajrnal/fal193/brown.txt.html. A concise description of the issue of environmental tobacco smoke. Pirkle, James. “Exposure of the U.S. Population to Environmental Tobacco Smoke.” Journal of the American Medical Association (April 24, 1996). An examination of the extent of exposure to environmental tobacco smoke experienced by the American public, written in formal scientific language. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Smoking: A Report of the Surgeon General. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Health Promotion and Educa-
Sexual dysfunction ✧ 803 tion, Office on Smoking and Health, 1986. An in-depth overview of the research regarding secondhand smoke. Watson, Ronald R., and Mark L. Witten, eds. Environmental Tobacco Smoke. Boca Raton, Fla.: CRC Press, 2000. Focuses on the pathological effects of secondhand smoke on pregnant women, newborns, youths, adults, and the elderly.
✧ Sexual dysfunction Type of issue: Men’s health, mental health, women’s health Definition: Lack or interest in or inability to perform sexual intercourse or other sexual acts. Sexual dysfunction may involve the persistent inability of a man to achieve and maintain an erection adequate for vaginal penetration and the successful completion of sexual intercourse, as well as disinterest in sex because of inadequate or unpleasurable sensation during intercourse. Performance anxiety refers to the fear of not being able to perform, while pleasure anxiety refers to the fear of feeling pleasure. Sex therapists have traditionally been much more concerned with the fear of not being able to perform. Historically, lack of desire has been considered a female disorder, whereas lack of performance has been considered a male disorder. “Impotence” as a diagnostic term retains its currency, whereas “frigidity” has largely been dropped from the field of sex therapy and research. It is still used, however, in the psychoanalytic literature. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (3d ed., 1980, DSM-III) used the category “inhibited sexual desire” for lack of erotic arousal: The term “inhibition” implies that the conditions for desire are present but that desire is being withheld. One of the implied accusations in the term “frigidity” is that the woman who does not experience erotic arousal is a cold, unfeeling, or withholding person. The work group on psychosexual disorders for the revision of the DSM-III published in 1987 recognized this difficulty and recommended that the condition be renamed “hypoactive sexual desire disorder.” One researcher points out that between 1974 and 1976, roughly 32 percent of couples seeking help received a diagnosis of low sexual desire. In the years 1977 and 1978, this figure increased to 46 percent of couples. In 1981-1982, the incidence of low-desire cases was 55 percent. The sex ratio of identified patients within couples also changed over these years. From 1974 to 1976, the female was the identified patient about 70 percent of the time. In 1977 and 1978, this figure had declined to only 60 percent. In 1982 and 1983, in a noteworthy change, 55 percent of all low-desire cases involved
804 ✧ Sexual dysfunction male low desire. Thus low sexual desire is clearly a problem affecting both men and women. Multiple Causes Most of the knowledge of the causes of low sexual desire is based on clinical experience, rather than on more empirical and objective research. It has become clear that there is no single cause for low sexual desire. Rather, many cases involve several causal factors working simultaneously. Virtually every standard work on sexual dysfunction lists religious orthodoxy as a major cause of sexual dysfunction. Some patients suffer from low sexual desire because they essentially lack the capacity for play (the obsessivecompulsive personality). Specific sexual phobias or aversions also may cause low sexual desire. Low-desire men almost uniformly have some degree of aversion to the vagina and female genitals. Women who have been sexually molested as children, or raped as adults, often have specific aversion reactions. Some patients fear that if they allow themselves to feel any sexual desire at all, they will lose all control over themselves and begin acting out sexually in ways that would have disastrous consequences. Fear of pregnancy is often a “masked” cause of low sexual desire among women. Depression, hormonal issues, the side effects of medication, relationship problems, lack of attraction to one’s partner, fear of closeness, and an inability to fuse feelings of love and sexual desire are among the many causes of low sexual desire in both men and women. Impotence It has been estimated that there are approximately ten million men in the United States suffering from impotence. In the past, it was thought that psychogenic causes accounted for 90 percent of impotence, with only 10 percent attributable to medical or postsurgical diseases, so-called physical or organic impotence. As medical knowledge increased, in the early 1990’s it was estimated that medical or organic causes accounted for 50 to 70 percent of all patients suffering from impotence. Blood tests to measure hormone levels and penile tumescence in sleep laboratory testing now allows for accurate determination of the true cause of impotence in patients. Yet even when it is attributable to organic causes, impotence has significant psychological implications for the male-female relationship. Impotence can be defined as the persistent inability to attain and maintain a rigid penis adequate for vaginal penetration and successful completion of intercourse. There are two types of impotence: primary and secondary. Primary impotence is the term used to describe the male who has never been able to achieve an erection adequate for sexual intercourse. This
Sexual dysfunction ✧ 805 is a relatively rare condition. Except in very unusual circumstances that might have involved a surgical procedure on the penis during childhood, primary impotence is not caused by any physical defect but instead has a psychologic basis. Men with primary impotence are most often found to have had a severely repressive childhood with strong religious or motherfigure relationships. These patients generally exhibit considerable conflict in their relationships with women and have hostile or fearful attitudes toward females. The majority of men with impotence have secondary impotence; that is, at one time in their lives they were capable of full erections and intercourse but have subsequently lost that ability. In the 1980’s, other medical terms for impotence came into common use, such as “erectile dysfunction.” Diabetes mellitus, arteriosclerosis, chronic kidney failure, cirrhosis, Parkinson’s disease, multiple sclerosis, spina bifida, spinal cord injury, and low levels of testosterone are also frequent organic causes of impotence. Masters and Johnson have stated that alcoholism is the second most common cause of impotence. Pelvic fractures and trauma, radiation therapy, radical pelvic surgery (including removal of the prostate, bladder, or rectum), and aortic aneurysm repair can cause nerve and blood vessel injuries that result in impotence and/or problems with ejaculation. Penile cancer, Peyronie’s disease, and priapism are also causes of organic impotence. Prescription drugs may account for 25 percent of patients with impotence, commonly those taken for treatment of hypertension. Treating Low Sexual Desire While many behavioral exercises may enhance arousal and orgasm, they often fail in increasing sexual desire or motivation. Many cases of low sexual desire not only are quite complex but are diverse in apparent etiology and maintenance factors as well. Each case of low desire must be examined on its own terms, and treatment must be tailored to the specific needs of the individual. Behavior therapy and social learning theory contributed most of the effective techniques that constituted sex therapy in the 1980’s. Other therapeutic approaches, however, have been used as adjunct techniques or proposed alternatives. One broad-spectrum approach attempts to integrate interventions from many theoretical orientations into a comprehensive treatment program, while remaining sensitive to the need to fine-tune the program to the individual. The first step in this broad-spectrum approach is experiential/sensory awareness. Many patients with low sexual desire are unable to verbalize their feelings and are often unaware of their responses to situations involving sexual stimulation. The goal of this phase of therapy is to help patients recognize, using bodily cues, when they are experiencing feelings of anxiety, pleasure, anger, or disgust.
806 ✧ Sexual dysfunction The second stage is the insight phase of therapy, in which patients, with the help of the therapist, attempt to learn and understand what is causing and maintaining their low desire. Frequently, patients with low sexual desire have misconceptions and self-defeating attitudes about the cause of the problem. Patients are helped to reformulate attitudes about the cause of the problem in a way that is conducive to therapeutic change. The third stage, the cognitive phase of therapy, is designed to alter irrational thoughts that inhibit sexual desire. Patients are helped to identify self-statements that interfere with sexual desire. They are helped to accept the general assumption that their emotional reactions can be directly influenced by their expectations, labels, and self-statements. Patients are taught that unrealistic or irrational beliefs may be the main cause of their emotional reactions and that they can change these unrealistic attitudes. With change, patients can reevaluate specific situations more realistically and can reduce negative emotional reactions that cause low desire. The final element of this treatment program consists of behavioral interventions. Behavioral assignments are used throughout the therapy process and include basic sex therapy as well as other sexual and nonsexual behavior procedures. Behavioral interventions are used to help patients change nonsexual behaviors that may be helping to cause or maintain the sexual difficulty. Assertiveness training, communication training, and skill training in negotiation are examples of such behavioral interventions. The treatment of psychogenic impotence includes supportive psychotherapy and behavior-oriented tasks. If, during the course of evaluation, symptoms of depression such as loss of libido and appetite or sleep difficulties are present without a physical basis, the patient is often treated with an antidepressant medication. As mental depression lessens, sexual interest and potency will often return. Treating Organic Causes Treatment programs for organic impotence are geared toward the problems of each individual and are often age-dependent. From 1980 to 1990, there were major advances not only in the diagnosis but also in the treatment of erectile insufficiency; moreover, many of those major treatment advances were nonsurgical. As a result of these nonsurgical advances and their positive rate of success, men often are encouraged to begin their treatment program with the most conservative technique possible. It has been estimated that approximately 90 percent of patients with erectile insufficiency are adequately treated with one of the following medical programs: oral medication, self-injection, and vacuum tumescence devices. Often the first step to medical management of erectile dysfunction is oral medication. Generally, these medications cause smooth muscle relaxation, thereby enhancing the blood flow into the penis. The drug Viagra (silde-
Sexual dysfunction ✧ 807 nafil), introduced in 1998, allows sufficient blood flow for an erection over a four- to five-hour period. Viagra boasted a success rate of almost 80 percent and was immediately in great demand. Concerns arose, however, about its misuse to enhance sexual performance instead of to treat impotence. Medications to increase sexual desire are also being investigated by various pharmaceutical companies in conjunction with the Food and Drug Administration (FDA). These medications became available for experimental use in the early 1990’s. Penile injection with drugs is a treatment for male impotence that was popularized in France in 1982. Penile injection with vasoactive compounds to effect an erection, however, had not yet been approved by the FDA in the United States. Thus patients were required to sign a legal release of liability if this method of treatment was chosen. In 1990, there were approximately 80,000 males using self-injection therapy in the United States. This technique is relatively painless and quick, producing results in ten to twenty minutes. Treatment is initiated by administering a test dose of the medication. During this initial stage of treatment, the medication dosage level is adjusted. The patient is then taught the injection technique, given instructions on how to care for the medication and equipment, and given an assessment of erectile response. This method is considered simple, safe, and highly successful (with a success rate of approximately 75 to 80 percent). The major complications are priapism and penile scarring, which occurs in 1 to 2 percent of cases. Another nonsurgical option available is vacuum tumescence therapy. This device enables the patient to attain penile enlargement and rigidity by inducing blood flow into the penile shaft. Once the blood flow is induced by the creation of a vacuum, it is trapped by the use of an occlusive device applied at the base of the penis. Although it produces a successful erection in approximately 75 percent of cases, the vacuum tumescence device and the accompanying obstructing rubber occlusive device prevent the ejaculate from being expelled in most cases. Many men with erectile dysfunction are best treated by surgical reconstruction. This group represents approximately 10 percent of the entire impotent population. Penile revascularization is one option. The patients who are best treated with penile revascularization are typically men under fifty years of age. Generally, these men are nonsmoking, healthy individuals whose potency problems are caused by a single lesion or injury. The purpose of penile revascularization is to channel more blood into the corpora cavernosal and thereby increase the corpora cavernosa pressure. Pressure can be increased by a variety of methods, including bypass artery-to-artery, bypass artery-to-vein, or closure of specific leaking areas in the corpora cavernosa. Although available since the mid-1930’s, penile prosthetics made its greatest strides after the introduction of synthetic materials (plastics) in the
808 ✧ Sexual dysfunction 1950’s. Since then, major changes in design, function, and surgical technique have evolved. The prosthetics available by the 1990’s were of three basic varieties: simple rods, flexible rods, and hydraulic devices (one-piece, two-piece, and multicomponent). Once implanted, prosthetics give the patient a return to “normal erectile dynamics.” Although the tumescencedetumescence cycle is a result of the patient’s prosthesis, sensation, satisfaction, and often even ejaculation remain as they were prior to surgery. —Genevieve Slomski See also Alcoholism; Arteriosclerosis; Diabetes mellitus; Heart disease; Infertility in men; Infertility in women; Hypertension; Medications and the elderly; Menopause; Parkinson’s disease; Prostate cancer; Sexually transmitted diseases (STDs); Stress; Women’s health issues. For Further Information: Kaplan, Helen Singer. The Sexual Desire Disorders: Dysfunctional Regulation of Sexual Motivation. New York: Brunner/Mazel, 1995. This book provides current thinking on disorders of sexual desire and directions for contemporary treatment. Leiblum, Sandra R., and Raymond C. Rosen, eds. Sexual Desire Disorders. New York: Guilford Press, 1988. A groundbreaking collection of papers on disorders of sexual desire. The authors assume that sexual desire is an extraordinarily complicated aspect of human life that requires a multifaceted approach in order to be understood. One of the questions raised in the volume is “Are there unknown genetic or constitutional factors that can account for low sexual desire?” Written for the specialist but comprehensible to the layperson as well. Miller, Karl E. “Treatment of Antidepressant-Associated Sexual Dysfunction.” American Family Physician 61, no. 12 (June 15, 2000): 3728. Many classes of antidepressants, including the selective serotonin reuptake inhibitors (SSRIs), can impair sexual function. Few studies have examined this adverse effect, particularly in women. Michelson and associates evaluated the effectiveness of buspirone and amantadine in the treatment of sexual dysfunction associated with fluoxetine use. Phillips, Nancy A. “Female Sexual Dysfunction: Evaluation and Treatment.” American Family Physician 62, no. 1 (July 1, 2000): 127-136. Sexual dysfunction includes desire, arousal, orgasmic, and sex pain disorders. Primary care physicians must assume a proactive role in the diagnosis and treatment of these disorders. Basic treatment strategies, which may be successfully provided by primary care physicians for most sexual dysfunctions, are discussed.
Sexually transmitted diseases (STDs) ✧ 809
✧ Sexually transmitted diseases (STDs) Type of issue: Epidemics, public health Definition: Diseases acquired through sexual contact or passed from a pregnant woman to her fetus. Sexually transmitted diseases (STDs), formerly called venereal diseases, have plagued humankind for centuries. The most prevalent, serious STDs are syphilis, gonorrhea, nongonococcal urethritis, trichomoniasis, genital herpes, genital warts, viral hepatitis, and acquired immunodeficiency syndrome (AIDS). Others, troublesome but not as serious, include lice, scabies, and vaginal yeast infections. They are passed on from one person to another mostly by sexual contact, although some of these diseases may be acquired indirectly through contaminated objects or blood. In addition, nearly all these diseases can be passed on from an infected mother to her fetus, which may cause birth defects, severe and damaging infections, or even death. A person can acquire several STDs at the same time, and since recovery from an STD does not confer immunity, a person can get them again and again. Many of these diseases are asymptomatic, which allows them to spread and cause serious complications before a victim is aware of being infected. Finally, some STDs are treatable and some are not. Common Sexually Transmitted Diseases Syphilis is caused by a bacterium that normally infects the penis in males and the vagina or cervix in females, but it can also enter through a cut on the mouth or other parts of the skin. Once inside, the bacteria grows at the site of entry, then spreads throughout the body through the lymph and blood vessels. The symptoms of syphilis are caused by the efforts of the immune response of the patient to fight off the infection. The disease occurs in three stages: primary, secondary, and tertiary. In primary syphilis, a flat, firm, painless, red sore called a chancre appears at the site of entry two to ten weeks after infection. Secondary syphilis is characterized by a red rash that appears two to ten weeks after the disappearance of the primary lesion. The rash will disappear in a few weeks. Without treatment, 40 percent of patients will progress to the tertiary stage within three to ten years. Tertiary syphilis is characterized by the formation of severe lesions called gummas on the skin, bones, or internal organs. Gummas on the spinal cord, brain, or heart can lead to seizures, insanity, or death. Almost all pregnant women with untreated primary or secondary syphilis will transmit the bacteria through the placenta to the developing baby, who will develop congenital syphilis. Many babies with congenital
810 ✧ Sexually transmitted diseases (STDs) syphilis are spontaneously aborted or stillborn. Many others are born with characteristic birth defects, secondary or tertiary syphilis, or neurological damage, and may die shortly after birth. Gonorrhea is caused by the bacterium gonococcus, which infects the urethra in males and the cervix, vagina, or urethra in females. Most infected males get urethritis (inflammation of the urethra) along with symptoms of a pus-containing discharge from the penis and painful urination. Untreated, 1 percent of these men will develop complications of urethral blockage, epididymitis, prostatitis, and infertility. Between 20 and 80 percent of women infected with gonococcus are asymptomatic or show only mild symptoms. Symptoms include burning or high frequency of urination, vaginal discharge, fever, and abdominal pain. In 20 to 30 percent of untreated women, gonococcus will spread to the Fallopian tubes and cause pelvic inflammatory disease (PID), which can lead to infertility. Infected mothers can transmit the bacteria to their babies as they pass through the birth canal, causing ophthalmia neonatorum, a type of conjunctivitis that can cause blindness if untreated. Most cases of nongonococcal urethritis (NGU) are caused by chlamydia. This bacterium infects the urethra in males and the cervix or urethra in females. The symptoms of chlamydia infection are often mild and go unnoticed. Males experience mild urethritis with a watery discharge, frequent urination, and painful urination. Females are either asymptomatic or experience mild cervicitis or urethritis. Complications include epididymitis in males and PID and infertility in females. Infants born to mothers with cervicitis can develop eye or lung infections. Trichomoniasis is caused by a protozoan. In both sexes, the disease is often mild or asymptomatic. In males, the organism infects the prostate, seminal vesicles, and urethra. About 10 percent of infected males show signs of mild urethritis, with a thin, white urethral discharge. Secondary bacterial infection can lead to more severe urethritis and inflammation of the prostate and seminal vesicles. In females, the organism can infect the vulva, vagina, and cervix. Females may suffer from severe vaginitis, which includes a tender, red, and itchy genital area, and a profuse, frothy, foul-smelling, greenish-yellow discharge. Newborns may acquire the infection from an infected mother during delivery. Viruses Most genital herpes infections are caused by herpes simplex virus type 2, but some are caused by herpes simplex virus type 1. The virus infects the penis in males and the cervix, vulva, vagina, or perineum in females. Two to seven days after infection, painful blisters appear in the genital area that ulcerate, crust over, and disappear in a few weeks. Herpesviruses are unique in that they can remain latent in the nerves and cause a recurrent infection at any
Sexually transmitted diseases (STDs) ✧ 811 time in the future. Fever, stress, sunlight, or local trauma may trigger the virus to come out of hiding and cause a recurrent infection. The virus can be transmitted from an infected mother to her baby either congenitally, through the placenta, or neonatally, as it passes through the birth canal. In congenital or neonatal herpes, the virus can infect all parts of the body, the death rate is high, and survivors commonly have long-term neurological damage and recurrent infections. Viral hepatitis is also a STD. At least three variants of the virus—hepatitis A virus (HAV), HBV, and HCV—are known to be transmitted sexually. HBV is the form most commonly transmitted sexually. Vaccines are available to immunize persons at risk for HAV and for HBV. Genital warts are caused by human papillomaviruses (HPVs). In males, the warts appear on the penis, anus, and perineum. They are found on the vagina, cervix, perineum, and anus in females. The warts themselves may be removed, but the infection remains for the life of the patient. HPV infection seems to increase a woman’s risk for cervical cancer. AIDS is caused by the human immunodeficiency virus (HIV). This virus is acquired through sexual contact as well as through intravenous drug use and blood transfusions. HIV infects and inactivates the T helper cell that is needed by the immune system to respond to and fight off infections. Without T helper cells, the immune system eventually becomes nonfunctional, and the affected person becomes susceptible to every type of infection possible. Two-thirds of all AIDS patients get pneumonia caused by Pneumocystis carinii. Other common diseases associated with AIDS patients are tuberculosis and other mycobacterial infections, viral infections such as those caused by cytomegalovirus and herpesviruses, fungal infections, cancers such as Kaposi’s sarcoma, and neurological disorders. HIV can also be transmitted from an infected mother to her baby through the placenta. Virtually every person infected with HIV will eventually die of AIDS, usually within six years. Treating Sexually Transmitted Diseases All the bacterial and the protozoal STDs can be treated and cured with antibiotics. It is important to seek early diagnosis and treatment of these diseases for three reasons: First, to prevent the disease from spreading; second, to prevent the various complications associated with the diseases; and third, to prevent the infection of infants by pregnant mothers. There is no cure for STDs caused by viruses; there are only drugs that slow the progress of the infection. Syphilis is commonly treated with penicillin, or with erythromycin, tetracycline, or cephaloridine in patients who are allergic to penicillin. In most patients receiving appropriate therapy during primary or secondary syphilis, the active disease is totally and permanently arrested. Treatment during the
812 ✧ Sexually transmitted diseases (STDs) latent stage stops the development of symptoms of the tertiary stage. There is no successful treatment for patients in tertiary syphilis. Treatment of gonorrhea includes penicillin, ampicillin, tetracycline, or spectinomycin. In the mid-1970’s, an antibiotic-resistant strain of gonococcus appeared that was resistant to penicillin. These cases are treated with cephalosporins. Tetracycline or erythromycin is used to treat NGU caused by chlamydia, and trichomoniasis is treated with metronidazole. Genital herpes is treated with antiviral agents such as acyclovir. Topical application of acyclovir is helpful in reducing the duration of primary, but not recurrent, infections. The use of oral acyclovir to suppress recurrent infections may cause more severe and more frequent infections once the therapy has stopped. Neonatal herpes is treated with acyclovir or vidarabine, which can reduce the severity of the infection but cannot reverse any herpes-related neurological damage or prevent recurrent infections. Genital warts can be removed by chemicals, freezing, electrocautery, or laser therapy. Antiviral drugs are useful in treating some STDs: acyclovir for genital herpes, zidovudine for AIDS, and interferon for hepatitis virus. They slow the progress of the disease in some persons, but they do not cure it. Preventing Sexually Transmitted Diseases The only 100 percent effective way to prevent STDs is abstinence. Since many of these diseases can be spread through sexual activity other than intercourse, abstinence must include all sexual activity. The use of a condom or any other barrier method is only somewhat helpful. Preventing the spread of AIDS includes screening blood supplies, organ donors, and semen donors, and avoiding contact with infected body fluids through sexual contact, blood transfusions, or intravenous drug use. Prevention of transmission of STDs from infected mothers to their babies involves early diagnosis and treatment of the mothers before birth and preventive medication of the babies after birth. Control of STDs in a population is complex, since it is both a medical and a social problem. It is important that persons who contract an STD receive early diagnosis and adequate treatment that will prevent further spread of the disease, serious complications, and infection of infants. This is difficult because many STDs are asymptomatic; therefore, people do not know they have the disease and have no reason to seek treatment. Many persons contract STDs from asymptomatic carriers. In addition, social stigma or embarrassment reduces the motivation of a victim to seek prompt medical care. Adequate treatment of STD victims is difficult if they do not want to return for subsequent treatment or will not take all their medication. Finally, people often contract several STDs at the same time, so detection of one STD should routinely instigate testing for other STDs. Effective education to change sexual behavior must be predicated upon
Sexually transmitted diseases (STDs) ✧ 813 the motivation and cognitive development of the student. One-third of all cases involve teenagers and young adults; sexual activity in this age group is on the rise, and members of this group are more likely to have multiple sex partners. Prostitution for money or drugs also increases the incidence of STDs. Other control measures include development of vaccines for these diseases, mandatory reporting of all STDs, and education of the population regarding the dangers and risks involved in acquiring these diseases. —Vicki J. Isola; updated by Armand M. Karow See also AIDS; AIDS and women; Epidemics; Herpes; Preventive medicine; Terminal illnesses; Yeast infections. For Further Information: Brodman, Michael, John Thacker, and Rachael Kranz. Straight Talk About Sexually Transmitted Diseases. New York: Facts on File, 1993. The senior author, a physician, and his colleagues present information for the general reader about the transmission, effects, and prevention of chlamydia, gonorrhea, genital warts, genital herpes, hepatitis, syphilis, and AIDS. Contains a glossary, a list of resources, and an index. Eng, Thomas Rand, and William T. Butler, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, D.C.: National Academy Press, 1997. This collection of well-written essays is the recommendation of a sixteen-member expert committee for the prevention and control of STDs in the United States. Little, Marjorie. Sexually Transmitted Diseases. Philadelphia: Chelsea House, 2000. This work, designed for students in grades nine and up, provides some historical information on STDs. Little covers both the curable diseases, such as syphilis and gonorrhea, as well as AIDS. Symptoms, diagnoses, treatments, and prevention are discussed. Murphy, Charles. What Wild Ecstasy: The Rise and Fall of the Sexual Revolution. New York: Simon & Schuster, 1997. This book gives a historical context to sexuality and sexually transmitted diseases and discusses contemporary changes in sexual behavior. Shaw, Michael, ed. Everything You Need to Know About Diseases. Springhouse, Pa.: Springhouse Press, 1996. This well-illustrated consumer reference, compiled by more than one hundred doctors and medical experts, describes five hundred illnesses and conditions, their causes, symptoms, diagnosis, treatment, and prevention. A valuable reference book for everyone interested in health and disease. Of particular interest is chapter 11, “Sexual Disorders and Diseases.”
814 ✧ Sick building syndrome
✧ Sick building syndrome Type of issue: Environmental health, industrial practices, occupational health, public health Definition: An illness caused by exposure to indoor air pollutants during which more people than normal suffer from multiple symptoms of sickness for no apparent reason or with no identifiable cause; there is often no record of related or prior illnesses. The average person spends 80 to 90 percent of the day indoors. The longer one spends in an affected environment, the more severe the sick building syndrome (SBS) symptoms can become. SBS is often a problem in office buildings but can be evident in homes, schools, nurseries, and libraries. Since the 1970’s, buildings have become more airtight in response to energy crisis concerns. Many heating, ventilating, and air-conditioning (HVAC) systems have been designed to recirculate indoor air rather than draw in fresh, filtered air from outside. Also, systems that bring in polluted outdoor air may contribute to building-related illnesses. A lack of ventilation is one primary cause of the trapping of natural and anthropogenic indoor pollutants and the onset of SBS. The symptoms of SBS appear to increase in severity with time spent in the affected building and decrease or disappear with time away from the building. Symptoms include respiratory problems such as coughing; increased allergic reactions and sneezing; irritation of the eyes, throat, nose, and skin; and headaches. Some patients even experience severe fatigue and flulike symptoms. Not all individuals exposed to the same indoor contaminants experience similar symptoms, and some inhabitants feel no ill effects. Microenvironments may exist that cause inhabitants of offices sharing a common wall to experience unique symptoms. Many symptoms are similar to those of common allergies or illnesses, and sufferers may dismiss the problem without seeking help. A rise in SBS cases may be related to increased usage of synthetic building materials, greater stress and regimentation in the workplace, and the general increase in number of workers employed in office settings. There is no one cause of SBS, but there are many sources of indoor pollution that may lead to SBS, including secondhand tobacco smoke, ozone and heat from photocopiers and computers, new carpet and furniture that offgas volatile organic compounds (VOCs—compounds composed exclusively of hydrogen and carbon), asbestos, lead in paint, formaldehyde, microbials, respirable and inhalable particulates, dust mites, and gases such as carbon monoxide. Biological contaminants that are found where temperature and moisture levels are high are bacteria, pollen, mildew, and mold, all of which can increase SBS symptoms when inhaled. Computers
Sick building syndrome ✧ 815 seem to be a significant contributor to the onset of SBS because of increased heat production, which often results in the installation of air-conditioning systems that can exacerbate the problem. The computer display screen can also cause eye strain and headaches. Diagnosing Sick Buildings SBS should be distinguished from building-related illnesses caused by exposure to specific indoor contaminants that can be definitively diagnosed. Alveolitis, bronchospasm, rhinitis, and conjunctivitis can be caused by airborne allergens becoming lodged in the alveoli of the lungs, the bronchi of the lungs, the nose, or the eyes, respectively. Legionnaires’ disease is associated with a bacteria commonly transmitted through a contaminated water source such as evaporative condensers or potable water distribution systems. SBS is rarely attributed to one specific exposure and is therefore more difficult to detect and treat. Minor complaints by office workers should be accepted as serious, and investigation should begin to determine if indoor air quality is acceptable. Steps should be taken to identify the cause of a suspected outbreak of SBS. If no obvious breakdown of ventilation systems or major pollution sources are identified, additional precautionary measures should be taken. Filters should be cleaned, ventilation systems checked, humidity conditions lowered, and new carpets and paints allowed to off-gas and settle before spending time in the newly renovated areas. Alternative solutions include the addition of common household plants that extract contaminants in the air through their leaves, particularly formaldehyde, benzol, phenol, and nicotine. A study conducted at the Botanical Institute at the University of Cologne in Germany showed that such hydroculture plants, or plants lacking soil, are efficient at absorbing pollutants and transforming 90 percent of the chemical substances into sugars, oxygen, and new plant material. These plants provide moisture to the air without the contribution of fungus spores. Another new treatment being considered is an indoor ecosystem composed of rocks, plants, fish, and microorganisms that inhales dirty air and exhales much cleaner air. In the work environment, the health problems associated with SBS often lead to lost productivity among employees, high absenteeism, and the possibility of increased litigation. Scientists are unsure if increased incidences of cancer are related to exposure to contaminants in home and work environments. It is felt that avoiding prolonged exposure to indoor pollutants or reducing the number of indoor contaminants can add to the length and quality of one’s life and lessen the symptoms and incidences of sick building syndrome. —Diane Stanitski-Martin
816 ✧ Skin cancer See also Allergies; Asbestos; Environmental diseases; Multiple chemical sensitivity syndrome; Occupational health; Radon; Secondhand smoke; Smoking. For Further Information: Godish, Thad. Sick Buildings: Definition, Diagnosis, and Mitigation. Boca Raton, Fla.: Lewis, 1995. Written as a reference work and is intended for a variety of readers, including architects, those conducting indoor air quality investigations, public health and environmental professionals, and university students. It defines and discusses the issues related to SBS. Redlich, Carrie A., Judy Sparer, and Mark R. Cullen. “Sick-Building Syndrome.” The Lancet 349 (April 5, 1997). A thorough overview of the causes, symptoms, and treatments of SBS. U.S. Environmental Protection Agency. Sick Building Syndrome. Washington, D.C.: U.S. Environmental Protection Agency, Indoor Environments Division, Office of Air and Radiation, 1991. Discusses causes of SBS, describes building investigation procedures, and provides general solutions for resolving the syndrome.
✧ Skin cancer Type of issue: Environmental health, public health Definition: Malignancies of the skin (and sometimes spreading to the internal organs) caused by the ultraviolet radiation in sunlight. When living tissue is irradiated by the higher-energy part of the sunlight spectrum, its molecular structure is disrupted, and the development of unwanted cells is likely to occur. Such changes take place because of the formation of free radicals in the deoxyribonucleic acid (DNA) molecules that constitute the genetic code. The result is skin cancer, the most common form of cancer in both men and women in the United States. Types of Skin Cancer Skin neoplasms may be benign or malignant, acquired or congenital, although the majority are benign and acquired. The common mole (the medical term for which is melanocytic nevus) is a neoplasm of benign melanocytes which is often present at birth and is known as a birthmark. Such moles are generally harmless unless they are large in size, in which case they may have up to a 10 percent chance of becoming malignant. Other melanocytic nevi are strawberry hemangiomas and port-wine stains, which are of vascular origin.
Skin cancer ✧ 817 The most common forms of skin cancer are the basal cell and squamous cell carcinomas, which arise from the corresponding part of the keratinocytes of the epidermis and are caused by the cumulative effects of ultraviolet radiation on the skin. They are generally localized, however, and rarely metastasize. These cancers are easily identified as persisting sores or crusting patches that grow mostly on sun-exposed parts of the body such as the hands, neck, arms, and nose. They can be treated with routine surgical procedures. A malignant melanoma is formed from the pigment-forming melanocyte and almost certainly undergoes metastasis. It should therefore be removed surgically at the earliest possible stage. If the melanoma is detected at a later stage, chemotherapy and irradiation are the techniques usually applied. A malignant melanoma appears as a lesion that increases in size and turns several colors, such as black, blue, white, and brown. Symptoms such as itching, bleeding, and pain are not as common at first but are encountered at the later stages of development. Two other skin malignancies may be fatal: mycosis fungoides and Kaposi’s sarcoma. Mycosis fungoides is a skin lymphoma that may be confined to one location for ten or more years before it metastasizes to internal organs, with death following. As a result, it is difficult to track this skin cancer, both clinically and histologically, and several biopsies may be required to ascertain its presence. On the other hand, Kaposi’s sarcoma occurs either as lesions (commonly among older Mediterranean men) or as skin abnormalities in HIV-infected people. The sarcoma is derived from skin blood vessels and appears as violet patches or lesions. As long as it is contained only in the skin, it is not fatal. Once the inner organs are affected, however, death is imminent, even though the lesions may be treated with irradiation and chemotherapy. The Effects of Sunlight on Skin Extensive skin exposure to sunlight, such as at the beach, leads to the polymerization of skin chemicals (known as catecholamines) and the subsequent formation of different types of epidermal pigmentation (the melanins), which are responsible for tanning. Tanning occurs only if there is gradual exposure to sunlight; otherwise, a sunburn will arise. Photoprotection is believed to be one of the major biological functions of the melanin pigment. It appears that melanin formation can participate effectively in reducing the harmful effects of sunlight by an array of photoinduced chemical reactions, which result in the consumption of scavenging active oxygen species such as the superoxide anion and hydrogen peroxide. It has been determined that in biological systems, superoxide and hydrogen peroxide are formed in small quantities during normal processes. Both are known to produce several biological effects, most of which are harmful
818 ✧ Skin disorders with aging to tissues. It should be pointed out, however, that although melanin may act as a free radical scavenger, it may also become energetically overloaded and may change to a toxic state. Evidence exists that melanin increases the radiative damage to cells, which leads to sunlight-induced skin cancer. In other words, melanin formation is good enough only when moderate exposure to sunlight occurs. Future Risks of Skin Cancer In the atmosphere 12 to 48 kilometers above the earth’s surface lies a small layer of ozone. The ozone layer absorbs the harmful ultraviolet radiation from the sun, thus providing the mechanism for the heating of the stratosphere. A reduction in this layer would lead to a large increase of ultraviolet rays intruding into the atmosphere, thus increasing the incidence of skin cancer. In addition, as the average life span steadily increases, the incidence of skin cancer will increase as well. The development of effective sunscreens and sunglasses with high ultraviolet blocking are recommended for people who are exposed to large amounts of sunlight, such as sunbathers and hikers. —Soraya Ghayourmanesh See also Cancer; Chemotherapy; Environmental diseases; Radiation; Skin disorders with aging; Sunburns. For Further Information: Arnold, Harry L., Richard B. Odom, and William James. Andrews’ Diseases of the Skin. 8th ed. Philadelphia: W. B. Saunders, 1990. Lookingbill, Donald P., and James G. Marks. Principles of Dermatology. Philadelphia: W. B. Saunders, 1986. Rook, Arthur, et al., eds. Textbook of Dermatology. 4th ed. 3 vols. Oxford, England: Blackwell Scientific Publications, 1986. Siegel, Mary-Ellen. Safe in the Sun. New York: Revised. Walker, 1995.
✧ Skin disorders with aging Type of issue: Elder health, public health Definition: Disorders of the skin and hair associated with changes due to aging. All skin structures and functions are adversely affected by the aging process. Skin changes occur because of intrinsic factors related to inevitable tissue
Skin disorders with aging ✧ 819 aging, as well as extrinsic factors, primarily exposure to ultraviolet light. Skin damage caused by ultraviolet light is referred to as photodamage, while skin change caused by ultraviolet rays is referred to as photoaging or dermatoheliosis. Chronically sun-exposed skin looks leathery, thickened, and deeply creased. Overall, melanocytes decrease in number with age, leaving the skin more sensitive to ultraviolet rays. Darker skin has more protective melanocytes and therefore shows less damage from the sun’s ultraviolet rays. The development of many noncancerous (benign) and cancerous (malignant) skin lesions is related to the effects of ultraviolet rays. Changes occur in the structure of all layers of the skin with age. As cell reproduction in the epidermis declines, the skin layer becomes less dense, and the skin will appear thinner. In the very old, the skin looks like parchment; the fragile, thinner skin is easily torn. Superficial blood vessels are more prominent, and easy bruising occurs because the small blood vessels lose the support originally provided by the connective tissue and subcutaneous pad. The blood vessels are more easily traumatized, resulting in irregularshaped, purplish, superficial hemorrhages of various sizes called actinic or senile purpura, which can last for several weeks. These purpuric areas can occur spontaneously from the leakage of superficial capillaries. Senile purpura are frequently seen on the hands and forearms. The area of attachment between the epidermis and dermis decreases with age, enabling the skin to tear more easily with shearing force. Other age-related changes include a decrease in the function of the sebaceous and sweat glands located within the skin. The sebum produced by the sebaceous glands lubricates the hair follicle and, to a lesser degree, lubricates the skin. A decline in function results in a diminished production of oil and drier skin. Sebum has antimicrobial properties, so the decrease makes the skin surface more vulnerable to infection. The decline in sweat production contributes to dryness of the skin. Drier skin with less perspiration results in a condition called xerosis. The exact cause of xerosis is unknown, but it is typically, and commonly, seen in the elderly. The skin is rough, dry, and flaky. The dryness causes skin to itch (pruritus). Low humidity, harsh soaps, hot baths, rough clothing, and exposure to sun can compound the itchiness. Scratching can cause breaks in the skin that can become infected. With less sweat production, the cooling mechanism of perspiration and evaporation is lost or diminished. This increases the risk of hyperthermia or heat stroke in the elderly. Structural changes in the collagen and elastic fibers of the dermis of the skin cause a loss of suppleness and elasticity. The skin becomes progressively more inelastic and lax, resulting in wrinkling and sagging. Facial wrinkling begins as early as the second decade of life as a result of repeated muscle movement associated with facial expressions. These wrinkles can be seen around the eyes and mouth and over the forehead as aging occurs. Additional fine, diffuse wrinkles appear over the skin with the loss of moisture
820 ✧ Skin disorders with aging and elasticity of the dermal layer and the decrease in the subcutaneous or fatty layer of the skin. A decrease in the elasticity and turgor also results in loose or drooping skin seen most obviously under the chin, along the jaw, beneath the eyes, and in the earlobes. Changes in Skin Function Age changes cause the barrier functions of the skin to be less effective, and the elderly are more prone to develop contact dermatitis caused by sensitivity to such substances as leather goods, certain metals, and formaldehyde in clothing fabric. A decrease in Langerhans cells leads to a decline in immune response by the skin and an increased risk for skin infection. The elderly are also more prone to photosensitivity reactions when exposed to the sun. Photosensitivity is a side effect of a number of medications frequently taken by older adults. Nerve endings for pain and temperature perception that are located in the skin decline with age. The decrease in function can lead to frostbite and burns. Once injury to the skin occurs, tissue repair and healing will be a slower process in the elderly, partly because of the decreased vascularity of the dermis and decreased cell reproduction. This is true of all wound healing; the process takes longer in the elderly, and wound separation is more likely to occur. With a decrease in the subcutaneous layer, which serves as a “padding” or “cushion,” bony prominences and joints appear more conspicuous, sharper, and more angular; at the same time, hollows around the bony skeleton deepen. These changes are apparent over the upper chest, shoulders, and neck. Because of the loss of padding, the elderly are more likely to sustain injuries from a fall, and bedridden elderly are more prone to developing pressure ulcers (bedsores) over bony prominences. Since the subcutaneous fat pad also serves as insulation, other consequences of loss of the subcutaneous layer are feeling cold more easily and vulnerability to hypothermia. With age, skin color appears less uniform and more blotchy. Functioning melanocytes do not spread evenly, so areas of hyperpigmentation and hypopigmentation occur. These changes are generally related to photodamage and are more apparent in fair-complected individuals. Increased freckling and lentigo are common. Senile or solar lentigines, also called age spots or liver spots, are round, flat, brown areas of various sizes with well-defined borders. They occur in chronically sun-exposed areas, usually over the face and back of the hands and wrists. Lentigo appear during the middle decades of life, and the number and size increase with age. Whitish, depigmented patches, termed pseudoscars, appear as well. Senile or cherry angiomas are tiny, red, slightly raised lesions that turn brown with age. Cherry angiomas are vascular in origin. They appear over the trunk and arms in midlife and increase with age. Telangiectasias, which
Skin disorders with aging ✧ 821 are small, superficial, dilated blood vessels, are frequently seen over the nose, cheeks, and thighs. Skin Disorders Senile or seborrheic keratosis is a common, pigmented skin growth that usually first appears in middle age. They develop from the keratin-containing cells of the skin; increased melanocytes give them their dark color. Keratoses are yellow-brown to black, raised, wart-like lesions that become darker and larger over time. They vary in size and have a sharp border, and most appear to be set on top of the skin surface. Sun exposure does not seem to be a factor in their development, since they appear on covered body surfaces, such as the back. It is not clear what factors do contribute to their development, but there appears to be a familial tendency. Seborrheic keratoses originally appear as small, flat, tan areas. They most commonly develop on the trunk, face, scalp, and neck and increase in number with age. They can appear singularly or in profusion over the body. Dermatosis papulosa nigra is a form of seborrheic keratosis seen in darkly pigmented individuals. These lesions are small and raised and may be pedunculated. Multiple lesions develop over the face and neck. Seborrheic keratoses are benign growths, creating a cosmetic rather than a medical problem. The growths can be removed with cryotherapy, electrodesiccation, or laser therapy. Actinic or solar keratoses, unlike seborrheic keratoses, are precancerous. They appear as tannish-red or pigmented, roughened or scaly patches on sun-exposed areas, such as the hands, forearms, face, bald scalp, and ears. Solar keratoses are treated with cryotherapy, fluoroplex cream, or laser therapy. Cutaneous horns, which develop from one type of actinic keratoses, are skin-colored, hard projections of keratinized skin. They vary in size from a few millimeters to several millimeters and usually grow on the hands or forehead. Although usually benign, in some cases the base can be cancerous, so removal and biopsy is usually recommended. Skin tags or acrochordons are also more common with increasing age. They are soft, skin-colored or pigmented, pedunculated growths that develop frequently on the neck, axilla, inner thigh, and other areas of friction. Skin tags are small, usually 1 to 3 millimeters. They can appear singly or in large numbers. Skin tags present no health problem and are easily removed. Keratoacanthoma is a skin-colored elevation of the skin with a central area of keratin. These lesions develop rapidly, usually on sun-exposed areas in individuals over fifty years of age, and resolve spontaneously over a few months. Because they closely resemble squamous cell carcinomas, a biopsy is indicated. Sebaceous gland hyperplasia frequently occurs on the forehead and nose. The lesion appears as a yellow, slightly raised area with a central depression, ranging in size from 1 to 3 millimeters. It is important to differentiate these
822 ✧ Skin disorders with aging benign lesions from basal cell carcinoma. Sebaceous hyperplasia is most often the result of chronic sun damage. Sun damage can also lead to solar elastosis, a condition characterized by a thickening of the fibers in the dermal layer. Other features of sun-damaged skin are nodularity, comedones or blackhead, ruddiness, and telangiectasias. Treatment generally includes topical tretinoin (Retin A). Although herpes zoster (shingles) can occur at any age, the vast majority of cases occur in those over forty years of age, perhaps because of the decline in immune system functioning with age. In a significant number of elderly persons, postherpetic neuralgia or pain persists after the herpes lesions have healed. The pain can continue for months or indefinitely. Although two malignant skin cancers, basal cell and squamous cell carcinomas, commonly occur in the elderly, they rarely metastasize beyond the site of origin. Both types occur more often in males and in fair-skinned individuals. Skin manifestations can occur with systemic medical disorders. One common example in the elderly is the skin changes that occur in the lower extremities resulting from circulatory problems. When venous blood drainage from the lower extremities is slowed, increased blood pressure in the venous system results (venous insufficiency). The increased pressure causes leakage from the blood vessels, which creates edema or fluid accumulation in the tissue. If the condition persists, the skin becomes tight, red, and scaly. The condition is referred to a stasis dermatitis or gravitational eczema. Hyperpigmentation develops over the anterior, lower leg from iron in the red blood cells being deposited in the tissue, a condition referred to as hemosiderosis. A chronic situation of decreased circulation and edema can result in skin breakdown or ulcer formation. Leg ulcers can also be the result of decreased arterial blood flow. —Roberta Tierney See also Aging; Cancer; Cosmetic surgery and aging; Hair loss and baldness; Skin cancer; Smoking; Temperature regulation and aging. For Further Information: Freedberg, Irwin M., Arthur Z. Eisen, Klaus Wolff, K. Frank Austen, Lowell A. Goldsmith, Stephen I. Katz, and Thomas B. Fitzpatrick, eds. Fitzpatrick’s Dermatology in General Medicine. 5th ed. New York: McGraw-Hill, 1999. An in-depth, comprehensive text describing etiology, morphology, symptoms, and treatment of skin disorders. Ham, Richard J., and Philip D. Sloane, eds. Primary Care Geriatrics: A CaseBased Approach. 3d ed. St. Louis: Mosby Year Book, 1997. Case studies featuring geriatric patients in an ambulatory health care setting. Porth, Carol Mattson, ed. Pathophysiology. 5th ed. Philadelphia: J. B. Lippincott, 1998. Presents anatomy and physiology of body systems followed by pathophysiologic changes; includes one chapter on skin.
Sleep changes with aging ✧ 823 Sams, W. Mitchell, Jr., and Peter J. Lynch, eds. Principles and Practice of Dermatology. 2d ed. New York: Churchill Livingstone, 1996. Comprehensive discussion of skin disorders. Singleton, Joanne K., Samuel A. Sandowski, Carol Green-Hernandez, Theresa V. Horvath, Robert V. DiGregorio, and Stephen P. Holzemer. Primary Care. Philadelphia: J. B. Lippincott, 1999. Care of adult patients seen in a medical office, with one section focusing on the care of skin problems.
✧ Sleep changes with aging Type of issue: Elder health, mental health Definition: Disturbances of normal sleep patterns. Sleep problems are reported in approximately 40 percent of the elderly population and can result from a number of causes. For example, the changes seen in sleep might be the result of a normal aging process. They might also be secondary to a medical or psychiatric condition, or they might be the result of poor sleep hygiene. Sleep hygiene includes, among other factors, sleep schedule, bedroom acoustics and lighting, daytime napping, dietary habits, exercise (or lack thereof), exposure to daylight, and use of alcohol and caffeine. Each of these can affect the quality of an individual’s sleep. In general, older individuals experience a number of age-related changes in their sleep patterns. Included among these changes are spending more time in bed, spending less time asleep, decreased sleep efficiency, and taking more time to fall asleep. Research suggests that much of this change in sleep quality is not accounted for by medical or psychiatric problems. Some sleep disturbances are affected by diseases (such as dementia), which increase in prevalence with age; however, most research suggests that when health factors are controlled for, the prevalence of sleep complaints in the elderly are less than previously thought. Sleep disorders that are age-related include sleep-related breathing disturbance (SRBD), or sleep apnea, and periodic leg movement during sleep (PLMS), or nocturnal myoclonus. However, it is not clear whether the presence of SRBD or PLMS has any debilitating effect on daytime functioning in the elderly, so the clinical significance of these disorders is questionable. A disproportionate number of prescriptions for sedatives are given to the elderly who complain of poor sleep quality. These sedatives, while perhaps useful for the transient relief of sleep disorders, have limited usefulness for the chronic treatment of sleep disturbances. Tolerance develops, and the administration of these drugs, ironically, can worsen the quality of sleep in those individuals already experiencing sleep disturbances.
824 ✧ Sleep changes with aging Circadian Rhythms Sleep is clearly a behavior that follows a rhythmic pattern. Not only does an individual cycle between sleep and wakefulness during a twenty-four-hour period, but also sleep itself follows a regular pattern of rapid eye movement (REM) and non-REM sleep during the night. Research suggests that some of the disturbances in sleep seen with age are the result of changes in circadian rhythms. However, these changes in circadian rhythmicity and sleep quality with age might be reversible. Circadian rhythms are regulated by the brain structures (the suprachiasmatic nucleus and the pineal gland) and neurochemicals (serotonin and melatonin) that make up the circadian system. This system regulates a number of physiological and behavioral functions, including body temperature and hormonal rhythms, in addition to the sleep-wakefulness rhythm. Age-related changes in the circadian system include a decrease in amplitude (the range of changes between the maximum and minimum values) and an advance in phase (a specific measuring point linked to a particular clock time). The most consistently reported change with age is diminished amplitude (reduced release of melatonin), which affects sleep quality by decreasing time spent sleeping during the night. This reduction in sleep quality can result in impaired alertness and performance the following day. Phase shifting results in a particular phase (for example, temperature regulation) occurring earlier according to clock time. For example, older adults regularly go to bed earlier than younger adults, and this change in behavior might be a function of an earlier phase of the body temperature rhythm. Declines in body temperature are a cue for sleeping, and if these declines occur earlier in the evening, a change in sleeping behavior could follow. These changes in rhythmicity might result from a number of factors, including decreases in the sensitivity of the eye to light, changes in the biochemistry or structure of key sites in the circadian system, and reduction in exposure to light in the elderly. It has also been found that there are reductions in the release of melatonin, a hormone with soporific qualities. If reduced light and reductions in melatonin underlie the changes in the circadian system that occur with age, it is possible that these changes can be attenuated with therapy. Phototherapy and exogenous administration of melatonin are examples of therapies that might restore circadian rhythmicity and improve the overall quality of sleep in aging individuals. Sleep changes with age can result from a number of causes. Some of these disturbances might be secondary to other medical or psychiatric problems; some are caused primarily by aging itself. In addition, judgment of sleep quality is, in many ways, a subjective appraisal. Disruption of sleep during the night might be very troubling for one individual but merely annoying for another. For these reasons, a careful examination of the overall health of the aging individual, as well as that individual’s sleep hygiene, is necessary in any evaluation of sleep disturbance. The growth in the number of sleep
Sleep disorders ✧ 825 laboratories and sleep disorder clinics in the United States has made such evaluations more feasible than in the past. —Kevin S. Seybold See also Aging; Depression; Depression in the elderly; Light therapy; Medications and the elderly; Menopause; Overmedication; Seasonal affective disorder (SAD); Temperature regulation and aging. For Further Information: Carlson, Neil R. “Sleep and Biological Rhythms.” In Physiology of Behavior. 6th ed. Boston: Allyn & Bacon, 1998. Cowley, Geoffrey, and Anne Underwood. “Exploring the Secrets of Age.” Newsweek 132, no. 17 (October 26, 1998). Medina, John J. The Clock of Ages: Why We Age—How We Age—Winding Back the Clock. New York: Cambridge University Press, 1996. Turek, Fred W. “Sleep/Rhythm: Aging and John Glenn’s Return to Space at Age Seventy-seven.” Journal of Biological Rhythms 13, no. 6 (December, 1998). Vitiello, Michael V. “Sleep Disorders and Aging: Understanding the Causes.” The Journals of Gerontology 52A, no. 4 (July, 1997).
✧ Sleep disorders Type of issue: Elder health, mental health Definition: Any abnormal pattern of sleep which threatens normal function. Brain activity measured in sleeping subjects has been used to classify sleep into stages. Stage 1 is the lightest sleep and stage 4 is the deepest. A sleeper moves from stage 1, through stages 2 and 3, and to stage 4, and then back through stages 3 and 2 to stage 1. This cycle occurs every ninety to one hundred minutes throughout the night. During the latter part of the sleep period, stage 1 sleep is associated with brain activity as intense as that seen in waking subjects. During these periods of intense brain activity, rapid eye movements (REMs) are observed; as a result these periods are referred to as REM sleep and the other sleep stages are referred to as non-REM sleep. Sleep disorders can be divided into four broad categories: the insomnias (disorders of initiating or maintaining sleep), the hypersomnias (disorders of excessive sleep), disorders of the sleep-wake cycle, and the parasomnias (disorders of partial arousal such as sleepwalking and night terrors). For those who suffer from a sleep disorder, life can become a daily struggle, often with severe physical, financial, and social consequences.
826 ✧ Sleep disorders Insomnia Insomnia is a subjective complaint of nonrefreshing sleep. Patients believe that their ability to function during the day is impeded by short or poorquality sleep. Most people experience transient insomnia at various times in their lives; chronic insomnia is defined as insomnia lasting longer than three months. Some insomniacs require a long period to fall asleep, some wake up after a few hours and cannot fall asleep again, and some may not know that they have awakened briefly hundreds of times during the night. The sleep patterns of the insomniac can vary from night to night, increasing anxiety. Electrical monitoring of brain activity shows that most insomniacs have only a slightly reduced total sleep time, with few changes in sleep stages. Insomnia can be caused by medical problems that interfere with breathing, such as sleep apnea, in which patients have multiple episodes each night when they stop breathing. A single episode can last ten seconds to two minutes, and in some severe cases, up to 50 percent of sleep time can be spent without breathing. Sleep apnea is often seen in obese men and women because of obstruction of the air passage. Clinical signs include irregular snoring and daytime sleepiness. Insomnia can also be caused by neurological problems, muscular problems, or conditions that cause pain. Periodic leg movement can (but does not always) cause multiple awakenings during the night, as can a related disorder called restless leg syndrome, which is characterized by a creeping sensation in the legs. Insomnia can be a symptom of clinical depression. Surveys have shown that insomniacs have a higher level of stress, tension, and anxiety than normal sleepers. In addition, insomnia can occur when behavioral patterns do not encourage sleep. The use of caffeine or engaging in arousing activities just prior to bedtime can contribute to poor sleep. The normal aging process usually causes a decrease in total sleep time and in stage 1 sleep and an increase in fragmented sleep, resulting in drowsiness and sometimes depression. Hypersomnia The hypersomnias are defined by excessive daytime sleepiness (EDS) and include the group of patients who are unable to stay awake during the day. Several external circumstances can contribute to EDS, such as jet lag, shift work, medications, or some of the disorders underlying insomnia. In addition, narcolepsy, a central nervous system disorder, is characterized by the overwhelming need to sleep several times a day. These sleep attacks often occur without warning. Narcoleptics can also experience cataplexy, or sudden muscle weakness when in emotionally charged situations that cause anger, laughter, or fear. They may also experience hallucinations when sleep begins or sleep paralysis upon waking that can last for several minutes. Narcolepsy affects 0.05 percent of the population and causes significant
Sleep disorders ✧ 827 hardship to those afflicted. It can pose a danger if the person falls asleep while operating a car or when in a dangerous environment. Parasomnia The parasomnias, or disorders of arousal, include sleepwalking and night terrors. Both of these disorders occur predominantly in childhood, although they can be experienced by adults. When brain activity is characterized by an electroencephalograph (EEG), there are elements of both wakefulness and REM sleep, often in the deepest stages (3 and 4). This finding dispels the myth that sleepwalkers are acting out dreams, since dreaming occurs during REM sleep. Sleepwalking activity can vary in length. The person usually has his or her eyes open, can respond verbally, and can move about normally. Sleepwalkers are usually aware of the environment at some level, although their judgment is impaired and they can sometimes injure themselves. Night terrors involve signs of panic such as shrieking, sweats, and frenzied movements and can be distinguished from nightmares, which involve little movement and more extensive memory. Both sleepwalking and night terrors are usually not recalled, and there is little connection between these syndromes and psychiatric disease. Both may be exacerbated by sleep deprivation, stress, fever, or medications. Treating Sleep Disorders For insomnia associated with an underlying psychiatric or medical problem, treating the primary problem problem usually returns the sleep pattern to normal. Symptomatic treatment of the insomnia itself is provided only when the cause of the sleep disturbance cannot be treated. There are two major approaches: treatments emphasizing the use of drugs or technical aids and treatments emphasizing a change in behavior. Benzodiazepines are the most commonly prescribed drugs for sleeplessness. These drugs are usually taken about thirty minutes before bedtime, causing drowsiness and thus decreasing the amount of time it takes to fall asleep. Benzodiazepines alter the stages of sleep, decreasing the amount of stage 1 and REM sleep and increasing the amount of stage 2 sleep. When used alone, benzodiazepines are very safe and have few side effects; if they are combined with other drugs, however, there can be a toxic interaction. Some impairment of function may exist upon waking. Benzodiazepines should be used for only a short period of time. After thirty days, the drug becomes less effective unless the dosage is increased to an unsafe level. When the drug is discontinued, the original symptoms of insomnia usually recur and often an even more severe rebound insomnia may occur for a brief period.
828 ✧ Sleep disorders To treat insomnia that is caused by periodic leg movements, a muscle relaxant is sometimes used. For patients whose sleep apnea is not resolved by weight reduction, mechanical devices that hold the air passage open during sleep are usually employed. Orthodontic aids or tongue retainers may provide relief, and other patients wear a mask which holds the air passage open, providing a continuous airflow during sleep. Since insomnia is often caused by poor habits that condition the sleeper to remain awake, the problem can sometimes be solved by a simple commitment to avoid naps, reduce caffeine and alcohol intake, eat light meals in the evening, reduce noise in the sleep environment, and establish a regular bedtime. Many insomniacs are so preoccupied with the fear that they will not sleep well that they become tense as bedtime approaches. Techniques that teach people to relax their muscles or meditation to decrease mental activity may reduce this anxiety and promote sleep. Patients who experience better sleep when away from their normal sleeping location may have “learned” to associate the bedroom environment with wakefulness. To overcome this problem, stimulus control is used to try to strengthen the bedroom as a cue for sleep. This method requires that patients use the bedroom only for sleeping and go to bed only when sleepy. Most important, if they do not fall asleep within ten minutes of lying down, they should get up, go into another room, and engage in a mundane activity, coming back to the bedroom only when sleepy. Excessive daytime sleepiness is treated in different ways depending on its cause. If the cause is sleep apnea or periodic leg movements, the disorder is handled as described above. In other cases of sleep fragmentation, medication is used to prevent arousal during the night. The excessive daytime sleepiness found in narcoleptics is usually treated with drugs that act as central nervous system stimulants. Other symptoms of narcolepsy are usually treated with antidepressant drugs that suppress REM sleep. Of these, gamma hydroxybutyrate has been shown to be effective and to cause limited side effects. Short naps taken throughout the day seem to prevent many of the symptoms associated with sleep attacks. The Future of Sleep Research Most sleep disorders were discovered in the 1960’s and 1970’s. Since then, the number of sleep centers and laboratories that are studying sleep and its accompanying disorders has grown tremendously. These sleep centers have been instrumental in elucidating the primary disorders of sleep and in educating the general public concerning sleep management and the safety risks that result from abnormal sleep. Research laboratories are investigating the anatomical, chemical, and physiological mechanisms of sleep and sleep abnormalities.
Smog ✧ 829 Current research includes genetic studies to determine whether sleep disorders are inherited. There appears to be a significant genetic component to several sleep characteristics, including bedtime, sleep duration, insomnia, narcolepsy, snoring, and sleep apnea. It is expected that, as scientists come to understand more about the nature and mechanisms of the brain and normal sleep, further understanding of the causes and treatments for sleep disorders will be forthcoming. —Katherine B. Frederich See also Aging; Chronic fatigue syndrome; Depression; Depression in children; Depression in the elderly; Memory loss; Sleep changes with aging; Stress. For Further Information: Carskadon, Mary A., ed. Encyclopedia of Sleep and Dreaming. New York: Macmillan, 1993. An extremely important and comprehensive resource which provides well-written articles on all facets of sleep and sleep disorders. Dement, William C., and Christopher Vaughan. The Promise of Sleep. New York: Random House, 1999. Over this book’s four sections, the authors cover the basics, such as “Daily Sleep Need,” “Alternative Therapies,” and “Sleeping Pills.” Gives sleep, one of humanity’s greatest basic needs, the attention it deserves. Dotto, Lydia. Losing Sleep: How Your Sleeping Habits Affect Your Life. New York: William Morrow, 1990. Discusses the physical and social consequences of sleep disorders, with an emphasis on sleep loss. In an easy-to-read style, the author reports on the effects that a modern, frenetic lifestyle has on sleep and its ramifications for waking hours as well. Hobson, J. Allan. Sleep. New York: Scientific American Library, 1995. This beautifully illustrated volume provides an overview of past and contemporary sleep research. The author draws upon neurology and psychology to provide an interdisciplinary approach to his topic. Reite, Martin, and Nagel Ruddy, eds. Concise Guide to Evaluation and Management of Sleep Disorders. 2d ed. Washington, D.C.: American Psychiatric Press, 1997. Gives an overview of the symptoms and treatments available for different types of sleep disorders.
✧ Smog Type of issue: Environmental health, industrial practices, public health Definition: Originally a blend of the words “smoke” and “fog,” the term was coined to describe the severe air pollution that resulted when smoke from factories combined with fog during a temperature inversion; the word was
830 ✧ Smog later broadened to include photochemical smog—first noticed in the Los Angeles Basin—which resulted from sunlight acting on unburned hydrocarbons emitted from automobiles. As one ascends upward from the earth’s surface, the air temperature drops by about 5.5 degrees Fahrenheit every 1,000 feet. Temperature inversions occur when this normal condition is reversed so that a blanket of warm air is sandwiched between two cooler layers. The temperature inversion restricts the normal rise of surface air to the cooler upper layers, in effect placing a lid over a region. When air cannot rise, the air currents that carry pollutants away from their sources in cities stagnate, causing pollution levels to increase drastically. A combination of severe air pollution, prolonged temperature inversion, and moisture-laden air may result in a what has been termed “killer fog.” Several acute episodes of killer fog occurred during the twentieth century. One was in the Meuse Valley of Belgium. During the first week of December, 1930, a thick fog and stagnant air from a temperature inversion concentrated pollutants spewing forth from a variety of factories in this heavily industrialized river valley. After three days of such abnormal conditions, thousands of residents became ill with nausea, shortness of breath, and coughing. Approximately sixty people died, primarily elderly people or those with chronic heart and lung diseases. The detrimental effects on health were later attributed to sulfur oxide gases emitted by combusting fossil fuels concentrated to lethal levels by the abnormal weather. The presence of coal soot, combined with moisture from the fog, exacerbated the effect. A second episode occurred in Donora, Pennsylvania, during the last week of October, 1948. Donora is situated in a highly industrialized river valley south of Pittsburgh. A four-day temperature inversion with fog concentrated the gaseous effluents from steel mills with the sulfur oxides released by burning fossil fuels. Severe respiratory tract infections began to occur, especially in the elderly, and 50 percent of the population became ill. Twenty people died, a tenfold increase in the normal death rate. A third major episode occurred in London, England, in early December, 1952. At that time, many citizens burned soft coal in open grates. When a strong temperature inversion and fog enveloped the city for five consecutive days, residents began complaining of respiratory ailments. By the time the inversion had lifted, four thousand excess deaths had been recorded. In this case it was not only the elderly who were affected: Deaths occurred in all age categories. During the next decade London experienced two additional episodes: one in 1956, which claimed the lives of one thousand people, and one in 1962, which caused seven hundred deaths. The decline in mortality rates resulted from restricting the use of soft coal, with its high sulfur content, as a source of fuel. Sulfur oxide compounds are responsible for
Smog ✧ 831 causing lung problems during these episodes; therefore, killer fogs have been more accurately renamed “sulfurous smogs.”
Fumes from automobile exhaust contribute to the formation of photochemical smog. (PhotoDisc)
Photochemical Smog Photochemical smog, first noticed in the Los Angles Basin in the late 1940’s, has been an increasingly serious problem in cities. Unlike sulfurous smogs, moisture is not part of the equation, and smoke-belching factories dumping tons of sulfur oxide compounds into the atmosphere are not required. Rather, photochemical smog results when unburned hydrocarbon fuel, emitted in automobile exhaust, is acted upon by sunlight. The Los Angeles Basin, hemmed in by mountains to the east and ocean to the west, has a high density of automotive traffic and plenty of sunshine. Varying driving conditions mean that gasoline is never completely consumed; instead, it is often changed into other highly reactive substances. Sunlight acts as an energy catalyst that changes these compounds into a variety of powerful oxidizing agents, which constitute photochemical smog. This type of smog has a faint bluish-brown tint and typically contains several powerful eye irritants. The chemical reactions also produce aldehydes, a class of organic chemical best typified by an unpleasant odor. The complicated chemistry of photochemical smog also produces ozone, which is extremely reactive; it damages plants and irritates human lungs. Since ozone production is stimulated by sunlight and high temperatures, it becomes a particularly pernicious problem during the summer, especially
832 ✧ Smoking during morning rush hours. Under temperature inversion conditions, the ozone created in photochemical smog can increase to dangerous levels. Ozone is highly toxic. It irritates the eyes, causes chest irritation and coughing, exacerbates asthma, and damages the lungs. Photochemical smog and ozone are now common ingredients in urban air. Although acute episodes of ozone-induced mortality are rare, concern is growing about the detrimental long-term consequences of the brief but repetitive exposures consistently inflicted upon commuters. It appears as though no curtailment of the problem will be possible in urban areas in the United States without significant changes in transportation, strict limits on growth, and radical alterations in lifestyle. —George R. Plitnik See also Asthma; Emphysema; Environmental diseases; Lung cancer; Smoking. For Further Information: Elsom, Derek M. Smog Alert: Managing Urban Air Quality. London: Earthscan, 1996. Discusses photochemical smog and what can be done to control it. Grant, Wyn. Autos, Smog, and Pollution Control: The Politics of Air Quality Management in California. Brookfield, Vt.: Edward Elgar, 1995. Explains the air pollution situation in California. Grant discusses why the pollutioncontrol devices mandated by the state cannot hope to clean the air but can only keep the air quality from deteriorating further. Hinrichs, Roger A. Energy: Its Use and the Environment. Philadelphia: Saunders College Publishers, 1996. An excellent overview that discusses the complicated relationship between energy use and its environmental effects. Chapter 8 details air pollutants, air-quality standards, and automotive emission control devices.
✧ Smoking Type of issue: Public health, social trends Definition: The inhalation of tobacco smoke, the main avoidable cause of death in the United States and many other developed nations. More than 10 percent of North Americans over the age of sixty-five smoke cigarettes, putting themselves and those with whom they live at risk for significant health problems. These risks appear to increase both with age and with the number of years of smoking. After World War II, more women began smoking. Because the diseases related to smoking usually take years to develop, it was only in the last part of the twentieth century that rates of
Smoking ✧ 833 smoking-related disease among women began to approach those of men. On the other hand, research indicates that smoking cessation appears to be beneficial, even in a person who has smoked for many years. The Health Effects of Smoking Cigarette smoking has long been known to have adverse effects. Smokers get more wrinkles than nonsmokers, so they tend to look older than their chronological age. They also are more likely to develop gum disease and lose teeth, adding to the changes related to eating, such as alterations in sense of smell and taste, that are normal as people age. Loss of teeth leads to difficulty chewing, which in turn leads to difficulties with digestion. Most people who lose teeth eventually develop loss of the bone that should support their teeth, making it increasingly difficult to fit dentures. Smokers are ten times more likely to get lung cancer than nonsmokers. Lung cancer is now the number one cause of cancer death in women, as well as in men. In addition to lung cancer, smokers have a higher incidence of cancers of the head and neck, esophagus, colon, rectum, kidney, bladder, and cervix. Smokers are twenty times more likely to have a heart attack than nonsmokers. In older people, the major risk factor for disease of the coronary arteries is hypertension, but smoking is still significant, especially when combined with other risk factors for heart disease, such as diabetes or high cholesterol. Smoking and diabetes are also the two most important risk factors for diseases of the veins and arteries of the lower leg. Those who continue to smoke once these diseases develop are much more likely to require limb amputation than those who quit. Smokers may develop chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis, and are eighteen times more likely than nonsmokers to die of diseases of the lungs other than cancer. Older smokers also show decreases in muscle strength, agility, coordination, gait, and balance. The changes in these areas make them seem five years older than their actual age. Smoking has long been thought to be associated with peptic ulcer disease. In addition, smoking makes the symptoms of many diseases worse or increases the risk of complications in patients with allergies, diabetes, hypertension, and vascular disease. Male smokers are at greater risk of experiencing sexual impotence. Female smokers tend to experience an earlier menopause and are at increased risk for hip fracture than nonsmokers. Smokers are more likely to develop glaucoma than nonsmokers. Studies completed in 1996 indicated an increased risk with smoking for macular degeneration, the leading cause of blindness in older adults. The evidence is mixed on smoking and Alzheimer’s disease, but a 1998 study contradicted earlier work and found that the risk is greater in smokers than nonsmokers. Finally, smokers are at greater risk of death or injury caused by cigaretterelated fires.
834 ✧ Smoking Smoking and Medications Cigarette smoking tends to speed up the processes in the liver for breaking down, using, and eliminating medications, both nonprescription and prescription. This means that medications may not perform as expected in the body. Smokers may need to take medications more frequently or in greater doses than nonsmokers, so it is important for health care providers to know that a person smokes. The drugs known to be affected by smoking include sedatives, narcotic and synthetic narcotic painkillers, certain antidepressants, anticoagulant medications, asthma medications, and beta blockers. These changes are of particular concern in the older population for a number of reasons. First, older people (whether smokers or nonsmokers) tend to need more medications than younger people. With each additional drug, the risk of serious drug interaction and other adverse effects increases. Second, changes in body composition and function that alter the metabolism of drugs come with age, making medication use somewhat riskier in older persons, in terms of adverse effects and complications. The additional changes associated with smoking increase these risks significantly. The dangers of passive smoking are well documented. The effects seem to be more harmful in children than in adults, but adults who are affected are at increased risk for cancer, heart disease, noncancerous lung diseases, and allergies. The Benefits of Smoking Cessation Numerous studies have shown that smoking cessation has health benefits in as little as one year, such as reducing the risk of heart attack and coronary artery disease. Within two years of smoking cessation, the risks of stroke and diseases of the blood vessels in the lower leg are reduced as well. Even though chronic lung disease is not reversible, those who quit smoking slow the decline in lung function considerably. Risks for cancers also decrease significantly with smoking cessation and are similar to the cancer risk for nonsmokers in ten to thirteen years. These findings indicate that it is worthwhile even for older people to give up smoking. Because smoking is an addiction, it may be difficult to quit, particularly after years of cigarette use. Most smokers have to stop several times before quitting permanently. Setting a quit date, attending support group meetings, taking it one day at a time, undergoing hypnosis, making a contract with a friend or a health care provider, substituting carrot sticks for cigarettes, increasing exercise (particularly swimming), and breathing deeply all seem to be helpful techniques. Nicotine replacement systems are available in the United States on a nonprescription basis, but it is important for older people, particularly those with health problems or who are taking multiple medications, to consult a health care professional prior to using them. It is also important that anyone using these aids stop smoking completely. It is
Snakebites ✧ 835 possible to get a toxic dose, perhaps even a fatal one, by smoking and using nicotine replacement simultaneously. —Rebecca Lovell Scott See also Addiction; Broken bones in the elderly; Cancer; Dental problems in the elderly; Emphysema; Heart attacks; Lung cancer; Macular degeneration; Osteoporosis; Secondhand smoke; Skin disorders with aging; Strokes; Tobacco use by teenagers; Vision problems with aging. For Further Information: “The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline.” JAMA: The Journal of the American Medical Association 275, no. 16 (April 24, 1996). Benowitz, Neal L., and the Society for Research on Nicotine and Tobacco. Nicotine Safety and Toxicity. Oxford, England: Oxford University Press, 1998. Hales, Diane. “Tobacco Use.” In An Invitation to Health, 9th ed. Pacific Grove, Calif.: Brooks/Cole, 1996. Ott, A. “Smoking and Risk of Dementia and Alzheimer’s Disease in a Population-Based Cohort Study: The Rotterdam Study.” The Lancet 351, no. 9119 (June 20, 1998). Vogt, Molly, et al. “Smoking and Mortality Among Older Women: The Study of Osteoporotic Fractures.” Archives of Internal Medicine 156, no. 6 (March 25, 1996).
✧ Snakebites Type of issue: Public health Definition: The penetration of skin or flesh by the fangs of a snake. A snakebite is a wound that results from the flesh penetration created by the hollow teeth, or fangs, of a snake and sometimes the injection of venom into the bloodstream. Venom is usually encountered in snakes, although other animals and insects use it, often as part of their defense system. Venomous snakebites have a different effect based on the size of the victim, the location of the bite, the quantity of venom injected, and the time elapsed between the snakebite and the administration of antivenin therapy. Any part of the body is subject to this injury, but statistically legs, feet, and arms are by far the most commonly affected areas. The symptoms of a snakebite include swelling or discoloration of the skin, a racing pulse, weakness, shortness of breath, nausea, and vomiting. Other symptoms include dilation of the pupils, shock, convulsions, twitching, and
836 ✧ Snakebites slurred speech. In extreme cases, severe pain and swelling and sometimes paralysis, unconsciousness, and even death may occur. Snake venom contains an array of substances that are usually proteins in nature and that create tissue damage in several ways. The most important kinds of damage are nerve destruction, in which case the venom is called neurotoxic, and blood and tissue destruction, in which case the venom is hemotoxic. Neurotoxins have the tendency to paralyze the nervous system and lead to heart and respiratory failure. On the other hand, hemotoxins destroy arteries, veins, and blood corpuscles and lead to internal hemorrhaging. Different snakes have various degrees of toxins. Cobra venom is usually neurotoxic, while rattlesnake venom is hemotoxic. The development of gangrene in the location of the snakebite is possible unless the victim is treated promptly. Treating Snakebites The victim of a snakebite may exhibit mild to severe symptoms. Although the strength of venom of different snakes differs widely, snakebite treatment should be imposed as soon as possible in order to reduce the possibility of a fatality. This treatment should address two points: how to restrict the venom to the smallest body area possible and how to remove as much venom as possible. Thus, all contractions of the body and limb movement should be reduced immediately to a minimum to avoid spreading the venom. This is accomplished by immobilizing the affected area, preferably in a horizontal position and definitely lower than the heart. Any exertion and/or excitement by the bitten child increases the pulse rate and blood circulation, which leads to easier spreading of the venom. This is the same reason that stimulants should be avoided. Statistically, more than three-quarters of snakebites occur on the lower leg or forearm. Current first aid recommendations do not include ice, any incision, the application of oxidizers such as potassium permanganate, or the administration of aspirin, ibuprofen, acetaminophen, or alcohol. Instead, the bitten part should be wiped, and a relatively tight tourniquet that reduces the lymphatic flow without cutting off the blood supply to the affected area should be applied. A nurse or other emergency medical service employee should check the pulse at the bitten area to ensure adequate blood flow. It is also recommended that the bandage be released every half hour for half a minute. It is also helpful to take the snake, whether alive or dead, to the hospital for proper identification. If the swelling extends more than 5 inches within the first twelve hours after the bite, antivenin is given through intravenous transfusion in a hospital. Antivenin preparations are extracted by the immunization of animals such as horses, and their efficiency is dependent on the purification and concentration of the substance. Antivenins are usually specific, but some, such as
Speech disorders ✧ 837 that for tiger snake venom, appear to protect against the venom of more than one snake. If there is no swelling and increasing pain around the bite within thirty minutes, then the wound is one of the approximately one-third of bites by poisonous snakes in which venom is not injected. A notable exception is the bite of the coral snake, in which swelling takes place despite the venom infusion. After the victim sees a doctor, several nutrients can be taken that appear to relieve pain and symptoms. They include vitamin C, which serves as a detoxifier and lessens infection; calcium gluconate, which relieves pain; and pantothenic acid, which serves as an antistress vitamin. —Soraya Ghayourmanesh See also First aid; Poisoning; Zoonoses. For Further Information: Altimari, William. Venomous Snakes: A Safety Guide for Reptile Keepers. St. Louis: Society for the Study of Amphibians and Reptiles, 1998. Julivert, Maria Angels. The Fascinating World of Snakes. New York: Barron’s Educational Series, 1993. Mattison, Christopher. The Encyclopedia of Snakes. New York: Facts on File, 1995. Simon, Seymour. The Poisonous Snakes. New York: Four Winds Press, 1981. Tu, Anthony T., ed. Reptile Venoms and Toxins. Handbook of Natural Toxins 5. New York: Marcel Dekker, 1991.
✧ Speech disorders Type of issue: Children’s health, mental health Definition: Dysfunction in the brain-coordinated use of speech organs. The development of speech occurs in several distinct stages. Newborns make involuntary noises in response to physical stimuli. Babies begin to enjoy making these noises at about two months of age. About nine months after birth, they start to imitate the sounds and inflections of the speech of others around them. Beginning at twelve to eighteen months of age, children start to vocalize in a meaningful way. In due time, they learn to speak. In many cases, however, a child has some difficulties with the use of speech or with its development to appropriate levels within expected time spans. Such children suffer from speech disorders including stuttering, lisping, and lack of speech comprehension. Others are born with physical problems, such as cleft palate, which make appropriate speech impossible without medical intervention. Smaller numbers of people develop speech
838 ✧ Speech disorders disorders later in life for various reasons, including accidents that damage the brain or the mechanical organs of speech, as well as the physical and mental ravages of advanced age. Categorizing Speech Disorders Speech disorders fall into three main categories: problems associated with speech production, difficulties of articulation, and dysfunction in the ability to utilize language. Although they are frequently hereditary, the genetic cause is often unclear. There is often a psychogenic aspect as well. Another broad means of categorizing speech disorders is by dividing them into causative organic and nonorganic groups. The term “organic speech disorder” is used to indicate birth defects or later injuries to the brain or the structures, muscles, and connective tissues that are required to produce speech. The disorders for which no such origin can be clearly identified fall into the nonorganic group. Usually, they are attributed solely to psychogenic factors. It is probable, however, that they have subtle organic causes beyond present methods of identification. Speech disorders may be associated with articulation, voice, fluency, language, and dementia. The cures for all these types of speech disorders vary; they include the interactive participation of teachers in school systems and the attention of speech professionals such as audiologists, surgeons, psychiatrists, and physical therapists. Each case must be analyzed carefully and then treated individually. Even so, varied success is obtained. A Variety of Treatments Disorders of articulation are quite common and range from mild problems (for example, a lisp) to those which are so extreme that the speech of afflicted individuals becomes unintelligible. Many of the most severe disorders arise from organic impairment of motor control in the speech musculature, which may be attributable to stroke, cleft palate, or even the loss of lips or other speech system components. Frequently, efforts at remediating such problems must include surgical and dental treatment. After any necessary corrective surgery and/or dentistry, many treatment regimens focus on behavior modification. Affected individuals receive instruction regarding the physical basis of their problems and are then trained to overcome them as effectively as possible. The use of psychological and psychiatric counseling is considered to be of great value. Some experts suggest, however, that the main effect of such therapy is to enable afflicted individuals to live comfortably with the imperfections in articulation that remain after all treatments are tried. Voice disorders occur when the phonatory mechanism is dysfunctional. They range from the consequences of laryngeal, oral, or respiratory disease
Speech disorders ✧ 839 to the misuse of the phonatory system, which may reflect psychological state. Such functional disorders, if left untreated for too long, may lead to organic damage. In the case of pitch abnormalities, causative factors may include psychological tension, an undersized larynx, misformed vocal cords, and hearing problems, either individually or in various combinations. Disorders of voice quality likewise have many physical sources, including larynx and vocal cord abnormalities, and ones of psychogenic origin. The disorders associated with loudness range from overly loud voices caused by workplace noise or hearing loss to extremely soft ones that are generally psychogenic. Treatment of all such disorders begins with the disqualification of treatable organic problems. In the case of psychogenic disorders, psychiatric counseling can be extremely helpful. Disorders of fluency most often involve stuttering, also called dysfluency, which features spasmodic hesitation and the prolongation or repetition of sounds. In addition, stuttering is often accompanied by tics and other uncontrolled body movements. The basis for the problem is unclear, and different experts point to learned behavior, psychogenic origins, or organic roots. There is no cure for dysfluency, but it can be greatly diminished. Treatment usually involves both psychiatric counseling and behavior and/or speech modification by speech-language pathologists as well as by other related speech professionals. Such therapy varies widely from individual to individual and with the age of the patient. Language disorders are characterized by the diminished ability to use or to understand spoken language. In children, these disorders are often identified as language delay, or development aphasias. They are most often thought to be attributable to mental retardation, hearing loss, or autism. When lost hearing is not the main problem, the treatments for such language problems often involve behavior modification techniques. In all cases in which hearing loss is an important component, its correction is the first effort; such efforts may work wonders. When hearing problems cannot be remediated entirely, however, the overall treatment will be much less successful because hearing the speech of others is so important to speech development. True aphasia is very often viewed as speech impairment; it occurs in adults as a result of stroke, accidents that produce severe head trauma, or dementia. Treatment should begin as soon as possible after aphasia is observed. Some rapid and spontaneous healing of lost language ability occurs, and this healing can be maximized by the efforts of speech-language pathologists. The continued treatment of aphasias is very important and usually follows careful evaluation of its causes. Progressive, long-term advances are often possible, but complete recovery is rare. The use of sign language or personal computers for interpersonal communication may be necessary.
840 ✧ Speech disorders Emotional and Social Impact Speech disorders often have disastrous psychological and economic effects on the afflicted person. Young children may be traumatized if speech disorders are not treated early; in severe cases, they may have difficulty entering the workforce or obtaining an education. The diagnosis of speech problems by schoolteachers is an important step. Once a problem is observed, the child’s family can be advised concerning special education available through the school system or local programs. There is also help available for older people who develop speech problems because of aging, dementia, or harmful workplace conditions. In all cases, once a sound treatment plan is developed, it is essential that the afflicted person follow it rigorously. Miracles should not be expected; rather, sustained interaction between the treatment team, especially the patient and a speech-language pathologist, must be undertaken. Furthermore, the psychological support of the patient’s family and friends has been recognized as a crucial factor in many successful treatment plans. —Sanford S. Singer See also Alzheimer’s disease; Autism; Children’s health issues; Cleft lip and palate; Dyslexia; Learning disabilities; Strokes. For Further Information: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Revised 4th ed. Washington, D.C.: Author, 2000. This classic text contains diagnostic criteria and other useful facts about a variety of mental disorders, including those associated with speech dysfunction. Berkow, Robert, and Andrew J. Fletcher, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Rahway, N.J.: Merck Sharp & Dohme Research Laboratories, 1999. Contains useful data on the characteristics, etiology, diagnosis, and treatment of speech disorders and related processes. Although the text is designed for physicians, the material should be useful to general readers as well. Cole, Patricia R. Language Disorders in Preschool Children. Englewood Cliffs, N.J.: Prentice Hall, 1982. This book by an expert speech-language pathologist explains the modalities associated with solving speech-language disorders. Solid and well referenced, it covers language development, disorders, diagnosis, and treatment. Daniloff, Raymond, Gordon Schuckers, and Lawrence Feth. The Physiology of Speech and Hearing: An Introduction. Englewood Cliffs, N.J.: Prentice Hall, 1980. This introductory book is thorough and uses clear, simple language. Most important to the reader are the chapters that provide an overview of speech and hearing, neuroscience, and acoustics. Winitz, Harris, ed. Human Communication and Its Disorders: A Review, 1987. Norwood, N.J.: Abex, 1987. This authoritative text covers in detail the
Spina bifida ✧ 841 prominent disorders of human communications: their occurrence, symptoms, and treatment. Both organic and nonorganic aspects of these communication problems are carefully explored and referenced.
✧ Spina bifida Type of issue: Children’s health Definition: A birth defect that results from a mistake early in the development of the spinal cord. The development of the fetal nervous system starts a few weeks after conception and continues until well after birth. The central nervous system begins with the formation of a thickened layer of tissue, called the neural plate, along the back of the embryo. The edges of this plate curl up to form ridges, and the whole plate rolls up into a slender tube running from the head to the rump. This cylinder is then covered over by tissues that will form the surface of the back. The front end of this tube will expand to become the brain, and the rest of the tube will form the spinal cord. The tube must seal itself along its entire length. If the neural tube fails to seal, a small opening called a neuropore will remain at some point along its length. Depending on where the opening is, a variety of abnormalities can result. When the posterior region of the neural tube fails to close, the result is spina bifida. This flaw in the neural tube in turn affects the assembly of the muscle, bone, and skin in this region. In spina bifida, which means “divided spine,” the vertebrae of the backbone do not join together properly. The severity of spina bifida depends on how much damage has been done to the lower spinal cord region. In its mildest form, the only evidence of a problem may be that two of the bones in the spine fail to form quite right. If several vertebrae are involved, the membranes that protect the surface of the spinal cord can bulge outward, forming a ball-like mass in this region. The problems that result depend on how much of the spinal membrane is involved in this bulge. In the most severe cases, the vertebrae fail to protect the spinal cord, so that the nervous tissue itself is also involved and an opening to the outside remains at the base of the spinal cord. Additional problems with nervous system development may result, including improper fluid balances in the brain (hydrocephalus). Symptoms and Treatment Because the brain and spinal column fail to develop properly in spina bifida, a variety of mental, behavioral, and physical symptoms can result. The nerve
842 ✧ Spina bifida connections at the base of the spine are likely to be affected, resulting in paralysis in the lower back and legs, problems with bladder and bowel function, and loss of sensation. Because the development of the brain can also be affected, mental abilities may be impaired. Effective measures have been developed to minimize the effects of spina bifida. Often, surgery is performed within twenty-four to forty-eight hours of birth to close any opening in the child’s lower back and to reconstruct the spine and other tissues in this area. Problems with feet and legs may also be dealt with surgically. If the child has symptoms of hydrocephalus, the excess fluid will be drained. Bladder and bowel function will be regulated, such as by catheterization. Eventually, prosthetic devices may be fitted to assist the child’s movement. Mental health and physical therapy experts will also be involved to assist in overcoming learning hurdles, monitoring physical development and training, and making emotional adjustments. Prevention and Understanding Late in the twentieth century, new insights were gained into the causes of spina bifida. The mutated genes involved were identified, and it was learned why they do not work properly. Studies of neural tube defects in mice revealed how these defects occur and how best to prevent them. It is now known that the diet of a pregnant woman can influence neural tube development. The vitamin folic acid, if taken starting at the time of conception, can decrease the risk of spina bifida by as much as 75 percent. Other less dramatic effects of diet on spina bifida rates have also been identified. Support organizations for families can help them cope with the challenges of caring for children with spina bifida. Physical therapy, counseling, and various group activities are available. Thanks to improved treatment and support, it is now possible for children with this condition to lead long and healthy lives. —Howard L. Hosick See also Amniocentesis; Birth defects; Cerebral palsy; Children’s health issues; Genetic counseling; Genetic diseases; Hydrocephalus; Mental retardation; Prenatal care; Screening. For Further Information: Bloom, Beth-Ann, and Edward L. Seljeskog. A Parent’s Guide to Spina Bifida. Minneapolis: University of Minnesota Press, 1988. McLone, David. An Introduction to Spina Bifida. Reprint. Washington, D.C.: Spina Bifida Association of America, 1998. Nightingale, Elena O., and Melissa Goodman. Before Birth: Prenatal Testing for Genetic Disease. Cambridge, Mass.: Harvard University Press, 1990.
Sports injuries among children ✧ 843
✧ Sports injuries among children Type of issue: Children’s health, public health Definition: Injuries such as sprains, strains, fractures, contusions, dislocations, and overuse syndromes that are common and prevalent in children and teenagers who participate in recreational and competitive sports. An estimated 10 to 20 percent of children who participate regularly in sports will sustain an injury that will keep them on the sidelines for longer than one week at least once before high school graduation. The ratio of male-tofemale injuries is similar prior to puberty but increases to an estimated rate of 3.7:1 following puberty, as boys experience greater increases in size and strength. The greatest number of injuries to boys occurs during football and wrestling, whereas the greatest number of injuries to girls occurs in softball and gymnastics. In the United States, more than 5 million children between the ages of five and eighteen are treated in hospital emergency rooms annually for sports-related injuries. Children are more susceptible than adults to injuries because they are still growing, may not yet be physically or mentally prepared, and are often subjected to unsafe playing conditions or equipment. Many injuries can be prevented and occur because of a lack of appropriate conditioning and recent entry into a sport. More total injuries occur during practice, but competitive events show the highest injury rate per unit time. Injuries to the lower extremities are more common than those to the upper extremities, and soft tissue injuries such as sprains account for a vast majority of a child’s downtime from sports participation. Acute Injuries Pediatric sports injuries fall into two main categories: acute injuries and chronic repetitive overuse injuries. Acute injuries occur as a result of trauma and range from fractures and dislocations to brain and spinal cord injuries. Of all children who suffer traumatic brain injuries in the United States, 21 percent resulted from sports and recreational activities. Ankle sprains, the most common trauma injury in children, result in soft tissues being crushed, stretched, or torn. Sprains are graded into three degrees of severity, with the more common sprains involving the ankle turning inward but the more severe sprains involving the ankle turning outward. A first-degree sprain involves mild-to-moderate overstretching of ligaments. If it is treated quickly and properly, very minimal swelling (edema) and joint instability will occur and a return to activity can be expected within one to three weeks. In a second-degree sprain, edema and bruising (ecchymosis) will occur within seconds following injury as a result
844 ✧ Sports injuries among children of partial tearing of some ligament fibers. A period of three to six weeks of active rest may be required before a return to complete activity. A third-degree sprain generally involves a complete rupture of nearly all ligament fibers, marked edema, severe pain, and an inability to walk or maintain balance. A popping or snapping sound is often heard by the athlete and others close by. Eight to twelve months are often required for ligaments to heal, with current surgical techniques being only moderately successful. The application of cold (cryotherapy) and elevation as quickly as possible after injury will greatly reduce ankle pain, hasten recovery, and reduce the risk of further injury. Immediate ice application reduces acute tissue damage and accelerates healing during rehabilitation, thus minimizing time lost to injury. The anesthetizing sensation of cryotherapy follows a four-stage progression of cold, burning, pain, and numbness that generally takes between five and fifteen minutes. Edema is caused by the accumulation of blood (local internal bleeding) and is one of the body’s protective mechanisms to bring antibodies and white blood cells (leukocytes) to the site of injury. When open bleeding does not occur, however, the more blood that collects in an injured area, the longer it will take to heal. Several cryotherapy modalities are effective, including ice massage, ice bags or towels (crushed or shaved ice conform better than cubes), or ice water immersion using a bucket. Refreezable flexible silicone gel packs and cooling chemical sprays using ethyl chloride or fluoromethane are also available. Ice massage is accomplished by freezing water in a styrofoam cup,
Doctors seek to ensure that injuries sustained during childhood do not interfere with developing bones and muscles. (PhotoDisc)
Sports injuries among children ✧ 845 peeling back the styrofoam, and gently massaging the skin in a circular pattern. At least one ice modality capable of reducing skin temperature to less than 10 degrees Celsius (50 degrees Fahrenheit) should be standard equipment on the sidelines of all athletic contests. Cold application should be intermittently applied for twenty to thirty minutes every one and a half to two waking hours until pain and swelling subside. Skin should be allowed to return to normal temperature before reapplication, and the region should never be iced longer than sixty continuous minutes in order to avoid the possibility of frostbite. Cryotherapy generally needs to be continued for at least twenty-four to seventy-two hours and as long as two to three weeks, depending on the severity of the injury. The acronym RICE—rest, ice, compression, elevation—is easy to remember as the proper treatment for sprains. Injuries involving the knee are also common in pediatric sports participants and may cause serious lifelong disability. A pop or snap coming from the knee area may signal a tear of the anterior cruciate ligament, whereas a ripping sound from a partially bent knee position results from tearing of the supporting structures of the kneecap (patella). Osgood-Schlatter disease, the partial separation of the growing end of the shinbone from the rest of the bone shaft, is common in boys during early puberty, when overly strong quadricep muscles cause avulsion (tearing) or microscopic disorganization at the attachment of the tendon below the kneecap. Finger dislocations are possible during sports that require hand contact with the opponent or object or as a consequence of falling. They should be reduced (put back in place) as soon as possible after injury by a competent caregiver and followed up by an X ray to assess the possibility of an avulsion fracture. A subungual hematoma results from a blow to a fingernail or toenail. Pain relief can be provided by burning a hole through the nail using a hot paper clip, thus enabling the blood that accumulates under the nail to escape. Contusions occur in the area of the pelvis known as the iliac crest. They cause pain and disability out of proportion to the severity of the injury because of the large number of muscles attached there. Prolonged rest and the use of crutches are often required, in addition to possible local injection of an anesthetic agent or steroid compound. Repetitive Use Injuries Overuse syndromes in pediatric sports are caused by sudden increases in training load (doing too much too soon) or inappropriate training, such as improper weight-training techniques and lack of proper warmup and stretching. Highly motivated athletes are the highest risk for overtraining because intensity of conditioning seems to contribute more to these injuries than training duration.
846 ✧ Sports injuries among children Some athletes have developed overtraining syndrome as a result of emotional stress brought on by excessive expectations by coaches or the media. Chronic overtraining is usually associated with a combination of physical and emotional stress that exceed the athlete’s coping capability. Symptoms of overtraining include severe and prolonged fatigue, decreased appetite and weight loss, increased incidence of infection and injury, iron-deficiency anemia, disturbed sleep, and emotional irritability. Little Leaguer’s elbow is a result of overuse that often causes separation, fragmentation, or irregularity of the medial epicondyle of the upper arm bone called the femur. This condition has been reduced in both total occurrence and severity by recently implemented rules for Little League baseball that limit a pitcher to a maximum of six innings of play per week. Shinsplints involve pain along the medial aspect of the distal two-thirds of the weight-bearing bone below the knee called the tibia. Shinsplints are most often seen in poorly conditioned runners and are associated with running on hard surfaces, improper footwear, and abnormal foot alignment of either a structural or a functional nature. The use of an orthotic shoe insert often helps alleviate the problem, and the possibility of a stress fracture should be considered during diagnosis. Stress fractures are small cracks in the outer parts of bones, which occur most often during repetitive weight-bearing sports such as running. These fractures are caused by a combination of factors, including rapid increases in training load (intensity, duration, and/or frequency), inappropriate training (chronic downhill running, improper footwear, and/or training on hard surfaces), biomechanical abnormalities, and low bone-mineral content brought on by insufficient dietary calcium relative to the metabolic need of the individual athlete. Female athletes suffering from eating disorders and/ or irregular menstruation are at an especially high risk for stress fractures, particularly if their diet is low in calcium. Stress fractures are estimated to constitute 5 to 10 percent of all athletic injuries, with running, gymnastics, aerobic dance on hard floors, and basketball having the greatest injury occurrence. Protection and Prevention The use of sport-specific safety equipment has been shown to reduce pediatric sports injuries, but the use of proper protective gear is often neglected because of the use of inappropriate equipment, a lack of awareness by coaches and family, and shortages in available funds. The use of helmets and other headgear prevents and reduces the severity of head injuries and in the United States has been either mandated or strongly recommended for children participating in the following sports: football, rugby, wrestling, baseball, softball, bicycling, hockey, boxing, lacrosse, skateboarding, skating, snowmobiling, and equestrian sports. Face protection on the helmet has
Sports injuries among children ✧ 847 prevented tens of thousands of serious injuries in sports such as hockey and football. Protective gear such as wrist, knee, and elbow pads for sports such as in-line skating are considered by many to be as important to injury prevention as learning the basic skills. Pads for the knees and shins provide not only protection but also shock absorption during sports such as volleyball, basketball, and soccer; they are especially important for female athletes who are susceptible to knee injuries. Softer baseballs have been developed to reduce the risk of severe ball impact injuries. Safety bases to reduce the risk of sliding injury and chest protectors to protect the chest and internal organs have become standard equipment. Mouth guards that protect the mouth, teeth, cheeks, and tongue against blows that can cause jaw fractures have been recommended by the American College of Pediatrics for use in all contact sports. Athletic supporters, also known as jock straps, should be worn by all male participants, particularly during contact and collision sports. The level of severity of injuries in both male and female athletes increases with advancing age and level of competition. Many research studies have shown that a less-developed child competing against a more mature child has a much greater risk of injury. Many sports organizations now match and group children according to body weight, physical maturity, and skill level, particularly in competitive contact sports. Postinjury Support Pediatric sports participants who have suffered recurrent ankle injuries or simply have weak ankles are often faced with the decision to use tape or braces to increase ankle stability. Four factors—the cost, the athlete, the injury, and the sport—determine which option is best. Athletes concerned about cost and convenience usually choose braces over the hassle of repeatedly finding a qualified person for a tape job. In 1998, taping a basketball player’s ankles for every practice and game cost just over a hundred dollars per season, whereas the cost of a quality brace lasting a maximum of two seasons was approximately twenty-five dollars. A majority of athletic training and physical therapy research studies indicate that braces are often slightly more effective for overall ankle support and protection. Tape is more commonly used after an injury, however, because it allows an experienced trainer or therapist much more flexibility during application regarding tightness, amount of tape, and ability to support specific ankle regions. The two basic categories of braces, lace-up and hinge, both have their advantages and disadvantages, with the choice depending somewhat on whether the device is used for injury prevention or postinjury. Lace-up braces often do not offer enough support for athletes coming off an injury, whereas athletes in some sports often complain that hinge-type braces are uncomfortable. —Daniel G. Graetzer
848 ✧ Sterilization See also Anorexia nervosa; Children’s health issues; Drug abuse by teenagers; Eating disorders; Exercise and children; Falls among children; First aid; Heat exhaustion and heat stroke; Physical fitness tests for children; Safety issues for children; Steroid abuse. For Further Information: Long, Toby M., and Holly Lea Cintas. Handbook of Pediatric Physical Therapy. Baltimore: Williams & Wilkins, 1995. A succinct but comprehensive reference on the specialty of pediatric physical therapy. Offers informative chapters on how to assess a child, design and implement a treatment plan, and determine when more advanced medical attention is required. Micheli, Lyle J. “Pediatric and Adolescent Sport Injuries: Recent Trends.” Exercise and Sport Sciences Reviews 14 (1986): 359-374. An excellent review of common pediatric sports injuries. Ratman, Jeffrey, ed. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 3d ed. Baltimore: Williams & Wilkins, 1998. An excellent overview text from the American College of Sports Medicine on the fundamentals of exercise physiology, with chapters on appropriate exercise programs for children and emergency plans and procedures.
✧ Sterilization Type of issue: Medical procedures, men’s health, women’s health Definition: The surgical prevention of pregnancy. Sterilization, of either a woman or a man, is a permanent method of surgical contraception that is used to render a couple incapable of conceiving children. Female sterilization involves the blockage or removal of the Fallopian tubes, the ovaries, or the uterus. Male sterilization involves the interruption of the vas deferens, the pathway of sperm from the testicles. The vas deferens may be reconnected, while many of the sterilization procedures performed on women are considered irreversible. Far more women than men choose to be sterilized. In 1993, it was estimated that more than one hundred million women had elected to be sterilized, worldwide, and that more than one million American women elected to be sterilized each year. One reason that female sterilization is a popular form of contraception with women is because it represents a onetime effort that is usually both simple and the cause of only mild side effects. Another advantage is the high success rate.
Sterilization ✧ 849 Female Sterilization Interruption of the Fallopian tubes is the preferred form of female sterilization surgery for three reasons. First, these operations are relatively minor surgical procedures and are unlikely to be very risky. In addition, premature menopausal symptoms are not produced because the menstrual cycle continues. Finally, when carried out appropriately, interruption of the Fallopian tubes can sometimes be reversed if the patient changes her mind as a result of altered marital arrangements, lifestyle, or financial circumstances. In many cases, a 1-centimeter to 1.5-centimeter section in the middle of each Fallopian tube is removed surgically or burned away via electrocoagulation. Alternatively, in a procedure called tubal ligation, plastic or metal clips are used to close off each tube, or similar tube closure is effected by making a loop in each Fallopian tube and closing it off with a tight plastic ring or band. Frequently, the method used to damage the Fallopian tubes is a form of surgery called laparoscopy. The patient is given a general anesthetic, a very small incision is made close to the navel, and a flexible lighted tube is inserted. This laparoscope is equipped with fiber optics and enables an examining physician to see into the abdominal (peritoneal) cavity. Visibility of the Fallopian tubes is enhanced by pumping harmless carbon dioxide gas or nitrous oxide gas into the abdomen, distending it. The surgical tools for cauterization, cutting, or banding tubes are passed through the laparoscope, and the chosen surgical interruption procedure is carried out. The entire procedure often takes less than thirty minutes, and patients can usually go home in a few hours. Full recovery occurs after only one or two days of bed rest, followed by a week of curtailed physical and sexual activity. Some physicians prefer to carry out sterilization by use of a larger surgical incision through which the tubes are altered directly. The physicians who use this method believe that it is safer and more sure of success and that it has a greater potential for reversibility. Other methods for sterilization through Fallopian tube surgery are culdoscopy and chemical means. Culdoscopy, in which an optical instrument and surgical tools reach the Fallopian tubes through the uterus, has a somewhat lower success rate than do laparoscopy and the direct method. Chemical methods for tubal closure have also been attempted and are not viewed as viable because of a low success rate and frequent, serious postoperative complications. The other avenues available for sterilization are ovariectomy (removal of the ovaries) and hysterectomy (removal of the uterus). Both of these types of sterilization surgery are much more serious and risky, and both are totally irreversible. Ovariectomy is usually utilized only when both ovaries are diseased. This procedure produces an early menopause because most of a woman’s female hormones are made by the ovaries’ graafian follicles. Hysterectomy is the most uncommon form of female sterilization because it
850 ✧ Sterilization requires even more extensive surgery and can have fatal complications. While the operation is sometimes carried out when a woman has completed her desired family, most hysterectomies are performed in cases of severe and widespread endometriosis and in the presence of other serious gynecological problems. Male Sterilization A vasectomy is quite simple, brief, and relatively painless and only rarely results in physical or psychological complications. In addition, after vasectomy only one-tenth of a percent of involved couples experience undesired pregnancies. Vasectomy has no effect on sexual desire or male hormone production. It is also relatively easy to reverse such surgery, if so desired. Consequently, the method has become quite popular. In the United States, for example, it was estimated in 1993 that 250,000 to 350,000 men would undergo this sterilization surgery each year. Vasectomy involves the surgical interruption of the vas deferens, the tube through which sperm leave the testicle. Vasectomy is carried out after identifying the position of each tube and injecting it with a local anesthetic. A one-inch-long incision is made in the scrotum, each tube is cut near its middle, a small piece of the tube is removed to keep the cut ends apart, and all the ends are closed with sutures, by cauterization, or with metal or plastic clips. Vasectomy has a short recovery period and does not stop ejaculation during postoperative intercourse. It is important to note, however, that azoospermia (lack of sperm) is achieved only after six to fifteen postoperative ejaculations. Therefore, to ensure sterility, it is critical that the condition of azoospermia has been achieved before the patient carries out intercourse without condoms or other protective measures. After two consecutive sperm counts indicate azoospermia, unprotected intercourse is deemed safe. Physical and Emotional Complications The complications of all types of Fallopian tube surgery can include internal bleeding, blood-clotting problems, injury to the intestines and the other abdominal organs, and abnormal postoperative menstrual cycles. It is estimated, however, that these complications occur in less than 1 percent of patients. A more frequent problem is the difficulty of restoring fertility by reconnecting the Fallopian tubes, with only a 20 to 40 percent success rate. When the Fallopian tubes are damaged but not entirely closed off, they may reconnect and cause an ectopic pregnancy, in which a fertilized egg implants in one of the tubes and begins to grow into a fetus. Ectopic pregnancy can be fatal to the pregnant woman; it is corrected by surgical removal of the fetus. Fortunately, ectopic pregnancy is relatively uncommon.
Sterilization ✧ 851 Hysterectomy is never a highly recommended female sterilization operation. Rather, it is used mostly in those cases where other uterine health problems are sufficiently severe to make the process sensible. These problems may include recurrent and heavy vaginal bleeding, severe endometriosis, and chronic pelvic inflammatory disease (PID). This extensive surgery results in a high rate of complications and a significant number of deaths. A woman may seek sterilization when she is having an abortion or soon after giving birth to an undesired child. Such a decision, perhaps made hastily at a time of intense emotional stress, is not advisable. It is essential that a sterilization operation be performed only after careful reflection. Divorce or the death of a spouse and subsequent remarriage may cause a sterilized woman regret should she desire more children. Severe psychological problems for both the patient and her family may accompany female sterilization. Therefore, it is highly recommended that these women, their families, and both partners in married couples consult a gynecologist and a psychological counselor before proceeding with female sterilization surgery. In contrast, health complications occur in less than 5 percent of vasectomy patients. In addition, these problems are usually minor and almost never lead to fatalities. Skin discoloration, swelling, and oozing of clear fluid from the scrotum incision are common symptoms immediately following the surgery, but they spontaneously disappear as the healing process continues. Less frequently, inflammation and a condition called sperm granuloma can occur when sperm leak out of the cut portion of the vas deferens closest to the testicle. A granuloma produces severe inflammation, pain, and swelling. When this condition does not subside spontaneously, the granuloma must be removed surgically. Controversy and Research A source of discontent with available sterilization techniques is their total or poor reversibility. An unexpectedly large segment of sterilized men and women have come to regret their decisions regarding sterilization. All hysterectomies and Fallopian tube removals are irreversible, and a low reversibility rate is seen even in the two most popular—and potentially reversible—sterilization methodologies: Fallopian tube interruption and vasectomy. Consequently, research has been directed toward methods that will enable greater reversibility. One direction has been to expand the understanding of Fallopian tube and vas deferens anatomy and functionality. For example, destruction of the nerves that control the operation of these organs can make the recovery of fertility incomplete or impossible even when corrective surgery reverses the original interruption of continuity. This discovery has led to the development of more sophisticated interrup-
852 ✧ Sterilization tion surgery that is less likely to damage vas deferens or Fallopian tube nerve integrity. Many other surgical techniques have been attempted, including the placement of removable plugs in the Fallopian tubes or of tiny, faucetlike valves in the vas deferens that allow or stop the ejaculation of sperm. Other methods to ensure reversible sterilization may include hormones, vaccines against eggs and sperm, and chemical treatments. —Sanford S. Singer See also Abortion; Birth control and family planning; Condoms; Hormone replacement therapy; Hysterectomy; Laparoscopy; Menopause; Menstruation; Women’s health issues. For Further Information: Corson, Stephen L., Richard J. Derman, and Louise B. Tyrer, eds. Fertility Control. Boston: Little, Brown, 1985. The chapter on sterilization and other surgical methodology gives a detailed exposition of techniques and includes diagrams. Other aspects of fertility control are covered well, and each chapter has an extensive bibliography. Mastroianni, Luigi, Jr., Peter J. Donaldson, and Thomas T. Kane. Developing New Contraceptives: Obstacles and Opportunities. Washington, D.C.: National Academy Press, 1990. This book on contraceptive measures other than sterilization by surgery also contains considerable useful information on sterilization practices and legalities. Provides useful insights and allows the reader to consider other effective, long-term methods of contraception, excluding surgery. An excellent bibliography is included. Sherwood, Lauralee. Human Physiology: From Cells to Systems. 4th ed. Belmont, Calif.: Wadsworth, 2001. This college text provides details about the menstrual cycle, hormones, and the endometrium. Many useful definitions, diagrams, and glossary terms are included. Van Keep, Pieter A., Kenneth E. Davis, and David de Wied, eds. Contraception in the Year 2001. New York: Elsevier Science, 1987. This conference proceeding covers many important issues in fertility control. Included are demographics of contraception need; a discussion of male and female contraception via hormones, vaccine sterilization, and mechanical methods; and predictions for the future. Many useful concepts are developed, and an excellent bibliography is provided. Wigfall-Williams, Wanda. Hysterectomy: Learning the Facts, Coping with the Feelings, Facing the Future. New York: Michael Kesend, 1986. Discusses sterilization as a motive for hysterectomy, in addition to severe endometriosis. Offers guidelines for the choice of a physician or surgical procedure and explores possible aftereffects, such as depression and changes in sexual function. A glossary and many references are included.
Steroid abuse ✧ 853
✧ Steroid abuse Type of issue: Ethics, mental health, occupational health Definition: The use of illegal anabolic steroids to increase athletic performance, with negative side effects on physical and psychological health. Steroids continue to provide many valuable medical benefits for conditions such as asthma, spastic colon, and other common medical conditions. Unfortunately, however, steroid abuse, particularly of anabolic steroids, continues to be an important problem. Recent estimates suggest that about 1.1 percent of college athletes are using anabolic steroids. A 1997 report by the National Collegiate Athletic Association (NCAA) demonstrated that this was a decrease from the 4.9 percent of student athletes who reported using steroids in 1989. Nationwide, according to the NCAA, collegiate football players were reported to have the highest rate of use, at 2.2 percent. The survey suggested, however, that this lowered rate may reflect underreporting. Factors such as the illegality of the drug use or a lack of social acceptability in acknowledging such personal behavior may be responsible. Such assertions of underreporting also are based on other reports that 5 to 12 percent of male high school students and 1 percent of female high school students have used anabolic steroids. Further, among athletes not in college, reported rates are much higher. Ninety-five percent of weight lifters report use, followed by 99 percent of power lifters, 80 percent of track-and-field athletes, 70 percent of football players, and 40 percent of sprinters. The Negative Effects on Mind and Body A lack of social acceptability around steroid abuse has resulted partially from the more than seventy side effects associated with steroid use, including such immediate problems as rage, depression, and highly aggressive behavior. Reports have included findings of teenagers committing acts as brutal as murder, without any prior history of criminal or aggressive behavior, while under the influence of steroids. While such acts are rare, the connection between steroids and out-of-control rage is well known. In addition, steroid abuse has been linked with such long-term problems as heart attacks, strokes, and changes in the reproductive system. It is likely that increasing attention will be focused on these kinds of long-term effects, both in research and in terms of problem reporting. Increases in the access to anabolic steroids are also partly responsible for an increase in the visibility of and attention to such problems. Social research also has demonstrated important findings related to steroid use in college students and in athletes. One study, for example,
854 ✧ Steroid abuse demonstrated that college students consistently rated anabolic steroid-using athletes more negatively than drug-free athletes. In fact, students tended to evaluate anabolic steroid-using athletes just as negatively as they would an athlete who was using cocaine. In another study, researchers demonstrated that steroid use is not only physically reinforcing but also psychologically reinforcing. Specifically, in interviews with thirty-five male self-reported anabolic steroid users, lower levels of anxiety related to the perception of one’s physique and higher levels of satisfaction with one’s upper body were demonstrated, relative to the control subjects. There was a psychological gain associated with the steroid use that was directly related to the shorterterm physical benefits of their use. Future work in this area will likely explore these psychological factors and focus on how to intervene effectively. Additionally, it is likely that social interventions will be explored. Athletics remains competitive and financially lucrative, and so special attention will need to be paid to the social context in which steroid abuse occurs. —Nancy A. Piotrowski See also Addiction; Drug abuse by teenagers; Exercise; Exercise and children; Sports injuries among children. For Further Information: Craig, Charles R., and Robert E. Stitzel. Modern Pharmacology. 5th ed. Boston: Little, Brown, 1997. This college-level pharmacology text contains easyto-comprehend sections on steroids, including their chemistry, synthesis, physiological activity, and pharmacological activity. Clinical conditions resulting from abnormal levels of specific steroids are described. Lin, Geraline C., and Lynda Erinoff, eds. Anabolic Steroid Abuse. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse, 1990. Addresses the health aspects of anabolic steroids and doping in sports. Includes bibliographical references. Wilson, Jean D., and Daniel W. Foster. Williams Textbook of Endocrinology. 9th ed. Philadelphia: W. B. Saunders, 1998. The definitive upper-level text that discusses the biological and clinical aspects of endocrinology in detail. Contains several chapters dealing with steroids and steroid hormones. Profusely illustrated, this authoritative text will provide in-depth understanding of particular aspects of steroid hormone effects.
Stress ✧ 855
✧ Stress Type of issue: Mental health Definition: A psychophysiological response to perceived pressures in the environment, including danger; prolonged stress contributes to hormonal imbalances, immune system collapse, susceptibility to disease, cancer, and death. Stress is a psychophysiological response within an individual animal to a perceived danger. Stress involves a complex interplay of nervous and hormonal reactions to internal and external stimuli. All living organisms respond to stimuli, usually by means of gene-regulating chemical messengers called hormones. Physiological Responses to Stress Stress is a biochemical response to danger that occurs within animals. The nervous system detects danger from internal or external stimuli, usually external stimuli such as predators, competitors, or life-threatening events. Increased electrical conductivity along millions of nerve cells targets various tissues to prepare the body for maximum physical activity. Among the tissues affected are the skeletal muscles, the heart muscle, the hormone-secreting glands of the endocrine system, the immune system, the stomach, and blood vessels. Under nerve-activated stress, skeletal muscles will be poised for contraction. The heart will beat faster, thereby distributing more blood and nutrients to body cells, in the process accelerating the breathing rate to distribute more oxygen. Blood vessels will constrict. The stomach and other intestinal organs will decrease their activity, including a decreased production of mucus that protects against acid. Heightened nerve activity also will trigger the production of various hormones from the immune system, specifically hormones that influence bodily metabolism such as thyroxine and epinephrine (adrenaline). These hormones target body tissue cells to prepare the body for increased output in the face of danger. Massive production of epinephrine will trigger maximum physical readiness and extraordinary muscular output, a phenomenon often referred to as the fight-or-flight response. This response and other evolutionary stress adaptations endure within the individual for only seconds or minutes. The stresses that humans face are based on these behavioral adaptations. Much human stress is artificial, however, and lasts not for minutes but for hours, days, weeks, months, and years. Such stresses involve the same nervous and endocrine system responses, but they are usually brought about by perceived danger, not true danger. Human societies impose norms and rules for the behavior of the indi-
856 ✧ Stress viduals who compose the society. People must adhere to the societal norms or face punishment. In fast-paced technological societies, increasing bureaucratization and organization place less emphasis on the individual and more emphasis on process and productivity. People must face deadlines, be on time, produce quotas, generate company profit, and meet the demands of family, colleagues, and administration simultaneously. The result is a continuous fight-or-flight response in which individuals fear losing their jobs and means of supporting themselves and their families. Stress and Disease The physiological manifestations of prolonged stress are devastating. Continued hyperactivity of nerve impulses and overproduction of hormones at incorrect developmental stages lead to the abnormal functioning of internal organs. The stomach undersecretes mucus, thereby leading to ulcers. The heart muscle contracts too rapidly, leading to higher pulse and respiration rates. The blood vessels constrict for lengthy periods of time, thereby causing the heart to pump harder and leading to high blood pressure and heart disease. Hormone overproduction leads to incorrect cell instructions and gene activation/inactivation, causing abnormal tissue functioning and cellular transformation leading to cancer. The immune system weakens under abnormal signaling by hormones, thereby decreasing the body’s ability to defend itself from disease. A clear link exists between stress and susceptibility to infectious disease. Furthermore, there is a tendency for strokes, heart attacks, cancer, and sudden death to occur in individuals who recently have experienced major traumatic events in their lives. Too little attention has been given to the effects of everyday living upon the physical well-being of people. Environmental stimuli, nervous and endocrine systems, and physiological rhythms within the body are intricately connected. Most bodily processes follow a self-regulatory, homeostatic pattern that is rhythmic, linear, stable, and predictable. Such rhythms are sensitive to subtle chemical changes in the cellular and organismal environment. An orderly, homeostatic process in the body can collapse into disorderly, nonlinear, and unpredictable chaos because of the slightest disturbance. Stress is a disturbance that imbalances the nervous and endocrine systems, which subsequently imbalance cells and organ systems throughout the human body. A wide variety of human illnesses and disorders have been associated with stress: heart disease, cancer, stroke, mental illness, allergies, accidents, alcoholism, drug abuse, asthma, chronic fatigue, depression, suicide, and deviant behavior, among others. These stress-related diseases and disorders are responsible for the majority of deaths, hospitalizations, and visits to physicians by people in highly technological societies such as the United States, Japan, and Western Europe. In the United States alone, several billion
Stress ✧ 857 dollars are spent each year for medications to treat stress-related illnesses that otherwise could be prevented by antistress methodologies. Treating Stress An important focus for health care has become the treatment of stress. Health education programs emphasize the importance of physical fitness and stress reduction in everyday living. Stress-reducing methodologies for the individual include time management, peer counseling and support, relaxation time, family bonding, self-esteem improvement, and exercise. These approaches greatly enhance an individual’s quality of life and help the individual to cope positively with stressful events. All these stress reduction techniques emphasize an individual’s personality and the more efficient use of an individual’s free time. Relaxation, social interaction, and physical activity help the body to return to normal physiological rhythms following the numerous stressful events that every person faces daily. Individuals in American and Western societies are coming to realize that a slower, more relaxed living pace is essential for reducing stress and the millions of cases of stress-related disease that occur each year. Stress reduction should be a prime focus of medical research and education. The simplicity of educating the public with respect to stress can yield incredible savings in terms of lives saved, quality of lives improved, length of human life spans increased, and money saved. —David Wason Hollar, Jr. See also Addiction; Alcoholism; Alcoholism among teenagers; Alcoholism among the elderly; Alternative medicine; Biofeedback; Cancer; Death and dying; Depression; Depression in children; Depression in the elderly; Domestic violence; Drug abuse by teenagers; Eating disorders; Exercise; Exercise and children; Exercise and the elderly; Factitious disorders; Headaches; Heart attacks; Postpartum depression; Schizophrenia; Sexual dysfunction; Sleep disorders; Suicide; Suicide among children and teenagers; Suicide among the elderly; Ulcers. For Further Information: Gaudin, Anthony J., and Kenneth C. Jones. Human Anatomy and Physiology. New York: Harcourt Brace Jovanovich, 1989. This introductory anatomy textbook for undergraduates provides a basic presentation of human physiology that is understandable to the layperson. Chapter 17, “The Endocrine System,” discusses the major human hormones in detail. Glass, Leon, and Michael C. Mackey. From Clocks to Chaos: The Rhythms of Life. Princeton, N.J.: Princeton University Press, 1988. Glass and Mackey’s book is an innovative study of linear and nonlinear dynamics in human physiological processes. They cite numerous experimental studies deal-
858 ✧ Strokes ing with such topics as electrocardiograms, reflexes, hormonal balances, and imbalances within physiological processes. They emphasize and mathematically model dynamical diseases. Monroe, Judy. Coping with Ulcers, Heartburn, and Stress-Related Stomach Disorders. New York: Rosen, 2000. Designed for students in grades seven and up, this book discusses different types of ulcers, irritable bowel syndrome, food intolerances and allergies of all types, and heartburn and acid reflux. Fictional scenarios involving teens suffering from different disorders run throughout the book, from the development of symptoms through the process of diagnosis and treatment. Newton, Tim, with Jocelyn Handy and Stephen Fineman. Managing Stress: Emotion and Power at Work. Thousand Oaks, Calif.: Sage Publications, 1995. This book addresses job stress and offers stress management techniques for coping with it. Includes a bibliography and an index. Schafer, Walt. Stress Management for Wellness. New York: Holt, Rinehart and Winston, 1987. Schafer’s textbook is a simple presentation of stress, both positive and negative, for the layperson. He describes how stress affects the body and how it may contribute to illness and death. Includes numerous tests for identifying high personal stress levels and discusses stress reduction measures.
✧ Strokes Type of issue: Elder health, mental health, public health Definition: An interruption of blood supply to the brain due to an obstruction in the circulatory system. According to the National Stroke Association (NSA), more than 500,000 people in the United States experience a stroke each year. Strokes are one of the leading causes of death in those over sixty-five and account for about 145,000 deaths each year. Two-thirds of those experiencing a stroke are elderly. Strokes can have devastating physical, financial, emotional, and social effects that impact the entire family. Strokes are also a major cause of elderly people going to live in a nursing home. The medical term for stroke is cerebrovascular accident (CVA), suggesting that this event happens suddenly and is related to brain circulation. A stroke is defined most simply as an interruption in the blood supply to the brain. When the brain does not get enough oxygen for whatever reason, brain cells can die and leave permanent damage. A transient ischemic attack (TIA) can be a warning sign of stroke. TIAs occur when the brain lacks sufficient oxygen to cause a person to exhibit some signs of stroke, such as slurred speech, difficulties with vision, weakness
Strokes ✧ 859 or numbness in the face or extremities, loss of balance, or altered consciousness. However, the effects of a TIA last no more than twenty-four hours and go away without leaving any deficits. Sometimes laypeople refer to TIAs as ministrokes, but people experiencing TIAs should consider this a warning sign of a future stroke and seek medical treatment. Causes and Risk Factors Strokes can be caused by clots, hemorrhage, narrowing of vessels, and high blood pressure. The most common cause of stroke is a thrombus, a clot that originates in the brain because of narrowing of blood vessels. Narrowing of vessels can also lead to lack of oxygen to the brain. Such narrowing is often related to arteriosclerosis, or fatty deposits along the vessel walls, as seen in the carotid arteries of the neck. Older people may have an occlusion in these major arteries, which supply the brain with blood, and may need surgery to clean them out to avoid having a stroke. Clots can also come from other parts of the body. For example, a blood clot in the leg could break off and travel to the brain, causing an occlusion. This type of clot is called an embolus. A hemorrhagic stroke results when a weakened blood vessel leaks or bursts. This could be from an aneurysm, a defective artery, high blood pressure, or a combination of these. In this case, blood leaking into brain tissue causes damage and results in the effects seen after a stroke. Several factors put a person more at risk for stroke. Risk factors that a person cannot control include age, gender, race, and heredity. The risk for stroke increases with age. Men generally experience more strokes than women; after menopause, however, the numbers are more even. African Americans, especially African American men with heart disease, have more strokes than Caucasians. Finally, a family history of strokes also increases the risk. Such information should be given to one’s primary care provider. The risk factors that can be controlled include high blood pressure (also called hypertension), high cholesterol, heart disease, diabetes, smoking, obesity, a sedentary lifestyle, and stress. The good news is that these risk factors can be changed to reduce the risk of stroke. Prevention of stroke thus centers on making changes related to these factors. Warning Signs and Effects It is essential that older people be aware of the warning signs of stroke. Knowing these symptoms can help a person decide when to seek help and can provide a better chance for recovery. TIAs happen before at least 10 percent of strokes, so they should be considered a warning sign. The NSA gives several warning signs of strokes. These include numbness or tingling in the face, arms, or legs; difficulty speaking; headache; blurred or other disturbed vision; dizziness; loss of consciousness; and sudden weakness or paralysis (often affecting just one
860 ✧ Strokes side of the body). If any of these signs are manifested in an older person, they should seek medical treatment right away. The effects of strokes are numerous and vary from person to person. No one can predict the exact effect of a stroke, as the deficits seen depend on the area of damage within the brain. Since a large portion of the brain controls speech and cognition, communication is often affected. People surviving a stroke may not be able to speak or may have trouble understanding what is said to them. These types of problems with the use of language are referred to as aphasia. The muscles involved with speech and swallowing are closely related, so individuals may experience deficits in both of these areas. Certain swallowing problems may lead to aspiration and subsequent pneumonia. Thus, a speech therapy evaluation is often needed for any individuals exhibiting problems with eating, swallowing, or speech. Dietary modifications may be necessary for the person to swallow safely. Additionally, some stroke survivors require a feeding tube to maintain proper nutrition while participating in rehabilitation of the swallowing muscles and retraining of the swallowing mechanism. Other problems can affect such senses as sight and touch perception. Visual problems may range from blurred vision to double vision to partial or total blindness. Stroke survivors may also experience cognitive difficulties, including memory loss, trouble recalling words, inability to remember how to perform familiar tasks, and difficulty sequencing things. They may also neglect the part of the body that is paralyzed or weak, or they may not recognize a paralyzed arm as part of their own body. A shorter attention span is also common after stroke. Weakness (hemiparesis) and paralysis (hemiplegia) occur on the side of the body opposite the damage within the brain; if a person suffers damage from a stroke on the left side of the brain, one may observe right-sided weakness of the arm and leg. Strength generally returns to the legs first, but weakness or paralysis of the arm and hand may be slower to return or may even be permanent. These types of problems lead to difficulty in performing activities of daily living, such as dressing, eating, and bathing. Other tasks that may be harder after a stroke include using the telephone, cooking, shopping, doing laundry, resuming a job, and driving. Some deficits are more common with right- and left-sided brain damage. Those with a left-sided stroke (right-sided weakness) tend to have swallowing problems and may require a feeding tube for some time after the stroke. They generally have a slow and cautious behavior style and may be fearful when learning new tasks. Those with a right-sided stroke (left-sided weakness) tend to be more impulsive and may not acknowledge that anything is wrong with them. They pose a safety risk to themselves by overestimating their abilities and have a high rate of falls. Disabilities in those with a right-sided stroke may be less obvious to others but nonetheless put the person at risk for injury.
Strokes ✧ 861 Treatment Older adults should know the warning signs of a stroke and go to the nearest emergency medical facility if exhibiting such symptoms. Medical treatments, such as the use of tPa (a medication that may be given to dissolve blood clots), are available in many hospital emergency rooms. This drug can actually reverse the stroke effects in many people, leaving no residual impairment if given appropriately. However, tPa is used only in the case of a stroke caused by a clot and is effective only if given within the first three hours after the onset of symptoms. For this reason, it is crucial for a person suffering from a stroke to get to an emergency room where a computed tomography (CT) scan or magnetic resonance imaging (MRI) of the head can be performed so that a proper diagnosis can be made. Rehabilitation is most crucial in the three-month period following the stroke. According to the Copenhagen Stroke Study, people with minimal weakness in the legs after stroke made optimum progress within three weeks and not much progress after nine weeks. For those with more severe weakness or paralysis, not much recovery was seen after eleven weeks. Overall, however, most stroke patients did recover the ability to walk within the first eleven weeks after the stroke. These research findings underscore the importance of early rehabilitation. Stroke survivors have better recovery when treated by a team of rehabilitation professionals in a setting designed specifically for this type of recovery. Physical, occupational, and speech therapy (if needed) should begin in the hospital as soon as possible. Physical therapy focuses on lower extremity strengthening, helping the person learn exercises for the legs and regain walking skills. Occupational therapy centers attention on use of the arms and hands to perform key life activities, such as dressing, bathing, and eating. The occupational therapist also assists the person in resuming home management skills, such as doing laundry and cooking, as well as in reentering the community with a physical limitation. The speech therapist, also called a speech-language pathologist, assists patients in regaining speech, relearning skills that may be impaired because of memory problems or aphasia, and setting up an appropriate diet. Nurses in inpatient rehabilitation help patients with medication schedules, nutrition, skin care, bowel and bladder retraining, and family education. The social worker helps patients and families connect with resources in the community, figure out insurance problems, and make discharge plans. The patient’s physician will help diagnose and treat medical problems and complications, and a psychologist or psychiatrist is generally available for counseling with the person and the family if needed. Together, this interdisciplinary rehabilitation team helps patients and families achieve their goals. Most patients get better outcomes if transferred to a rehabilitation unit or center soon after the stroke to receive more intensive therapy with the goal of home discharge. —Kristen L. Easton
862 ✧ Sudden infant death syndrome (SIDS) See also Arteriosclerosis; Cholesterol; Diabetes mellitus; Heart disease; Hypertension; Incontinence; Mobility problems in the elderly; Obesity; Smoking; Stress; Vision problems with aging. For Further Information: Gresham, Glen E., Pamela W. Duncan, and Harold P. Adams, Jr., et al. Post-Stroke Rehabilitation: Clinical Practice Guidelines. Rockville: U.S. Department of Health and Human Services, 1995. Poststroke clinical guidelines compiled for health care professionals by a panel of nineteen experts in the field. Nakayama, Hirofumi, Henrik Stig Jorgensen, Hans Otto Raaschou, and Tom Skyhoj Olsen. “Recovery of Upper Extremity Function in Stroke Patients: The Copenhagen Stroke Study.” Archives of Physical Medicine and Rehabilitation 75 (April, 1994). A landmark study using a large sample that studied the length of time taken for return of arm and hand function in stroke survivors. Paullin, Ellen. Ted’s Stroke: The Caregiver’s Story. Cabin John, Md.: Seven Locks Press, 1988. The wife of a stroke survivor discusses their journey after his stroke. Sandin, Karl J., and Kristin D. Mason. Stroke Rehabilitation. Boston: ButterworthHeinemann, 1996. A practical and informative guide to stroke care with a strong medical focus; written by physicians but in user-friendly terms.
✧ Sudden infant death syndrome (SIDS) Type of issue: Children’s health Definition: The abrupt death of an infant for which postmortem examination fails to demonstrate an adequate cause. The distribution of sudden infant death syndrome (SIDS) is worldwide. Incidence rates vary from 0.12 to 3.0 for every thousand live births. In the United States, rates range from 1.6 to 2.3 for every thousand live births, with considerable ethnic variation: 0.5 among Asians, 1.3 among whites, 1.7 among Latinos, 2.9 among African Americans (5.0 for those of low socioeconomic status), and 5.9 among American Indians. Possible Risk Factors A variety of genetic, environmental, and social factors have been associated with an increased risk of SIDS. The most prominent is sleeping in the prone (face down) position; other associations include cold weather, overheating,
Sudden infant death syndrome (SIDS) ✧ 863 the hours of the day from midnight to 9:00 a.m., and poor socioeconomic conditions, including overcrowding. A young, unmarried mother, especially if she has had no prenatal care, is more likely to have an infant die from SIDS. So is the mother who smokes (before or after the birth), is anemic, or ingests narcotics. Prematurity, especially with a history of apnea or damage to the immature lungs from elevated levels of inspired oxygen while on a respirator, also increases the risk. Males are at a higher risk for SIDS than are females; so are the brothers and sisters of infants with SIDS. Likewise, a previously aborted episode of SIDS (a “near miss”) increases risk. On average, Apgar scores (a measure of infant health immediately after birth) are lower in infants with SIDS than they are in surviving peers. In a family that has lost an infant to SIDS, the risk for the next or subsequent child is about five times the usual risk. Most risk factors, however, are associated with only a twofold or threefold elevation of incidence. Therefore, predicting which infants will die unexpectedly is extremely difficult. Recent immunization is not a risk factor. Although the peak incidence of SIDS is around three months of age and coincides with normally low levels of circulating immunoglobulins, the syndrome is not associated with any known pathogen. Pathologists report a wide variety of findings in their postmortem reports—especially changes in the brain and other parts of the body that suggest chronic or intermittent hypoxemia. Yet pathologists also fail to find an increase in the number of cells in tissue of the carotid bodies, a chemoreceptor that responds to decreases in blood oxygen tension; such a finding weighs against the presence of chronic hypoxia. Possible Mechanisms Like many other aspects of this disease, the mechanism or mechanisms of death in SIDS are unknown. Does the infant stop breathing, or does some cardiac irregularity occur? An immature cardiorespiratory control mechanism involving the nervous system is the most common hypothesis. D. P. Davies and Madeleine Gantley of the University of Wales College of Medicine believe that an important mechanism underlying SIDS is failure of respiratory control at a vulnerable stage of development—more a physiological syndrome than a disease in the accepted sense. These doctors hypothesize that the disturbance to this delicate equilibrium might upset the regulation of breathing, sometimes leading to death. Epidemiological risk factors, such as an upper-respiratory infection (which is not uncommon), are somehow linked with destabilizing influences to breathing. By avoiding or modulating these factors, the risk of death can be reduced. Although the pathogenesis of SIDS remains unclear, Anne-Louise Ponsonby and her colleagues at the University of Tasmania in Australia propose that SIDS be considered as a biphasic event, with the first set of factors
864 ✧ Sudden infant death syndrome (SIDS) operating to predispose the infant and the second set of factors acting as loading factors that operate at a critical stage of the infant’s development. They believe that a warm environment could lead to sudden infant death by direct hyperthermia; a thermolabile, sudden fall in blood pressure leading to a diminished oxygen supply to the brain; impaired respiratory control; altered sleep state; or depressed arousal. An asphyxial mode of death would also be more likely, particularly in heavily dressed infants found prone. Prevention Strategies Since the causes and mechanisms of death from SIDS may continue to be unknown, strategies that might reduce the incidence of this syndrome seem imperative. Cold weather and the hours of midnight to 9:00 a.m. bring increased risks for SIDS, but a closer look explains that other risk factors are involved. Overheating as a response to cold weather and leaving the infant alone at night (particularly in Western countries) may be more important. Babies sleeping alone could lose external sensory stimulation that may help stabilize breathing patterns. Davies and Gantley, citing experimental work with mothers and infants co-sleeping in sleep laboratories, have shown how patterns of breathing may interact. They say that the alertness of the babies’ caregivers to early symptoms of illness might also be important. French doctors studied the seasonal variation of death from SIDS in their country for a two-year period in the early 1980’s. They concluded that for babies born in the spring, the third month of age was not necessarily associated with the highest SIDS risk. Babies born during other seasons, however, exhibited a normal pattern of increasing risk between the first and third months. Age was an especially critical factor among babies who reached three months of age during the winter months. If they reach this age in July or August, they are less susceptible to SIDS. This finding, then, leads to a consideration of the risk of overheating. Explanations for the association between cold weather and SIDS include hypothermia, increased viral illness, and indirect hyperthermia. New Zealand doctors looked at the role of thermal balance in SIDS by investigating the death scene. They found that infants who died of SIDS were significantly more likely to be overdressed for the room temperature at the death scene and in the prone position, when compared to control infants. They also suggest that parents may have responded to infections in their babies by increasing the amount of clothing and bedding or by otherwise warming the infant. The government of New Zealand initiated a program of education for parents recommending that the prone sleeping position be avoided, that mothers not smoke, and that breast-feeding be encouraged. (Most experts believe that breast-feeding itself does not reduce risks for SIDS. Rather, closer and more frequent contact with mothers is the operative factor.)
Sudden infant death syndrome (SIDS) ✧ 865 A similar education program for parents in Avon, England, was initiated, but it omitted advice on breast-feeding and included suggestions to avoid overheating after a retrospective case-control study that suggested a nearly ninefold relative risk for SIDS from infants sleeping prone. New Zealand and Avon both reported fewer deaths from SIDS after their parental education programs were introduced. The Department of Health extended Avon’s campaign nationally. Parental Education and the Emotional Toll In dealing with SIDS, one factor looms most important: Education of parents makes all the difference. In 1991, for example, England’s Scarborough district reported a 50 percent fall in the SIDS death rate after parents were advised not to overwarm their small infants. That same year, four other districts in England reported a similar reduction after parents were advised not to let their infants sleep in a prone position. The Foundation for the Study of Infant Deaths and the Department of Health recommend both procedures: a supine sleeping position and prevention of overwarming. These successes raise two issues: the overall decline in rates of SIDS worldwide in industrial countries and parental guilt. For a number of years, the incidence of SIDS was generally falling. This decline slowed considerably in the 1980’s. How much, then, did the parental education programs actually lower the incidence rate in these English districts? No one can say with certainty, but one thing is clear: If doctors make recommendations regarding sleeping positions and warming, they run the risk of inducing guilt in parents who have not followed their recommendations—or, alternatively, who have followed the recommendations but have still lost an infant to SIDS. Parents who have lost a child to SIDS are grief-stricken. They are not prepared for such a tragedy, and their grief is compounded by guilt, because no definitive cause for SIDS has been identified and, as a result, parental behavior seems to be implicated. Investigations conducted by police, social workers, or others who become involved only add to this guilt. Parents may be confronted by questions of whether they positioned their infant correctly or overdressed the child. Regardless of these behaviors, however, the factors causing the death may not have been under the parents’ control. Concern for the confusion of SIDS with child abuse should not be ignored, nor should the efforts of the National Sudden Infant Death Syndrome Foundation to provide information about psychosocial support groups and counseling for families of SIDS victims. —Wayne R. McKinny, M.D. See also Children’s health issues; Death and dying; Premature birth; Terminal illnesses.
866 ✧ Suicide For Further Information: Behrman, Richard E., ed. Nelson Textbook of Pediatrics. 16th ed. Philadelphia: W. B. Saunders, 2000. This standard pediatric textbook has been around for years and deservedly so. Its excellent chapter on sudden infant death syndrome is a thorough review of what was known about the disease at the time of the book’s publication. Minimal medical jargon makes it readable by laypersons. Berger, Edward C., ed. SIDS and Sleep Disorders: A Review of the Literature. St. Paul, Minn.: Aequitron Medical, 1990. This thorough review of the literature brings together much useful information. The results of cited studies are presented in easy-to-grasp charts and lists. Berkow, Robert, and Andrew J. Fletcher, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Rahway, N.J.: Merck Sharp & Dohme Research Laboratories, 1999. Published since 1899, this classic medical book covers SIDS thoroughly and is easy to read. Southall, D. P., and M. P. Samuels. “Reducing Risks in the Sudden Infant Death Syndrome.” British Medical Journal 304 (February 1, 1992): 265-266. These acknowledged experts in SIDS have written a thoughtful, thorough review on reducing the risks of SIDS. They strongly suggest that current interventions and socioeconomic factors need monitoring.
✧ Suicide Type of issue: Mental health, public health Definition: The taking of one’s own life; it is among the leading causes of death in the United States and Canada and a source of long-term distress for surviving family members and friends. A suicide occurs about every two hours in Canada and about every seventeen minutes in the United States. Suicide has been determined to be among the leading causes of death in the United States, Canada, and many other nations ever since such data began to be collected. Suicide is the eighth leading cause of death in the United States, taking more than thirty thousand lives each year. It is the fifth leading cause of death in Canada, taking about 3,500 lives per year. Although there are many more suicides in the United States, with its larger population, than in Canada, Canada has a higher suicide rate: fourteen per 100,000 as compared with twelve per 100,000 in the United States. These rates are about average for industrialized nations which, as a group, have experienced a leveling off of suicide rates after their steady rise between the mid-1980’s and the mid-1990’s. There are several notable similarities in suicides in North America, whether in Canada or the United States. Men are about four times more
Suicide ✧ 867 likely than women to commit suicide. The risk of death by suicide is higher for males at all age levels than for women and increases as men move through the life course. Men over the age of sixty-five have the highest suicide rates. Women are at the greatest risk of suicide in their early adult years. Young women are most likely to attempt suicide, but elderly men are most likely to end their own lives, most often by using firearms and other lethal methods. Youth suicide, defined as suicide committed by persons between the ages of fifteen and twenty-four, has more than tripled in the United States and Canada since the end of World War II. Teenagers and young adults are at particularly high risk of self-inflicted death, because they are at relatively low risk of dying from heart disease and cancer, the two leading causes of death. In both the United States and Canada, surveys have found that it is not uncommon for people to have had thoughts about suicide or even to have made attempts at some point in their lives, usually while they were in their teens or in their later adult years. It is clear that many people have moments when they think about suicide, although most do not act on their impulses. In the United States, the suicide rate has consistently been higher among whites than among African Americans or Asian Americans. Some Native American groups, especially their youth, have had very high suicide rates. Suicide rates are also high among Native Canadians in the Yukon and Northwest Territories. General Risk Factors for Suicide The factors placing people at higher risk of committing suicide include living alone, having few connections to society (limited contacts with family, limited social life), experiencing the recent death of a loved one, experiencing the recent loss of an important relationship for reasons other than death, having a progressively disabling condition or terminal illness, using alcoholic beverages to excess (including binge drinking) or using other mind-altering drugs, being depressed, and being affected by either personal or society-wide periods of economic crisis. Most people undergoing these experiences do not commit suicide, and it would be a mistake to assume that they are suicidal. For example, some people enjoy living alone. Similarly, the stress of a progressively disabling condition or terminal illness is borne by many people who continue to find meaning in their lives and have no inclination to commit suicide. It is not difficult situations themselves, but how persons interpret and cope with them that is most important. Nevertheless, there is a general tendency for suicidal thoughts and actions to occur more frequently in people who are experiencing one or more of these situations. As might be expected, the risk increases when several of these factors are present at the same time. For example, depressed persons might lose close
868 ✧ Suicide personal relationships, become more depressed, withdraw, and use alcohol or drugs in an attempt to mask their emotional pain. There is also continual interaction between individuals, families, and societal events. For example, unemployment and business failures in a distressed economy place extra pressures on families, leading to increased risk of suicidal behavior. Young people may feel that their opportunities are being blocked; elderly people may fear that they are outliving their resources. Does Suicide Run in Families? Some families have a history of multiple suicide attempts from generation to generation. How this should be interpreted is a matter of controversy. Some people believe that the disposition to suicide is inherited. There is some support for this position from studies of twins as well as the biology of depression. The theory that has garnered the most support is that some families have a genetic trait that results in a problem with the metabolism of serotonin, a substance that is involved in the transmission of impulses within the central nervous system. People with this genetic problem are more likely than others to be depressed, have large mood swings, engage in antisocial behavior, and abuse drugs as well as make suicide attempts. There has been some success in providing medicinal relief to people who have biological markers associated with depression, thereby reducing their suicidal tendencies. Some observers have pointed out that many depressed and suicidal people are not biologically predisposed to these tendencies. Such people develop their self-destructive inclinations through experiences of loss, frustration, and anxiety about future events. Furthermore, even in suicideprone families it is likely that the dysfunctional patterns of interaction are key factors. Repeated experiences of rejection and abuse may be the trigger for self-destructive behaviors. It is argued that the key to suicide prevention in all families, whether or not they have possible genetic predispositions to depression, is that family members should learn to live harmoniously with one another and solve everyday conflicts in a competent manner. It is further argued that suicide attempts can become a “family style” of dealing with problems, whether or not a biological component is also present. Although there continue to be different opinions about possible inheritance factors in multisuicide families, it is clear that both medical and counseling approaches can be useful in prevention efforts. Preventing Suicide Many people have experienced suicidal crises and made strong and enduring recoveries. For example, most of those who have been prevented at the last moment from leaping from San Francisco’s Golden Gate Bridge have
Suicide ✧ 869 been grateful for their rescue and made no subsequent suicide attempts. There is no guarantee that preventing suicide at one point in time will open the road to a life of renewed purpose and satisfaction, but the many cases of positive outcomes provide a sound basis for hope. Several approaches can be effective in preventing suicide. First, it is important to recognize and treat depression. Persons who show the warning signs of possible suicide, be they youths or elderly people, should be seen by physicians who are knowledgeable about diagnosing depression. Many family practitioners as well as psychiatrists have this skill. Medications can reduce depression and suicidal feelings in some people. Physicians may recommend individual or family counseling as well. Communities should support suicide education programs in the schools. Such programs may be offered separately or as part of a broader program to improve awareness of mental health issues and skills. It is also important that communities offer programs to prevent alcohol and drug abuse, especially among youths. Many suicidal, as well as accidental and homicidal, deaths involve the use of alcohol or other drugs. Families should support and make use of crisis telephone services and suicide-prevention centers. Many persons have been helped through suicidal crises by sympathetic counseling and having somebody to listen to them. Frequently, persons on the verge of a suicide attempt have both prolife and prodeath feelings, the balance of which can be affected by the response of others. It is important to take suicide threats seriously and to listen to person’s accounts of their experiences, feelings, and plans without imposing value judgments. If there is reason to believe that a suicide attempt is imminent, it is important to seek immediate help from friends, relatives, clergy, teachers, physicians, or other resource persons. Another form of suicide prevention involves befriending those who are socially isolated— those who are strangers to the community, those who are elderly and limited in their mobility, and those who have recently lost their spouses or companions. Individuals and community organizations that reach out to lonely and depressed people can be highly effective in reducing the impulse to self-destruction. Helping the Survivors of Suicide The grief experienced at the death of a family member or friend is often intensified when their lives have been lost through suicide. Some communities have established peer support groups, in which families that have experienced a suicide can share their feelings and encourage one another’s recovery. Other communities do not have support groups that specifically deal with suicide, but they do have groups for persons whose family members have died because of other causes. Often grief support groups have experienced counselors as moderators, but it is the mutual help given by all
870 ✧ Suicide the participants that usually proves most valuable. Many support groups are church-related; others are offered through local mental-health agencies. The family relations and counseling departments of local colleges and universities are also resources for locating and creating peer-support groups. Stress reactions, depression, and communications difficulties often occur in families that have lost a member through suicide. Family counseling has proven to be effective for many such families, enabling them to resolve their conflicts, build on their strengths, and carry on with their lives. By being open to discussion, friends and neighbors can help families socially and emotionally recover from the grief of suicidal deaths. Too often, persons are afraid to refer not only to deaths by suicide, but also even to those who have taken their own lives. This contributes to families’ sense of social isolation. It is usually far more helpful to acknowledge such deaths for what they are and to share memories of deceased persons. Suicidal deaths are tragedies, but they are not stigmas unless persons choose to make them so. —Robert Kastenbaum See also Depression; Depression in children; Depression in the elderly; Ethics; Euthanasia; Postpartum depression; Suicide among children and teenagers; Suicide among the elderly; Terminal illnesses. For Further Information: Conroy, David L. Out of the Nightmare: Recovery from Depression and Suicidal Pain. New York: New Liberty Press, 1991. Discusses suicide from the viewpoint of both individuals and society, with particular focus on ways in which self-destruction can be prevented. Heckler, Richard A. Waking Up, Alive. New York: Ballantine Books, 1994. Describes the journey from loss and depression to a suicide attempt, followed by eventual recovery from the self-destructive impulse. Hendin, Herbert. Suicide in America. 2d ed. New York: W. W. Norton, 1995. Examines suicide in relationship to violence, alcoholism, and sexual orientation in young and elderly adults. Kastenbaum, Robert. Death, Society, and Human Experience. 6th ed. Boston: Allyn & Bacon, 1998. Explores the ways in which individual and societal interactions either increase or decrease suicidal behavior. Quinnett, Paul. G. Suicide: The Forever Decision. New York: Continuum, 1992. Suggests ways of overcoming depression and despondency in finding alternatives to suicide.
Suicide among children and teenagers ✧ 871
✧ Suicide among children and teenagers Type of issue: Children’s health, mental health, social trends Definition: The intentional act of killing oneself when done by a young person, usually motivated by the desire to completely stop consciousness of unendurable psychological and/or physical pain. Childhood and adolescence are times of great change and personal growth, more so than at any other point in the life span. They are when the internal definitions of self are established. The idiosyncracies of normal child and adolescent development, as distinct from that of adults, play a role in suicide attempts among the young. Children do not have the cognitive ability to grasp the permanence of death; adolescents do not have the affective ability to appreciate the psychological impact of suicide on those left behind. The young often imagine what life after death will be like, that they will be able to come back to life later, that the goals of suicide will be realized in some meaningful way, or that their life will actually be better after suicide (as if they will be able to reap the benefits). An older boy who attempts suicide to get back at his parents because they are too strict often believes that his act will make his parents change, that somehow life as their son will be better. An adolescent girl who takes an overdose because of a recent breakup often believes that her death will make her former boyfriend want to date her again. Suicide for the young usually springs from a perspective of hopelessness; they have come to believe there is no other way to deal with the problems at hand. Teenage star athletes may feel that life has lost all meaning if they cannot play professionally, and they plan their demise as a way to deal with this shame. Sometimes—and this occurs more with adolescents than with children—suicide results from almost no planning at all but from an impulsive act initiated by a strong, sudden emotional response. Rising Suicide Rates Youthful suicide is underrecognized as a significant health issue even though it brings death to more children and adolescents than homicide. While suicide rarely occurs before the age of ten, it is the sixth-leading cause of death in children aged ten to fourteen and the third-leading cause of death in adolescents aged fifteen to nineteen. Twelve out of every one hundred adolescent deaths in the United States are the result of suicide, about five thousand annually. This rate is increasing, tripling in the forty years between 1952 and 1992. Clinicians and researchers alike have cited the prevalence of single-
872 ✧ Suicide among children and teenagers parent households, the increase in drug and alcohol abuse among minors, the exposure to media violence, and the increase in reporting suicides as contributing to a psychological climate that fosters suicidal thinking and behavior. Far from abhorrent, suicide becomes an answer to problems, a way to undo shame, and a final way to overcome the stressful challenges of life. Although girls are three times more likely to attempt suicide than boys, boys have a higher success rate, by five to one, because the means that they choose, such as hanging or shooting, often have greater lethality. In the United States, the rate among whites is greater than among nonwhites, although among the subset of adolescent African American males, the rate has been increasing to equal that of whites. The most common means to commit suicide for all ages and populations is deliberate ingestion of poisons or medications. Risk Factors and Warning Signs Child and adolescent risk factors for suicide may be internal or external. Internal factors include psychiatric conditions such as depression, bipolar (manic-depressive) disorder, anxiety disorder, conduct disorder, and alcohol or substance abuse. Internal factors also include having been sexually or physically abused, having personal knowledge of someone who committed suicide, and having made a previous attempt oneself. Almost one in ten children who try to commit suicide but who fail on the first attempt will eventually succeed. Research on adult suicide victims shows them to have lower levels of 5-hydroxyindoleacetic acid, a metabolite of serotonin. Serotonin is an important neurochemical for regulating emotions and outlook. External risk factors increasing risk are exposure to domestic violence, availability of firearms, availability of potent and therefore dangerous medications, and a family history of psychiatric affective disorders. Often, the most likely precipitants for suicide are life stressors. The breakup of a romantic relationship, intense conflict with parents, or difficulty with teachers or coaches can serve as catalysts in someone who is already at high risk. Bipolar disorder and schizophrenia most commonly have their onset in late adolescence and young adulthood, and it is often during a first depressive episode with one of these illnesses that suicide is attempted. Subtle behavior changes may hint at an upcoming suicide attempt. Some children make veiled statements of intent such as “There’s nothing to look forward to,” “You’d be better off without me,” or “I don’t want to go on any more.” They may even say “Goodbye” instead of “Good night.” Adolescents with intent may give away treasured belongings or show unexpected behavioral changes. The depressed can seem to improve; the agitated may become calm. These signs are not easy to read, however, and most who show evidence of these changes do not attempt to reach out to those around them.
Suicide among children and teenagers ✧ 873 Intervention and Prevention Treatment for suicide can be categorized as prevention before it is attempted (primary prevention), prevention after it is contemplated (secondary prevention), and prevention after it is attempted (tertiary prevention). Primary prevention is for children of all ages and begins indirectly at birth. Parents are the first teachers of coping skills, problem-solving resilience, and impulse control, as well as of high self-esteem and self-worth. They are also the first models of behavior, adaptation, and coping. The community and schools reinforce what children learn at home. They should address suicide awareness, alcohol and drug abuse prevention, and drop-out prevention specifically. Primary care specialists should ask their preadolescent and adolescent patients about domestic violence, drug and alcohol use, and suicidal ideation during routine examinations. It is a mistaken notion that asking about suicide plants the seed for suicide. Anyone distressed enough to be thinking about ending his or her life may be highly responsive to a caring professional who has taken the time to ask. Similarly, asking about suicide will not generate the attendant distress associated with thinking about suicide. After parents, schools play the most significant role in identifying children at risk. Teachers, administrators, and counselors should be familiar with warning signs and have mechanisms in place to facilitate psychological assessment and interventions as needed. Other primary prevention mechanisms include training in gun safety and safeguarding access to potent medications. Secondary prevention is for those children and adolescents who have begun to think about suicide for themselves. Again, parents and other caregivers at home are often the first to recognize the signs of increased stress. While it is hoped that parents have fostered a family climate of acceptance, candor, and honesty, often conflict with parents is the stressor, and the normal process of establishing an independent identity may make it difficult for children, especially adolescents, to confide in their parents. Schools provide secondary prevention through professional or peer counseling. In the aftermath of suicide in the school or even the local community, counseling should be made available to all students. Suicides decrease in communities with telephone hot lines, which work especially well with adolescents. Manned by trained staff members, who are often peers, they provide help, support, and guidance while guaranteeing anonymity. Any suicide attempt, even those less than wholehearted, must be taken seriously. In one study, half the parents of children who attempted suicide believed that their children were faking their emotional state or making a bid for attention. Even for those who are not really trying to take their own lives, the gestures themselves have a narrow range of safety, and miscalculations often occur. Their emotional state and psychological need for this degree of attention warrant professional intervention for dealing with the
874 ✧ Suicide among children and teenagers underlying cause for which the gesture is only a symptom. Tertiary prevention seeks to intervene so that there will not be a second attempt. Usually, the child or adolescent will be admitted to a hospital. This action removes the patient from the trigger for the attempt, an absolute must if the stressor is domestic violence. Another advantage to inpatient stay is that it provides the time and opportunity to evaluate the emotional and psychological status of the child and to initiate appropriate intervention and aftercare treatment. Whether the condition is acute or chronic, medication usually will be prescribed. Antipsychotic medications are often used, as are antidepressants; occasionally, they are employed in combination. When antidepressants are prescribed, usually the class of serotonin reuptake inhibitors (SRIs) are tried first. They have few side effects and are not particularly lethal if taken in overdose. Common brand names for these medications are Prozac, Paxil, and Zoloft. Each child and situation is unique, however, and the prescribing psychiatrist may select a different class of drugs altogether. The plan of care following hospital discharge, called the aftercare plan, will likely involve both individual and family treatment and possibly ongoing medication management. The need for individual treatment is clear: A child or adolescent is in psychological distress. The need for family therapy may be less obvious, although of equal importance. Often, underlying family issues are giving rise to an environment that fosters suicidal ideation and behavior, and these issues are better worked through in family rather than in individual treatment. —Paul Moglia and Virginia M. Witt, M.D. See also Alcoholism among teenagers; Child abuse; Children’s health issues; Death and dying; Depression in children; Drug abuse by teenagers; Schizophrenia; Stress; Suicide; Suicide among the elderly. For Further Information: Berman, Alan L., and David A. Jobes. “A Population Perspective: Suicide Prevention in Adolescents (Age 12-18).” Suicide and Life Threatening Behavior 25, no. 1 (Spring, 1995): 143-154. An excellent, clear summary of adolescent suicidal epidemiology using a primary-secondary-tertiary prevention perspective. Brent, David A. “Practitioner Review: The Aftercare of Adolescents with Deliberate Self-Harm.” Journal of Child Psychology and Psychiatry and Allied Disciplines 38, no. 3 (March, 1997): 277-286. Discusses a rational method to determine the level or intensity of aftercare for adolescents and their families. Focuses on the factors present in adolescents and their families that make repetition of suicidal attempts more likely. Jamison, Kay Redfield. Night Falls Fast: Understanding Suicide. New York: Alfred Knopf, 2000. Jamison, a distinguished psychologist and academic,
Suicide among the elderly ✧ 875 brings a rare combination of personal and academic experience to bear in this monumental work on suicide. Marcus, Eric. Why Suicide?: Answers to Two Hundred of the Most Frequently Asked Questions About Suicide, Attempted Suicide, and Assisted Suicide. San Francisco: HarperCollins, 1996. Written in a question-and-answer format, this guide deals with suicide specifically, as opposed to death in general. Suicide attempted, sought, or completed inevitably leaves the surviving families and loved ones with a host of questions that this easy-to-read book tries to answer. A useful guide. Zimmerman, James K., and Gregory M. Asnis, eds. Treatment Approaches with Suicidal Adolescents. New York: John Wiley & Sons, 1995. Written more for the professional than for a lay audience, this edited work attempts to synthesize the many methods of treating adolescents at risk. Valuable as a reference for parents to help make sense out of different treatment approaches and their outcomes.
✧ Suicide among the elderly Type of issue: Elder health, mental health, social trends Definition: The deliberate taking of one’s own life by an older individual. From 1980 to 1992, suicides among persons aged sixty-five and older in the United States increased 36 percent, from about forty-five hundred to more than six thousand. In 1992, persons aged sixty-five and older accounted for 13 percent of the population, but almost 20 percent of suicides. As people age, their suicide risk increases. Persons eighty-five and older have the highest rates of suicide in the United States. Group Differences Suicide rates among the elderly vary by gender. As with other age groups, the suicide rate is higher among men than women. One possible reason is that women cope better than men. They adjust better to role shifts and have better social support systems. Another possibility is that men are much more likely to use violent methods of suicide, particularly firearms, than women are. Suicide rates among the elderly also vary by ethnicity. Among the most prominent ethnic groups, the suicide rate is highest among American Indians. Rates are also high among Caucasian Americans, and relatively low among African Americans, Asian Americans, and Latinos. Each of these cultural groups are diverse. Within each there are subgroups with both higher and lower rates. Other group differences in suicide exist as well. At all ages, suicide is
876 ✧ Suicide among the elderly higher among single, separated or divorced, or widowed persons as compared to married persons. The methods for committing suicide vary by age and gender. About two-thirds of elderly suicides are committed with guns, compared with only about 57 percent of suicides among those younger than sixty-five. Elderly Caucasian American men are the group most likely to use guns, particularly if they live in a rural area and have not completed high school. Risk Factors for Suicide in Late Life Psychiatric disorders, such as depression, schizophrenia, anxiety disorders, and alcohol abuse or dependence, are the most important risk factors for suicide in the elderly. In one study, 80 percent of those who attempted suicide were admitted to an adult psychiatric inpatient hospital. They were found to have experienced major depression of late onset, especially psychotic depression. Among the elderly aged seventy-five and older who committed suicide, 71.4 percent had a mood disorder. This contrasts with 63.9 percent of those aged fifty-five to seventy-four who had a mood disorder. Chronic physical illness is another risk factor for suicide among the elderly. In one study, 94 percent of older suicides had physical problems at the time of death, and 57 percent had seen a health professional in the previous thirty days. The illnesses most frequently cited were diseases of the central nervous system (especially Alzheimer’s disease), malignancies, cardiopulmonary conditions, and urogenital diseases. Those with mixed Alzheimer’s and vascular dementia may be at a particularly high risk for suicidal thinking. The prospect of living many years with chronic pain or disability and subsequently becoming dependent upon the health care system or family members may be especially difficult for older persons who have achieved an independent lifestyle. A previous history of suicide attempt is a risk factor for suicide. Among all age groups, those who attempt suicide once are more likely to try again than those who have never attempted suicide. Previous history may be especially risky for elderly individuals because they have fewer failed suicide attempts than younger people. Other risk factors include hopelessness, stressful life events, and biological susceptibility. Financial trouble is less important as a risk factor for the elderly than for younger populations. Thus, the elderly people who are at most risk for suicide have probably had a major psychiatric disorder and attempted suicide in the past. They may also have a chronic physical problem, a sense of hopelessness about the future, other recent social stresses, and some biological susceptibility. Assessment and Intervention Asking simple, direct questions is recommended for evaluating suicide risk. A direct question such as, “Have you ever thought of hurting or killing
Suicide among the elderly ✧ 877 yourself?” can convey understanding and the willingness to take a person seriously. This does not provoke people to become suicidal. Most people will answer truthfully. Other useful inquiries include asking about vague suicidal thoughts, wishes to die, past attempts, and suicide plans. If someone reveals suicidal thinking or plans, follow-up questions should be about specifics. Does the person have a concrete plan? Does he or she have the means to carry out the plan? For example, does the person have a gun and know how to use it? When a person is suicidal, he or she may need a referral to a mental health professional, medication, or hospitalization. Mental health professionals who are treating a suicidal person begin with crisis intervention. The first priority is to preserve the person’s life, so the professional may violate confidentiality if the person is of imminent harm to himself or herself. Initially, clinicians try to establish a good working relationship in order to see the person through the immediate crisis. Clinicians may find that at times, a no-suicide, no-harm agreement can be useful. The clinician will often elicit support from the suicidal person’s social support system. The suicidal crisis is typically short term, lasting perhaps a few days. When it is resolved, the clinician can begin to address long-standing problems. For the underlying problems, psychotherapy and/or medication may be useful. Community strategies can also be helpful with suicidal older individuals. According to a 1995 article by D. De Leo and colleagues, ongoing phone calls and reminders to take their prescribed medicine decreases the expected frequency of suicide among elderly individuals. Educating health care providers and the general public about risk factors for elderly suicide may reduce the conditions that can lead to suicide. Reducing the availability of firearms decreases suicide risk, especially among men. Euthanasia In modern times, euthanasia has come to mean a physician actively causing a patient’s death. This contrasts with physician-assisted suicide, in which the patient self-administers a lethal dose of a drug that was prescribed by a physician who knew that its purpose was to induce death. One piece of evidence that attitudes in the United States toward euthanasia have become more positive is the acceptance of living wills, in which individuals decree that no heroic procedures or exceptional life-sustaining measures be employed in the event of their incapacitation. The prototype of the elderly suicide is a widower who is retired and lives alone. He is isolated from family and friends and is not active in church, community, or other social activities. He feels lonely, depressed, and helpless to do anything about his situation, and he may have other psychiatric problems as well. Though not terminally ill or in debilitating pain, he has recently seen a physician. He feels hopeless about the future and finds no
878 ✧ Suicide among the elderly meaning in his existence. He has turned to alcohol or other drugs to drown his sorrows. He has relatives who have committed suicide. He has attempted suicide in the past and has thought about suicide recently. He has a gun in his home. Though the myth is otherwise, the overwhelming majority of people who are terminally ill fight for life to the end. Only 2 to 4 percent of suicides occur in the context of terminal illness. A request for death comes from a person who is desperate, whether he or she is medically ill. In such cases, a comprehensive psychiatric assessment should include inquiring into the source of the person’s desperation. It should also include trying to relieve this source. Elderly individuals who are informed of acute, potentially fatal medical conditions may express angry preoccupation with suicide and request assistance in carrying out these wishes. The majority are motivated primarily by dread of what will happen to them, rather than by current pain or suffering. They fear debilitating pain, dependency on others, loss of dignity, the side effects of medical treatment, burdening of their family and friends, and death itself. Those who are medically ill may not know what to expect. When they can express their fears, their request for euthanasia may quickly disappear. Sociologists note that arguments about the right to suicide and assisted suicide for the elderly is a symbol of society’s devaluation of old age. Ageism results in easy acceptance of the concepts of euthanasia, rational suicide, and assisted suicide. It creates a society in which suicide is not only expected but even demanded of all who might be a burden. —Lillian M. Range See also Death and dying; Depression in the elderly; Euthanasia; Living wills; Suicide; Suicide among children and teenagers; Terminal illnesses. For Further Information: De Leo, D., G. Carollo, and M. L. Dello Buono. “Lower Suicide Rates Associated with a Tele-help/Tele-check Service for the Elderly at Home.” American Journal of Psychiatry 152, no. 4 (April, 1995): 632-634. A description of an actual telephone service for the elderly. Humphrey, D. Final Exit. Eugene, Oreg.: Hemlock Society, 1991. This bestseller describes how to commit suicide. Osgood, N. J. Suicide in Later Life: Recognizing the Warning Signs. New York: Macmillan, 1992. A well-done overview of facts, case studies, and ideas for intervention and prevention. Stillion, J. M., and E. E. McDowell. Suicide Across the Life Span: Premature Exits. 2d ed. Washington, D.C.: Taylor & Francis, 1996. The chapter “Suicide Among the Elderly” gives facts and vivid case studies.
Sunburns ✧ 879
✧ Sunburns Type of issue: Environmental health, public health Definition: An inflammation of the skin produced by excessive exposure to the sun, sunlamps, or occupational light sources. Sunburn is caused by overexposure to ultraviolet light coming directly from the sun or from artificial lighting sources, as well as from reflected sunlight from snow, water, sand, and sidewalks. Scattered rays may also produce sunburn, even in the presence of clouds, haze, or thin fog. Symptoms include red, swollen, painful, and sometimes blistered skin, chills, and fever. In severe cases, nausea, vomiting, and even delirium may be present. Depending on the severity of the burn, tanning and peeling will occur during recovery. Treatment and Therapy In order to reduce the heat and pain of sunburn, towels or gauze dipped in cool water can be carefully laid on the burned areas. Once the skin swelling subsides, cold cream or baby lotion can be applied to the affected areas. If the skin is blistered, a light application of petroleum jelly prevents anything from sticking to the blisters. Nonprescription drugs, such as acetaminophen, can be used to relieve pain and reduce fever. If necessary, a medical doctor can prescribe other pain relievers or cortisone drugs to relieve itching and aid healing. A number of risk factors can greatly intensify the affects of sunburn, including such genetic factors as fair skin, blue eyes, and red or blonde hair; the use of certain drugs, particularly sulfa drugs, tetracyclines, amoxicillin, or oral contraceptives; and exposure to industrial light sources, such as arc welders. For outdoor activities, a sunscreen or sunblock preparation should be applied to exposed areas of the body. Baby oil, mineral oil, or cocoa butter offer no protection from the sun. Brilliant colored and white clothing that reflect the sun into the face should be avoided. If tanning is a must, sun exposure should be limited to five to ten minutes on each side the first day, adding five minutes per side each additional day. Severe sunburn in childhood can lead to skin cancer later in life. —Alvin K. Benson See also Burns and scalds; Cancer; First aid; Skin cancer; Skin disorders with aging. For Further Information: Grob, J. J. Epidemiology, Causes, and Prevention of Skin Diseases. London: Blackwell Science, 1997.
880 ✧ Tattoos and body piercing Kenet, B. J., and P. Lawler. Saving Your Skin: Prevention, Early Detection, and Treatment of Melanoma and Other Skin Cancers. Chicago: Four Walls Eight Windows, 1994. Siegel, Mary-Ellen. Safe in the Sun. New York: Walker, 1990.
✧ Tattoos and body piercing Type of issue: Children’s health, social trends Definition: Piercing of the skin to implant devices or make designs. Tattooing is accomplished by a variety of techniques, usually by persons who are specialists. Coloring inks were available from the end of the nineteenth century and are now supplied in liquid forms. They can be applied in either the so-called European fashion, in which the coloring ink is applied over a small surface and an electric vibrating needle impregnates the epidermis and the dermis, or the American procedure, in which the needle contains the desired pigment. The skin is prepared in a variety of ways, usually by smearing a thin layer of petroleum jelly over the site to minimize the seepage of blood and tissue fluids that would otherwise obscure the artist’s view. When the tattoo is completed, the area is washed and then covered with an antiseptic ointment. Tattoos assume various geometric or curvilinear designs and can be executed over all of a person’s body or simply within a restricted area. Extensive tattooing may take several years to complete. The most obvious forms of body piercing, by both males and females, are performed in the ears, nose, nasal septum, tongue, navel, lips, scalp, eyelids, or cheeks. In some cultures, the lips or ears may be grossly distorted by inserting over time increasingly larger objects, such as pieces of horn, bone, wood, and even metal. In some cases, the particular style of body piercing may indicate a person’s marital status, group membership, or religious affiliation, or it may simply be cosmetic mutilation. Body piercing may also be performed on male or female genitals. The breasts, particularly the nipples, are a common site for the insertion of either closed or threaded rings. The infamous Prince Albert penal ring has acquired considerable fashion in Western cultures, being inserted in the top or either side of the glans. Cultural Contexts and Rites of Passage Tattoos and body piercing of the human body have been practiced by all cultures throughout the world to serve different functions: for religious purposes, as an indication of certain status changes or the accomplishment
Tattoos and body piercing ✧ 881 of culturally significant tasks, as a proof of ordeal, for medical reasons, as body art, as identification marks, to signify membership in either sacred or profane organizations, or to attain visions through mortification of the flesh. In the United States during the early twentieth century, it became popular for women to be tattooed for eyeliner, cheek blush, and even colored lips. Although tattooing and body piercing were once associated with motorcycle gang members, prisoners, and military personnel, these surgical procedures have become more popular with the general public. Tattooing and selfmutilation by body piercing are gaining popularity as forms of personal expression, particularly with women, who make up approximately 70 percent of the new business. A concern, however, is the increasing frequency of adolescents engaging in tattooing and body piercing. Today, body piercing in Western cultures is often viewed by teenagers and young adults as a rite of passage, sometimes symbolically in defiance of the established social order. When self-practiced, tattooing and body piercing can lead to infection and even septicemia, particularly when people use instruments and inks that are not sterile. In addition, there has been an increase in the incidence of blood-borne infections such as human immunodeficiency virus (HIV) and hepatitis B and C being transmitted through contaminated needles. —John Alan Ross See also Children’s health issues; Pain management. For Further Information: Armstrong, M. L. “Adolescent Tattoos: Educating vs. Pontificating.” Pediatric Nursing 21, no. 6 (November/December, 1995): 561-564. _______. “Adolescents and Tattoos: Marks of Identity or Deviancy?” Dermatology Nursing 6, no. 2 (April, 1994): 119-124. Gard, Carolyn. “Think Before You Ink: The Risks of Body Piercing and Tattooing.” Current Health 25, no. 6 (February, 1999): 24-25. Tattoos and body piercing seem to be very popular, but teens should consider the risks associated with these trends. Tattoo dyes can cause allergic reactions. Sperry, Kris. “Tattoos and Tattooing, Part I: History and Methodology.” The American Journal of Forensic Medicine and Pathology 12, no. 4 (December, 1991): 313-319. _______. “Tattoos and Tattooing, Part II: Gross Pathology, Histopathology, Medical Complications, and Applications.” The American Journal of Forensic Medicine and Pathology 13, no. 1 (March, 1992): 7-17.
882 ✧ Teething
✧ Teething Type of issue: Children’s health Definition: The eruption of the primary, or deciduous, teeth in infancy. A child’s teeth begin to develop about the second month of pregnancy. The first tooth does not usually appear above the gum line, however, until the sixth or seventh month after birth. The tooth is pushed upward through the gum by growth at the base of the tooth. At the same time, the root sheath grows downward toward the jaw. Studies indicate that dental development does not seem to be affected by nutrition, illness, or climate. In addition, there seems to be little difference between girls and boys in their dental development. Dental development follows a typical pattern. The teeth generally emerge in pairs. Usually, the lower central incisors are the first teeth to erupt, between five and seven months after birth, followed by the upper central incisors at six to eight months. The upper lateral incisors make their appearances between nine and eleven months, followed by the lower lateral incisors at ten to twelve months. The first molars, two upper and two lower, usually emerge between twelve and sixteen months. The cuspids follow next, at about sixteen to twenty months. The final deciduous teeth to emerge are the second molars, at twenty to thirty months. Most children will have twenty teeth, ten on the top and ten on the bottom, by their third birthday. By the time that they are six, most children begin to lose their primary teeth as the permanent teeth emerge. Although not permanent, a child’s primary teeth are important. The primary teeth are necessary for the child to chew solid food. In addition, they are important as space holders and guides for the permanent teeth. Teething Problems Some children have a more difficult time teething than do others. Common symptoms of teething in an infant include wakefulness, excessive drooling, fussiness, refusal to nurse, and finger chewing. An infant’s gums may also be swollen and tender. These symptoms have also been observed in animals as their teeth erupt. Some debate exists over other commonly held beliefs concerning symptoms associated with teething. Historically, fever, diarrhea, and ear pulling have been attributed to teething; however, there is no scientific evidence to suggest that teething causes any of these symptoms. In a 1992 article “Teething” in the Journal of Pediatric Health Care, Patricia T. Castiglia suggests that parents often attribute behaviors such as wakefulness to teething because it alleviates parental worry. She further argues that wakefulness at six to nine
Teething ✧ 883 months is caused by separation anxiety, not teething. Those researchers who have attempted to associate teething with disease have found it difficult to do so. The teething period is also the period when babies are no longer fully protected by the mother’s antibodies but have not yet built up antibodies of their own, thus rendering them susceptible to disease. Consequently, while diseases may coincide with the teething period, it is difficult to associate teething with disease. Nevertheless, most pediatricians agree that babies experience some discomfort from teething. Many believe that allowing the child to chew on a cold rubber teething ring or damp washcloth will relieve the pain. While some experts suggest offering frozen teething rings and/or frozen bagels or bread, others argue that neither should be given. They contend that the frozen teething ring can damage the baby’s gums, while bits of the frozen bagel can break off, potentially choking the baby. Likewise, there is little agreement about whether acetaminophen should be used. Most experts discourage using breast-feeding or a bottle to help a teething baby fall asleep. The milk pools around the new teeth, potentially causing decay. Indeed, many pediatricians suggest that a baby’s gums and new teeth should be wiped with a clean, damp gauze pad several times a day to remove traces of milk or juice from the mouth. Teething has been a concern for doctors and parents for many years. Theorists as early as Hippocrates attributed fever, convulsions, and diarrhea to teething. During the eighteenth and nineteenth centuries, many writers considered teething to be the leading cause of death among infants. During the last quarter of the twentieth century, however, the use of teething as a diagnosis for diarrhea, fever, and other childhood illnesses diminished among pediatricians, although studies indicate that some pediatricians continue to connect teething with diarrhea. —Diane Andrews Henningfeld See also Children’s health issues; Cleft lip and palate; Dental problems in children; Pain management. For Further Information: Castiglia, Patricia T. “Teething.” Journal of Pediatric Health Care. 6, no. 3 (May/June, 1992): 153-154. Gorfinkle, Kenneth. Soothing Your Child’s Pain: From Teething and Tummy Aches to Acute Illnesses and Injuries—How to Understand the Causes and Ease the Hurt. Lincolnwood, Ill.: Contemporary Books, 1998. Kump, Theresa. “The Facts About Baby Teeth: From Teething Pain to First Cleanings, Here’s What You Do.” Parents 70, no. 6 (June, 1995): 65-66. Rogoznica, June. “Teething Time.” Parents 74, no. 3 (March, 1999): 139-140. Shelov, Steven P., et al., eds. Caring for Your Baby and Young Child: Birth to Age Five. Rev. ed. New York: Bantam Books, 1998.
884 ✧ Temperature regulation and aging
✧ Temperature regulation and aging Type of issue: Elder health Definition: The maintenance of the optimal temperature range for efficient and comfortable performance of human body functions. Thermoregulation, the monitoring and controlling of body temperatures, is primarily coordinated by the hypothalamus, located in the brain. The process of thermoregulation becomes active when air temperature rises above or drops below approximately 22 degrees Celsius (72 degrees Fahrenheit), depending on the relative humidity. Tolerance of cool temperatures increases with body size, body fat, and muscle mass. The body also has two active strategies to maintain body temperature in cool environments: reducing heat loss or increasing internal body temperature. Body heat is normally lost through the skin’s surface. Blood vessels in the skin can narrow with cold temperatures and decrease blood flow, thus reducing heat loss. Shivering, which involves contraction of muscles, can rapidly raise metabolism and body temperature. Inactive older people tend to lose muscle mass with aging, thus decreasing the ability to raise body metabolism and temperature. In addition, elderly people are usually not able to contract skin vessels as efficiently as the young, thus decreasing their ability to minimize heat losses. Increased blood flow to the skin and sweating are the two primary body changes involved in reducing body temperature, thus preventing hyperthermia. Widening of skin blood vessels, increased blood flow from the heart, and redistribution of blood flow from the intestines, kidneys, and other organs can increase blood flow to the skin. Widening of skin blood vessels does not occur as efficiently in older people as it does in the young. In addition, the ability to increase blood flow from the heart and redistribute blood flow from vital organs to the skin can decrease with aging. Sweating also decreases with aging, possibly because of the increased sun damage to the skin over time. Hydration status also influences both sweating and the ability to redistribute blood flow to the skin. Older people tend to be less hydrated than the young, further decreasing their ability to thermoregulate in hot environments. Illnesses and a sedentary lifestyle are considered the greatest threats to thermoregulation in the elderly. Therefore, a healthy and active lifestyle is probably the best way to preserve thermoregulatory functions with aging. Proper nutrition helps reduce dehydration and overheating, while sunscreens may help preserve the structural functions of the skin, which are vital for thermoregulation. Appropriate clothing can also help with thermoregulation. Research suggests that postmenopausal women taking estro-
Terminal illnesses ✧ 885 gen maintain better hydration status and have improved functions of the skin, which helps with thermoregulation. —Laurence M. Katz See also Aging; Menopause; Skin disorders with aging. For Further Information: Arking, Robert. Biology of Aging: Observations and Principles. 2d ed. Sunderland, Mass.: Sinauer Associates, 1998. Becker, K., et al., eds. Principles and Practices of Endocrinology and Metabolism. 3d ed. Philadelphia: J. B. Lippincott, 2000. Cohen, Stephen. Sensory Changes in the Elderly. New York: American Journal of Nursing, 1981. Moeller, Tamerra P. The Sixth Sense: A Learning Guide About Sensory Changes and Aging. Washington, D.C.: National Council on the Aging, 1985. Schmall, Vicki L. Sensory Changes in Later Life. Rev. ed. Washington, D.C.: U.S. Department of Agriculture, 1991.
✧ Terminal illnesses Type of issue: Economic issues, elder health, ethics Definition: A medical condition that by its nature can be expected to cause a patient to die. Many controversial issues surround what determines when a disease process is terminal and the resulting choices and options for care. The top four fatal illnesses in the United States are ischemic heart disease, chronic obstructive pulmonary disease, diabetes mellitus, and malignant neoplasms or cancers. When an individual is diagnosed as terminally ill, his or her social status changes radically. Even though an individual was previously an important contributing member of the community, since the person is now dying, he or she may therefore be seen as less “valued.” The sick individual may be ignored by many former friends because of their personal discomfort with death. On the other hand, the sick person may no longer desire to interact with more than a handful of friends and family. As a result, the social sphere of the dying person becomes very small. Many former activities and broader interests disappear as the sick person becomes more focused on the task of dying. In 1977, E. Mansell Pattison defined three stages of the living-dying interval: acute, chronic, and terminal. In the acute stage, individuals face the knowledge of their imminent death and may react with anxiety, denial, or anger. In the chronic phases, individuals begin to confront their fears of
886 ✧ Terminal illnesses dying, such as loneliness and pain. They also deal with fears of what will happen after death. The final or terminal phase signals the end of hope and the beginning of withdrawal from the outside world upon realization of the inevitability of death. The goal of treatment for the dying, according to Pattison, is to help them cope with the first phase, help them live through the second, and move them toward the third. Rights of the Dying The process of dying takes a great deal of physical and psychic energy. Sedatives, painkillers, and some treatments can further reduce energy and cause disorientation and diminishing capabilities. As strength decreases, the dying are progressively less able to carry out activities of daily living. They become very vulnerable. Because those who are dying are generally in a weakened state, family members and health professionals are responsible to ensure their rights are not violated. The following are some of these rights. Patients have the right to open communication about death. Because individuals commonly deny that they are dying in the early stages, it is generally most sensitive to inform them first that their condition is serious and to allow them to ask more questions as they are ready to hear it. Knowledge of impending death allows dying persons to complete certain tasks before dying and to close their life in accordance with personal wishes. Additionally, full awareness of impending death allows an individual to make responsible decisions, such as where to die and what treatments to allow. The terminally ill have the right to a painless death, to the greatest extent possible. The dying want to be free from pain. A common fear among the terminally ill, especially the elderly, is that their death will be painful. Patients considering suicide most often cite fear of prolonged suffering and painful death as a reason. Pain is more than just an unpleasant physical sensation. It may impair function, lead to fear and anxiety, interfere with social relationships, and cause spiritual distress. Patients benefit from having been given “permission” to discuss their feelings about pain. They may have to unlearn reluctance stemming from previous encounters with unsympathetic or uninformed clinicians. Sometimes the terminally ill feel they must be brave or put on a front to help ease their family’s distress. Pain can isolate patients, especially when they must hide it from others, and isolation in itself increases the risk of suicide. Health professionals need to be reminded that the patient is the best judge of his own pain. Therefore, the terminally ill person needs to be involved in his or her own pain management. It becomes the individual’s responsibility to tell caregivers when the medication has not relieved the pain. Some physicians, unfortunately, have received little training in pain management and may not prescribe the right drug, dosage, or route. When concerned about regulation of controlled substances or concern about the
Terminal illnesses ✧ 887 individual becoming tolerant to analgesics, it can be difficult to convince a physician to change a medication order. Clinicians may be reluctant to give high doses of opioids to patients with advanced disease because of a fear of side effects such as constipation, nausea and vomiting, sedation and mental clouding, and respiratory depression. The clinician’s ethical duty—to benefit the patient by relieving pain—supports increasing doses, even at the risk of side effects. Because many patients with pain become opioid-tolerant during long-term opioid therapy, the clinician’s fear of shortening life by increasing opioid doses is usually unfounded. It may help to refer to the Patient Guide: Managing Cancer Pain (1994) published by the Agency for Health Care Policy and Research (AHCPR). The terminally ill person, too, may worry about becoming addicted to painkillers. They may worry about costs of the medication, or show concern about becoming tolerant to pain medications. It is feared, even though the medication is currently working, it will not work when the pain becomes worse. Noninvasive physical and psychosocial modalities can be used concurrently with drugs and other interventions to manage pain during all phases of treatment. Some physical modalities such as cutaneous stimulation, heat, cold, massage, pressure, vibration, exercise, repositioning, and acupuncture can involve family members, giving them interventions so they do not feel so helpless. The cognitive-behavioral interventions are an important part of pain management. Most of all, they help to give the patient a sense of control and to develop coping skills to deal with the pain. So, interventions like relaxation and imagery, cognitive distraction and reframing, short-term psychotherapy, support groups, and pastoral counseling introduced early in the course of illness are more likely to succeed because they can be learned and practiced by patients while they have sufficient strength and energy. With rare exception, the less invasive analgesic approaches should precede invasive palliative approaches as radiation therapy, nerve blocks, or neurosurgery to implant devices to deliver drugs to electrically stimulate neural structures. Fighting Isolation Those who are dying have the right to the presence of concerned others. One of the terminally ill person’s greatest fears is abandonment at the time of death. They fear that they will die alone. A high proportion of elders may spend their dying interval without a concerned person to help make medical decisions or advocate adequate medical treatment. The importance of a support person, especially during the final days, becomes apparent as the dying generally begin to lack interest in all visitors except one or two significant persons. Terminally ill people have the right to as much control over environment as possible. Because the dying so often experience loss of control over their
888 ✧ Terminal illnesses environment and declining health, it is imperative that family and health professionals allow the dying person as much control as possible, even in little things. Allowing patients some choice over meals, visiting hours, roommates, frequency of nursing interruptions, and medical treatments can greatly enhance their feelings of autonomy. The dying, like other patients, have the right to have all medical treatments fully explained. This includes a description of the prognosis and methods of treatment, as well as the potential risks, benefits, and side effects. Individuals also have the right to refuse treatment for their illness and to seek out alternative medicine, even those not condoned by the medical profession. For example, chemotherapy has a variable success rate and is accompanied by many uncomfortable side effects. Because of this, the patient may refuse the therapy, opting for a more comfortable, although perhaps shorter, life. The terminally ill seek quality of life over quantity of hours. Patients have the right to refuse all heroic, artificial efforts to sustain life. These issues are best spelled out in a living will. Living wills are advance directives that express the desires of competent adults regarding terminal care, life-sustaining measures, and other issues pertaining to their dying and death. Understanding the Patient Self-Determination Act On December 1, 1991, the Patient Self Determination Act, a federal law enacted to ensure patient rights, went into effect. This law required Medicare- and Medicaid-certified hospitals, nursing homes, home health agencies, hospices, and health maintenance organizations to implement procedures to increase public awareness regarding the rights of patients to make treatment choices. The law was particularly concerned with advance directives, documents specifying the type of treatment individuals want or do not want under serious medical conditions in which they might be unable to communicate their wishes to the physician. Advance directives generally take one of two forms: a living will or a durable power of attorney for health care. Living wills, which may vary from state to state, outline the medical care individuals want if they become unable to make their own decisions. A durable power of attorney for health care, on the other hand, designates another person to act as an “agent” or a “proxy” in making medical decisions if the individual becomes unable to do so. Substitute decision makers, however, are not necessarily perfect executors of patients’ wishes. In one study, family members named as surrogates were asked for their view of patients’ preferences on resuscitation. The surrogates correctly guessed what the patients (who were chronically ill, but still competent) wanted only 68 percent to 88 percent of the time. The study, however, pointed out a likely cause for surrogates’ misunderstanding: lack of discussion. Patients by and large simply assumed their families and physicians would know what they wanted.
Terminal illnesses ✧ 889 So, directives that include information on the patient’s attitudes on life, health, and health care eliminate guessing. The medical directive should ask what the goals of treatment in various clinical situations should be (for example, to prolong life, to provide comfort). Such information helps the proxy and health care professionals because the question is not always “What do you want to do with the ventilator?” but “What does quality of life mean to you?” Clinicians and ethicists in recent years have increasingly come to view artificial nutrition (tube feedings) and hydration (intravenous fluids) as medical treatment rather than as food and water. As such, they may be withdrawn, much like a ventilator. A family may not share that view, however, even if withdrawal of artificial nutrition and hydration is consistent with the terminally ill person’s wishes. Health care professionals must support the family by telling them that they are not “starving” the person but that these invasive procedures are only prolonging the dying process without curative powers. The burden of responsibility needs to be removed from the shoulders of family members, who may feel a duty to make sure caregivers continue treatment. Clergy and other support people need to be available to help the family deal with any lingering doubts. More often than not, however, families react to the change of focus from cure to ensuring a comfortable death not with guilt but with relief, especially when the patient’s wishes have been respected—that, in some measure, the dying person has been allowed to face death on his or her own terms. —Maxine M. McCue See also AIDS; AIDS and children; AIDS and women; Breast cancer; Cancer; Cervical, ovarian, and uterine cancers; Colon cancer; Death and dying; Depression; Depression in the elderly; Euthanasia; Living wills; Lung cancer; Medications and the elderly; Prostate cancer; Skin cancer; Suicide; Suicide among children and teenagers; Suicide among the elderly. For Further Information: Compassion in Dying: Guidelines and Safeguards. Portland, Oreg.: Compassion in Dying Federation, 1999. Ferrini, Armeda F., and Rebecca L. Ferrini. Health in the Later Years. 3d ed. Boston: McGraw-Hill, 1999. Easy-to-read textbook for students preparing to work with older people; provides a broad overview of health and aging. Ignatavicius, Donna D. Introduction to Long Term Care Nursing: Principles and Practice. Philadelphia: F. A. Davis, 1998. Written for student nurses, this text provides practical, accessible, need-to-know information in every chapter. Murphy, Patricia A., and David M. Price. “ACT: Taking a Positive Approach to End-of-Life Care.” American Journal of Nursing 95, no. 3 (March, 1995). Discusses how to use “aggressive comfort treatment” to ensure that the end comes peacefully for dying patients.
890 ✧ Tobacco use by teenagers Parkman, Cynthia A., and Barbara E. Calfee. “Advance Directives: Honoring Your Patient’s End-of-Life Wishes.” Nursing 27, no. 4 (April, 1997). This guide is useful for nurses in helping patient’s exercise their right to make end-of-life decisions.
✧ Tobacco use by teenagers Type of issue: Children’s health, public health, social trends Definition: The psychological, social, and behavioral habit of chewing or smoking tobacco products for their physical and psychological effects or for religious purposes. Most people who become adult smokers begin experimenting with cigarettes in their teenage years. In fact, if a person has not begun to smoke by their early twenties, it is unlikely that they will ever become a cigarette smoker. Among those who do start smoking, more than two-thirds have a desire to quit later, and most experience great difficulty in trying to do so. Children as young as five years of age have reported intentions to try cigarettes for the benefits that they perceive to result from smoking. Therefore, efforts to stop tobacco use must start early. Typically, the children who are most at risk for becoming smokers and developing nicotine dependence are those who have access to cigarettes and who are exposed to tobacco use. Children who have money to buy cigarettes or who have parents, older siblings, or friends who smoke or who think smoking is okay are more likely to become smokers. Exposure to advertisements or promotional materials related to tobacco products can also increase the odds that a child will smoke. Additionally, children with family problems or low levels of parental support, low self-esteem, problems controlling their behavior, school problems, problems with peers, and body- or self-image problems (particularly girls) are at greater risk. The Importance of Prevention Treatment for tobacco use can take several different forms: primary, secondary, and tertiary prevention. In primary prevention, treatment is applied to the population as a whole. An example might be antismoking campaigns advertised on television or educational programs focused on school-age children in which the dangers of tobacco use are made known. Another example might be the education of store clerks who sell cigarettes about laws making it illegal to sell cigarettes to minors. In secondary prevention, treatment is applied to individuals who are at a higher-than-average risk. Examples include children of smokers and chil-
Tonsillectomy ✧ 891 dren suffering from depression or anxiety who smoke to calm their feelings. Treatment may include giving these children health education information about why people use tobacco—such as social pressure, uncomfortable feelings, and boredom—and then teaching them other ways to handle those kinds of problems without using tobacco. In tertiary prevention, treatment is applied to individuals who are already nicotine dependent. People often try to quit on their own, which can be very difficult the longer they have been smoking, or they may seek out a health care professional for medical intervention (such as nicotine replacement patches or gum and prescription drugs) and psychological guidance on how to quit. Learning about why they smoke, new ways of meeting personal needs, and ways to break old behavioral habits can be as important as any medical intervention in learning how to quit. —Nancy A. Piotrowski See also Addiction; Asthma; Cancer; Children’s health issues; Drug abuse by teenagers; Lung cancer; Secondhand smoke; Smoking. For Further Information: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. Rev. 4th ed. Washington, D.C.: Author, 2000. Julien, Robert M. A Primer of Drug Action: A Concise, Nontechnical Guide to the Actions, Uses, and Side Effects of Psychoactive Drugs. 8th ed. New York: W. H. Freeman, 1998. Weil, Andrew, and Winifred Rosen. From Chocolate to Morphine: Everything You Need to Know About Mind-Altering Drugs. Rev. ed. Boston: Houghton Mifflin, 1998.
✧ Tonsillectomy Type of issue: Children’s health, medical procedures Definition: The removal of the palatine tonsils as a result of repeated infection. In common use, the term “tonsils” indicates two pinkish palatine tonsils, almond-shaped masses of soft lymphatic tissue located on either side of the back of the mouth. There are two other tonsil types: the lingual tonsils, positioned at the back of the tongue, and the pharyngeal tonsils (adenoids), found in the pharynx and near the nasal passages. Together, the three types of tonsils constitute an irregular band of lymphatic tissue which roughly encircles the throat at the back of the mouth. This tissue band is called Waldeyer’s ring. The surface of each tonsil is composed of many deep crypts
892 ✧ Tonsillectomy that, in the case of the palatine tonsils, often become the sites where food debris lodges or sites of bacterial and viral infections. The resulting inflammation of the tonsils is called tonsillitis. Acute and Chronic Tonsillitis In many cases, acute tonsillitis causes severe throat pain that is easily cured by antibiotic treatment, without recurrence. In others, it returns repeatedly, leading to chronically infected palatine tonsils. Infection of the pharyngeal tonsils (adenoids) causes ear infections and nasal congestion, and it sometimes produces hearing loss as a result of the obstruction of the Eustachian tubes, which lead from the ear to the throat. Severe, chronic tonsillitis is most often treated by surgery to remove the palatine tonsils. When such surgery is carried out, physicians often elect to remove the infected adenoids as well. This double surgery is called adenotonsillectomy. The lingual tonsils are rarely removed because they do not often become infected. While the exact function of the components of Waldeyer’s ring is not clear, they are seen as important to the production of bacteria-killing lymphocytes and antibodies, which protect the throat and digestive system from infection. For this reason, unlike in the past, the tonsils are removed only when absolutely necessary, and tonsillectomy (or adenoid infection) is most often treated with antibiotics; penicillin and cephalosporin are the drugs of choice. Usually, the onset of acute tonsillitis is signaled by sudden and severe throat pain, high fever, headache, chills, and diffuse pain in the lymph glands of the neck. These symptoms will normally clear up in five to seven days. The most dangerous form of tonsillitis is caused by streptococcal bacteria, usually the Streptococcus pyogenes species. Associated complications increase with the severity of the infection. In severe cases, the bacterial infection may spread upward into the nose, sinuses, or ears (from Although this procedure is performed less often than in the past, the removal of the tonsils may still be infected adenoids) or downward required by chronic or severe infections; the inset into the larynx, trachea, and shows the location of the tonsils. (Hans & Cassidy, lungs (from infected palatine tonsils). Inc.)
Transplantation ✧ 893 Especially severe cases of tonsillitis may lead to a deep infection of the throat involving peritonsillar abscess (quinsy). Many cases of quinsy must be treated by lancing the infected region, causing it to drain. The most severe complications of streptococcal tonsillitis are acute nephritis (kidney disease) and rheumatic fever, which may lead to serious heart problems. Both kidney and heart problems are attributable to immune reactions in these organs. Removing the Tonsils The tonsils of children are removed under general anesthesia. Tonsillitis in children is much more severe and frequent than in adults because the tonsils decrease in size as one gets older. Similarly, the surgery is more difficult and severe in children because of larger tonsil size. In most cases, tonsillectomy is a simple surgery with few complications. The entire recovery period from such a procedure is usually several weeks. Most patients experience severe throat pain during the first few days of the recovery period; but this pain diminishes rapidly with time. It is important for the patient to eat soft food during recovery in order to prevent bleeding, which can become dangerous in some cases. Palatine tonsils do not grow back after surgery. Tonsillectomy does not lead to freedom from sore throats, but it usually results in a decreased frequency and severity of throat infections. —Sanford S. Singer See also Antibiotic resistance; Children’s health issues. For Further Information: Berkow, Robert, and Andrew J. Fletcher, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Rahway, N.J.: Merck Sharp & Dohme Research Laboratories, 1999. Sabiston, David C., Jr., ed. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 16th ed. Philadelphia: W. B. Saunders, 2001. Tierney, Lawrence M., Jr., et al., eds. Current Medical Diagnosis and Treatment. 39th ed. New York: McGraw-Hill, 2000.
✧ Transplantation Type of issue: Medical procedures, treatment Definition: The transfer of tissue or organs from one individual to another, usually from cadavers or living related donors. Successful transplantation of vascularized organs takes both surgical skill and a thorough understanding of the immune system. Transplantation
894 ✧ Transplantation antigens are proteins expressed on the surface of an individual’s cells. Every individual has a unique set of these antigens inherited from his or her parents. The purpose of these antigens is to help the body recognize what is “self” and what is not. In this manner, bacteria and other pathogens harmful to the individual can be sensed as “nonself” and destroyed by the immune system. When an organ is transplanted between unrelated people (allotransplantation), that organ will not be recognized as self and will be destroyed— thus the phenomenon of rejection. In the same fashion, organs transplanted between identical twins, who are genetically identical, will be recognized as self and not be rejected. The first successful human transplant took advantage of this premise, when a kidney was transplanted between identical twins. Lymphocytes are white blood cells that are intimately involved in the body’s immune response. Along with other white cells, they protect the individual from invading bacteria, viruses, and fungi. Lymphocytes can also be divided into two subsets: B and T cells. The T lymphocyte is the main cell involved in the recognition and destruction of allotransplants. Receptors found on the T lymphocyte cell surface are stimulated by the foreign transplantation antigens found on allotransplants, initiating a cascade of events that leads to allotransplant destruction. Battling Rejection With the knowledge that T lymphocytes are responsible for rejection, methods of modulating T cells were developed. One of the first approaches was to destroy them using total-body irradiation. This method had only limited success, and the side effects of the radiation were severe. Attention then turned toward drugs that acted on T lymphocytes. Azathiaprine was one of the first drugs to be used successfully. By preventing the biosynthesis of essential components of cell growth (purines), azathiaprine inhibits T cells from replicating. Steroids were next found to have immunosuppressive properties, and from 1966 to 1978, azathiaprine and steroids were used in combination to prevent rejection in human kidney allografts. Although these drugs were effective, they were not specific for lymphocytes. Other cells were affected, and both immunosuppressive drugs had serious side effects when used in high doses. In 1978, a T-cell-specific inhibitory drug was tried clinically for kidney allotransplants for the first time, with good results. This drug, named cyclosporine, has since become the mainstay of immunosuppressive therapy for all vascularized allotransplants. In most transplant centers, patients who have received vascularized allotransplants are given a combination of the preceding three drugs, since each drug works differently on T-cell function. The harmful side effects of these drugs can be minimized by using all three in smaller amounts, thus prevent-
Transplantation ✧ 895 ing the side effects that occur when one or two of them are given in larger amounts. Most organs available for transplantation are from cadavers. It takes many hours to tissue-type the cadaver, find a recipient with the same antigens, and fly the organ to the recipient’s city. Only kidneys can be stored this long and still function. Therefore, only kidneys are matched for antigens. With organs such as the liver, heart, and pancreas, only the blood type is matched between donor and recipient. When these organs can be stored longer, antigens may eventually be matched for them as well. The development of organ preservation techniques has been of great importance because once organs are removed from the body, their function decreases with time. With current techniques, kidneys can be stored up to three days. The liver and pancreas are transplanted as soon as possible, however, with eighteen hours being the average storage time. Kidney Transplants Until 1960, renal failure was fatal. Kidney transplants offered the only hope to dying patients, as chronic dialysis machines had not yet become available. With the advent of dialysis, renal failure is no longer fatal and patients can live by having their blood filtered several times per week. Kidney transplantation, however, offers a significant improvement in the quality of life compared with dialysis. Thus, although more than 9,000 patients in the United States receive kidney transplants per year, another 8,500 patients usually appear on the national waiting list. With only about 13 percent of potential donors actually being utilized, there is much room for greater success. Diabetes, high blood pressure, and autoimmune diseases of the kidney are some of the more common conditions causing kidney failure. Combined kidney-pancreas transplants are being performed in diabetics who suffer from kidney failure, a common complication in long-standing diabetes. The new pancreas eliminates the patient’s need for insulin shots and prevents damage to the new kidney. Two donor options are available to the recipient awaiting a kidney transplant: living related and cadaveric. The first option involves removing a kidney from a willing family member and transplanting it into the recipient. Individuals normally have two kidneys, and removal of one does not significantly affect a healthy individual. The second option is for the recipient to be placed on a waiting list for a cadaveric kidney. When a cadaveric kidney that is of a compatible blood type for a particular recipient becomes available, arrangements are made to admit this patient to the hospital for transplant. Approximately 25 percent of all kidney transplants are living related. The advantages of a living related transplant are twofold for the recipient. First,
896 ✧ Transplantation the waiting period for a cadaveric kidney is eliminated, as the operation can be scheduled as soon as the recipient has been evaluated. Second, the kidneys from living related donors tend to work immediately, with better long-term results if antigens are shared. Because of cadaveric organ shortages, some medical centers will allow emotionally related but genetically unrelated volunteers to donate a kidney to a recipient. Such transplants usually occur between spouses. The use of paid donors is unlawful. A typical kidney transplant operation takes approximately three hours to perform. Usually, the patient’s own kidneys are not removed, and the transplanted kidney is placed in the pelvis. The vessels of the new kidney are sewn into the blood vessels that go down into the leg, known as the iliac vessels. After the transplant procedure, patients stay in the hospital around ten days before returning home. They must take medications every day to prevent rejection but otherwise are independent. Since 1964, the success of kidney transplants has increased dramatically. This improvement is attributable in part to better operative techniques and organ preservation solutions. The greatest impact on graft survival, however, was probably made by the introduction of cyclosporine in 1978. In 1964, less than 50 percent of cadaveric kidney transplants were functioning at the end of one year. In 1990, the one-year graft survival rate approached 90 percent. Nevertheless, there is a fairly constant rate of graft failure each year, which has been estimated to be around 7 percent. After ten years, it is estimated that only about 40 percent of cadaver grafts are functioning. This long-term failure is mainly the result of chronic rejection. Further improvements in immunosuppression are necessary to improve these figures. Liver Transplants The number of liver transplants being performed in the United States has grown rapidly since 1978 because of vastly improved graft and patient survival. Orthotopic liver transplantation is now considered the optimal form of therapy for end-stage liver disease in adults and children. Since there is no machine to take the place of the liver, transplantation is the only alternative in patients with liver failure. Cadaveric livers are the source for transplants because individuals have only one liver. Because of a shortage in cadaveric organs, many patients die each year waiting for a liver transplant. For this reason, a few medical centers have experimented with living related liver transplants, usually from parent to child. In this operation, one of the two lobes of the donor’s liver is removed and transplanted to the recipient. The remaining liver in the donor will grow back to normal size in one week. Because of the difficulty of this operation, however, only a few hospitals are willing to offer this option. One medical center is also experimenting with xenografts, using baboons as a donor source, with some short-term success.
Transplantation ✧ 897 The most common indication for liver transplants in children is a congenital abnormality of the liver and liver ducts called biliary atresia. In adults, the most common indication for transplant is liver failure from chronic hepatitis, a process that causes scarring and malfunction of the liver. Patients with cirrhosis (liver scarring) from alcohol use may also be considered for transplantation, but they must meet specific criteria, including proof of alcohol use cessation. Liver cancer has been treated with transplants but is limited to highly select cases because recurrence is common. A liver transplant is one of the most, if not the most, difficult operations to perform successfully. No machine can take the place of the liver during surgery, and speed is of the essence. The liver is the largest organ in the body, weighing about 5 pounds in an adult. Because the liver is so large, and its blood supply complex, it is necessary to remove the patient’s own liver in order to place the new liver. The average time for a liver transplant varies but ranges from five to thirty hours. One of the variables is whether the patient has had prior abdominal surgery, as this causes scarring in the abdomen. After surgery, the patient spends several days in the intensive care unit. The average postoperative time in the hospital for an uncomplicated liver transplant is around three weeks. The worst complication of liver transplant is nonfunction after surgery, which may be the result of rejection or technical problems. The only treatment is to find another liver for transplantation before the patient dies. Across the United States, the average one-year survival rate after a liver transplant is 70 percent, although some medical centers claim rates as high as 85 percent. No difference in survival is noted between adults and children. The most common cause of transplant failure is chronic rejection; retransplantation is possible, although results are not quite as good. Pancreas Transplants Pancreas transplants are almost as successful as kidney transplants. They are done exclusively for patients with complications of insulin-dependent diabetes mellitus (IDDM), also known as type I diabetes. In the United States, the incidence of IDDM is estimated at 10,000 to 20,000 new cases per year. Around half of these individuals will develop complications of diabetes such as renal failure and blindness. There is no way to predict which patients will develop these complications. Currently, combined pancreas-kidney transplants are done for diabetics who experience renal failure. The transplanted pancreas prevents damage from recurring in the new kidney and also makes the individual insulin-independent. Pancreas transplants are not performed for diabetics without complications because it is believed that the risk of immunosuppression is not worth the benefit of insulin independence. Cadaveric donors are the source of most transplanted pancreases. An individual has only one pancreas, and the operation to remove a segment
898 ✧ Transplantation for living related transplant is a difficult one. Only one medical center has much experience with this option; most do not offer it. One-year survival in combined pancreas-kidney transplant is greater than 80 percent. Unlike with liver transplants, short operative time for pancreas-kidney transplantation is not essential to patient survival. Both the pancreas and the kidney are placed into the pelvis, and the pancreas is anastomosed (sewn) to the right iliac vessels and the kidney to the left. Operative time is about ten hours. The patient’s own pancreas and kidneys are left in place because there is no advantage to removing them. Patients spend an average of two to three weeks in the hospital after the procedure. There is a higher incidence of acute rejection with combined pancreas-kidney transplants than with kidney transplantation alone. —Edmund C. Burke, M.D., and Peter N. Bretan, M.D. See also Birth defects; Cancer; Diabetes mellitus; Fetal tissue transplantation; Gene therapy; Hair loss and baldness; Heart disease; Parkinson’s disease. For Further Information: Nora, Paul F., ed. Operative Surgery: Principles and Techniques. 3d ed. Philadelphia: W. B. Saunders, 1990. Offers a concise, well-written chapter that summarizes the facts and operative details regarding kidney, liver, and pancreas transplantation. Written by leaders in the field of transplantation. Includes many illustrations of operations that will give the general reader an idea of how vessels are sewn together for transplantation. Sabiston, David C., Jr., ed. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 16th ed. Philadelphia: W. B. Saunders, 2001. An outstanding textbook that details all aspects of transplantation and immunology. The milestones in transplantation history are well covered. The authors of individual sections are all pioneers in the field of transplantation. The overall text tends to be quite detailed and technical, but the history sections can be followed easily by most readers. Schwartz, Seymour I., et al. Principles of Surgery. 7th ed. New York: McGrawHill, 1999. A chapter reviewing most aspects of surgical transplantation is provided in this text. The section on transplant immunology is particularly excellent, with most of the important terms clearly defined. Whitehead, E. Douglas, ed. Current Operative Urology 1990. Philadelphia: J. B. Lippincott, 1989. Includes a chapter that reviews kidney transplantation in adults from a practical viewpoint. Explains the selection and preparation process of recipients for kidney transplants. Also discusses all types of donors, including living related, living unrelated, and cadaveric donor options.
Tuberculosis ✧ 899
✧ Tuberculosis Type of issue: Epidemics, public health Definition: A chronic, highly infectious lung disease that can destroy tissue. Tuberculosis derives its name from the Latin word tubercle, which means “little lump.” Tubercles, or small nodules of diseased tissue, are often found in the lungs of infected individuals. In humans, bacteria that belong to the genus Mycobacterium cause tuberculosis. In the vast majority of cases, Mycobacterium tuberculosis, often referred to as the tuberculosis bacillus or the tubercle bacillus, is the responsible organism. In most cases, the lungs are the major organs affected, but other tissues and organs such as the bones, skin, and digestive tract may also be sites of infection. Poverty, overcrowding, unsanitary conditions, poor health, and poor nutrition provide ideal conditions for the spread of tuberculosis. It is found at a high frequency in the developing areas of the world, such as parts of Africa, Asia, and Oceania. Immigrants from these countries present a serious public health concern when they enter the United States and other countries. In the United States, the incidence of tuberculosis is still relatively high in African Americans, Asians, Pacific Islanders, American Indians, Alaskan natives, and Hispanics. Other individuals who have a greater risk for developing tuberculosis infection are inmates of correctional institutions, alcoholics, intravenous drug users, the homeless, and the elderly. People at a particularly high risk of developing tuberculosis after exposure are those whose immune systems are compromised or suppressed, such as cancer patients receiving chemotherapy, organ transplant recipients, or people with acquired immunodeficiency syndrome (AIDS). Diabetics and individuals with a lung condition known as silicosis are also at high risk of developing tuberculosis as a result of exposure to the disease. Silicosis is an occupational disease that develops as a result of exposure to silica. Silica is found in sand and is a crystalline material encountered by miners, tunnel diggers, stone cutters, glassmakers, and those involved in sandblasting operations. The Tuberculosis Bacillus Mycobacteria populations grow very slowly compared to other bacteria. Under optimal conditions, typical mycobacteria will divide every twelve to eighteen hours, while many other bacteria will divide in twenty to thirty minutes. Mycobacteria require oxygen for growth and they are very resistant to drying, most likely because of the lipids in their cell walls. Mycobacteria also resist many chemical and physical agents that would normally kill bacteria. This resistance allows them to survive both in the body and in the
900 ✧ Tuberculosis exterior environment. Cultures of Mycobacterium tuberculosis maintained in a laboratory usually remain viable for many years. These bacteria can also remain viable outside both a laboratory and the human body. They can retain their pathogenic properties in dried sputum for many months. They are sensitive to ultraviolet light, however, and are killed in about two hours after exposure to direct sunlight. The mycobacteria that cause tuberculosis are found in the droplets released when a person with active tuberculosis coughs, sneezes, or even talks. This mist of tiny droplets can remain aloft for hours. The manner by which a person becomes infected with tuberculosis usually involves the inhalation of these droplets. The tuberculosis bacilli can then be carried to the lungs. It is fortunate that most individuals who are exposed to tuberculosis will not develop the disease. Tuberculosis is less contagious than the common childhood diseases and is usually contracted only after long exposure to an infectious individual who has an active case of tuberculosis. Of all newly infected individuals, approximately 5 percent will show symptoms of tuberculosis within a year. The remaining infected individuals continue to have some risk of developing the disease at any time. Infection and Its Aftereffects When tuberculosis infection does occur, the initial period is referred to as the primary infection. During this period, an infected individual may not experience any symptoms of illness, or the symptoms may be nonspecific, such as low fever and tiredness. Tuberculosis bacilli in the lung become the focus of an attack by the body’s immune system. Primary tuberculosis may also involve the lymph nodes and the pleural cavity. This reaction may lead to the accumulation of fluid within the pleural cavity, accompanied by fever or chest pain. As a result of activities of the immune system and the ingestion of tuberculosis bacilli by white blood cells known as macrophages, the primary infection will often spontaneously subside without medical intervention. Yet, although healing occurs, the tuberculosis bacilli can remain in a somewhat dormant state, walled up in the primary lesions. They live within the cells of the immune system but do not divide. The bacilli can remain in this state for years or decades without producing further symptoms of the disease. Untreated individuals will remain infected throughout their lifetimes even though the disease is in remission. Most individuals recover from primary tuberculosis. In a small percentage of cases, however, the disease progresses and lung destruction occurs. The reactivation of the disease is referred to as secondary tuberculosis and most frequently occurs when the immune system is weakened. Destruction of lung tissue is a hallmark of this phase of the disease. Much of the damage produced in the lung is the result of efforts by the immune system to destroy the tuberculosis bacilli. Parts of the lung suffer tissue death and soften.
Tuberculosis ✧ 901 These lesions can merge, enlarge, liquefy, and discharge their contents of tuberculosis bacteria into the bronchi. The bacteria can spread to other parts of the lung and be coughed up in sputum, where they contaminate the environment and serve as a source of infectious organisms that spread the disease. Secondary tuberculosis, if untreated, is a chronic condition in which the symptoms worsen progressively to include fever, fatigue, loss of appetite, and weight loss. If the bacteria spread to other parts of the body, a condition known as miliary tuberculosis results. Multiple small lesions that resemble millet seeds are found throughout the body. The most common sites in which these lesions are found are the bones and joints, the urogenital system, lymph nodes, the meninges (membranes surrounding the brain and spinal cord), and the peritoneum. Individuals with AIDS are at an increased risk for contracting tuberculosis outside the lungs (extrapulmonary tuberculosis). Diagnosing the Disease On a global basis, close to ten million new cases of tuberculosis are diagnosed each year, and 1.5 million deaths are attributable to this disease. Every minute, ten new people become infected with tuberculosis; of these, three will die from it. Since tuberculosis presents a serious public health concern, many countries have employed strategies to prevent its spread. Control of the spread of tuberculosis could decrease the numbers of new cases seen each year. Improvements in living conditions, sanitation, and general standards of living have, in the past, been associated with the decreased incidence of tuberculosis in populations. These goals cannot easily be met in impoverished regions of the world. The medical approaches designed to inhibit the further transmission of tuberculosis include vaccination, rapid diagnosis, and the development of effective drug treatments. In the United States after the mid-twentieth century, measures were developed to diagnose tuberculosis and prevent its transmission. This program resulted in a marked decrease in death rates from tuberculosis. Total death rates declined dramatically until the mid-1980’s. Prior to this time, most cases of tuberculosis were found in the southeastern part of the country and on Indian reservations. By the 1990’s, tuberculosis was once again on the rise, but the distribution pattern of the disease had changed. Tuberculosis began to be seen more in African American and Hispanic patients and in individuals with AIDS. The rate of tuberculosis infection became much higher in patients with AIDS than in any other group in the population. In fact, all individuals newly diagnosed with tuberculosis are also presumed to have AIDS until laboratory tests prove otherwise. The tuberculin skin test is a safe and reliable diagnostic test for tuberculosis. When some of the proteins from the tubercle bacilli are injected into the skin of an individual exposed to tuberculosis, a characteristic skin
902 ✧ Tuberculosis reaction, characterized by redness and swelling around the injection site, appears in forty-eight to seventy-two hours. A positive test does not necessarily mean that a person has an active case of tuberculosis and could therefore be contagious; it merely indicates that at some time, past or present, a tuberculosis infection occurred, even if the individual did not display symptoms of the disease. The tuberculin skin test is not useful in those parts of the world where many individuals in the population have been vaccinated against tuberculosis with a vaccine composed of bacillus Calmette-Guérin (BCG). A tuberculin skin test will be positive in an individual who has been vaccinated with BCG, even though the individual has never been exposed to live tuberculosis bacilli. In the United States, BCG vaccination is not routinely performed because of the great value in tuberculin skin testing as a public health measure. All individuals who may become exposed to tuberculosis, such as medical personnel, are advised to receive the tuberculin skin test at regular intervals. If an individual should have a positive skin test, it is common practice to begin treatment with antituberculosis drugs. Other methods for the diagnosis of tuberculosis include the detection of acid-fast mycobacteria in sputum, chest X rays to examine the lungs, and the laboratory culture and examination of mycobacteria grown from clinical specimens. The latter procedure may take from four to six weeks because mycobacteria grow so slowly. The growth and examination of these organisms in the laboratory is necessary, however, to confirm diagnosis when tuberculosis is suspected because of the patient’s history and the lung damage seen on X ray but microscopic examination fails to show the presence of mycobacteria. Treating Tuberculosis The treatment of tuberculosis changed drastically in the last half of the twentieth century. In the place of quarantine in a sanatorium, a common practice to prevent the spread of the disease, or surgery to remove portions of the diseased lung tissue, tuberculosis patients are now treated with antituberculosis drugs and antibiotics on an outpatient basis. Once treatment is begun, individuals can no longer transmit the disease and are therefore not contagious. The most effective antituberculosis drugs include isoniazid, pyrazinamide, ethambutol, and the antibiotics rifampicin and streptomycin. The prescribed antituberculosis medications must be used for a long period, usually about nine months, to ensure the destruction of all live tuberculosis bacilli. An ever-increasing problem in the treatment of tuberculosis is the appearance of tuberculosis bacilli that are resistant to drug therapy. These bacteria develop resistance as a result of genetic mutation, and when such drug-resistant bacteria are present in a patient, the disease will not respond
Tuberculosis ✧ 903 to that particular drug. For this reason, most treatment procedures involve the use of three to four different antituberculosis drugs. The probability of the development of two or more separate mutations is much less than the development of a single mutation. Even though tuberculosis bacilli are less likely to be resistant to more than one drug, bacteria resistant to multiple drugs are emerging in populations throughout the world. Combined drug therapy is ineffective because these organisms can withstand exposure to several of the antituberculosis drugs at once. Without an effective means of treatment, patients who harbor these multiple-drug-resistant organisms are a continued source of infection to the community unless they are kept in isolation. Because of the long treatment period, some tuberculosis patients stop taking their medication before the destruction of all tuberculosis bacilli. Some of these patients discontinue their medication because their symptoms have disappeared and they believe that they are cured. A recurrence of the disease is highly probable when the full course of treatment is not followed. —Barbara Brennessel; updated by L. Fleming Fallon, Jr., M.D., M.P.H. See also AIDS; Antibiotic resistance; Childhood infectious diseases; Epidemics; Immunizations for children; Immunizations for the elderly; Occupational health; Screening. For Further Information: Daniel, Thomas. Captain of Death: The Story of Tuberculosis. Rochester, N.Y.: University of Rochester Press, 1997. This book is written for nonprofessional readers. It is interesting and well researched. Dormandy, Thomas. The White Death: A History of Tuberculosis. New York: New York University Press, 2000. Accessible scientific and sociological history are combined by Dormandy, a consulting pathologist in London, in this account of a tenacious disease that has claimed victims from ancient Egypt to nineteenth century New York City. Focusing mostly on western Europe and the United States, Dormandy vividly details the long struggle against tuberculosis. Lutwick, Larry I. Tuberculosis: A Clinical Handbook. Chicago: Chapman and Hall, 1995. This well-written book, intended for general practitioners and internists, provides an account of the disease, its manifestations, and prevention in children, adults, and HIV-infected patients. It covers epidemiology, microbiology, and the historical perspective and discusses skin testing, infection control, and ethical and legal aspects. Rom, William, and Stuart M. Garay, eds. Tuberculosis. Philadelphia: LippincottRaven, 1996. A group of experts wrote chapters for this book, which can be easily understood by general readers. Scharer, Lawrence, and John M. McAdam. Tuberculosis and AIDS: The Relationship Between Mycobacterium TB and the HIV Type 1. Amsterdam: Springer-
904 ✧ Ulcers Verlag, 1995. This book considers the relationship between tuberculosis and patients with AIDS. It is written for professionals but contains a wealth of information for general readers.
✧ Ulcers Type of issue: Mental health, public health Definition: In the case of peptic ulcers, open sores that develop on the mucous membranes lining the gastrointestinal tract. In the most general of terms, an ulcer is an open sore that does not respond readily to the normal processes of healing. It may occur on the skin itself or on internal mucous membranes. A corneal ulcer, for example, may occur as a result of infections stemming from local injuries of, or foreign objects lodged in, the eye. Circulatory disturbances associated with varicose veins or long periods in bed without sufficient body exercise can also cause skin ulcers. The latter form is sometimes referred to as bedsores. The most commonly occurring ulcer is the peptic ulcer, which occurs at various points in the gastrointestinal tract. Specifically, such ulcers affect the lower portion of the esophagus, the stomach (in which case the term “gastric” ulcer may be employed), and two locations in the small intestine: the duodenum and the jejunum. It has been estimated that, by the latter quarter of the twentieth century, approximately 10 percent of the general population in the United States and Western Europe stood a statistical chance of suffering from peptic ulcers. A substantially higher percentage of the population may suffer from a condition that resembles ulcers in its symptomatic levels of discomfort and pain but that does not actually involve lesions. This condition is called nonulcerous dyspepsia. When ulceration of the stomach or intestinal tissue advances past a certain stage, internal bleeding usually occurs. Reaction to this stage of deterioration may involve vomiting, in which case the granular bloody material that is expulsed resembles partially digested food and is brownish rather than red in color. This condition stems from the effect of acidic gastric juices on the blood that has been released. If bleeding from ulcers becomes evident through the presence of blood in the stools, the effect is different: The fecal material is black in color, a condition that was referred to in past generations as “tarry stool.” Conditions for Ulcer Formation The likelihood of ulcers forming in the gastrointestinal tract is increased if an imbalance occurs in the normal functioning of a specific phase of the
Ulcers ✧ 905 digestive process. That phase begins when, at the time that foods are taken into the mouth and swallowed, the body secretes gastric juice containing both acid and pepsin. The essential acid in gastric juice is hydrochloric acid, which is highly dangerous in its pure state and poisonous if swallowed directly. Pepsin is an enzyme produced in the lining of the stomach that has protein-degrading characteristics. Pepsin is secreted in an inactive chemical state and requires the presence of hydrochloric acid to convert it chemically to an active state. If this conversion does not make use of all the hydrochloric acid secreted, the excess acid is free to do damage to the sensitive tissue of the stomach or intestinal lining. Ulcers can occur in any of several areas of the gastrointestinal tract when excessive amounts or imbalanced component proportions of gastric juice are secreted. In recent times, doctors established that a continuing state of nervousness or hostility can cause gastric juice to flow almost continuously. Such hypersecretion will damage the mucous membranes lining the digestive tract unless a constant supply of food is taken in by the organism. Thus, the nervous eater who is constantly consuming foods may be unconsciously trying to control the potential development of ulcers in his or her gastrointestinal tract. The side effects on the body of constant nervous eating may be potentially as harmful as the localized effects associated with ulcers. The Process of Ulcer Formation In essence, what happens when an ulcer begins to form is that the acid and pepsin in the gastric juice begin to digest membrane tissue in the gastrointestinal tract itself. Normally, the stomach has a series of internal defenses to combat localized attacks by active gastric juice against its own sensitive membranes. In the first place, the mucous lining of the internal organs themselves forms a sort of barrier between membrane tissue and the combined food-gastric juice content of the functioning organ. The cells of the stomach lining also secrete a natural antacid in the form of bicarbonate of soda. If the normal presence of these two protective agents is insufficient to prevent deterioration of the stomach or intestinal lining, a more active struggle ensues in the area where an ulcer has begun to develop. Surface cells begin to constrict to form a more resistant surface area around the nascent lesion. If the process does not proceed too rapidly, damaged cells may be replaced by healthy cells in the immediate area of the lesion. Even more specialized reactions in the area of ulceration are associated with prostaglandins, chemical agents in the stomach lining that stimulate increased blood flow to nourish besieged cells. Prostaglandins can also bring about higher levels of antacid production and mucus accumulation where they are needed most.
906 ✧ Ulcers Contributory Factors Doctors are not in full agreement regarding the way in which certain externally introduced substances may cause, or seriously contribute to, ulcers. Most have concluded, however, that abusive substances—cigarettes, alcohol, and some over-the-counter drugs, especially aspirin—play a significant role. Cigarette smoking has been linked with the slowing down of essential body functions that either provide defenses against ulcers or contribute to their healing. One such function is the rate of blood flow itself, which is vital for the nourishment of cells that may be under attack by ulcers. Other side effects of smoking may include reduced production of prostaglandins, which make important contributions to the defensive reaction of the body against ulcerations. While alcohol apparently does not stimulate excessive acid production in the stomach, it does interfere with the healing processes vital in combating ulcers. Caffeine is known to be an important stimulator of acid secretions. Some doctors consider it to be second only to aspirin as a negative “foreign agent” affecting the sensitive mechanism of digestion in the stomach and small intestine. Aspirin shares a dubious reputation in this respect with a number of other drugs classified as nonsteroidal anti-inflammatory drugs (NSAIDs) that are used to treat arthritis and other muscular or joint inflammations. There is a widespread consensus that the occurrence of ulcers may be linked to external agents that are taken into the body. The simplest evidence of this hypothesis revolves around associations that have been established between the bacillus Helicobacter pylori (H. pylori) and ulcerous conditions in the stomach and intestines. Doctors had observed the presence of this bacillus (along with many others) in the human stomach for at least a century. Studies by the Australian researchers Bernard Marshall and J. R. Warner noted that a very high percentage (nearly 100 percent) of patients diagnosed as having ulcers also had substantial traces of H. pylori. Those researchers who wanted to find proof that medicine was on the verge of a major breakthrough organized a full campaign to prescribe drugs that were known to kill the suspect bacillus. It is now clear that H. pylori is a major contributing factor not only in ulcer development but also in the extremely high recurrence rate of relapse in healed patients. Because of the inflammation that the infecting organism causes in the stomach and duodenal linings, normal protective mechanisms break down. Once these barriers that protect the lining from damage by the acid and enzymes used in digesting food are gone, the process of ulceration begins. Even after the ulcer has healed, very high rates of recurrence are found unless the bacterial infection is eradicated. Because so many people are infected with these common bacteria but not everyone develops ulcers, other contributing factors are clearly present. In the vulnerable patient, a combination of the well-known risk factors along
Ulcers ✧ 907 with infection work together to bring about ulcers. It is now a routine treatment to administer antibiotics and stomach acid inhibitors simultaneously. Cure rate times and relapse rates have improved significantly. Ulcer Treatment Whatever the ultimate explanation concerning the causes of this surprisingly common ailment may be, the medical world remains devoted to the necessary use of a number of drugs to control the effects of gastric and peptic ulcers by fighting the flow of gastric juices that do the physical damage of ulceration. On the whole, these drugs, which are called histamine II blockers, aim at one objective: to block the formation of stomach acid. A similar effect is produced by several widely used (and markedly expensive) medicines that are prepared under commercial labels: Tagamet, Zantac, Pepcid, and Axid. The new drug class, acid pump inhibitors, such as Prilosec and others, also block stomach acid but by a different and nearly complete method: They prevent the stomach cells from actually making the acid, in the final step before it is secreted into the stomach. These drugs are effective even in the most difficult cases of ulceration. Much more complicated than the problem of treating normal cases of ulcers is the technical question of how to guard against the further deterioration of ulcers into different forms of gastrointestinal cancer. New forms of technology allow physicians to examine the inner mucous membranes of the intestines directly. One such device, called the fiber-optic endoscope, consists of a long tube that is passed through the esophagus and stomach to penetrate the upper portions of the small intestine. The fiber-optic endoscope not only views and photographs the surface areas affected by ulcers but also allows the physician to biopsy the tissue at the same time. —Byron D. Cannon; updated by Connie Rizzo, M.D. See also Alcoholism; Alcoholism among the elderly; Nutrition and aging; Nutrition and women; Stress. For Further Information: Bennett, J. Claude, et al., eds. Cecil Textbook of Medicine. 20th ed. Philadelphia: W. B. Saunders, 1996. The standard medical reference text. Difficult but complete, it covers the disease process from its inception through diagnosis, treatment, and course. Hunter, J. O., and V. Alun Jones, eds. Food and the Gut. London: Bailliere Tindal, 1985. A compendium of scholarly articles on a variety of medical problems that relate, directly or indirectly, to intestinal disorders, including ulcers. Janowitz, Henry D. Indigestion. New York: Oxford University Press, 1992. A general text exploring various symptoms of digestive ailments and what
908 ✧ Vision problems with aging causes them. Several chapters are devoted to peptic ulcers. ________. Your Gut Feelings. New York: Oxford University Press, 1987. An early, scientifically based contribution to general knowledge of the digestive processes and dangers of imbalances which may exist. Tierney, Lawrence M., Jr., et al., eds. Current Medical Diagnosis and Therapy. 37th ed. Norwalk, Conn.: Appleton and Lange, 1998. This text, updated yearly, is the point of reference for physicians and other health care practitioners. It incorporates each year’s biomedical research discoveries that have immediate, relevant, and applicable use for the patient.
✧ Vision problems with aging Type of issue: Elder health, public health Definition: Normal biological changes associated with aging that affect the structure and function of the eye, resulting in changes in vision and increased occurrence of eye diseases. The eye is supported and cushioned in the eye socket, or orbital, by a layer of fat called orbital fat. As a person ages, this fat breaks down and degenerates, and the eye may appear sunken or hollow. A second change that is easily observed is the loss of tone and elasticity of the skin and muscle that surrounds the eye. The skin around the eye loses the ability to stretch and snap back into shape. The result is that the skin above the eye tends to fold over the upper eyelid. Sometimes this extra fold of skin can increase the pressure on the eye or reduce overhead vision. The retina is also affected by the aging process. The cells of the retina, the photoreceptor cells that receive the light information and transmit it to the brain, are gradually lost over time and are not replaced. Also, the blood supply to the periphery (outer parts) of the retina decreases. This decrease in blood supply means that cells in the outer portion of the eye are not receiving as much nourishment from the blood. Sometimes a loss of peripheral vision, the ability to see things coming from the sides of the field of vision, results from this decrease in blood supply. All the arteries and veins that supply the eye with blood become narrower, or sclerosed, with age, just like all the other arteries and veins of the body. The macular area of the retina—the area of the retina that is responsible for the sharpest, central sight—collects the end products of the aging and dying photoreceptors. Many changes also occur with the outer components of the eye. The most obvious change is the hardening of the lens, causing an inability to focus objects that are close to the eye. The inability to see near objects (presbyopia) affects all individuals and usually begins around age forty-five. People who had completely normal sight will require reading glasses to
Vision problems with aging ✧ 909 correct this, while people who are nearsighted often need bifocals. The lens also becomes less transparent or more opaque. Sometimes this loss of transparency results from changes in lens proteins caused by exposure to ultraviolet (UV) light over time. The lens becomes brownish-orange or yellow in appearance. The yellowing causes changes in color vision; for instance, the perception of different shades of blue is more difficult because the yellowish color filters out blue light (like wearing a yellow pair of sunglasses) and allows more red and yellow light to enter the eye. This gradual loss of transparency of the lens can also lead to cataracts. The eye is filled with a watery, gelatinous substance called the vitreous humor. The vitreous humor may collect particles of debris that can be seen by the individual as “floaters” that occasionally cross the field of vision. The vitreous humor may become more watery and less gelatinous over time. This causes the gel to shrink, and it can become detached from the retina, resulting in visual impairment. With age, the cornea of the eye can lose its natural transparency and become more opaque, much like the lens does. Additionally, deposits of fats and lipids may accumulate in a circular ring bordering the cornea, known as the arcus senilis. Often decreased tear flow, or dry eye, becomes a problem with age. Since tears are important for keeping the surface (cornea) of the eye well lubricated, the outside of the eye can become damaged from being too dry. The pupil itself changes with age as well. It loses its ability to quickly accommodate, or change in response to, differences in the brightness or dimness or light. The pupil generally becomes smaller as a person ages, giving the individual an increased depth of focus in the central field of view but reducing the total size of the visual field. Age-Related Perceptual Changes in Vision Because of the many physical changes of the eye with age, the individual will experiences perceptual changes in vision. For instance, dark adaptation becomes more difficult since the pupil is less able to respond to changes in light brightness. Glare becomes a significant problem. Glare reduces the ability of all individuals to see because it creates a scattering of light that reduces the sensitivity of the viewed objects. Although people of all ages are affected by glare, this scattering is even more pronounced in older individuals who have much yellowing of the lens and cornea. Headlights from oncoming cars, for example, can literally blind the aged driver. Visual acuity—the ability to see small objects under normal lighting and contrast—also may suffer with age. Since the pupil opening is smaller (thus letting less light into the eye) and the lens and cornea are less transparent (thus scattering the light that does reach the eye), acuity decreases significantly with age. For every thirteen years of life, the amount of light needed
910 ✧ Vision problems with aging for the eye to function properly increases twofold because of the changes in the pupil, lens, and cornea. More light is needed for such tasks as reading and writing; this condition is sometimes called night blindness. This reduction in acuity may decrease visual performance in unfamiliar environments as insignificant objects become distracting. Also, the person will experience changes in color vision as already described, having more difficulty perceiving blues that are filtered out by the increasingly opaque lenses. Age-Related Eye Diseases One of the most common reasons for loss of sight in the elderly is agerelated macular degeneration (ARMD), also known as senile macular degeneration. The macula is the part of the retina where most of the photoreceptor cells are located. The macula is responsible for the sharp, central line of vision; when a person looks directly at an object, the macula is the part of the retina that collects the light information and transmits it to the brain. People who stare too long at a solar eclipse destroy their sight because the intense light damages the macula. There are two types of macular degeneration: dry and wet. Dry macular degeneration is caused by a decrease in the nutrient supply reaching the macular tissue. This is usually caused by a loss of blood vessels supplying this region of the eye. Vision loss from this type of macular degeneration is generally slow and less severe than the vision loss associated with wet macular degeneration. Often diet (eating foods rich in vitamins A, C, and E or taking ocular vitamin supplements) can slow or prevent dry macular degeneration. Wet macular degeneration is more serious, and the vision loss occurs more rapidly than with dry macular degeneration. With wet macular degeneration, waste products fail to be transported away from the retina. This results in an increase in fluid within the macula, and this fluid can accumulate in small pools. The pools of fluid stimulate the growth of small, weak blood vessels, which can hemorrhage (rupture) and cause vision loss. This type of macular degeneration is usually treated by laser surgery to seal off small vessels, keeping them from growing into the pools of fluid. A second age-related eye disease is glaucoma. Approximately 1 percent of all people over age forty have glaucoma. Glaucoma is an increase in pressure within the eye. This increase can be caused by overproduction of fluid by the eye or failure to drain eye fluid properly. The most common kind of glaucoma results from blockage of the fluid drainage system of the eye. The optic nerve that transmits the information collected by the photoreceptor cells to the brain is particularly sensitive to this increase in pressure. The increased pressure will damage the nerve and will ultimately cause blindness if the condition is not treated. Early symptoms of glaucoma are very hard to detect, and the pressure from fluid buildup can stay high for many years, causing the optic nerve to
Vision problems with aging ✧ 911 atrophy. The central vision of the eye is the last to be lost from glaucoma. Undiagnosed glaucoma results in approximately five thousand new cases of blindness each year in the United States. In the population over age seventy, glaucoma is one of the top three causes of blindness. Factors that increase the risk of developing glaucoma include smoking, stress, consuming large quantities of alcohol, high blood pressure, and prolonged use of steroid medication. The nerve damage from glaucoma is irreversible, but the disease can be slowed and vision loss prevented or lessened through medications. Cataract, or lens opacity, can develop any time from infancy to adulthood. The most common cataracts are age-related and often occur after age fifty. Although cataracts can result from a variety of causes, such as injury to the eye or toxins, most age-related cataracts result from the gradual decrease in transparency of the lens that happens with age. Cataracts are removed surgically when vision loss causes difficulty in performing daily activities, such as reading or watching television. Medications, particularly the prolonged use of steroids, may cause cataracts. Systemic illnesses, such as diabetes, can also cause cataracts. Symptoms of cataracts include blurred vision that is often noticed when reading or driving. Other symptoms include double vision, a decrease in the ability to judge distances, and increased sensitivity to glare. A final common eye disease among older individuals is diabetic retinopathy. This condition affects diabetics and results from the weakening of the small blood vessels that nourish the retina; it is the leading cause of blindness in individuals aged twenty to seventy-four. These weakened vessels can be damaged, leading to hemorrhage. New, weaker vessels may try to grow into the area of the hemorrhage and result in the formation of scar tissue. This scar tissue may eventually lead to retinal detachment and vision loss. Unless the macula is affected by this scar tissue, the diabetic will be unaware of the disease process. Therefore, diabetic patients should have annual eye examinations to screen for this problem. Patients with diabetic retinopathy do benefit from early intervention, such as laser treatment to seal leaky blood vessels and prevent fluid buildup. —P. Michele Arduengo See also Aging; Diabetes mellitus; Macular degeneration. For Further Information: Beresford, Steven, D. W. Muris, M. J. Allen, and F. R. Young. Improve Your Vision Without Glasses or Contact Lenses. New York: Simon & Schuster, 1996. A discussion of exercises, habits, and diets that contribute to visual health. D’Alonzo, T. L. Your Eyes! Clifton Heights, Pa.: Avanti, 1991. A reference guide to the working of the eye and explanation of eye diseases, risk factors, and treatments.
912 ✧ Vitamin supplements Shier, David, Jackie Butler, and Ricki Lewis. Hole’s Human Anatomy and Physiology. 7th ed. Boston: McGraw-Hill, 2000. Provides information about the development and structure of the eye, with many figures and drawings to illustrate. Shulman, Julius. Cataracts. Rev. ed. New York: St. Martin’s Griffin, 1995. A patient’s guide to symptoms, diagnosis, surgery, and recovery of cataracts. Zinn, Walter J., and Herbert Solomon. Complete Guide to Eyecare, Eyeglasses, and Contact Lenses. 4th ed. Hollywood, Fla.: Lifetime Books, 1996. Chapter 34 provides a concise description of age-related vision problems.
✧ Vitamin supplements Type of issue: Prevention, public health, social trends Definition: The use of nutritional supplements to compensate for vitamins and minerals perceived to be lacking in a regular diet. Adequate nutrition is the foundation of good health. Everyone needs the four basic nutrients: water, carbohydrates, proteins, and fats. It is important to choose the proper foods to deliver these nutrients and, as necessary, to complement the diet with supplements. Health-conscious adults have heard the message repeatedly that they can get the vitamins they need from the foods they eat, but surveys have shown that people in many countries fail to eat adequate amounts of fruit, vegetables, whole grains, and low-fat dairy foods. Should public health officials or registered dieticians recommend that people take supplements to compensate for poor eating habits? The answer to this question can be found in a discussion of vitamin supplements. The 1990’s brought to light much new information about human nutrition, its effects on the body, and the role that it plays in disease. The fuel for the body’s engine comes directly from the food that one eats, which contains many vital nutrients. Nutrients come in the form of vitamins, minerals, enzymes, water, amino acids, carbohydrates, and lipids (fats). These nutrients provide people with the basic materials that human bodies need to sustain life. One of the latest types of dietary supplements are nutraceuticals. These supplements are obtained from naturally derived chemicals in plants, called photonutrients, that make the plants biologically active. They are not nutrients in the classic sense: They are what determine a plant’s color, ability to resist disease, and flavor.
Vitamin supplements ✧ 913 Phytochemicals and Antioxidants Nutritionists have discovered that fruits and vegetables, grains, and legumes contain other healthful nutrients called phytochemicals. Researchers have identified thousands of phytochemicals and have the ability to remove these chemical compounds and concentrate them into pills, powders, and capsules. Phytochemicals are believed to be powerful ammunition in the war against cancer and other cellular mutations. Cancer is a mutation of body cells through a multistep process. Phytochemicals help to fight that disease by stopping one or more of the steps that lead to cancer. For example, a cancer process can be kindled when a carcinogenic molecule invades a cell, possibly from foods eaten or from air breathed. Sulforaphane, a phytochemical commonly found in broccoli, activates an enzyme process and removes the carcinogen from the cell before harm is done. Researchers and pharmaceutical companies sell concentrated forms of various phytochemicals found in such vegetables as broccoli, brussels sprouts, cauliflower, and cabbage. Several thousand phytochemicals have been identified. Because no single supplement can possibly compete with nature, some nutritionists recommend a shopping basket full of fruits and vegetables, as opposed to using expensive bottled supplements. Tomatoes, for example, are believed to contain an estimated ten thousand different phytochemicals. No discussion of supplements would be complete without mention of antioxidants. They are a group of vitamins, minerals, and enzymes that help to protect the body from the formation of free radicals. Free radicals are groups of atoms that can cause damage to cells and thus impair the immune system. This damage is also thought to be the basis for the aging process. Free radicals are believed to be formed through exposure to radiation and toxic chemicals such as cigarette smoke, as well as overexposure to the sun’s rays. Some common antioxidants are vitamin A and its precursor, beta carotene; vitamin C; and vitamin E. Zinc and the trace mineral selenium are thought to play an important role in neutralizing free radicals. Each vitamin or mineral has a recommended daily allowance (RDA). A higher supplementation dose of antioxidants is recommended by pioneering researchers in the field of alternative medicine, such as Andrew Weil, founder of the Center for Integrative Medicine in Tucson, Arizona. Weil recommends four antioxidant supplements—vitamins C and E, selenium, and mixed carotenes—to protect a person’s immune system further. Natural food supplements can be high in certain nutrients. Examples are aloe vera, bee pollen, fish oils, flaxseed, primrose oil, ginseng, ginkgo biloba, garlic, and oat bran. In general, natural food supplements are composed of by-products of foods that can provide a multitude of health benefits. The use of supplements is based both on modern research and development and on discoveries by mainstream scientists about the benefits of
914 ✧ Water quality various substances such as garlic and aloe vera. Natural supplements have been used for centuries in many parts of the world as alternative medicines. —Lisa Levin Sobczak, R.N.C. See also Aging; Alternative medicine; Cancer; Nutrition and aging; Nutrition and children; Nutrition and women; Preventive medicine. For Further Information: Balch, James F., and Phyllis A. Balch. Prescription for Nutritional Healing: A Practical A to Z Reference to Drug-Free Remedies Using Vitamins, Minerals, Herbs, and Food Supplements. 3d ed. Garden City Park, N.Y.: Avery Publishing Group, 2000. A guide to nutritional, herbal, and complementary therapies. Includes the latest research and theories on treatment of aging, HIV, and a host of other subjects. Hendler, Sheldon Saul. The Doctors’ Vitamin and Mineral Encyclopedia. New York: Simon & Schuster, 1990. An excellent presentation of the nutritional value of herbs, and a good introduction to micronutrients and other food supplements and their relation to health and diseases. Contains an excellent bibliography and a useful section on consumer questions and answers, as well as a section on drug-vitamin-mineral interactions. Machlin, Lawrence J., ed. Handbook of Vitamins: Nutritional, Biochemical, and Clinical Aspects. 2d ed. New York: Marcel Dekker, 1991. Although somewhat on the technical side, this book presents a wealth of information on vitamins, including their history, chemistry, synthesis, content in food, methods of analysis, metabolism, transport, biochemical function, deficiency signs, nutritional requirements and assessment, and toxic doses. The source for an in-depth analysis of a particular vitamin.
✧ Water quality Type of issue: Environmental health, epidemics, industrial practices, public health Definition: The evaluation of public water sources and the treatment of any contaminants that might jeopardize health. An estimated twenty-five thousand people die each day from such waterborne diseases as typhoid fever, cholera, and dysentery. Consequently, safe drinking water is essential for everyone’s health and welfare. To be safe for drinking, water must be free of disease-producing bacteria, undesirable tastes and odors, color, turbidity, and harmful chemicals. Since raw water is seldom pristine, most public potable water systems purify their water prior to distribution.
Water quality ✧ 915
Treatment plants must process raw water before it can be considered safe to drink. (PhotoDisc)
Many substances may occur naturally in raw water that are either harmful or unpalatable to people. Human discharge of many substances into the environment also contaminates water supplies. Contaminants, either natural or anthropogenic in origin, can be divided into three groups: organoleptic substances that pertain to the senses of vision, taste, and odor; inorganic and organic chemical substances, which could be toxic or aesthetically undesirable, or could interfere with water treatment processes; and harmful microorganisms, which usually result from human and animal wastes. The organoleptic parameters must be reduced to very low levels for drinking water to be acceptable for public use. Color, turbidity, and particulate matter represent visual problems. Color results from organic matter that leaches from soil or decaying vegetation. Turbidity results from suspended clay or organic matter that imparts a muddy and therefore undesirable appearance to the water. Particulate matter floating in the water is not only aesthetically undesirable but may also provide food for certain organisms. Decomposed organic material and volatile chemicals result in unpleasant tastes and odors in water. Iron, manganese, and aluminum are metals that are commonly found in water. Other metals such as lead, copper, cadmium, and silver are occasionally present, as are the nonmetals nitrate, fluoride, and phenols. These chemicals have both natural and anthropogenic origins. Chemically synthesized compounds such as pesticides, herbicides, and polychlorinated biphenyls (PCBs) are particularly dangerous because they can enter the food chain and accumulate in animal tissue.
916 ✧ Water quality Although most bacteria are harmless and indeed essential to life, some varieties (pathogens) can cause illness. These waterborne diseases include cholera, typhoid, and bacillary dysentery, which are common in areas without properly treated water. Viruses are pathogenic organisms that are much smaller and much harder to control than bacteria. Common viral diseases include poliomyelitis and infectious hepatitis. Cryptosporidium and giardia are protozoan waterborne parasites that are found in surface waters. They cause a severe form of gastroenteritis that can be deadly in people having immune-suppressed systems, as with acquired immunodeficiency syndrome (AIDS). Treating Raw Water The origin and characteristics of the raw water source govern the type of treatment necessary to provide safe drinking water. For example, groundwater may require only pH adjustment and minor disinfection if the source is relatively pristine. However, in heavily fertilized agricultural areas and locations where soluble iron and manganese are naturally present, ion exchange for nitrate removal and chemical treatment for iron and manganese removal may be needed. Surface water generally requires many more types of treatment, such as screening, sedimentation, chemical treatment, clarification, filtration, and disinfection. Bar screens to block fish and debris is a standard first step in treating raw surface water. The screens must be strong enough to prevent wood, game fish, and even shopping carts from getting into the treatment plant and damaging the machinery. The next step is usually a sedimentation basin where the larger suspended particles can settle out by gravity. This process may be accelerated by mixing chemicals with the water to form a flocculate precipitate, which helps settle the suspended particles. The chemical coagulation process removes natural color originating from peat, animal and vegetable debris, plankton, and other organic substances. Even after sedimentation, some of the finer particles in the water may still be in suspension and have to be removed by filtration. Sand filters provide an inexpensive and effective medium for the removal of fine solids in either raw water or partially treated water. Granular activated carbon (GAC) filters have been replacing conventional sand filters in recent years since they can remove a wide variety of undesirable organic compounds such as herbicides, pesticides, and chemical compounds that form naturally. They are also useful in the treatment of taste and odor. Indeed, many beverage manufacturers use GAC filters where water is a major component of the product, such as soda, beer, and fruit juice. Residential point-of-use kitchen filters for drinking water incorporate GAC filters as the major treatment technique. The final treatment process is disinfection, since pathogenic bacteria can pass through both the sedimentation basin and filtration. Drinking water
Weight changes with aging ✧ 917 standards require the absence of the indicator organisms fecal streptococci and the coliform group of bacteria, specifically fecal Escherichia coli, in the distributed water. Disinfection, which is the killing of harmful bacteria, is usually accomplished by chlorination. Chlorine is a very effective biocide. However, one major disadvantage of chlorine is that it is very reactive and can produce compounds such as trihalomethanes that are potentially carcinogenic. Other compounds produced by chlorine have taste and odor problems. Ozone and ultraviolet light are also powerful disinfectants but do not have the residual properties of chlorine, which protects water from contamination as it travels through the distribution system. Some of the water treatment plants built in the late twentieth century use a combination of ozonation for its effectiveness against cryptosporidium, giardia, and viruses; GAC filters for taste and odor control; and small amounts of chlorine as a residual biocide for the treated water in the distribution system. —Robert M. Hordon See also Chlorination; Environmental diseases; Fluoridation of water sources; Hazardous waste. For Further Information: American Water Works Association Research Foundation and Compagnie Generale des Eaux. Ozone in Water Treatment. Edited by Bruno Langlais, David A. Reckhow, and Deborah R. Brink. Chelsea, Mich.: Lewis, 1991. Outlines the design and operation of the ozone process within potable water plants. Broadwell, Michael. A Practical Guide to Particle Counting for Drinking Water Treatment. Boca Raton, Fla.: Lewis, 1999. A reference guide to filtration performance. Geldreich, Edwin E. Microbial Quality of Water Supply in Distribution Systems. Boca Raton, Fla.: Lewis, 1996. Discusses the processes and issues related to water quality in transmission pipes and storage reservoirs. Graham, Nigel, and Robin Collins, eds. Advances in Slow Sand and Alternative Biological Filtration. New York: John Wiley & Sons, 1996. Covers recent developments in sand filtration technology.
✧ Weight changes with aging Type of issue: Elder health, prevention, public health Definition: The alteration of body composition and resulting changed in weight caused by the slowing down of body functions due to aging.
918 ✧ Weight changes with aging Through most of the twentieth century, the progression of weight in both men and women followed a consistent pattern. Following adolescence, when maturation causes gains in weight, weight tends to stabilize for five to ten years. When middle age begins, weight increases to a maximum in men at about age fifty and in women at about age sixty-five. Afterward, there is a steady decline until around age eighty, where weight remains stable until death. There might be a dramatic decline in weight if the cause of death creates body wasting, as with cancer, but that loss is attributable to the disease process, not the aging process. In the 1990’s, the U.S. population as a whole increased in weight, from youths through the elderly, but the chronological ages for weight changes seemed to remain stable. As more Americans live to one hundred years and beyond, research may find a second decline in weight noted after age eighty. The Role of Genetics Genetic factors influencing weight occur through metabolic processes that affect body composition. Body composition is the relative amounts of lean mass, composed of more dense tissues such as bones and muscles, to fat mass, composed of less dense tissue or energy fat stores. The more dense the tissue present, the greater the weight of the person. Males, with a higher level of the hormone testosterone, have more dense bones, more muscle mass, larger organs, and less body fat. Their average weights are higher beginning at puberty and continuing throughout life. Females have higher levels of estrogen, the hormone to support pregnancy, so they have relatively more body fat in addition to the smaller lean mass and thus lower average weights. This gender variation is about 10 pounds throughout life. The genetics of aging and its effect on weight revolves around the control of metabolism and how nutrients are absorbed and digested. Metabolism is the sum of all the chemical events that occur in a living organism. The relationship to aging and also weight is how the fuel that runs the body is stored and utilized. How quickly fuel is used is the metabolic rate. An analogy is gasoline consumption in a car, measured in miles per gallon. It is not unusual for consumption to decrease as a car gets older and is less efficient. Aging causes fuel to be used less efficiently, demonstrated by a drop in the metabolic rate. If calories taken in exceed what is needed by the body, then the excess is stored as body fat. If a person does not decrease caloric intake in conjunction with the decrease in metabolic rate, the result will be increased fat weight. Because of the concomitant decrease in lean tissue, the change in body composition might not affect body weight for a time, but it appears that at least in the United States, body fat is increasing at a faster rate than lean mass is decreasing, as demonstrated by the increase in obesity across the life span.
Weight changes with aging ✧ 919 The Role of Environment Several environmental factors can affect body weight, but probably the most influential is financial. In the elderly, low income is often associated with poor nutrition, especially in urban regions where food costs tend to be higher even for staples. In at least one study of disease progression, the Baltimore Longitudinal Study on Aging, however, it was found that the greater the body weight, the longer time until death during chronic illnesses. This would suggest that a slight excess of body fat may be protective in the elderly, and, if economics prevent a healthy diet or even enough calories, then that outcome would not be possible. Adequate protein intake is essential to maintaining lean mass. Often the most common protein food source, meat, is also the most expensive item on the grocery list. Some elderly have not been given adequate information to know that other, cheaper sources are just as good, such as combining incomplete proteins from vegetable sources. This situation might even manifest itself in a higher body weight if the calories replacing the protein come from carbohydrates or fats, as excesses of both are stored as body fat. Unfortunately, lack of adequate protein affects not only lean mass but also overall health. Many of the essential parts of the immune system are made of proteins as well as the enzymes that help in cellular function. Lack of both reduces the ability to adapt to environmental stressors and is one of the main reasons the elderly often succumb to a viral disease such as pneumonia when a younger person would not. Another environmental factor relates to the weather and temperature. There is a tendency for everyone, not only the elderly, to put on fat weight during the winter. Subcutaneous body fat is the insulator that helps regulate body temperature, so repeated exposure to cold causes an increase in body fat stores for more efficient regulation. In many people, it is probably not so much the temperature directly—the microclimate can be managed with clothing and shelter—but the tendency to be less active in inclement weather. If the calories eaten are not used for activity, they are stored as fat. There may also be a relationship to the economic issue: elder health. More financially stable retirees might move to a warmer climate or travel to one for the winter; if they remain, they can afford to join a health club to exercise. Any of these factors could mitigate the weather problem associated with weight. The Role of Lifestyle There may be a strong association between lifestyle and economics, but some lifestyle choices can be made independent of finances. As with genetics and environment, lifestyle can affect weight in either direction. Education probably has the greatest effect on lifestyle. For a person to make the choices necessary to optimize health, he or she needs to have been given the information necessary to make educated decisions.
920 ✧ Weight loss medications Because lifestyle diseases became the greatest causes of death early in the twentieth century, in the latter half of the century researchers studied everything that can affect health, with weight as a major factor. The leading cause of death, cardiovascular disease, includes obesity as a major modifiable risk factor. Even with this knowledge, however, the American population as a whole grew progressively fatter, especially in the 1990’s. Research suggests that mortality and morbidity both decrease when weight, or more specifically fat, is kept within normal ranges. The lifestyle choice to be active has been a major component of education, both in schools and the media, and it seems that those who have had the greatest exposure to the message are also the most compliant. Activity, both cardiovascular (such as running, walking, biking, dancing, and swimming) and strength training (such as weight lifting) have been shown to affect body composition and in turn health in all age groups. Studies of both men and women in their sixties, seventies, eighties, and even nineties have demonstrated similar effects across all age groups. Cardiovascular exercise causes a decrease in body fat and thus weight from energy use, and strength exercise causes an increase in lean mass, both muscle and bones, increasing weight. —Wendy E. S. Repovich See also Cosmetic surgery and aging; Eating disorders; Exercise and the elderly; Liposuction; Malnutrition among the elderly; Muscle loss with aging; Nutrition and aging; Obesity; Obesity and aging. For Further Information: Castleman, Michael. “What Your Shape Doesn’t Say About You.” The Walking Magazine (March/April, 1997). Evans, William, and Irwin H. Rosenberg. Biomarkers: The Ten Keys to Prolonging Vitality. New York: Simon & Schuster, 1991. Hayflick, Leonard. How and Why We Age. New York: Ballantine Books, 1994. Nuland, Sherwin B. The Wisdom of the Body. New York: Alfred A. Knopf, 1997. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996.
✧ Weight loss medications Type of issue: Public health Definition: The use of drugs to assist in weight loss.
Weight loss medications ✧ 921 By the mid-1990’s, several drugs had come onto the market showing promise in helping people achieve weight loss. The most widely sought and prescribed of these were Fen-Phen (combining serotonergic fenfluramine and amphetamine-like phentermine) and Redux (dexfenfluramine, with similar properties and actions to fenfluramine). Fen-Phen inhibits the brain’s utilization of the neurochemical serotonin, which acts on the brain’s appetite control center in the hypothalamus, and suppresses appetite directly, much as traditional over-the-counter diet pills do. Other drugs, less widely used, included phentermine, mazindol, and fluoxitine. Benefits and Costs The hope and early evidence were that these medications would produce improved cardiac function, cholesterol and triglyceride profiles, blood sugar concentrations, and blood pressure; assist in the treatment of bulimia; and reduce weight in the obese and prevent weight gain in those at high risk for it, such as when an individual quits smoking. The drugs were intended to assist those with morbid obesity, obese persons with serious medical conditions, and obese persons who had failed to manage their weight using more conservative nutritional and behavioral methods. At no point did researchers intend the medications as quick fixes for those unwilling to exercise or unwilling to change their eating habits. Nevertheless, many physicians prescribed them to patients who were not significantly obese or who were merely overweight. Multiple studies across many different populations tended to show the same results. Measurable weight loss in those taking the drugs was between 5 and 15 percent, with weight regained one year after patients had stopped taking the drug. While the medications had few initial side effects—dry mouth, constipation, and drowsiness being the most common—and were unlikely to become physically addicting, concerns grew over the drugs’ potential to cause neurotoxicity and primary pulmonary hypertension. Health providers across all disciplines were particularly concerned that some patients were coming to rely on these medications to the prohibition of the sustained, hard work of developing lifestyle habits of healthy, proportional eating and exercise. In 1997, the Food and Drug Administration (FDA) withdrew approval of these medicines for treating obesity, and their marketing and distribution were discontinued. —Paul Moglia See also Anorexia nervosa; Eating disorders; Obesity; Obesity and aging; Obesity and children. For Further Information: American Dietetic Association. “Position of the American Dietetic Associa-
922 ✧ Well-baby examinations tion: Weight Management.” Journal of the American Dietetic Association 97 (1997): 71-74. Presents the official position of the association regarding approaches to weight management, including pharmacotherapy. A terse, more technical source. Peikin, Steven R. The Complete Book of Diet Drugs: Everything You Need to Know About Today’s Prescription and Over-the-Counter Weight Loss Products. New York: Kensington Books, 2000. A popular guide to prescription and over-the-counter drugs, dietary supplements, and other nutritional products that are used in weight control.
✧ Well-baby examinations Type of issue: Children’s health, medical procedures, prevention, public health Definition: The art and scientific procedure of the pediatric physical examination. A pediatrician or nurse practitioner usually performs the routine physical examination of an infant. Because the child may be frightened, some steps in the examination may be performed while the baby is being held in the parent’s lap. If the baby or child is ill, the health care provider will look for signs of dehydration and possible lethargic mental status. Dehydration is always checked in cases where fever is present. A child’s normal oral temperature is similar to an adult’s (98.6 degrees Fahrenheit). A rectal temperature will typically be 1 degree higher. It is not uncommon for a young child to have a temperature of 105 degrees with even a minor infection. Respiration and pulse are measured. Young children and infants breathe with their diaphragm; therefore, the movements of the abdomen can be counted. Periodic breathing is common in infants. Respiratory rates for newborns is 30 to 50 respirations per minute, Toddlers average rates of 20 to 40 respirations per minute. The pulse of a newborn baby is detected best over the brachial artery. The rate is usually in the range of 120 to 160 beats per minute; this figure declines as the child grows older. Blood pressure, length, weight, and head circumference charts are measured and checked against charts showing norms. Infants are weighed without clothing and are measured on a firm table. The head is measured at the maximum point of the occipital protuberance posteriorly and at the mid forehead anteriorly. The shape of the child’s head, such as flatness or swelling, is observed. Hair is checked for quantity, color, texture, and infestations. The presence of a fungus can be indicated by alopecia (hair loss), but this cause must be distinguished from trichotillomania. Hypothyroidism can be indicated by dry, coarse hair.
Well-baby examinations ✧ 923 An eye examination can give information about systemic problems and about the eyes themselves. The eyes are observed working together; reaction to light, pupil size, cornea haziness, excess tearing, vision, visual fields, and the distance between the eyes are checked. Observations for nystagmus (involuntary movement of the eyes) and for the abnormal upward outward eye slant and epicanthal folds associated with Down syndrome are also made. Newborns have about 20/400 vision, which improves to 20/40 by six months of age. During an ear examination, the tympanic membrane is checked for perforations, color, lucency, and bulging (indicating pus and or fluid) in the middle ear. A rough hearing acuity may be determined by eliciting from the child a startle reflex to sound. The nose is checked interiorly, and the nasal mucus is checked for watery discharge (indicating allergy) and mucopurulent discharge (indicating infection). The nasal septum and passages are also checked, and any foreign bodies are removed. The oral cavity examination consists of checking the lips for asymmetry, fissures, clefts, lesions, and color. The tongue is examined for color, size, coating, and dryness. The tonsils are observed for signs of infection and color, while the palate is observed for arch and possible lesions. The throat is examined for signs of inflammation and other problems. The neck is checked for tilt and range of motion. The thyroid gland is palpitated and evaluated for symmetry, consistency, and surface characteristics. Any other swellings are noted and their causes determined. The neurologic examination is extensive and begins with an assessment of a child’s milestones. An infant’s primitive reflexes—Moro, asymmetric tonic neck, Babinski, palmer grasp, rooting, and parachute reflexes—are checked. Cranial nerves that can be assessed at the child’s stage of development may be assessed. General sensation and response to touch and muscle tone and movement are checked for unusual responses. The musculoskeletal system and extremities are checked for gross deformities and congenital anomalies. Gait and stance are observed, as well as muscle tone and range of motion. Posture in older children may be observed for spinal curvatures. The lungs are checked to evaluate air movement, to identify breath sounds and chest sounds, and to inspect the shape of the chest. The physician will note any physical deformities and listen to rhythms that could indicate abnormal blood circulation. Indications of circulatory system problems in infants are cyanosis, clubbing of fingers or toes, tachycardia, peripheral edema, and tachypnea. Examining the abdominal contour and auscultation and palpation of the abdomen are done. In newborns, the genitals are checked for ambiguity, and the rectal area is checked for fissures or anal prolapse. Skin is checked for color, pigmentation, rashes, or burns. Vaccinations—either oral or by injection—and boosters are a part of
924 ✧ Wheelchair use among the elderly some well-baby visits. Occasionally, blood or urine samples are taken for analysis. The challenge of keeping the child calm enough for the clinician to perform a valid exam is important in the diagnostic process. Although an older child can usually be examined easily in standard adult order, this does not work well for pediatric patients. The younger the patient, the more important it is that crucially affected areas be examined first, before the child becomes upset or cries. Physicians and parents should work together to minimize a child’s fears during the examination. —Patricia A. Ainsa, M.P.H. See also Birth defects; Breast-feeding; Child abuse; Childhood infectious diseases; Children’s health issues; Colic; Immunizations for children; Learning disabilities; Malnutrition among children; Nutrition and children; Safety issues for children; Screening; Sudden infant death syndrome (SIDS); Teething. For Further Information: Albright, Elizabeth K. Pediatric History and Physical Examination. 4th ed. Laguna Hills, Calif.: Current Clinical Strategies, 2000. Barness, Lewis A. Manual of Pediatric Physical Diagnosis. 6th ed. St. Louis: Mosby Medical Publishers, 1991. Schwartz, M. William, ed. Clinical Handbook of Pediatrics. 2d ed. Baltimore: Williams & Wilkins, 1998. Zitelli, Basil J., Holly W. Davis, eds. Atlas of Pediatric Physical Diagnosis. 3d ed. St. Louis: Mosby-Wolfe, 1997.
✧ Wheelchair use among the elderly Type of issue: Elder health, treatment Definition: The use of wheelchairs to enhance personal mobility. While many Americans spend their old age without the aid of mobility assistance, many others require the use of walkers and wheelchairs to move from place to place. Wheelchair use is not confined to the elderly. People of every age group use wheelchairs. Many of the issues related to wheelchair use by the elderly are also applicable to wheelchair use by people of all ages. As the American population overall becomes older, however, these issues will become more significant and will likely affect the population at large.
Wheelchair use among the elderly ✧ 925 Wheelchairs as a Means of Liberation While people who do not use wheelchairs for mobility may view the wheelchair as a symbol of disability and confinement, many of those who must use the device are likely to see it as a symbol of liberation. This attitude is especially prevalent among disabled elderly who, after leading active lives, would find themselves confined to a house, apartment, or long-term care facility if wheelchairs were not available. The perception of wheelchairs as tools of liberation has caused all sorts of modifications to them. Motorized chairs are now available at relatively low prices. These chairs can be truly liberating, since they make it possible for the occupant to operate the vehicle without an aide. Motorized wheelchairs have baskets that can be attached so the occupant can move belongings from one place to another or can shop for many items at a grocery or department store. Various accessories, such as cup holders and shopping bags, are available for attachment to both motorized and manually operated chairs, making the use of the chair both more comfortable and more convenient. Many businesses provide motorized wheelchairs for the use of the disabled of all ages. As the number of elderly who need wheelchairs to shop and conduct other business increases, so will the number of businesses that provide these chairs. A business that had one chair available in 1999 may find that in 2010, it must have two or three chairs available. Increasingly, such businesses will have to think about establishing rules and regulations relative to the use of motorized wheelchairs. For both businesses and individuals, there may be insurance issues related to the use of such chairs. As more elderly people use wheelchairs, there will be modifications in home and building construction as well as employment of more people to assist wheelchair users. These modifications will include such things as lower curbs on showers and lower kitchen counters and range tops. Places of business will have to increase the space allocated for loading and unloading chairs so that several wheelchairs can be unloaded to sit side by side. As more elderly people use wheelchairs, the widths of wheelchair ramps and paths may have to be increased to at least 5 feet so that chairs moving in opposite directions can pass each other. Airports, restaurants, hotels, and motels are likely to employ more people who are trained to assist disabled elderly customers in wheelchairs. —Annita Marie Ward See also Canes and walkers; Disabilities; Mobility problems among the elderly; Safety issues for the elderly. For Further Information: Anderson, Robert C. A Look Back: The Birth of the Americans with Disabilities Act. Binghamton, N.Y.: Haworth Press, 1997.
926 ✧ Women’s health issues Batavia, Mitch. The Wheelchair Evaluation: A Practical Guide. Boston: ButterworthHeinemann Medical, 1998. Buchner, David. “Preserving Mobility in Older Adults.” The Western Journal of Medicine 167, no. 4 (October, 1997). Gostin, Lawrence O., and Henry A. Beyer, eds. Implementing the Americans with Disabilities Act: Rights and Responsibilities of All Americans. Baltimore: P. H. Brookes, 1993. Karp, Gary. Choosing a Wheelchair: A Guide for Optimal Independence. Sebastopol, Calif.: O’Reilly & Associates, 1998.
✧ Women’s health issues Type of issue: Women’s health Definition: The special health care needs of female patients. The life expectancy of women in the 1990’s was approximately 80 years, an increase of 30 years in the last 100 years. In many cases, the final years are fraught with health problems. Women’s health care received little attention from the health care community and medical researchers until the 1990’s. Women’s health care requires special attention because of the differences in the impact of health care concerns on women as compared with men. Gender Bias in Medicine Until the 1990’s, most medical research was conducted by men and on men. This meant that little was known about how illness affected women and how new treatments improved or damaged their quality of health. Women were either not considered at all or were not considered to be different enough to require research. Historically, funding has not been available for research on women’s health requirements or conditions. Researchers justified the lack of studies of women as a concern about damage to women during their reproductive years or concern about potential damage to the unborn children of pregnant women. As the result of male-only research policies, female medical research has been the exception rather than the rule. One of the most prevalent biases that has occurred in the provision of health care for women has been the willingness to ascribe women’s medical complaints to an emotional or stress-related condition. Hormones and genetic weakness have often been targeted as the cause of medical complaints. Women are characterized as weak and complaining. Women who visit a doctor because of chest pain, dizziness, or fatigue are likely to be treated for stress or depression. Conversely, when men complain of these symptoms, they are likely to be evaluated for heart disease, then aggressively
Women’s health issues ✧ 927 treated for heart disease, thus increasing the likelihood that they will recover from the condition. Women, because of delays in treatment, are less likely to experience positive health outcomes. In other health situations, women are treated too aggressively. For example, women who complain of vaginal bleeding or ovarian cysts in the past have been treated with complete hysterectomies (the removal of the uterus and other reproductive organs). Women with lumps in their breasts often received a total mastectomy. Older women, beyond the usual childbearing years, were particularly prone to this type of aggressive surgical intervention. The medical community, primarily consisting of men, justified this with the explanation that the reproductive organs and body parts were not necessary for women no longer able to bear children. Finally, health care has been beyond the reach of many women, particularly in the United States. Consequently, women are less able to procure preventive health care and early diagnostic screening for treatable forms of cancer. Again, the outcome for women is that because of these delays, they are more likely to die from diseases that are treatable in early stages. Furthermore, women’s preventive health care, such as Pap smears and mammograms, are not always covered by health insurance programs. Heart Disease Cardiovascular disease kills more than 500,000 women each year. More women than men die from cardiovascular disease each year. Nearly ten million women have some form of cardiovascular disease; one of every nine women experiences some form of heart disease by age forty-five, one in three by age sixty-five. Women who experience heart attacks are more likely to die than are men who experience heart attacks. Heart disease is the number one cause of death among women. An interesting difference between men and women with regard to heart disease is that women are less likely to develop coronary artery disease. When they do, it occurs later in life and develops more gradually. It is also more deadly in women and more difficult to diagnose. Women are more likely to experience angina (chest pain) prior to a heart attack, and they are more likely to develop heart failure and less likely to recover fully from heart attacks. Women often have symptoms of heart attack that are confusing to medical personnel. The pain may occur in the neck, jaw, arms, back, or chest. Some women may experience twinges of pain from a relatively young age. The pain of heart attack has been described as throbbing, pressure, burning, or stabbing. It may be intermittent for hours or days, or it may be constant. The pain may resemble pain associated with ulcers, gallbladder disease, hiatal hernia, or pleurisy. Certain factors place some women at greater risk than others for heart disease. High blood pressure or borderline hypertension, with blood pres-
928 ✧ Women’s health issues sure readings above 140/90, increase the risk for heart disease. High cholesterol, often the result of a diet high in animal fat, also increases the risk. Obesity, diabetes, and blood clots have all been correlated with heart disease. Stress that results in feelings of frustration and lack of self-efficacy also seems to be related. Estrogen appears to be the great protector of women during the premenopausal years: Women experience fewer problems associated with the cardiovascular system than do men in the same age range. At the time of the menopause, however, women are no longer protected as the levels of estrogen drop off. Other factors contribute to women’s risk for heart disease. Low socioeconomic status, family history of cardiovascular problems, and the use of oral contraceptives have been found to contribute to an increased risk of heart attack and heart disease. When more than one of the risk factors is present, the risk for heart disease increases substantially. Lupus Systemic lupus erythematosus (SLE), also known as lupus, is an autoimmune disease that most frequently attacks young women. SLE causes the body to become overactive in its immune responses, and the immune system attacks the body’s own tissue as if it were foreign and infective. Eight of nine individuals diagnosed with lupus are female, and the average age of onset is thirty. SLE occurs three times as often among African American women as among white women. Lupus is typically diagnosed and treated by a rheumatologist, the same type of medical doctor who treats arthritis. Lupus is classified as a connective tissue disorder, along with rheumatoid arthritis, scleroderma, and approximately one hundred other conditions. Symptoms vary, making diagnosis difficult. Patients often report unexplained fever, fatigue, stomach upset, hair loss, and joint pain, symptoms that can be related to a variety of other conditions. The American College of Rheumatology developed a list of diagnostic criteria for lupus, including a butterfly rash, characterized as a butterfly-shaped redness across the ridge of the nose and the cheeks (only 50 percent of patients develop this rash); discoid lesions, red, raised patches anywhere on the body (which occurs in about 15 percent of SLE sufferers); sunlight sensitivity; arthritis; chest and heart problems, such as pain, pneumonia, and pleurisy; kidney problems, such as the presence of high levels of protein in the urine; blood abnormalities, including certain forms of anemia and easy bruising caused by low levels of platelets; neurologic symptoms such as seizures and, in rare cases, psychosis; immunologic disruptions such as the false-positive report of the test for syphilis and the presence of certain antibodies at abnormal levels; and high antinuclear antibodies, which are also found in rheumatoid arthritis. Four of these indicators must be present in order for a diagnosis of lupus to be made.
Women’s health issues ✧ 929 In the past, the mortality rate for lupus patients was thought to be high. This was probably related to the difficulty in diagnosis and lack of care until a crisis had occurred. The current outlook for lupus patients is positive. Treatment strategies have enhanced the quality of life for lupus patients. Some of the drugs used include Placquenil and chloroquine, nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen, and immunosuppressants such as corticosteroids. Additionally, certain lifestyle changes, such as reduction of stress levels, proper diet, appropriate exercise, and protection from the sun, are important in the treatment of lupus. Lupus often goes into remission with the onset of the menopause. Lupus patients should be certain that they are aware of the problems that might occur with some of these treatments. Lupus patients occasionally experience difficulties associated with medications as well as complications from the disease. Corticosteroids can cause or contribute to osteoporosis, the loss of bone tissue. Steroids and anti-inflammatory drugs can cause gastrointestinal bleeding and anemia. Some lupus patients have reported numerous bouts of chickenpox and shingles, both caused by a virus called varicella-zoster virus. One of the most critical problems is renal dysfunction, which occasionally becomes a life-threatening problem. Physicians who treat lupus carefully monitor kidney function for this reason. If kidney dysfunction reaches a critical point, the patient may require dialysis or a kidney transplant. Pregnancy can present problems for lupus patients. The incidence of miscarriage is 25 to 30 percent for lupus patients. Most of the medications prescribed for lupus must be discontinued during pregnancy. Physicians suggest that women with lupus may want to wait to become pregnant until the disease has been in remission for at least six months. Those with severe kidney involvement may do best to avoid pregnancy altogether. Women with lupus are more likely to experience pregnancy complications, such as toxemia and preeclampsia. These women are also more likely to give birth prematurely. On rare occasions, the newborn may have neonatal lupus, a temporary form of lupus most often characterized by a rash, blood abnormalities, and irregular heartbeat. Diabetes Mellitus This endocrine system disorder is characterized by abnormal insulin secretion and difficulty in metabolizing glucose. Diabetes mellitus may be type I, in which the body does not produce sufficient insulin, usually starting before the age of twenty-five, or it may be type II, in which the body loses the ability to process insulin effectively, usually occurring later in life. Some women develop diabetes during pregnancy, called gestational diabetes. Type I diabetes usually requires the use of insulin for treatment, whereas type II diabetes is often managed with adjustment to the diet and/or certain oral
930 ✧ Women’s health issues medications. Early symptoms include frequent urination, frequent urination at night, and excessive thirst and hunger. Women with diabetes may experience frequent vaginal yeast infections and urinary tract infections. Diabetics often experience decreased circulation, which can slow the healing of wounds. Diabetics are encouraged to practice good hygiene and to pay particular attention to their feet, where circulation is poor. Another complication that occurs in diabetics is diabetic retinopathy, a condition that can eventually result in blindness. Diabetic neuropathy, damage to spinal and cranial nerves, may cause motor weakness, a loss of sensation, and pain. Women with diabetes must be particularly cautious in their selection of birth control techniques. Certain birth control pills are contraindicated for women with cardiovascular problems and diabetes because these pills can also lead to decreased circulation. In a few instances, diabetic women are cautioned against pregnancy because of the increased likelihood of complications such as toxemia and preeclampsia. Screening for gestational diabetes is generally done early in pregnancy. Women and Cancer It appears that cancer is gender neutral, affecting men and women alike. Cancer is the number two killer of women in America. Although women seem to focus most of their concerns about this disease on cancer of the reproductive system, lung cancer is one of the leading killers of women: 46,000 women die from it each year, largely because of higher rates of smoking by women. Some research indicates that the inhalation of secondhand smoke has also increased the rate of lung cancer in women. Symptoms of lung cancer include a persistent cough, blood in the sputum, chest pain, and chronic bronchitis. If lung cancer is identified, early surgery is often effective in containing it. The overall survival rate for cancer: 13 percent of all individuals diagnosed with cancer survive five years beyond the diagnosis. In the 1990’s, 180,000 women were diagnosed each year with breast cancer, and 46,000 died each year from breast cancer and its complications. At the age of twenty-five, a woman has a 1 in 20,000 chance of developing breast cancer. By the age of thirty-five, this number increases to a 1 in 600 chance. By the age of sixty-five, a woman has 1 chance in 15 of developing breast cancer. The major risk factors associated with the development of breast cancer (besides age) are having a family history of breast cancer, having experienced menarche (the onset of menstruation) before the age of ten, and becoming pregnant for the first time after the early thirties. Other risk factors include a deficiency of vitamin A, radiation exposure, excess weight, excessive drinking of alcohol, and a high-fat diet. Colorectal cancer (cancer of the colon and rectum) is diagnosed in about 74,000 women each year, and more than 28,000 die each year from these forms of cancer. Because of fears about reproductive cancer, women often
Women’s health issues ✧ 931 fail to obtain the simple screening test for colorectal cancer. This test, called “stool for occult blood,” is conducted by placing a small amount of fecal matter on a special card. A technician in a laboratory or physician’s office will then place a chemical on the card to reveal the presence of blood in the stool. If blood is present, the physician can then conduct additional testing to determine the source of the blood. Eighty percent of patients diagnosed with colorectal cancer early are completely cured with surgery alone. Those who are at highest risk for colorectal cancer include those with a family history of the disease; those who eat a low-fiber, high-fat diet, and those with a medical history of other bowel problems. Each year, thirteen thousand women are diagnosed with bladder cancer. Urban women and women exposed to certain industrial toxins are at the greatest risk for bladder cancer. Another fifteen thousand women are diagnosed with melanoma of the skin, or skin cancer, each year. Those at greatest risk have been overexposed to the sun. Clearly, with most forms of cancer, survival is enhanced through screening such as Pap smears, breast selfexamination (BSE), and stool examination. Additionally, a low-fat, highfiber diet, moderate exercise, and low alcohol consumption will reduce the risk of cancer. Finally, women must be attuned to the message of their bodies. Early treatment contributes to improved opportunities for cure. Headaches Women seem to experience more headaches than do men. This is thought to be related to the hormone estrogen or changing levels of this hormone. Many times, women report a subsidence of headaches after menopause. Lack of sleep and stress are the most frequent causes of headaches, but there are other triggers, such as caffeine products (coffee and cola drinks), alcoholic beverages, and foods containing monosodium glutamate (MSG), nitrates and nitrites, and tyramine (such as yogurt). Headaches are a common complaint of women taking birth control pills. Headaches are thought to be the result of swelling in blood vessels in the brain and around the head. Physicians recommend elimination of possible triggers for headaches as a first stage in treatment. It is rare for narcotic drugs to be prescribed for the treatment of headaches; rather, a number of medications have been developed that decrease the swelling of the blood vessels. Women with chronic headache conditions may need to take such medications as a preventive measure. Depression Eight million women experience a significant episode of depression each year. One in four women has a serious episode of depression in her lifetime, although only 20 percent of these women seek treatment for depression. In
932 ✧ Women’s health issues all industrialized nations, women experience higher rates of depression than men, usually double the incidence. Symptoms of depression include irritability most of the time, profound sadness, reduced interest in daily activities, difficulty sleeping or sleeping too much, dramatic changes in appetite and eating habits, unexplained fatigue, feelings of worthlessness and guilt, difficulty concentrating, and recurrent suicidal thoughts. Many of these symptoms can be indicative of a physical condition, and women must be cautious to pursue other explanations for these symptoms before simply accepting the diagnosis of depression. —Sharon L. Larson See also Abortion; Abortion among teenagers; Aging; AIDS and women; Alzheimer’s disease; Anorexia nervosa; Breast cancer; Breast surgery; Cervical, ovarian, and uterine cancers; Chronic fatigue syndrome; Circumcision of girls; Cosmetic surgery and women; Depression; Domestic violence; Eating disorders; Endometriosis; Heart disease and women; Hormone replacement therapy; Hysterectomy; Infertility in women; Mammograms; Mastectomy; Menopause; Menstruation; Nutrition and women; Osteoporosis; Pap smears; Postpartum depression; Prenatal care; Sexual dysfunction; Sexually transmitted diseases (STDs); Yeast infections. For Further Information: Blau, Sheldon P., and Dodi Schultz. Living with Lupus: All the Knowledge You Need to Help Yourself. Reading, Mass.: Addison-Wesley, 1993. Discusses the symptoms and diagnosis of systemic lupus erythematosus, as well as medical and lifestyle choices used to treat it. Boston Women’s Health Book Collective. Our Bodies, Ourselves for the New Century. New York: Simon & Schuster, 1998. Diethrich, Edward B., and Carol Cohan. Women and Heart Disease. New York: Ballantine Books, 1994. Self-diagnostic test to determine risk, women’s warning signs, and discussion of treatment options for women with heart disease. McPherson, Ann, ed. Women’s Problems in General Practice. 3d ed. New York: Oxford University Press, 1993. A detailed examination of diseases and disorders of women, with suggestions about how to utilize the health care system. Semler, Tracy C. All About Eve: The Complete Guide to Women’s Health and Well-Being. New York: HarperCollins, 1995. Presents a thorough discussion of women in the health care environment, with particular attention to the biases against women in medicine.
Worms ✧ 933
✧ Worms Type of issue: Children’s health, public health Definition: Invertebrates, usually flatworms or roundworms, that act as human parasites. In common usage, the term “worm” includes many other wormlike organisms, a few with medical importance: Some fly larvae (or maggots) can cause human infections, some caterpillars are covered with irritating hairs, and leeches have had a place in medical history (of misuse to “bleed” victims and, more recently, of help with swelling or the reattachment of limbs). To control many parasitic worms, a society must be affluent enough to provide water treatment, plumbing, and sewage treatment; fuel to cook fish and meat thoroughly; and regular medical care for the general population. Flatworms Flatworms are primitive organisms in the phylum Platyhelminthes. The class Turbellaria are mostly free-living, planaria-like worms, although some are in intermediate stages of becoming parasitic. Tapeworms in the class Cestoda and flukes in the class Trematoda are the most serious parasitic worms, particularly in tropical and subtropical regions. Flukes that are medically important to humans are in the order Digenea. Schistosomes are flukes that live in the blood system; other adult flukes live in bile ducts, in the lungs, or along the digestive tract. A few are known to infect the body cavity, urogenital system, or eyes of victims. Control requires understanding not only the effect that the adults have on a human host but also the complex life cycle that flukes have developed to ensure a continuous chain of offspring in successive hosts. Blood flukes affect more than 200 million people and are second only to malaria as a world health problem. The human blood fluke, Schistosoma mansoni, has both male and female individuals and is long and hairlike. This blood fluke feeds on blood and clings to the walls of small veins in the large intestine. The strategy of all parasitic worms is to produce vast numbers of eggs. Some of these breach the intestinal wall and pass out with human wastes into the environment. Modern plumbing and sewage treatment can stop the fluke life cycle at this point. In poorer tropical countries, however, the fluke eggs are soon washed into ponds, ditches, or rice paddies, where they immediately hatch. The larvae, coated with cilia, swim about in search of a snail. Boring into the flesh of the snail, the larva sheds its cilia and develops into a sporocyst. This sporocyst absorbs nutrients and asexually subdivides; eventually, as many as 200,000 tadpolelike cercarias will develop from the one larva. Erupting through the surface of the snail, the cercarias
934 ✧ Worms swarm near the water surface. People working in rice paddies or wading or swimming in streams are infected when the cercaria bores through the skin to reach a blood vessel and complete its life cycle. The Chinese liver fluke, Clonorchis sinensis, represents a life history involving two intermediate hosts. In this more representative fluke, the adults are hermaphroditic— possessing both male and female organs. Large numbers of eggs are released from the host’s liver into the bile duct, where they pass through the digestive tract and are shed in the feces. When the eggs are washed into the bottoms of ponds, streams, and paddies, many are eaten by snails. This releases the larva, which burrows into the snail’s tissues and becomes a sporocyst. The sporocyst subdivides into redia, an active feeding stage that eventually develops many cercariae. The cercariae erupt from the snail and swim through the water to infect native fish. The cercariae encyst in the meat of the fish and wait until the fish is eaten by a human or other mammal. If the fish is not thoroughly cooked, the cyst coating will be digested in the intestine and the young fluke will emerge. From there, it will eventually move to the smaller bile passages of the liver. Using its suckers to anchor, the fluke feeds on blood, causing both anemia and liver blockage. Tapeworms are unique parasitic flatworms where adults are specialized for living in the digestive tract of vertebrates. By relying on the host’s digestive system, tapeworms have lost all evidence of an alimentary canal in both larval and adult stages. A tapeworm possesses a head with hooks and suckers by which it hangs on the gut lining. Beyond a short growing region are bags called proglottids which are constantly budded off, younger ones nearer the neck show developing testes and ovaries, while the most distant proglottids are large sacs of maturing eggs. One common large tapeworm of humans is the beef tapeworm. When eggs are shed with human feces, some eggs may find their way to vegetation and be eaten by cattle. The tapeworm egg coating is digested, and the larval tapeworm migrates across the intestinal wall and flows with the blood to the muscle. There it grows into a tapeworm bladder, which can be seen as measly beef by meat inspectors. When such meat is not thoroughly cooked, digestion releases the enclosed tapeworm, which begins to grow in the intestine of the new host. Mature beef tapeworms can grow to 10 meters in length and release thousands of egg-laden proglottids. Roundworms Most roundworms, of the phylum Nematoda, are free-living. They are widely distributed across the land, streams, and oceans. The large Ascaris lumbricoides is a roundworm parasite that invades the human intestine. A mature female worm can produce 200,000 eggs a day, which are expelled with the host’s feces. These minute eggs are easily washed through the soil and ingested by a new host. Hatching in the small intestine, the baby worms
Yeast infections ✧ 935 burrow into the body and are soon in the bloodstream or lymph. Fine capillaries of the lungs eventually filter them out; the worms bore across into the bronchial tubes, where they are coughed up and then swallowed, returning the roundworms to the intestine to mature. Damage occurs when the worms migrate through the body or when infestations are very large and cause blockage, especially in small children. Among the more serious diseases caused by roundworms are elephantiasis and trichinosis. —John Richard Schrock See also Children’s health issues; Food poisoning; Parasites; Zoonoses. For Further Information: Buchsbaum, Ralph, et al. Animals Without Backbones. 3d ed. Chicago: University of Chicago Press, 1987. Desowitz, Robert S. New Guinea Tapeworms and Jewish Grandmothers. New York: W. W. Norton, 1987. Schmidt, Gerald D., Larry S. Roberts, and John Janovy. Foundations of Parasitology. 5th ed. Boston: Wm. C. Brown, 1996. Zeibig, Elizabeth A. Clinical Parasitology: A Practical Approach. Philadelphia: W. B. Saunders, 1997.
✧ Yeast infections Type of issue: Women’s health Definition: An overgrowth of Candida, a single-celled fungus naturally present in certain parts of the body. Yeast infections, also called candidiasis or moniliasis, affect approximately 75 percent of all women at some time in their lives, most frequently between the ages of sixteen and thirty-five. This overgrowth of Candida, a single-celled fungus naturally present in certain parts of the body, may affect the vagina, skin, or mouth (thrush). Yeast infections result from an imbalance in the body’s system caused by illness or infection, certain medications (broadspectrum antibiotics or birth control pills), or physical or mental stress. Studies have linked some chronic or difficult-to-treat yeast infections to the human immunodeficiency virus (HIV) that causes acquired immunodeficiency syndrome (AIDS). The fungus can be passed between sexual partners. Common symptoms of vaginal candidiasis are an irritating itch, soreness, and a thick, white discharge. Other possible symptoms include discomfort during intercourse, abdominal pain, and burning during urination. Treatment is usually with one of two antifungal medications, available in cream or suppository form: clotrimazole or miconazole nitrate. These
936 ✧ Yoga medications, once available only by prescription in the United States, were approved for over-the-counter use in 1990. The Food and Drug Administration (FDA) has also approved fluconazole, an oral antifungal medication that can cure a yeast infection in a single dose, available only by prescription. Because Candida organisms thrive in warm, moist places, prevention includes keeping the vaginal area dry and cool. Wearing loose, natural-fiber clothing and cotton-crotch underwear is recommended, as is limiting the use of deodorant tampons and feminine hygiene products. —Bonnie Flaig See also AIDS; AIDS and women; Antibiotic resistance; Condoms; Diabetes mellitus; Sexually transmitted diseases (STDs); Women’s health issues. For Further Information: Willis, Judith Levine. Getting Rid of Yeast Infections. Rockville, Md.: Department of Health and Human Services, Public Health Service, Food and Drug Administration, 1997. Winderlin, Christine, and Keith Sehnert. Candida-Related Complex: What Your Doctor Might Be Missing. Dallas: Taylor, 1996.
✧ Yoga Type of issue: Mental health Definition: A mental discipline, originating in India, designed to master consciousness, to offer spiritual insight, and to induce tranquillity. The word “yoga” is related to the English term “yoke.” Of Sanskrit origin, yoga has a double implication. One meaning of the word is “union,” the joining (or “yoking”) of the individual to the ultimate reality behind the universe. A second inference is the concept of discipline, the training or subjugation of the self, as the mind prevails over both matter and itself, to bring consciousness into perfect harmony with the power behind the cosmos. Common in the major Eastern religions of Hinduism, Buddhism, and Jainism, yoga originated in ancient India as a spiritual technique to help the individual obtain release (moksha) from karma, or the endless cycle of birth-death-rebirth, and attain nirvana (the bliss of self-transcendence). The Hindu classic the Bhagavad Gita (the song of the Blessed Lord), dating from the second century b.c.e., envisioned three types of release: the way of knowledge (jnana marga), the way of action (karma marga), and the way of devotion (bhakti marga). Building on the philosophy of release, yoga facilitated techniques for the person to transcend the physical, mental, and spiritual bonds to the “world of illusion.”
Yoga ✧ 937 Of the many forms of yoga, Hatha Yoga (or “physical yoga”), involving bodily discipline, has been extremely popular in the West. In the East, Raja Yoga (or “royal yoga”), pioneered by the Indian philosopher Patanjali, who lived in the second century b.c.e., has been popular. Raja Yoga moves through eight steps: vows of nonviolence and restraint (yama), an attempt at internal control and tranquillity (niyama), the perfection of particular bodily postures (asana), a mastery of breath control (pranayama), discipline of the senses to exclude the external world (pratyahara), concentration on a single object (dharana), meditation (dhyana), and the trance-state (samadhi), accomplished through a union with Brahman (ultimate reality). The Practice of Yoga Until relatively recently, yoga has been neglected by Western medicine because it operates from a different set of premises. Yoga is based on the belief that a “subtle body” exists within the body (paralleling the physiological system) that has seven major centers (chakras), each with its own particular energy and functions. Yoga is designed to tap into the power contained in each of these centers. Recent studies suggest that the various yoga techniques do, in fact, produce the effects that their teachers predict, including reduction of tension, heart rate, blood pressure, and anxiety. The more remarkable powers claimed by yoga masters—such as levitation, total immunity to pain, and mental projection—have yet to be demonstrated in parapsychology laboratories. —C. George Fry See also Alternative medicine; Biofeedback; Exercise; Exercise and the elderly; Holistic medicine; Meditation; Physical rehabilitation; Preventive medicine; Stress. For Further Information: Goldberg, Burton, comp. Alternative Medicine: The Definitive Guide. Puyallup, Wash.: Future Medicine, 1993. Jacobs, Jennifer, ed. The Encyclopedia of Alternative Medicine: A Complete Family Guide to Complementary Therapies. Boston: Journey Edition, 1996. Kastner, Mark, and Hugh Burroughs. Alternative Healing: The Complete A-Z Guide to over 160 Different Alternative Therapies. La Mesa, Calif.: Halcyon, 1993. Mills, Simon, and Steven J. Finando. Alternatives in Healing. New York: New American Library, 1988.
938 ✧ Zoonoses
✧ Zoonoses Type of issue: Epidemics, public health Definition: Diseases that can be transferred to humans from their primary animal hosts. Some types of contact between humans and animals result in the transmission of infectious diseases to humans, which are called zoonoses. Approximately 150 types of zoonoses can be transmitted either directly or indirectly to human beings. Direct exposure results from coming in contact with an infected animal or its excrement, blood, or saliva. Indirect exposure results from being bitten by an insect carrying an infected animal’s blood. Incubation periods for zoonoses can range from a few days to several years. The most common symptoms are headache, fevers, general malaise, diarrhea or bloody stool, and sometimes skin rashes, eruptions, or inflammation. Most zoonoses can be diagnosed and treated. In most cases, treatment will clear up the disease with no lasting aftereffects. If the infected person waits too long for treatment, however, therapy may take longer, and problems may persist. In rare cases, surgery is necessary, and in even rarer cases, death can occur. Diseases from Pets Cat-scratch fever is a bacterial infection which can result when a human is bitten, nipped, or scratched by a feline. Symptoms include a blistery inflammation at the site of the infection, fever, malaise, and sometimes swelling of the lymph nodes. Such symptoms appear two to thirty days after the skin is broken and generally last about a month. The infection will generally clear up on its own, but, after washing the affected area with soap and water, a consultation with a physician is recommended. Approximately twenty thousand people are infected annually with cat-scratch fever, mostly children. It is important for parents to instruct children not to play roughly with cats. Sporotrichosis is a fungal infection transmitted by cats. The fungus is found as mold on decaying vegetation, soil, and timber, usually found along southern U.S. waterways and in places with similar climates. Left untreated, the fungus can spread throughout the human body. The organism enters the body through a cut or abrasion in the skin or through inhalation of the fungus. Protozoan toxoplasmas are found in the feces of cats, as well as in undercooked meat and unwashed raw fruits; they cause a condition called toxoplasmosis. The toxoplasmas may enter the human body through the skin or by respiration. Extreme care should be taken, especially by pregnant women, when disposing of used cat litter. In pregnant women, the disease
Zoonoses ✧ 939 invades fetal tissues, causing damage to the baby’s central nervous system. The antibiotic spiramycin is effective in combating the disease’s effects. Almost all newborn puppies carry roundworms, and because children love to cuddle puppies, the children often pick up the worms without knowing it. Symptoms in humans are a cough, fever, headache, and poor appetite. Treatment for both humans and puppies is with anthelmintic (worm-destroying) drugs. It is important that all puppies be seen by a veterinarian when very young. Salmonella bacteria in food cause gastroenteritis, inflammation of the mucous membrane of the stomach and intestine. Symptoms of the disease are severe, bloody diarrhea and sometimes dehydration. While usually found in uncooked meat, salmonella bacteria can be present on pet turtles raised on farms. Many of these strains of salmonella are quite resistant to commonly used antibiotics, thus making treatment difficult and allowing the disease to spread. When this information came to the attention of the U.S. government, the shipping of live turtles from their farms was banned and various laws were enacted to restrict the interstate and international trade of the reptiles. Shipment of turtle eggs is still allowed, however, and as many as 20 percent of these eggs may carry the bacteria. Diseases from Farm and Wild Animals Anthrax is an infectious disease of warm-blooded animals such as cattle or sheep, caused by the bacterium Bacillus anthracis. The disease can be transmitted to humans by the handling of infected products, such as the animals’ hair. The disease is characterized by lesions in the lungs and by external ulcerating nodules. Brucellosis is characterized by repeated fevers accompanied by weakness and joint pain. It is contracted from the amniotic and fetal membranes of pregnant and newborn animals. More typical in farm animals, it can also be present in dogs that are bred. While it is not fatal, it does cause severe flulike symptoms. It can be difficult to treat and cure completely. An infection that often strikes herded animals such as cows, deer, or elk is a subspecies of tuberculosis caused by Mycobacterium bovis. Individuals who come in contact with such animals, such as veterinarians, farmers, and slaughterhouse workers, are most susceptible to this disease because they breathe in the tiny droplets of bacteria. In addition to lung infections, other diseases are reported to be associated with the M. bovis bacterium. Treatment for infected individuals is with antibiotics. Rabies is an acute viral disease of the nervous system of warm-blooded animals, usually transmitted through the bite of the infected animal. Rabies can be found in a small number of animal species across the world. There are two main types: urban rabies, carried mainly by domesticated animals such as dogs; and sylvatic rabies, carried by wild animals such as bats.
940 ✧ Zoonoses Symptoms of the disease include fever, nausea, vomiting, shortness of breath, abdominal pain, and a cough. If left untreated, the muscles become paralyzed and breathing and heartbeats stop, causing death. There are three methods of treating the disease: vaccination of people at risk of exposure before any exposure has occurred; animal control and immunization, especially preexposure immunization; and postinfection treatment, usually a series of expensive, painful shots. Generally, the incubation period for rabies in humans is three weeks to three months. There have been cases, however, in which the victim was bitten by a rabid animal a year before the onset of the disease. Worldwide, approximately eighteen thousand people per year are treated for possible rabies infection. While domesticated animals, such as dogs and cats, can be treated against the development of rabies, it is difficult to inoculate wild animals, mostly because vaccines are not licensed for use on them. One method to attempt to control rabies in wild animals is the use of edible bait laced with vaccine. Diseases from Insects and Other Arthropods The bite of mosquitoes infected with encephalitis can cause this disease in humans. The illness is an infection of the lining of the brain; symptoms include a high fever, general malaise, and usually a very strong headache. Another disease transmitted by the bite of mosquitoes is malaria, which is caused by sporozoan parasites. Symptoms include intermittent chills and fever. Malaria may persist for years, and once the disease has been contracted, those affected are discouraged from donating blood, to avoid passing it on to others. Lyme disease is usually caused by the bite of a deerfly or tick. The disease was named for an area of Connecticut where it was first discovered. A doctor treating patients with flulike symptoms and skin inflammations realized that patients complaining of the symptoms walked in woody areas and been in contact with brush, weeds, and flowers where tiny ticks and deerflies could have been harbored. The insects preyed on deer and other animals in the area, then probably jumped or were brushed off the host animal into the grass. (Bitten animals may become infected with the disease as well.) Cases of Lyme disease have been found in almost every state, most reported in the Midwest and on the East Coast. Humans can develop the disease from a tick or deerfly bite; there is no evidence yet that a bite or scratch from an infected animal can transmit the disease. The bacterium Borrelia burgdorferi is responsible for Lyme disease. Its symptoms include inflammation, skin lesions and redness, joint inflammation, fever, fatigue, general malaise, and headaches or a stiff neck. These symptoms may last for weeks after the bite. Nerve-related disorders and heart ailments may follow the preliminary symptoms. Early treatment is a
Zoonoses ✧ 941 fourteen-day regimen of antibiotics, which can then be followed by treatment with antimicrobial agents until symptoms cease. Later stages of Lyme disease, such as arthritis and heart disorders, can be treated with penicillin-type antibiotics. Nevertheless, joint and muscle pain may persist for several weeks. Rocky Mountain spotted fever is another disease caused by tick bites. The disease is found in all areas of the United States, not only in the Rocky Mountains. Symptoms include headache, fever, and skin rash. Early diagnosis and antibiotic treatment is very important in order to prevent more serious complications. Plague is an infectious disease transmitted by the bite of a rodent flea infected with the bacillus Yersinia pestis. Bubonic plague results in the formation of buboes, or swellings of the lymph glands. The Black Death was caused by the same bacterium and was probably pneumonic plague; this form is transmissible between people and is characterized by black patches appearing on the skin of its victims. Both types cause fevers and heavy coughing. Before the discovery of antibiotics, most victims died from this very contagious disease. Most spider bites result in redness and itchiness or soreness at the site. They usually heal by themselves in a few days. The bites of some venomous spiders, however, such as the brown recluse, or violin, spider (Loxosceles reclusa), can cause serious complications in humans. Symptoms of the bite of a brown recluse spider include an eruption which turns black in the center, surrounded with a characteristic bull’s-eye pattern of red, white, and blue circles. The sore is accompanied by flulike symptoms, weight loss, and extreme fatigue. If treatment is not sought, the flesh at the site becomes gangrenous, and surgery is necessary. Preventing the Spread of Zoonoses Prevention plays the largest part in avoiding transmission of these diseases. People should wash their hands after touching or being in contact with animals, even if they do not appear to be sick or infected. Parents should instruct children to be careful when playing with pets. Humans should not care for wild animals as housepets. Hunters and hikers should take care when traveling through wooded areas so as not to pick up ticks or other insects; wearing clothing that covers the body, with socks rolled over pantlegs and gloves fitting over long sleeves, can help in these instances. Finally, pregnant women should avoid contact with animal feces in order to avoid contracting toxoplasmosis. —Carol A. Holloway See also Allergies; Asthma; Environmental diseases; Epidemics; Food poisoning; Influenza; Lice, mites, and ticks; Lyme disease; Mad cow disease; Parasites; Plague; Snakebites; Worms.
942 ✧ Zoonoses For Further Information: Biddle, Wayne. Field Guide to Germs. New York: Henry Holt, 1995. This comprehensive book is easily accessible to the nonspecialist and includes a discussion of nearly every virus, bacterium, and fungus known to cause human and nonhuman animal disease. The history of the microbe and the treatment of diseases are included. Hugh-Jones, Martin E., William T. Hubbert, and Harry V. Hagstad. Zoonoses: Recognition, Control, and Prevention. Ames: Iowa State University Press, 2000. This handbook on zoonoses includes bibliographic references and an index. Schlossberg, David, ed. Infections of Leisure. Washington, D.C.: ASM Press, 1999. This volume brings together a collection of essays, each addressing a different setting for the transmission of disease. Chapter titles include “At the Shore,” “Freshwater: From Lakes to Hot Tubs,” “The Camper’s Uninvited Guests,” and “Perils of the Garden.” Swabe, Joanna. Animals, Disease, and Human Society: Human-Animal Relations and the Rise of Veterinary Medicine. New York: Routledge, 1999. This book takes a historical perspective on zoonoses, discussing such things as the intensification of livestock production and the domestication of animals and how these trends have effected disease transmission. Zeibig, Elizabeth A. Clinical Parasitology: A Practical Approach. Philadelphia: W. B. Saunders, 1997. Presents all the guidelines needed to perform, read, and interpret parasitology tests. Each chapter contains thorough descriptions of parasitic forms, drawings with structures labeled, typical characteristics, and look-alike parasites.
Glossary ✧ 943
✧ Glossary abscess: a painful, localized collection of pus in any part of the body caused by tissue infection and deterioration acidosis: a condition characterized by surplus hydrogen in the body, causing an abnormally low pH active immunity: immunity resulting from antibody production following exposure to an antigen adenopathy: the enlargement of any gland (often the lymph gland) adenosine triphosphate (ATP): a high-energy compound found in the cell which provides energy for all bodily functions adenovirus: a virus with genetic material in the form of DNA that can be engineered to carry genes for gene therapy adhesion: the “gluing” together by scar tissue of internal organs and tissues, often caused by endometriosis or infections; a common cause of pelvic pain adipose tissue: fat; a soft tissue of the body composed of cells (adipocytes) that contain triglyceride, a compound consisting of glycerol and fatty acids adrenal gland: a small organ located near the kidney that is responsible for the production of certain sex hormones, including testosterone and small amounts of estrogen advanced life support: a variety of life support procedures, including the administration of drugs and electrical defibrillation aerobic exercise: vigorous, sustained activity requiring oxygen for energy production and sustainable for prolonged periods of time alcohol dependence: repeated use of alcohol despite the presence of negative consequences over the course of at least a year allergy: an overreaction of the immune system to a substance that does not affect the general population allotransplantation: the transplantation of tissue or organs between unrelated individuals alopecia: hair loss alveoli: the milk-producing cells of the mammary gland alveolus: the bony ridge where teeth grow amelogenesis imperfecta: a dental disorder affecting the enamel of the tooth amenorrhea: the cessation of menstruation amniotic sac: a thin, very tough membranous sac that contains amniotic fluid and the embryo or fetus of a mammal, bird, or reptile anaerobic: metabolism involving the breakdown of energy substrates without using oxygen anaphylaxis: an immediate immune reaction, triggered by mediators that cause vasodilation and the contraction of smooth muscle
944 ✧ Glossary anemia: a condition in which there is a lower-than-normal concentration of the iron-containing protein in red blood cells, which carry oxygen anorexia nervosa: a disorder characterized by the phobic avoidance of eating, the relentless pursuit of thinness, and fear of gaining weight antibody: a protein secreted by lymphocytes in response to antigens, such as bacteria or viruses, enabling these cells to destroy those foreign materials; also called immunoglobulin antidepressant: a medication that acts in the brain to decrease a sad or depressed mood antidote: anything that counteracts the effect of a substance such as a homeopathic remedy antigen: a chemical substance, often on a bacterial or viral surface, containing substances that activate the body’s immune response antivenin: an antidote given to snakebite victims to combat the effects of venom that has been injected into the bloodstream aphasia: a partial or total loss of the ability to articulate ideas that often results from brain damage apnea: absence of breathing arrhythmia: an abnormal heart rhythm, either in speed or force asymptomatic: a medical condition without any symptoms atherosclerosis: a buildup of fatty deposits or plaques which reduces the inner diameter of the arteries through hardening or thickening, obstructing the normal flow of blood atria: the chambers in the right and left top portions of the heart that receive blood from the veins and pump it to the ventricles atrophy: a wasting away; a diminution in the size of a cell, tissue, organ, or part attenuation: the weakening or elimination of the pathogenic properties of a microorganism autosomal recessive disease: a disease which is only expressed when two copies of a defective gene are inherited, one from each parent autotransplantation: transplantation in which the recipient serves as his or her own donor (such as a skin graft); may also refer to transplantation between genetically identical individuals (identical twins) bacteria: microscopic single-celled organisms that multiply by means of simple division, a few species of which cause disease basal ganglia: a collection of nerve cells deep inside the brain, below the cortex, that controls muscle tone and automatic actions such as walking basal metabolic rate: the minimal energy expended for maintenance of the vegetative functions of the body (respiration, heat production, and so on), expressed as calories per hour per square meter of body surface basic life support: a variety of life support procedures, including rescue breathing and chest compressions
Glossary ✧ 945 benign: referring to a tumor made of a mass of cells which do not leave the site where they develop binge drinking: a pattern in which a person drinks very high quantities of alcohol (such as five or more drinks on any one occasion) but does not necessarily drink every day or in a steady pattern biofeedback: the provision of information about biological or physiological processes with the objective of empowering the individual to make conscious changes in those processes biopsy: a surgical procedure in which a lump or an abnormality is removed bipolar disorder: a disturbance of mood and behavior involving rapid alternations between extreme elation and depression body composition: measurement of the percentage of fat-free and fat weight as determined by methods such as hydrostatic weighing and skinfold measurement body mass index (BMI): weight in kilograms divided by height in meters, squared (kg/m2); since this value is relatively independent of height and sex, the same standard values can be used for all adults, both men and women bonding: a process in which a mother forms an affectionate attachment to her infant immediately after birth bradycardia: slowness of the heartbeat bronchioles: small air tubes leading to the air sacs of the lungs bulimia: a disorder characterized by binge eating followed by self-induced vomiting Calorie: 1 kilocalorie, which is the amount of heat (energy) needed to raise the temperature of 1 kilogram of water by 1 degree Celsius; used to measure the energy value of food and the cost of physical activity cancer: one of a group of diseases in which cells divide uncontrollably and do not contribute to the function of the body cannula: a narrow tube used in surgery to drain fluid, to deliver cell suspensions for a transplant, or to administer medications capacitation: a change that the sperm goes through when in the female reproductive tract which causes it to swim more vigorously and enables it to fertilize the egg carbohydrates: compounds containing carbon, hydrogen, and oxygen; the major source of energy for the human body carcinogen: a cancer-causing substance, usually a chemical that causes mutations cardiopulmonary resuscitation (CPR): a procedure in which a rescuer rhythmically compresses the victim’s chest to achieve blood circulation and exhales into the victim’s mouth to provide oxygenation cardiovascular disease: any of a group of diseases that affect the heart, including coronary artery disease, hypertension, congestive heart failure, congenital heart defects, and valvular heart disease
946 ✧ Glossary central nervous system: the brain and spinal cord cerebral cortex: the outer part of the cerebrum, responsible for higher nervous functions cerebrospinal fluid (CSF): the fluid that bathes and nourishes the inner and outer surfaces of the brain and spinal cord cervix: the bottom portion of the uterus, protruding into the vagina chemotherapy: drugs, usually given by vein, that are used to kill cancer cells that have or may have spread to parts of the body beyond the breast and lymph nodes cholecystectomy: the surgical removal of the gallbladder chorionic villi: the fingerlike projections of the placenta that function in oxygen, nutrient, and waste transportation between a fetus and its mother chromosome: a long thread of DNA that includes many genes and is complexed with protein circadian rhythm: a physiological process which occurs in twenty-four-hour cycles, such as the sleep-wake cycle cirrhosis: chronic liver disease characterized by nonfunctional tissue, blocked blood circulation, liver failure, and death clinical trial: a research study to compare standard treatment against potentially better treatment cognitive: relating to the mental process by which knowledge is acquired colostrum: the secretion from the breast before the onset of milk compulsion: a persistent, irresistible urge to perform a stereotyped behavior or irrational act, often accompanied by repetitious thoughts (obsessions) about the behavior computed tomography (CT) scan: a detailed X-ray picture that identifies abnormalities of fine tissue structure congenital disease: a disease resulting from heredity or acquired while in the womb conjunctivitis: inflammation of the conjunctiva, which lines the back of the eyelid, extends into the space between the lid and the globe of the eye, and goes over the globe to the transparent tissue covering the pupil connective tissue: tissues possessing a highly vascular structure which form support and connecting structures of the body (for example, cartilage, ligaments, and tendons) contusion: a painful and swollen area caused by a blow to a muscle or bone coronary arteries: blood vessels surrounding the heart that provide nourishment and oxygen to heart tissue coronary artery disease (CAD): a disease which results in a narrowing of the coronary arteries and a concomitant reduction of oxygen supply to the heart muscle corpus luteum: a yellow cell mass produced from a graafian follicle after the release of an egg
Glossary ✧ 947 cryopreservation: a special process that enables living cells to survive in a frozen state crypt: a pit or cavity in the surface of a body organ (such as a tonsil) cuspids: the teeth on either side of the lateral incisors; also known as the canines or eyeteeth cutaneous: pertaining to the skin cyclothymia: a mood disorder characterized as a less intense form of bipolar disorder debridement: the removal of all foreign material and contaminated and devitalized tissues from or adjacent to a traumatic or infected lesion until healthy surrounding tissue is exposed deciduous teeth: a child’s first set of teeth, which will be replaced by the child’s permanent teeth; also known as the primary or baby teeth defibrillation: the application of electrical energy through the chest in order to correct abnormal heart function and restore a normal heart rhythm dehydration: excessive loss of the body’s water content delirium: an acute condition characterized by confusion, a fluctuating level of consciousness, and visual, auditory, and tactile hallucinations delirium tremens: severe alcohol withdrawal syndrome, with symptoms including confusion, delirium, terrifying hallucinations, and severe tremors delusions: a false view of what is real dental caries: bacterially caused destruction of the tooth; also called tooth decay or cavities deoxyribonucleic acid (DNA): the chemical molecule that transmits hereditary information from generation to generation depression: a general term covering mild states (sadness, inhibition, unhappiness, discouragement) to severe states (hopelessness, despair) dermis: the sensitive layer of skin located beneath the epidermis detoxification: a medical process in which a person ceases using alcohol and has the symptoms of withdrawal controlled so that no further physical damage occurs to the body dilation: making something wider or larger dislocation: the separation of bones in a joint, which causes damage to the surrounding ligaments disseminated: spread throughout the body dominant gene: a gene which can express its effect when an individual has only one copy of it double-blind study: an experimental design in which neither the experimenter nor the subjects know which subjects are receiving the active treatment Down syndrome: an inherited disease that produces moderate to severe mental retardation durable power of attorney: designation of a person who will have legal authority
948 ✧ Glossary to make health care decisions if the patient becomes incapable of making decisions dysfunction: the disordered or impaired function of a body system or organ dyslexia: difficulty in reading, with an implied neurological cause dysthymia: a mood disorder characterized as a less intense form of depressive disorder E. coli: a common bacterium that inhabits the human intestinal tract eating disorder: weight gain or loss resulting from compulsive overeating, anorexia nervosa, or bulimia eclampsia: a condition during pregnancy characterized by high blood pressure and seizures ectopic pregnancy: the development of a fertilized egg in a Fallopian tube instead of the uterus, which can be fatal to the mother unless it is corrected surgically edema: the accumulation of an excessive amount of fluid in cells or tissues efficacy: the extent to which a drug or procedure works as expected under ideal conditions, such as in the laboratory electrocardiogram (EKG or ECG): a mechanical representation of the electrical activity generated by the heart and recorded on paper or displayed on a cathode-ray tube electroconvulsive therapy: the use of electric shocks to induce seizure in depressed patients as a form of treatment electroencephalogram (EEG): a graphic record of the brain’s electrical activity electrolytes: ionized salts in blood, tissue fluid, and cells, including salts of potassium, sodium, and chloride embryo: the cells growing after conception until the eighth week of pregnancy emphysema: the overinflation of bronchial tubes and alveoli with air, resulting in reduced lung function endemic disease: a disease which is usually present in a population and whose frequency does not fluctuate greatly endometriosis: a female reproductive disease in which cells from the uterine lining (the endometrium) grow outside the uterus, causing severe pain and infertility and sometimes the need for hysterectomy enzymes: catalysts that facilitate chemical reactions in the body epidemic: a marked increase in the frequency of a disease in a population, compared to historical experience epidemiology: the study of the distribution and dynamics of disease in populations epidermis: the outer skin layer epididymis: an organ attached to the testis in which newly formed sperm reach maturity erythematous: related to or marked by reddening
Glossary ✧ 949 estrogen: the female sex hormone produced by the ovaries and the adrenal gland responsible for the development of female secondary sex characteristics; the three types produced by the body are estradiol, estrone, and estriol etiology: the science of causes or origins, especially of diseases euthanasia: the practice of withholding medical treatments that might sustain life that would otherwise expire naturally; also associated with the administration of drugs by physicians in order to avert prolonged suffering Fallopian tubes: the structures located between the uterus and ovaries that are responsible for the transport of the egg; also called oviducts fetal alcohol syndrome: a medical condition in a child resulting from alcohol use by the mother during pregnancy, usually evidenced by facial abnormalities and mental impairments fetus: in humans, the unborn child from the eighth week after its conception to birth fibrillation: wild beating of the heart, which may occur when the regular rate of the heartbeat is interrupted flatulence: the presence of excessive gas in the stomach and intestines, which is expelled from the body follicle: a spherical structure within the ovary that contains a developing ovum and that produces hormones foremilk: the milk released early in a nursing session, which is low in fat and rich in nutrients gametes: the egg and sperm cells that unite to form the fertilized egg (zygote) in reproduction gangrene: necrosis (tissue death) caused by the obstruction of the blood supply gene: a master molecule that encodes the information needed for the body to carry out one specific function general anesthesia: anesthesia that induces unconsciousness genome: a complete set of genetic information for an organism glycogen: the form that glucose takes when it is stored in the muscles and liver graafian follicle: any of the ovarian follicles that produce eggs hallucinations: a false or distorted perception of objects or events heart rate: the number of times the heart contracts, or beats, per minute Heimlich maneuver: an emergency technique that dislodges objects trapped in a patient’s airway by pushing the patient’s diaphragm up quickly but carefully hereditary: something that is passed down from generation to generation through the genes
950 ✧ Glossary hindmilk: the milk released late in a nursing session, which is higher in fat content histamine: a compound released during allergic reactions which causes many of the symptoms of allergies homeostasis: the maintenance of constant, linear conditions within a system, such as the maintenance of human body temperature, pH, and hormonal levels at stable states hormone: a chemical signal that serves to coordinate the functions of different body parts hospice: an alternative to hospitalization for the terminally ill or aged that allows for the dignified acceptance of impending death hydrocephalus: a condition resulting from the accumulation of fluid inside the brain, which exerts pressure on neighboring cells hypersomnia: a group of disorders characterized by excessive daytime sleepiness or of an inability to stay awake during the day hyperthermia: environmentally influenced elevated body temperature hypoplasia: underdevelopment hypothermia: environmentally influenced lower-than-normal body temperature hypoxia: cellular damage resulting from constriction of the blood vessels because of low potassium and oxygen levels in the blood hysterectomy: a surgery that removes part or all of the uterus iatrogenic: resulting from medical treatment idiopathic: referring to a medical condition with no known cause immune system: the body system that is responsible for fighting off infectious disease immunity: the capacity to resist a disease caused by an infectious agent in vitro: a process that has been taken from an organism and placed in a laboratory container (such as a test tube or dish) for observation in utero: a Latin term meaning “in the womb” in vivo: a process as it occurs naturally in a living organism incidence: the number of new illnesses or events occurring over a specified period of time among a specific population infertility: the inability to produce a normal pregnancy after one year of intercourse in the absence of contraception inflammation: a response of the body to tissue damage caused by injury or infection and characterized by redness, pain, heat, and swelling insomnia: the complaint of poor-quality sleep, which can be caused by a difficulty in falling asleep or a difficulty in maintaining sleep ischemia: a local anemia or area of diminished or insufficient blood supply caused by mechanical obstruction of the blood supply (commonly, narrowing of an artery) islets of Langerhans: clusters of cells scattered throughout the pancreas that
Glossary ✧ 951 produce three hormones involved in sugar metabolism: insulin, glucagon, and somatostatin karyotype: a photograph of the chromosomes taken from the cells of an individual, which can be used to predict the sex of a fetus or the presence of a large chromosomal abnormality kwashiorkor: the condition that results from consuming a diet that is sufficient in energy (kilocalories) but inadequate in protein content laparoscopy: a surgical procedure in which a small incision is made near the navel and the organs of the abdominal cavity are viewed with a lighted tube latent: lying hidden or undeveloped within a person libido: a person’s sex drive ligaments: flexible bands of fibrous tissue that attach bones and cartilage to keep joints together living will: a legally binding document instructing a physician not to prolong life by externally administered life support systems if the patient is unable to express his or her decision concerning forms of medical treatment local anesthesia: anesthesia that numbs the feeling in a body part, administered by injection or direct application to the skin lymph nodes: structures that drain tissue fluid, bacteria, and tumor cells lymphocytes: agranular leukocytes that differentiate into B lymphocytes and T lymphocytes and play a fundamental role in the immune response malaise: a feeling of lack of health or debility, often indicating or accompanying the onset of illness malignant: referring to a tumor which is capable of losing cells, which can travel via blood or lymph fluid to other sites mammogram: an X ray of the breasts marasmus: the condition that results from consuming a diet that is deficient in both energy and protein mastectomy: removal of the breast menarche: the initial menstruation, and thus the ability to conceive, in human females menstrual cycle: the cycle of hormone production, ovulation, menstruation, and other changes that occurs on an approximately monthly schedule in women meiosis: the type of cell division that produces the cells of reproduction, which contain one-half of the chromosome number found in the original cell before division metabolism: the sum of the physical and chemical processes by which living matter is produced, maintained, and transformed
952 ✧ Glossary metastasis: the process whereby tumor cells spread from one part of the body to another migraine: a type of headache characterized by pain on one side of the head, often accompanied by disordered vision and gastrointestinal disturbances minerals: inorganic elements found in the body and in food that are essential for normal body functions mitosis: the type of cell division that occurs in nonsex cells, which conserves chromosome number by equal allocation to each of the newly formed cells molars: the grinding teeth located at the back of the mouth musculoskeletal: pertaining to or comprising the skeleton and the muscles mutagen: a substance or event that effects a permanent, inheritable change in the genetic makeup of an organism mutation: an alteration in the DNA sequence of a gene myocardial infarction: irreversible damage to heart muscle tissue caused by insufficient oxygen supply to that tissue; commonly called a heart attack myocardium: the muscle tissue that forms the walls of the heart, varying in thickness in the upper and lower regions narcolepsy: a disorder in which sufferers experience an overwhelming need to sleep during the day, as well as sudden muscle weakness, hallucinations, or sleep paralysis necrosis: the death of one or more cells or a portion of a tissue or organ resulting from irreversible damage neonatal: the period of time succeeding birth and continuing through the first twenty-eight days of life neoplasm: the new and abnormal formation of a tumor nervous system: the system in the body, including the brain, that receives and interprets stimuli and transmits impulses to other organs neuropathy: malfunction of the nerves neurotransmitter: a chemical in the brain that sends a signal from one brain cell to another nursing caries: dental caries in infants caused by nursing with a bottle obsessive-compulsive: having a preoccupation with a specific idea (such as body image) and showing uncontrollable related behavior (such as dieting) oncogene: a gene that functions normally to allow cells to progress through the cell cycle but which, when mutated, can cause cancer orchitis: inflammation of the testis organic disease: a disease caused or accompanied by an alteration in the structure of the tissues or organs ossicles: three small bones in the middle ear that convey sound pressure
Glossary ✧ 953 changes from the tympanic membrane (eardrum) to the cochlea; commonly called the hammer (malleus), anvil (incus), and stirrup (stapes) osteoporosis: a bone disorder in which the bone’s mineral content is decreased over time, resulting in a weakening of the skeleton and susceptibility to bone fractures ovary: the female gonad located in the pelvic cavity, where egg production occurs; the principal organ that produces the hormones estrogen and progesterone oviducts: the pair of tubes leading from the top of the uterus upward toward the ovaries; also called the Fallopian tubes ovulation: the process in which an ovum is released from its follicle in the ovary during the middle of the menstrual cycle ovum (pl. ova): the egg or reproductive cell produced by the female, which when fertilized by a sperm from the male will develop into an embryo oxytocin: the hormone secreted from the posterior pituitary gland that stimulates the mammary glands to eject milk and stimulates the uterus to contract after birth Parkinson’s disease: a disease in which the dopamine-secreting cells of the midbrain degenerate, resulting in uncontrolled movement and rigidity passive immunity: immunity resulting from the introduction of preformed antibodies pathogen: a disease-causing organism pharmacology: the science that deals with the chemistry, effects, and therapeutic use of drugs pharynx: the throat pica: the ingestion of nonfood substances placebo: a treatment that is therapeutically inert placenta: the membrane sac developed from the uterine wall that passes nutrients to the fetus through interconnected blood vessels plaque: an accumulation of matter within artery walls that can impede blood flow; also, a sticky film that accumulates on teeth pneumonia: a respiratory tract infection that can be caused by bacteria or viruses; the major complication of influenza and the major cause of influenza deaths prenatal care: medical and nutritional assistance intended to maximize the health of the expectant mother and her fetus prevalence: the number of individuals at a particular time who have a disease or a given characteristic primary infection: a person’s first infection with a particular virus progesterone: a hormone produced in the ovaries, adrenal gland, and placenta (of pregnant women) that prepares for and sustains pregnancy prone: lying face-downward
954 ✧ Glossary prophylactic treatment: a treatment focusing on preventing disease, illness, or their symptoms from occurring prostaglandins: chemical signals that have local effects on the organ that produces them proteins: complex organic compounds that are the main substances used in the body to build and repair tissue protozoan: a single-celled organism more closely related to animals than are bacteria; only a few drugs are available that will kill protozoa without harming their animal hosts psychosis: a severe mental disorder characterized by loss of normal intellectual and social function and withdrawal from reality psychotherapy: the “talk” therapies that target the emotional and social contributors and consequences of depression ptosis: downward drooping or sagging of tissue, caused by the influence of gravity or the loss of muscular or other support quickening: the point at which a fetus first begins to move in the uterus rabies: an acute virus disease of the nervous system of warm-blooded animals, usually transmitted through the bite of a rabid animal rapid eye movement (REM) sleep: the period of sleep in which intense brain activity can be measured and during which dreaming occurs recessive gene: a gene which can express its effect only when an individual has two copies of it, one from each parent recombinant DNA: the technology of joining or recombining DNA molecular fragments of different types or from different organisms; also, the fragments themselves rehabilitation: the restoration of normal form and function after injury or illness respiratory distress syndrome: a disease of lung immaturity which can be fatal and is likely to be found in children who will be born prematurely retrovirus: a virus whose genetic material is in the form of RNA; it can be used to carry genes for gene therapy rhinitis: inflammation of the nasal mucous membrane; also called hay fever ribonucleic acid (RNA): the material contained in the core of many viruses that is responsible for directing the replication of the virus inside the host cell sanatorium: an institution designed for the treatment of chronic illnesses, such as tuberculosis seasonal affective disorder: a mood disorder associated with the winter season, when the amount of daylight hours is reduced secondhand smoke: smoke that is inhaled indirectly from the burning cigarettes or cigars of others or from exhaled tobacco smoke sepsis: an infection in the circulating blood
Glossary ✧ 955 shunt: a tube that is surgically inserted to drain excess fluid away from an area sinoatrial node: the section of the right atrium that determines the appropriate rate of the heartbeat sleep apnea: a cessation of breathing during sleep, which interrupts the normal sleep cycle spasm: an involuntary muscle contraction; a painful spasm is called a cramp spina bifida: a birth defect involving malformation of vertebrae in the lower back, often resulting in paralysis and lower-body organ impairment sprain: a dynamic injury to a ligament, generally not caused by an outside force strain: a tearing injury to a muscle or tendon, most often caused by an outside force subcutaneous: under the skin substance abuse: the continued use of a psychoactive substance for at least one month despite impairment of psychological, social, occupational, or physical functioning supine: lying face-upward syrup of ipecac: a plant extract that induces vomiting when orally administered; it can be used to induce vomiting after ingestion of a poisonous substance tachycardia: rapid beating of the heart tendons: fibrous tissues that attach muscle to bone teratogen: a substance or event that causes malformation in a developing fetus testis (pl. testes): either of two male gonads that are suspended in the scrotum and produce sperm tolerance: a condition in which the same dose achieves a lesser effect, or in which successively greater doses of an abusable substance are required to achieve the same desired effect tourniquet: a strip of nonstretching material tied tightly between a wound and the heart to stop blood flow to the wound entirely toxemia: high blood pressure largely attributable to pregnancy toxicology: the science devoted to the study of poisons toxin: a poisonous substance that is a product of the chemical processes of a living organism toxoplasmosis: the infection of humans, other mammals, or birds with disease caused by toxoplasmas that invade the tissues and may seriously damage the central nervous system, especially that of an infant triage: quick evaluation of victims before administering emergency assistance trimester: any of the three consecutive three-month periods during pregnancy tuberculosis: a highly variable, communicable disease of humans and some other vertebrates caused by the tubercle bacillus
956 ✧ Glossary tumor: a mass of cells characterized by uncontrolled growth, which can be either benign or malignant ultrasonography: an imaging technique that uses high-frequency sound waves to view fetuses in the womb, as well as other internal structures urinary tract infections: infections of the bladder, kidneys, urethra, and ureters uterus: a hollow, muscular organ located in the pelvic cavity of females in which a fertilized egg develops; also called the womb vaccine: a preparation of killed microorganisms, or living virulent organisms, administered to produce or increase immunity to a particular disease varicocele: a swollen testicular vein in the scrotum occurring as a result of improper valvular function vascular: relating to or containing blood vessels ventricles: the chambers in the right and left bottom portions of the heart that receive blood from the atria and pump it to the arteries vertebra (pl. vertebrae): the individual bones that are stacked upon one another to form the vertebral column, or spine virulence: a measure of the severity of disease virus: a noncellular particle of protein and nucleic acid that can reproduce only inside a cell and that usually causes damage to its host vitamins: organic substances essential for normal metabolism and the growth and development of the body withdrawal: a physical and mental conditions, such as nausea, shaking, blurred vision, chills, irritability, visual distortions, and convulsions, following decreased intake of an abusable substance xenotransplantation: the transplantation of tissue or organs between different species (such as baboon to human) zygote: the single cell formed after fertilization that has the capacity to develop into a new individual
Alphabetical List of Entries Chemotherapy, 172 Child abuse, 176 Childbirth complications, 184 Childhood infectious diseases, 187 Children’s health issues, 191 Chlorination, 197 Choking, 198 Cholesterol, 200 Chronic fatigue syndrome, 202 Circumcision of boys, 208 Circumcision of girls, 213 Cleft lip and palate, 216 Colic, 222 Colon cancer, 224 Condoms, 227 Cosmetic surgery and aging, 229 Cosmetic surgery and women, 231
Abortion, 1 Abortion among teenagers, 7 Acupuncture, 9 Addiction, 13 Aging, 21 AIDS, 30 AIDS and children, 36 AIDS and women, 41 Alcoholism, 43 Alcoholism among teenagers, 48 Alcoholism among the elderly, 53 Allergies, 56 Alternative medicine, 62 Alzheimer’s disease, 69 Amniocentesis, 77 Anorexia nervosa, 83 Antibiotic resistance, 86 Arteriosclerosis, 90 Arthritis, 93 Asbestos, 99 Asthma, 102 Attention-deficit disorder (ADD), 107 Autism, 112
Death and dying, 234 Dementia, 239 Dental problems in children, 244 Dental problems in the elderly, 252 Depression, 256 Depression in children, 262 Depression in the elderly, 265 Diabetes mellitus, 268 Disabilities, 274 Domestic violence, 279 Down syndrome, 287 Drowning, 293 Drug abuse by teenagers, 295 Dyslexia, 300
Biofeedback, 117 Birth control and family planning, 121 Birth defects, 126 Breast cancer, 133 Breast-feeding, 137 Breast surgery, 143 Broken bones in the elderly, 147 Burns and scalds, 149
Eating disorders, 305 Elder abuse, 311 Electrical shock, 316 Emphysema, 318 Endometriosis, 323 Environmental diseases, 325 Epidemics, 331 Ethics, 336
Cancer, 152 Canes and walkers, 157 Cardiac rehabilitation, 160 Carpal tunnel syndrome, 165 Cervical, ovarian, and uterine cancers, 167 957
Alphabetical List of Entries Hospice, 473 Hospitalization of the elderly, 476 Hydrocephalus, 481 Hypertension, 483 Hypnosis, 487 Hysterectomy, 490
Euthanasia, 341 Exercise, 346 Exercise and children, 351 Exercise and the elderly, 356 Factitious disorders, 364 Failure to thrive, 367 Falls among children, 368 Falls among the elderly, 370 Fetal alcohol syndrome, 372 Fetal tissue transplantation, 373 First aid, 376 Fluoridation of water sources, 378 Fluoride treatments in dentistry, 381 Food irradiation, 382 Food poisoning, 385 Foot disorders, 390 Frostbite, 395
Iatrogenic disorders, 495 Illnesses among the elderly, 497 Immunizations for children, 504 Immunizations for the elderly, 508 In vitro fertilization, 511 Incontinence, 515 Infertility in men, 520 Infertility in women, 525 Influenza, 530 Injuries among the elderly, 535 Lactose intolerance, 537 Laparoscopy, 538 Laser use in surgery, 541 Law and medicine, 544 Lead poisoning, 550 Learning disabilities, 552 Lice, mites, and ticks, 558 Light therapy, 563 Liposuction, 565 Living wills, 567 Lung cancer, 568 Lyme disease, 571
Gene therapy, 396 Genetic counseling, 399 Genetic diseases, 403 Genetic engineering, 408 Genetically engineered foods, 411 Hair loss and baldness, 414 Hazardous waste, 418 Headaches, 421 Health insurance, 426 Hearing aids, 432 Hearing loss, 435 Heart attacks, 439 Heart disease, 442 Heart disease and women, 447 Heat exhaustion and heat stroke, 450 Herpes, 452 Hippocratic oath, 458 HMOs, 461 Holistic medicine, 465 Homeopathy, 467 Hormone replacement therapy, 471
Macular degeneration, 574 Mad cow disease, 577 Malnutrition among children, 580 Malnutrition among the elderly, 586 Malpractice, 590 Mammograms, 594 Mastectomy, 599 Medications and the elderly, 604 Meditation, 609 Memory loss, 611 Meningitis, 613 Menopause, 616 958
Alphabetical List of Entries Menstruation, 620 Mental retardation, 625 Mercury poisoning, 629 Miscarriage, 632 Mobility problems in the elderly, 632 Morning-after pill, 638 Multiple births, 639 Multiple chemical sensitivity syndrome, 643 Münchausen syndrome by proxy, 645 Muscle loss with aging, 648
Premature birth, 741 Prenatal care, 744 Preventive medicine, 747 Prostate cancer, 751 Prostate enlargement, 755
Natural childbirth, 651 Necrotizing fasciitis, 654 Noise pollution, 656 Nursing and convalescent homes, 658 Nutrition and aging, 663 Nutrition and children, 666 Nutrition and women, 673
Safety issues for children, 772 Safety issues for the elderly, 779 Schizophrenia, 782 Scoliosis, 786 Screening, 790 Seasonal affective disorder (SAD), 796 Secondhand smoke, 800 Sexual dysfunction, 803 Sexually transmitted diseases (STDs), 809 Sick building syndrome, 814 Skin cancer, 816 Skin disorders with aging, 818 Sleep changes with aging, 823 Sleep disorders, 825 Smog, 829 Smoking, 832 Snakebites, 835 Speech disorders, 837 Spina bifida, 841 Sports injuries among children, 843 Sterilization, 848 Steroid abuse, 853 Stress, 855 Strokes, 858 Sudden infant death syndrome (SIDS), 862 Suicide, 866
Radiation, 756 Radon, 757 Reaction time and aging, 759 Recovery programs, 760 Reproductive technologies, 764 Resuscitation, 766 Reye’s syndrome, 771
Obesity, 675 Obesity and aging, 681 Obesity and children, 684 Occupational health, 689 Osteoporosis, 692 Overmedication, 697 Pain management, 700 Pap smears, 702 Parasites, 703 Parkinson’s disease, 708 Pesticides, 711 Phenylketonuria (PKU), 715 Physical fitness tests for children, 718 Physical rehabilitation, 720 Plague, 725 Poisoning, 727 Poisonous plants, 731 Postpartum depression, 735 Pregnancy among teenagers, 736 959
Alphabetical List of Entries Suicide among children and teenagers, 871 Suicide among the elderly, 875 Sunburns, 879
Vision problems with aging, 908 Vitamin supplements, 912 Water quality, 914 Weight changes with aging, 917 Weight loss medications, 920 Well-baby examinations, 922 Wheelchair use among the elderly, 924 Women’s health issues, 926 Worms, 933
Tattoos and body piercing, 880 Teething, 882 Temperature regulation and aging, 884 Terminal illnesses, 885 Tobacco use by teenagers, 890 Tonsillectomy, 891 Transplantation, 893 Tuberculosis, 899
Yeast infections, 935 Yoga, 936
Ulcers, 904
Zoonoses, 938
960
Category List Malnutrition among children Mental retardation Multiple births Münchausen syndrome by proxy Nutrition and children Obesity and children Phenylketonuria (PKU) Physical fitness tests for children Poisoning Pregnancy among teenagers Premature birth Prenatal care Reye’s syndrome Safety issues for children Scoliosis Secondhand smoke Speech disorders Spina bifida Sports injuries among children Sudden infant death syndrome (SIDS) Suicide among children and teenagers Tattoos and body piercing Teething Tobacco use by teenagers Tonsillectomy Well-baby examinations Worms
Children’s Health Abortion among teenagers AIDS and children Alcoholism among teenagers Amniocentesis Anorexia nervosa Asthma Attention-deficit disorder (ADD) Autism Birth defects Breast-feeding Burns and scalds Child abuse Childbirth complications Childhood infectious diseases Children’s health issues Choking Circumcision of boys Circumcision of girls Cleft lip and palate Colic Dental problems in children Depression in children Domestic violence Down syndrome Drowning Drug abuse by teenagers Dyslexia Eating disorders Electrical shock Exercise and children Failure to thrive Falls among children Fetal alcohol syndrome Fluoride treatments in dentistry Genetic counseling Genetic diseases Hydrocephalus Immunizations for children Lead poisoning Learning disabilities
Economic Issues Disabilities Health insurance HMOs Hospitalization of the elderly Law and medicine Living wills Malpractice Terminal illnesses 961
Category List Reaction time and aging Safety issues for the elderly Skin disorders with aging Sleep changes with aging Sleep disorders Strokes Suicide among the elderly Temperature regulation and aging Terminal illnesses Vision problems with aging Weight changes with aging Wheelchair use among the elderly
Elder Health Aging Alcoholism among the elderly Alzheimer’s disease Arthritis Broken bones in the elderly Canes and walkers Cosmetic surgery and aging Dementia Dental problems in the elderly Depression in the elderly Domestic violence Elder abuse Emphysema Exercise and the elderly Falls among the elderly Foot disorders Hair loss and baldness Hearing aids Hearing loss Heart attacks Hospitalization of the elderly Hypertension Illnesses among the elderly Immunizations for the elderly Incontinence Injuries among the elderly Living wills Macular degeneration Malnutrition among the elderly Medications and the elderly Memory loss Menopause Mobility problems in the elderly Muscle loss with aging Nursing and convalescent homes Nutrition and aging Obesity and aging Osteoporosis Overmedication Pain management Parkinson’s disease Prostate cancer Prostate enlargement
Environmental Health Allergies Asbestos Asthma Cancer Chlorination Emphysema Environmental diseases Epidemics Fluoridation of water sources Food irradiation Food poisoning Frostbite Genetically engineered foods Hazardous waste Heat exhaustion and heat stroke Lead poisoning Lung cancer Lyme disease Mad cow disease Mercury poisoning Multiple chemical sensitivity syndrome Noise pollution Parasites Pesticides Plague Poisoning Poisonous plants Radon Secondhand smoke 962
Category List Hospice Iatrogenic disorders In vitro fertilization Law and medicine Malpractice Morning-after pill Münchausen syndrome by proxy Overmedication Reproductive technologies Secondhand smoke Steroid abuse Terminal illnesses
Sick building syndrome Skin cancer Smog Sunburns Water quality Epidemics AIDS AIDS and children AIDS and women Antibiotic resistance Childhood infectious diseases Epidemics Food poisoning Herpes Illnesses among the elderly Influenza Lyme disease Mad cow disease Meningitis Necrotizing fasciitis Parasites Plague Sexually transmitted diseases (STDS) Tuberculosis Water quality Zoonoses
Industrial Practices Asbestos Chlorination Food irradiation Genetically engineered foods Hazardous waste Lead poisoning Mad cow disease Mercury poisoning Pesticides Sick building syndrome Smog Water quality Medical Procedures Abortion Abortion among teenagers Acupuncture Amniocentesis Biofeedback Breast surgery Cardiac rehabilitation Chemotherapy Circumcision of boys Circumcision of girls Cosmetic surgery and aging Cosmetic surgery and women Fetal tissue transplantation First aid Fluoride treatments in dentistry Gene therapy
Ethics Abortion Abortion among teenagers Child abuse Circumcision of boys Circumcision of girls Death and dying Domestic violence Elder abuse Ethics Euthanasia Fetal tissue transplantation Genetic counseling Genetic engineering Hippocratic oath 963
Category List Autism Biofeedback Birth defects Child abuse Death and dying Dementia Depression Depression in children Depression in the elderly Disabilities Domestic violence Down syndrome Drug abuse by teenagers Dyslexia Eating disorders Elder abuse Factitious disorders Genetic counseling Headaches Holistic medicine Hospice Hydrocephalus Hypnosis Illnesses among the elderly Incontinence Learning disabilities Light therapy Mastectomy Meditation Memory loss Mental retardation Münchausen syndrome by proxy Overmedication Pain management Postpartum depression Reaction time and aging Recovery programs Schizophrenia Seasonal affective disorder (SAD) Sexual dysfunction Sleep changes with aging Sleep disorders Speech disorders Steroid abuse
Genetic engineering Homeopathy Hormone replacement therapy Hypnosis Hysterectomy Immunizations for children Immunizations for the elderly In vitro fertilization Laparoscopy Laser use in surgery Light therapy Liposuction Mammograms Mastectomy Pain management Pap smears Physical fitness tests for children Physical rehabilitation Resuscitation Screening Sterilization Tonsillectomy Transplantation Well-baby examinations Men’s Health Circumcision of boys Condoms Hair loss and baldness Infertility in men Prostate cancer Prostate enlargement Sexual dysfunction Sterilization Mental Health Addiction Aging Alcoholism Alcoholism among teenagers Alcoholism among the elderly Alzheimer’s disease Anorexia nervosa Attention-deficit disorder (ADD) 964
Category List Heart disease and women Immunizations for children Immunizations for the elderly Injuries among the elderly Mammograms Nutrition and aging Nutrition and children Nutrition and women Pap smears Physical fitness tests for children Prenatal care Preventive medicine Safety issues for children Safety issues for the elderly Screening Vitamin supplements Weight changes with aging Well-baby examinations
Stress Strokes Suicide Suicide among children and teenagers Suicide among the elderly Ulcers Yoga Occupational Health Allergies Arthritis Asbestos Burns and scalds Cancer Carpal tunnel syndrome Disabilities Emphysema Hearing loss Lung cancer Multiple chemical sensitivity syndrome Noise pollution Occupational health Radiation Secondhand smoke Sick building syndrome Steroid abuse
Public Health Allergies Alternative medicine Antibiotic resistance Arteriosclerosis Asbestos Asthma Birth control and family planning Burns and scalds Cancer Cervical ovarian & uterine cancers Childhood infectious diseases Chlorination Choking Cholesterol Chronic fatigue syndrome Colon cancer Condoms Death and dying Dental problems in children Dental problems in the elderly Diabetes mellitus Drowning Electrical shock Emphysema
Prevention Amniocentesis Arteriosclerosis Cardiac rehabilitation Chlorination Cholesterol Exercise Exercise and children Exercise and the elderly Falls among children Falls among the elderly Fluoridation of water sources Fluoride treatments in dentistry Genetic counseling Heart disease 965
Category List Nutrition and children Obesity Obesity and aging Obesity and children Occupational health Osteoporosis Parasites Parkinson’s disease Pesticides Phenylketonuria (PKU) Physical fitness tests for children Plague Poisoning Poisonous plants Pregnancy among teenagers Prostate cancer Prostate enlargement Radiation Radon Recovery programs Reye’s syndrome Safety issues for children Scoliosis Screening Secondhand smoke Sexually transmitted diseases Sick building syndrome Skin cancer Skin disorders with aging Smog Smoking Snakebites Sports injuries among children Strokes Suicide Sunburns Tobacco use by teenagers Tuberculosis Ulcers Vision problems with aging Vitamin supplements Water quality Weight changes with aging Weight loss medications
Environmental diseases Exercise Exercise and children Exercise and the elderly First aid Fluoridation of water sources Food irradiation Food poisoning Frostbite Genetic diseases Genetically engineered foods Hazardous waste Headaches Health insurance Hearing loss Heart attacks Heart disease Heat exhaustion and heat stroke Herpes Hospitalization of the elderly Hypertension Iatrogenic disorders Illnesses among the elderly Immunizations for children Immunizations for the elderly Infertility in men Infertility in women Influenza Lactose intolerance Lead poisoning Lice mites & ticks Lung cancer Lyme disease Mad cow disease Malnutrition among children Malnutrition among the elderly Meningitis Mercury poisoning Multiple chemical sensitivity syndrome Muscle loss with aging Necrotizing fasciitis Noise pollution Nutrition and aging 966
Category List Obesity and aging Pregnancy among teenagers Recovery programs Reproductive technologies Secondhand smoke Smoking Suicide among children and teenagers Suicide among the elderly Tattoos and body piercing Tobacco use by teenagers Vitamin supplements
Well-baby examinations Worms Zoonoses Social Trends Abortion Abortion among teenagers Addiction Aging Alcoholism Alcoholism among teenagers Alcoholism among the elderly Alternative medicine Alzheimer’s disease Anorexia nervosa Arteriosclerosis Breast surgery Breast-feeding Cholesterol Cosmetic surgery and aging Cosmetic surgery and women Death and dying Diabetes mellitus Disabilities Domestic violence Drug abuse by teenagers Eating disorders Elder abuse Exercise Exercise and the elderly Hair loss and baldness Health insurance HMOs Holistic medicine Homeopathy Hospice Infertility in men Infertility in women Liposuction Living wills Morning-after pill Natural childbirth Nursing and convalescent homes Obesity
Treatment Acupuncture Antibiotic resistance Biofeedback Canes and walkers Cardiac rehabilitation Chemotherapy Fetal tissue transplantation First aid Fluoride treatments in dentistry Gene therapy Hearing aids Homeopathy Hormone replacement therapy Hospitalization of the elderly Hypnosis Laparoscopy Laser use in surgery Light therapy Mastectomy Medications and the elderly Morning-after pill Nursing and convalescent homes Overmedication Pain management Physical rehabilitation Recovery programs Reproductive technologies Resuscitation Transplantation Wheelchair use among the elderly 967
Category List Incontinence Infertility in women Liposuction Mammograms Mastectomy Menopause Menstruation Miscarriage Morning-after pill Multiple births Natural childbirth Nutrition and women Osteoporosis Pap smears Postpartum depression Pregnancy among teenagers Premature birth Prenatal care Reproductive technologies Sexual dysfunction Sterilization Women’s health issues Yeast infections
Women’s Health Abortion Abortion among teenagers AIDS and women Amniocentesis Anorexia nervosa Birth control and family planning Breast cancer Breast surgery Cervical ovarian & uterine cancers Childbirth complications Chronic fatigue syndrome Circumcision of girls Condoms Cosmetic surgery and women Domestic violence Eating disorders Endometriosis Fetal alcohol syndrome Foot disorders Heart disease and women Hormone replacement therapy Hysterectomy In vitro fertilization
968
INDEX Adult Children of Alcoholics (ACoA), 763 Adult day care, 75 Adult Protective Services, 314 Advance directives, 480, 567, 888 Advanced life support, 943 Adverse drug reactions, 697 Aerobic exercise, 346, 352, 357, 359, 363, 687, 943 African sleeping sickness, 706 Age-related macular degeneration, 574, 910 Age spots, 820 Aging, 21-29, 239; cosmetic surgery and, 229-231; dental problems and, 252-256; exercise and, 24, 356-364, 371, 633, 650, 920; muscle loss with, 23, 357, 361, 633, 648-651; nutrition and, 586, 649, 663-666; obesity and, 681-684, 920; reaction time and, 27, 759-760; reproductive system and, 27; skin disorders and, 23, 818-823, 884; sleep changes with, 25, 823-825; temperature regulation and, 28, 535, 820, 824, 884-885; vision problems and, 24, 574, 908-912; weight changes with, 23, 649, 682, 917-920 AIDS, 30-36, 811; children and, 36-41; women and, 41-43 Air pollution, 326, 814, 830 Air quality, 326, 814, 830 Al-Anon, 761 Alateen, 761-762 Alcohol, 48, 372, 548, 729; medications and, 698; pregnancy and, 50, 372; ulcers and, 906 Alcohol dependence, 48, 943 Alcohol poisoning, 729 Alcohol testing, 548 Alcoholics Anonymous (AA), 46, 760 Alcoholism, 15-16, 43-48; elderly and, 53-56; impotence and, 805; recovery programs for, 760; teenagers and, 48-53, 295
Abdominal fat, 681 Abdominal pain, 222 Abortion, 1-7, 458; AIDS and, 42; fetal tissue transplants and, 374; selective, 642; spontaneous, 632; teenagers and, 7-9 Abortion pill, 638 Abscess, 943; tooth, 254 Abstem, 46 Abuse; child, 150, 176-184, 282, 369, 645, 728; elder, 285, 311-316; partner, 283 Accidents, 535, 779 Acetaminophen, 97, 606, 728, 771 Acetylcholine, 708 Achilles tendon, 392 Acid pump inhibitors, 907 Acidosis, 943 Acquired immunodeficiency syndrome. See AIDS Acrochordons, 821 Actinic keratoses, 821 Actinic purpura, 819 Active immunity, 943 Activities of daily living, 658, 660 Acupressure, 63 Acupuncture, 9-13, 63 Acyclovir, 455, 812 ADA deficiency. See Adenosine deaminase (ADA) deficiency ADD. See Attention-deficit disorder (ADD) Addiction, 13-21, 295; recovery programs for, 761 Adenocarcinoma, 224, 569 Adenopathy, 943 Adenosine deaminase (ADA) deficiency, 398, 410 Adenosine triphosphate (ATP), 346, 943 Adenoviruses, 396, 943 Adhesion, 943 Adipose tissue, 943 Adrenal gland, 943 Adrenaline, 855
969
Index Alkylating agents, 173 Allergies, 56-62, 104, 206, 731, 943; asthma and, 104; chronic fatigue syndrome and, 204; food, 58, 668 Allotransplantation, 894, 943 Alopecia, 415, 943 Alpha-fetoprotein, 291, 482 Alprazolam, 260 Alternative medicine, 62-68 Alveoli, 103, 319, 322, 943 Alveolus, 943 Alzheimer’s disease, 69-77, 240, 502, 563, 659; malnutrition and, 588 AMA. See American Medical Association Amebic dysentery, 706 Amelogenesis imperfecta, 247, 250, 943 Amenorrhea, 84, 307, 616, 622, 692, 943 American Cancer Society, 597 American Medical Association, 459; abortion and, 1; assisted suicide and, 343; euthanasia and, 345 Aminoguanidine, 272 Amnesia, 612 Amniocentesis, 77-82, 130, 290, 765 Amnioinfusion, 4 Amniotic fluid, 78 Amniotic sac, 943 Amputation, 499, 833 Anabolic steroids, 853 Anaerobic, 943 Anaerobic exercise, 360 Analgesics, 97, 887 Anaphylactic shock, 58 Anaphylaxis, 60, 943 Androgenetic alopecia, 414 Anemia, 588, 944; pregnancy and, 738 Anencephaly, 626 Aneurysms, 499, 503, 859 Angina, 25, 160, 439, 443, 448 Angiography, 575 Angiomas, 820 Angioplasty, 441, 446, 449, 542 Ankylosing spondylitis, 96 Anodontia, 246, 250 Anomia, 71
Anorexia nervosa, 83-85, 305-307, 944 Anoxia, 555 Antabuse, 46 Antacids, 607, 905 Anthrax, 939 Antibiotic resistance, 86-90, 496, 902 Antibiotics, 86, 615; antitumor, 174 Antibody, 944 Antidepressants, 115, 259, 874, 944 Antidote, 944 Antigens, 894, 944 Antihistamines, 60 Antimetabolites, 173 Antioxidants, 587, 913 Antivenin, 836, 944 Anxiety, 698 Aphasia, 839, 944 Apnea, 826, 863, 944 Appetite suppressants, 678 Arcus senilis, 909 Aromatherapy, 65 Arrhythmias, 444, 446-447, 768, 944 Arteriosclerosis, 90-93, 271, 439, 443, 498, 859 Arthritis, 27, 93-99, 698; Lyme disease and, 572 Arthropods, 705, 941 Articulation, 838 Artificial insemination, 521, 527, 765 Artificial respiration, 767 Asbestos, 99-102, 326 Asbestosis, 100 Ascaris lumbricoides, 705 Aseptic meningitis, 614 Asian flu, 531 Asperger’s syndrome, 114 Aspirin, 701, 728, 771, 906 Assault, 315 Assisted living, 69 Assisted suicide, 343, 878 Asthma, 58, 102-107, 488; smoking and, 195, 802 Astigmatism, 542 Asymptomatic, 944 Asystole, 768 Atherectomy, 441 Atherosclerosis, 25, 90, 447, 498, 944 Athletes, 350, 853
970
Index ATP. See Adenosine triphosphate (ATP) Atria, 944 Atrial fibrillation, 444 Atrophy, 944 Attention-deficit disorder (ADD), 107-112 Attenuation, 944 Auditory dyslexia, 302 Aura, 421 Autism, 112-117 Autoimmune disorders, 27, 96, 204, 206 Autonomic nervous system, 118 Autosomal dominant diseases, 404 Autosomal recessive diseases, 404, 944 Autotransplantation, 944 Azathiaprine, 894 AZT, 33
Bereavement, 236 Bereavement counseling, 475 Beriberi, 582 Beta-agonists, 106 Bifocals, 909 Bile, 25 Binge drinking, 49, 296, 945 Binge eating, 308 Biofeedback, 64, 117-121, 517, 945 Biomagnification, 714 Biopsy, 702, 945 Bipolar disorder, 257, 736, 945 Birth control, 121-126, 227, 765 Birth defects, 126-133, 193, 216, 276, 289, 400, 641, 838, 841; learning disabilities and, 554 Birthing centers, 653 Birthmarks, 543, 816 Bites; animal, 939; human, 179 Bleeding, 377, 543 Blepharoplasty, 229 Blind spot, 574 Blindness, 574, 810, 911 Blisters, 395, 453, 810, 879 Blood clots, 859 Blood pressure, 362, 439, 483-484 Blood thinners, 605 Blood transfusions, 59 Blue bloaters, 319 Blurred vision, 574, 860 BMI. See Body mass index (BMI) Body composition, 348, 649, 681, 834, 918, 945 Body mass index (BMI), 367, 681, 684, 945 Body piercing, 880-881 Body shape, 681 Bonding, 945 Bone loss, 650, 692 Bone marrow, 156, 175 Bones, 23, 692; broken, 147 Boosters, 508 Botulism, 386 Bovine growth hormone, 413 Bovine spongiform encephalopathy, 577 Braces, orthopedic, 788, 847 Bradycardia, 359, 444, 498, 945
Babies, 922 Baby blues, 735 Bacillus Calmette-Guérin (BCG) vaccine, 902 Bacteria, 86, 944; flesh-eating, 654 Bacterial meningitis, 614 Balance, 361 Balance disorders, 25, 54, 370 Baldness, 24, 230, 414-418 Balloon angioplasty, 441, 446, 449 Barbiturates, 698 Bargaining, 236 Basal cell carcinoma, 817, 822 Basal ganglia, 944 Basal metabolic rate, 27, 944 Basic life support, 944 BCG vaccine. See Bacillus Calmette-Guérin (BCG) vaccine Beattie, Melody, 762 Bedsores, 480, 820, 904 Bee stings, 58 Behavioral therapy, 18 Benign, 945 Benign cells, 153 Benign prostatic hyperplasia, 755 Benign senescent forgetfulness, 239, 611 Benzodiazepines, 827
971
Index Brain, 27, 481, 502, 588, 613, 708, 759, 858; dyslexia and the, 301 Brain damage, 626, 860 Breast cancer, 133-137, 402, 595, 599, 674, 930 Breast-feeding, 137-143, 666, 675 Breast milk, 139, 667 Breast surgery, 136, 143-146, 232, 600 Breathalyzer, 548 Breathing, 322, 357, 377, 922 Breech birth, 186 Bridges, 253 Broad-spectrum antibiotics, 86 Broken bones; elderly and, 147-149, 370 Bronchioles, 103, 322, 945 Bronchitis, 319, 321, 833 Bronchodilators, 105 Brow lifts, 229 Brown bag days, 607 Brown recluse spider, 941 Brucellosis, 939 Bruises, 178, 181, 819 Bubonic plague, 331, 725, 941 Bulimia, 308, 798 Bunions, 394 Burns, 149-152, 317, 535, 776, 820; child abuse and, 179 Bypass surgery, 441, 446 Byssinosis, 327
568-571, 758, 833, 930; nutrition and, 674; obesity and, 677, 683; ovarian, 167-172; pesticides and, 715; phytochemicals and, 913; prostate, 501, 751-754; skin, 23, 816-818, 822; smoking and, 801; uterine, 167-172, 702; women and, 930 Candidiasis, 935 Canes, 157-159, 781 Cannula, 945 Capacitation, 945 Capillaries, 819 Carbohydrates, 945 Carbon monoxide, 326, 801 Carcinogens, 100, 225, 380, 800, 945 Cardiac rehabilitation, 160-165, 350 Cardiopulmonary resuscitation (CPR), 200, 293, 767, 945 Cardiovascular disease, 160, 945 Cardiovascular system, 25, 357 Carpal tunnel syndrome, 165-167, 690 Cartilage, 94 Casts, 788 Cat-scratch fever, 938 Cataplexy, 826 Cataracts, 24, 542, 911 Cats, 938 Cavities, 248-249, 251, 253; prevention, 382 Cell therapy, 66 Cellular clock theory of aging, 22 Central nervous system, 946 Cephalopelvic disproportion, 186 Cerebral cortex, 946 Cerebrospinal fluid (CSF), 481, 946 Cerebrovascular accident, 858 Cervical cancer, 167-172, 702 Cervix, 490, 526, 946 Cesarean section, 184, 745 Chagas’ disease, 707 Chancre, 809 Chemicals, 418, 643, 711 Chemotherapy, 134, 155-156, 172-176, 226, 600, 888, 946 Cherry angiomas, 820 Chest compressions, 767 Ch’i, 9, 63
Cachexia, 648 Caffeine, 516, 745; breast milk and, 142; insomnia and, 826; pregnancy and, 193; ulcers and, 906 Calcitonin, 694 Calcium, 587, 665, 674, 693, 695 Caloric restriction, 28 Calories, 677, 945 Cancer, 27, 133, 152-157, 172, 479, 503, 833, 945; asbestos and, 100; breast, 133-137, 402, 595, 599, 674, 930; cervical, 167-172, 702; colon, 224-227, 501, 930; Down syndrome and, 289; fluoride and, 380; food irradiation and, 383; gene therapy and, 398; hysterectomy and, 494; lasers and, 543; lung, 100, 501,
972
Index Chronic obstructive pulmonary disease, 319-320, 501, 833 Cigarettes, 890. See also Smoking Circadian rhythms, 65, 797, 824, 946 Circulatory problems, 605 Circumcision; boys, 208-213; girls, 213-216 Cirrhosis, 26, 44, 897, 946 Clean Air Act, 99, 552 Cleft lip, 216-221 Cleft palate, 216-221 Climacteric, 27 Clinical trial, 946 Clitoris, 214 Cloning, 412, 513 Cluster headaches, 422, 425 Coal, 327, 830 Cobalt 60, 383 Cocaine, 16, 299 Codependency, 762 Codependents Anonymous (CoDA), 763 Co-Dependents of Sex Addicts (COSA), 762 Cognitive, 946 Cognitive skills, 70, 759 Cognitive therapy, 17 Coitus interruptus, 123 Cold, 721 Cold sores, 453 Colic, 222-224 Collagen, 23, 819 Colon, 501 Colon cancer, 224-227, 501, 930 Colon therapy, 66 Colonoscopy, 225 Color vision, 909 Colorado tick fever, 560 Colostrum, 139, 946 Coma, 730 Compulsion, 946 Compulsive behavior, 113 Computed tomography (CT) scan, 946 Comstock Law, 123 Con artists, 315 Condom catheters, 518 Condoms, 123, 227-228 Conductive hearing loss, 432, 435
Chickenpox, 190, 453, 455; Reye’s syndrome and, 771 Child abuse, 150, 176-184, 282, 369, 645, 728 Childbirth; complications of, 184-187; depression following, 735; natural, 651-654 Childhood infectious diseases, 187-191, 194, 506 Childproofing, 200, 369, 772 Children; AIDS and, 36-41; dental problems in, 218, 244-252; depression in, 262-264; drowning and, 294; effects of smoking on, 194, 802; exercise and, 351-356, 686; falls among, 181, 368-369, 773; health issues and, 177, 191-196, 718; immunizations for, 193, 504-507; lead poisoning and, 551; malnutrition among, 580-586; nutrition and, 367, 580, 666-673; obesity and, 684-689; physical fitness tests for, 718-720; safety issues for, 200, 369, 772-779; sports injuries among, 355, 843-848; suicide among, 871-875 Chinese medicine, 9 Chiropractic, 64 Chlamydia, 812 Chlorinated hydrocarbons, 712 Chlorination, 197-198, 327, 917 Chlorine, 197, 917 Chloroform, 198 Choking, 198-200, 535, 776 Cholecystectomy, 539, 946 Cholecystitis, 500 Cholesterol, 90, 92, 200-202, 500, 673, 683, 928 Cholinesterase inhibitors, 73 Chorionic villi, 946 Chorionic villus sampling, 81, 130, 291, 765 Chromosomal abnormalities, 79, 127, 626 Chromosomes, 287, 291, 400, 404, 946 Chronic bronchitis, 321 Chronic fatigue syndrome, 202-208 Chronic illnesses, 478; suicide and, 876
973
Index Confusion, 71, 480 Congenital disease, 946 Congestive heart failure, 25 Conjoined twins, 640 Conjunctivitis, 810, 946 Connective tissue, 946 Constipation, 699 Contact dermatitis, 58, 820 Contraception. See Birth control; Condoms; Hysterectomy; Sterilization Contusions, 845, 946 Convalescent homes, 658-663; elder abuse in, 313 Coordination, 361 Cornea, 909 Corneal sculpting, 542 Coronary arteries, 946 Coronary artery bypass graft, 449 Coronary artery disease, 443, 445, 447, 749, 927, 946 Coronary bypass surgery, 441, 446, 749 Corpus luteum, 525, 621-622, 946 Corticosteroids, 106 Cortisone, 694 Cosmetic surgery, 565; aging and, 229-231; women and, 231-233 Coughing, 198 Coumadin, 605 Cox inhibitors, 97 CPR. See Cardiopulmonary resuscitation (CPR) Crab lice, 559 Crack, 299 Creutzfeldt-Jakob disease, 577 Cri du chat syndrome, 128, 404 Cribs, 773 Crime against the elderly, 314, 536 Crohn’s disease, 501 Cross-linkage theory of aging, 22 Crowns, 253 Cryokinetics, 722 Cryopreservation, 513, 522, 947 Cryotherapy, 844 Crypt, 947 Culdoscopy, 849 Cushing’s syndrome, 676 Cuspids, 947
Cutaneous, 947 Cutaneous horns, 821 Cyanosis, 319 Cyclosporine, 894 Cyclothymia, 258, 947 Cystic fibrosis, 398 Cytomegalovirus, 454, 456 D & C. See Dilation and curettage (D & C) D & E. See Dilation and evacuation (D & E) Dairy products, 537 Dalmane, 698 DDT, 712 Deafness, 433, 657 Death, 234-239, 341, 632, 862, 866; children and, 871 Debridement, 947 Deciduous teeth, 947 Decubital ulcers, 480 Deductibles, 427 Defibrillation, 947 Defibrillators, 768 Dehydration, 54, 536, 884, 922, 947 Delirium, 480, 733, 947 Delirium tremens, 44, 947 Delusions, 782, 947 Dementia, 69-70, 239-244, 267, 588, 611, 659 Denial, 235 Dental caries, 947 Dental problems; children and, 218, 244-252; elderly and, 252-256 Dentin, 253 Dentinogenesis imperfecta, 247, 250 Dentistry; fluoride treatments in, 381-382 Dentures, 253, 255 Deoxyribonucleic acid. See DNA Depo-Provera, 125 Depression, 256-262, 947; children and, 262-264; dying and, 236; elderly and, 55, 265-268, 876; hysterectomy and, 493; memory loss and, 612; postpartum, 735-736; suicide and, 867; summer, 796; winter, 796; women and, 931
974
Index Dermatitis, 732, 820 Dermatitis, contact, 58 Dermis, 947 DES. See Diethylstilbestrol Desensitization, 61 Detached retina, 909, 911 Detoxification, 51, 67, 947 DHEA, 22 Diabetes mellitus, 268-274, 362, 408, 500, 588, 677, 683, 929; fetal tissue transplants and, 375; transplantation and, 897 Diabetic retinopathy, 911 Dialysis, 409, 484, 895 Diastolic pressure, 484 Diathermy, 721 Diazepam, 698 Diet pills, 921 Diethylstilbestrol, 638 Dieting, 83, 678-679, 683, 686 Digestive system, 25 Dihydrotestosterone (DHT), 415 Dilation, 947 Dilation and curettage (D & C), 4 Dilation and evacuation (D & E), 4 Dioxin, 327 Diphtheria, 190, 506, 510 Disabilities, 274-279, 433, 925; insurance for, 427 Disease, 331 Dislocations, 845, 947 Disorientation, 55 Disseminated, 947 Diuretics, 54, 606, 694 Diverticulosis, 501 Dizziness, 370 DNA, 22, 412, 947; testing, 548 DNR status. See “Do not resuscitate” status “Do not resuscitate” status, 76, 567 Dogs, 939 Domestic violence, 279-287, 312 Dominant gene, 947 Dopamine, 708, 784 Double-blind study, 947 Double vision, 860 Down syndrome, 72, 79-80, 127, 287-293, 626, 745, 947
DPT vaccine, 506 Drinking water, 100, 197, 327, 378, 914 Driving, 536, 635, 637, 759, 780 Drowning, 293-295, 775 Drug abuse, 730; pregnancy and, 193; recovery programs for, 761; steroids and, 853; suicide and, 868; teenagers and, 295-300 Drug interactions, 54-55, 698, 834 Drug resistance, 86 Dry eyes, 909 Dry skin, 819 Durable power of attorney, 76, 345, 568, 888, 947 Dust mites, 560 Dying, 234-239, 473 Dysfunction, 948 Dysgraphia, 302 Dyslexia, 300-305, 553, 948 Dysmenorrhea, 622 Dysthymia, 258, 948 E. coli, 948 Ears, 433, 923 Earwax, 435 Eating disorders, 83, 305-311, 622, 948; stress fractures and, 846 Ebola virus, 335 ECG. See Electrocardiogram (EKG or ECG) Eclampsia, 738, 948 Ectodermal dysplasia, 246 Ectopic pregnancy, 850, 948 Eczema, gravitational, 822 Edema, 319, 948 EEG. See Electroencephalogram (EEG) Efficacy, 948 Eggs, 511 EKG. See Electrocardiogram (EKG or ECG) Elastin, 23 Elder abuse, 282, 285, 311-316 Elderly; alcoholism among, 53-56; broken bones in, 147-149, 370; dental problems and, 252-256; depression and, 55, 265-268, 876; exercise and, 24, 356-364, 371, 633, 650, 920; falls and, 148, 370-371,
975
Index Enzyme therapy, 66 Enzymes, 948 Epidemics, 331-336, 531, 792, 948 Epidemiology, 948 Epidermis, 948 Epididymis, 948 Epstein-Barr virus, 203, 454, 456 Erectile dysfunction, 805 Erection, 804 Eruption cysts, 245 Erythematous, 948 Erythroblastosis fetalis, 59 Erythropoietin, 409 Estrogen, 170, 472, 617, 621, 635, 918, 928, 949 Ethics, 336-341, 410, 458, 514, 547, 549, 642, 793 Etiology, 949 Euthanasia, 341-346, 458, 877, 949 Excessive daytime sleepiness, 826 Executors, 75 Exercise, 346-351, 485, 723; cardiac rehabilitation and, 160; children and, 351-356, 686; diabetes mellitus and, 273; elderly and, 24, 356-364, 371, 633, 650, 920; osteoporosis and, 693; pregnancy and, 746; weight loss and, 678 Eye examinations, 575 Eye surgery, 541 Eyelid surgery, 229 Eyes, 24, 574, 923
633, 779; hospitalization of, 476-481; illnesses and, 497-504; immunizations for, 508-511; injuries among, 535-537, 779; malnutrition among, 586-589, 665; medications and, 54, 267, 479, 604-609, 697; mobility problems in, 157, 632-638, 648, 708, 781, 924; nutrition and, 586, 649, 663-666; obesity and, 681-684, 920; safety issues for, 149, 370, 779-782; skin disorders and, 23, 818-823, 884; sleep changes and, 25, 823-825; suicide among, 875-878; temperature regulation in, 28, 535, 820, 824, 884-885; vision problems in, 24, 574, 908-912; wheelchair use among, 781, 924-926 Electrical shock, 316-318 Electrocardiogram (EKG or ECG), 768, 948 Electroconvulsive therapy, 260, 948 Electrocution, 318 Electrodermal response, 118 Electroencephalogram (EEG), 118, 948 Electrolyte imbalance, 308 Electrolytes, 948 Electromagnetic fields, 328 Electromyograph, 118 Embolus, 859 Embryo, 126, 217, 841, 948 Emphysema, 318-323, 327, 501, 543, 833, 948 Enamel, 253-254 Encephalitis, 940 Endemic disease, 331, 948 Endocrine system, 26 Endometrial cancer, 170 Endometriosis, 323-325, 491, 512, 526, 539, 948 Endoscopy, 479, 907 Endurance training, 634 Enemas, 66 Energy medicine, 66 Environmental diseases, 128, 194, 325-331, 333 Environmental tobacco smoke, 801
Face lifts, 229, 232-233 Factitious disorders, 364-367 Failure to thrive, 39, 367-368 Fallen arches, 391 Fallopian tubes, 526, 849, 949 Falls; children and, 181, 368-369, 773; elderly and, 148, 370-371, 633, 779 Families Anonymous, 762 Family planning, 121-126 Family size, 122 Family violence, 280 Farm animals, 939 Farsightedness, 24, 542 Fat, 92, 201, 348, 565, 675, 918
976
Index Fat deposition, 682; medications and, 605 Fat-soluble medications, 606, 698 Fatigue, 202 FDA. See Food and Drug Administration (FDA) Feet, 391 Fen-Phen, 921 Fertility, 122 Fertility drugs, 527, 642 Fertilization, 512 Fetal alcohol syndrome, 45, 50, 193, 372-373, 746, 949 Fetal distress, 185 Fetal tissue transplantation, 373-376, 576, 710 Fetoscope, 81 Fetus, 81, 547, 949 Fibrillation, 440, 444, 949 Fibroids, uterine, 491 Fight-or-flight response, 855 Fires, 535 First aid, 376-378, 723, 767 Fish, 630 Flatfeet, 391 Flatulence, 949 Flatworms, 706, 933 Flavr Savr tomato, 412 Fleas, 725, 941 Flesh-eating bacteria, 654 Flexibility, 348 Floaters, 909 Flu. See Influenza Fluency, 839 Flukes, 706, 933 Fluoridation of water sources, 249, 254, 327, 378-381 Fluoride, 249, 379, 381 Fluoride treatments in dentistry, 381-382 Fluorosis, 248, 250 Flurazepam, 698 Folic acid, 582 Follicles, 414, 949 Food, 586, 676; genetic engineering of, 411-414; irradiation of, 382-384 Food allergies, 58, 668
Food and Drug Administration (FDA), 339, 389, 468 Food Guide Pyramid, 669 Food poisoning, 385-390 Foot disorders, 390-394 Foremilk, 139, 949 Forensic medicine, 545 Foreskin, 209 Forgetfulness, 55, 70, 240 Formaldehyde, 326 Formula, 667 Fractures, 147, 369; child abuse and, 179, 182; hip, 147, 370, 780; stress, 846; tooth, 254 Framingham Heart Study, 91 Fraternal twins, 639 Free radicals, 23, 816, 913 Freud, Sigmund, 489 Frostbite, 395-396, 820 Functional incontinence, 516 Fungicides, 712 Galactosemia, 405 Gallbladder, 500 Gallbladder removal, 540 Gallstones, 25, 500 Gamblers Anonymous (Gam-Anon), 762 Gamete intrafallopian transfer (GIFT), 513, 527 Gametes, 949 Gangrene, 271, 395, 722, 949 Gastrointestinal system, 25, 500 Gastroplasty, 679 Gene, 949 Gene therapy, 396-399, 406, 409 General anesthesia, 949 Genetic counseling, 79, 129, 292, 399-403, 405, 745 Genetic diseases, 79, 127-128, 400, 403-407; learning disabilities and, 554; screening for, 794 Genetic engineering, 396, 408-411, 460; vaccines and, 506 Genetically engineered foods, 411-414 Genetics, 22 Genital herpes, 453, 810, 812 Genital warts, 811-812
977
Index Genome, 949 German measles, 188 Giardiasis, 706 GIFT. See Gamete intrafallopian transfer (GIFT) Gingival hyperplasia, 255 Gingivitis, 245, 255 Glaucoma, 24, 833, 910 Glucose, 268, 271-272 Glucose intolerance, 362 Glucosuria, 269 Glycogen, 949 Glycolysis, 360 Goiter, 582 Gonorrhea, 810, 812 Gout, 95 Graafian follicle, 949 Granulomas, 851 Gravitational eczema, 822 Gray hair, 24 Grief, 55, 236 Growth, 152 Growth hormone, 635 Growth impairment, 367, 372 Guardians, 75 Gum disease, 245, 254, 833 Gums, 246, 253-255
Health maintenance organizations. See HMOs Hearing aids, 432-435 Hearing loss, 24, 432, 435-438, 657; speech disorders and, 839 Heart, 358, 439, 498 Heart attacks, 25, 91, 119, 160, 439-443, 446-447, 749, 769, 833, 927, 952 Heart block, 444 Heart disease, 90, 160, 442-447, 478; vitamins and, 587; women and, 447-450, 617, 673, 927 Heart failure, 25, 319, 445, 499 Heart rate, 349, 949 Heartbeat, 444 Heat, 721 Heat exhaustion, 450-452 Heat loss, 884 Heat stroke, 450-452, 819 Heel lifts, 393 Heels, 391 Height loss, 23 Heimlich maneuver, 199, 377, 776, 949 Helplessness, 266 Hemorrhoids, 501 Hepatitis, 190, 506, 811, 897 Herbal medicine, 66 Herbal remedies, 607, 699 Herbicides, 711, 915 Hereditary, 949 Heroin, 16 Herpes, 203, 452-458, 810, 812 Herpes simplex, 453, 455 Herpes zoster, 190, 822 High blood pressure. See Hypertension High chairs, 773 High-density lipoproteins (HDLs), 201 Hindmilk, 139, 950 Hip fractures, 147, 370, 780 Hippocratic oath, 345, 458-461 Histamine, 57, 950 Histamine II blockers, 907 HIV, 31, 38, 41, 204, 811; yeast infections and, 935 HMOs, 426, 428, 461-464, 791 Holistic care, 473-474 Holistic medicine, 62, 465-467
Hair, 414, 922 Hair growth, 24, 417 Hair loss, 24, 230, 414-418; chemotherapy and, 155 Hair transplantation, 230, 416 Hairpieces, 416 Hallucinations, 72, 733, 949 Hare lip, 216 Harrington rod technique, 789 Hay fever, 58 Hayflick, Leonard, 21 Hazardous waste, 327, 418-420 HDLs. See High-density lipoproteins (HDLs) Headaches, 117, 421-426, 657, 931 Healing process, 26, 147, 820 Health care reform, 593 Health insurance, 426-432, 462, 791; scams, 315
978
Index Home births, 653 Homeopathy, 66, 467-471 Homeostasis, 950 Hong Kong flu, 531 Hookworm, 705 Hormonal therapy, 174 Hormone replacement therapy, 471-472, 617, 635, 674, 694 Hormones, 26, 471, 855, 950 Hospice, 466, 473-476, 950 Hospitalization; elderly and, 476-481; insurance for, 427 Hot flashes, 616 HRT. See Hormone replacement therapy Human immunodeficiency virus. See HIV Huntington’s disease, 375, 400 Hurler’s syndrome, 375 Hydrocephalus, 481-483, 502, 950 Hydrochloric acid, 664, 905 Hydrotherapy, 64, 722 Hyperactivity, 107 Hyperalimentation, 307 Hyperlipidemia, 269 Hyperopia, 542 Hypersomnia, 950 Hypertension, 25, 119, 444, 483-486, 683, 927; exercise and, 362; obesity and, 677 Hyperthermia, 864, 950 Hypnosis, 487-490 Hypodontia, 246, 250 Hypoplasia, 950 Hypothalamus, 450, 676 Hypothermia, 293, 536, 950 Hypothyroidism, 676 Hypoxia, 950 Hysterectomy, 5, 168, 170, 324, 490-495, 616, 849, 851, 927, 950 Hysterotomy, 5
Imaging, 595 Immune system, 27, 206, 894, 950 Immunity, 950 Immunizations; children and, 193, 504-507; elderly and, 508-511 Immunoglobulins, 140 Immunosuppressive drugs, 894 Implants; dental, 253 Impotence, 753, 804; smoking and, 833 In utero, 950 In vitro, 950 In vitro fertilization, 511-515, 528, 765 In vivo, 950 Inborn errors of metabolism, 405 Incidence, 950 Incontinence, 515-520 Independent living, 636 Infant mortality, 192 Infants, 922 Infectious diseases, childhood, 187-191, 194, 506 Infertility, 512, 765, 950; men and, 189, 520-525; women and, 492, 525-530 Infibulation, 214 Inflammation, 950 Influenza, 498, 508, 530-535; Reye’s syndrome and, 771 Influenza B, 189, 506 Informed consent, 793 Infrared light, 721 Inhalers, 106 Injuries; elderly and, 535-537, 779 Insecticides, 711 Insects, 940 Insomnia, 25, 698, 826, 828, 950 Institutionalized elders, 313 Insulin, 268, 270, 362, 408 Insurance, 426; automobile, 637; disability, 427; hospitalization, 427 Insurance scams, 315 Intelligence quotient. See IQ Intercourse, 804 Interferon, 175 Intermediate care facility, 659 Intermittent claudication, 499 Intestinal bypass surgery, 687
Iatrogenic disorders, 479, 495-497, 950 Ibuprofen, 606, 771 Identical twins, 640 Idiopathic, 950 IgE antibodies, 104 Illnesses; elderly and, 478, 497-504
979
Index Intrauterine device (IUD), 125 Intrinsic factor, 664 Iodine, 582 IQ, 625 IQ scores, 114 Iron, 665 Iron-deficiency anemia, 582, 588 Irradiation, 382 Ischemia, 443, 950 Islets of Langerhans, 950
Law and medicine, 343, 544-550, 591 Law of Similars, 467 Laxatives, 607, 699 LDLS. See Low-density lipoproteins (LDLs) Lead poisoning, 195, 327, 550-552, 555, 626, 729, 778 Learned helplessness, 266 Learning disabilities, 195, 301, 552-558 Lecithins, 78 Legionnaires’ disease, 815 Lens, 24, 908 Leukemia, 289 Levinson, Harold N., 304 Levodopa, 710 Libido, 951 Lice, 558-563 Life expectancy, 21 Life span, 21 Life support, 344, 460, 549 Ligaments, 94, 951 Light therapy, 65, 261, 563-564, 799 Lipoproteins, 201 Liposuction, 565-567 Listeria, 386 Lithium, 46, 260 Little Leaguer’s elbow, 846 Liver, 44, 606 Liver spots, 820 Liver transplantation, 896 Living wills, 76, 344, 567-568, 877, 888, 951 Local anesthesia, 951 Longevity, 21 Longevity research, 28 Low birth weight, 738 Low-density lipoproteins (LDLs), 90, 201 Lumbar puncture, 614 Lumpectomy, 134, 600 Lung cancer, 334, 501, 568-571, 930; asbestos and, 100; radon and, 758; smoking and, 833 Lung disease, 319, 833-834 Lungs, 102, 319, 357 Lupus, 96, 928 Lyme disease, 334, 560, 571-573, 940 Lymph nodes, 951 Lymphocytes, 30, 894, 951
Jaw, 253 Joints, 93, 572 Kala-azar, 707 Kaposi’s sarcoma, 30, 817 Karyotype, 951 Karyotyping, 81, 291, 405 Kegel exercises, 517, 746 Keratoacanthoma, 821 Keratoses, 821 Ketonuria, 269 Kevorkian, Jack, 343 Kidney failure, 271, 483 Kidney stones, 502 Kidney transplantation, 895 Kidneys, 501, 606 Killer fog, 830 Killer T cells, 31 Kinesiology, 66 Kinesthetic imprinting, 303 Korsakoff’s psychosis, 44 Kübler-Ross, Elisabeth, 235 Kwashiorkor, 580, 951 Kyphosis, 96 Labor, 632 Lactation, 138 Lactic acid, 347, 360 Lactose intolerance, 537-538 Lamaze method, 652 Landfills, 419 Language disorders, 839 Language skills, 71 Laparoscopy, 324, 538-541, 849, 951 Large intestine, 501 Laser use in surgery, 541-544 Latent, 951
980
Index Macrophages, 30, 322 Macular degeneration, 574-577, 910; smoking and, 833 Mad cow disease, 577-579 Magnetic field therapy, 67 Malaise, 951 Malaria, 940 Male pattern baldness, 414 Malignancy, 154 Malignant, 951 Malnutrition, 141; children and, 580-586; elderly and, 586-589, 665; women and, 622 Malocclusion, 254 Malpractice, 590-594 Mammograms, 594-599, 601, 951 Managed care, 428-429, 462 Manic-depressive disorder. See Bipolar disorder MAO inhibitors. See Monoamine oxidase (MAO) inhibitors Marasmus, 580, 951 Marijuana, 299 Massage, 723 Mastectomy, 134, 599-604, 927, 951; preventive, 402; radical, 135 Measles, German, 188 Measles, red, 187, 332, 506 Medicaid, 430, 661 Medical errors, 495 Medical experts, 545 Medicare, 430, 477, 661; hospice and, 475 Medications, 729, 886; elderly and, 54, 267, 479, 604-609, 697; falls and, 370; poisoning and, 535; smoking and, 834; weight loss, 678 Meditation, 63, 609-610, 937 Meiosis, 951 Melancholia, 782 Melanin, 24, 817 Melanocytes, 816, 819-820 Melanoma, 817 Melatonin, 23, 26, 797, 824 Memory loss, 71, 239, 267, 502, 611-613 Men; health issues and, 414, 752, 755; infertility in, 520-525
Menarche, 620, 951 Ménière’s disease, 437 Meningitis, 189, 613-616 Menopause, 27, 472, 493, 616-620 Menorrhagia, 623 Menstrual cycle, 951 Menstrual extraction, 3 Menstruation, 141, 324, 616, 620-624 Mental impairment, 69, 659 Mental incompetence, 242 Mental retardation, 289, 372, 625-629 Mercury, 630 Mercury poisoning, 327, 629-631 Mercy killing, 341 Meridians, 10 Metabolism, 27, 348, 405, 649, 663, 697, 834, 918, 951 Metastasis, 154, 952 Methyl mercury, 630 Microcephaly, 626 Middle ear, 433 Middle-ear infections, 436 Midwifery, 653 Mifepristone, 638 Migraines, 421, 424, 952 Milk, 413, 587; breast, 139, 667 Milk ducts, 138 Mineral deficiencies, 582, 587 Minerals, 587, 665, 671, 952 Minigrafts, 230 Minoxidil, 416 Miscarriage, 374, 632, 641 Misdiagnosis, 496 Mites, 558-563 Mitosis, 952 Mitral valve prolapse, 447 Mobility problems, 275; elderly and, 157, 632-638, 648, 708, 781, 924 Molars, 952 Moles, 816 Monoamine oxidase (MAO) inhibitors, 259, 698 Mononucleosis, 203, 454, 456 Mood disorders, 256 Morning-after pill, 638-639, 765 Mosaicism, 287 Mosquitoes, 705, 940 Motor impairments, 275
981
Index Motor skill development, 353 Mouth disorders, 253 Multiple births, 639-643, 745 Multiple chemical sensitivity syndrome, 195, 643-645 Multiple infarct dementia, 241, 612 Mumps, 188 Münchausen syndrome, 365 Münchausen syndrome by proxy, 645-648, 728 Muscle loss with aging, 23, 357, 361, 633, 648-651 Muscles, 347, 361, 648, 718 Musculoskeletal, 952 Mushrooms, 733 Mutagen, 952 Mutations, 128, 153, 400, 952 Mycobacteria, 899 Mycosis fungoides, 817 Myocardial infarctions. See Heart attacks Myocardium, 952 Myomectomy, 491 Myopia, 542
Niacin, 582 Nicotine, 15, 801; breast milk and, 142 Night blindness, 24, 581, 910 Night terrors, 827 Night vision, 370 Nightmares, 827 Noise pollution, 656-657 Nonsteroidal anti-inflammatory drugs (NSAIDs), 97, 701 Norplant, 125 Nose, 923 NSAIDs. See Nonsteroidal anti-inflammatory drugs (NSAIDs) Nurses, 474 Nursing caries, 249, 252, 952 Nursing homes, 69, 75, 658-663; elder abuse in, 313; overmedication in, 699 Nutrients, 580, 586, 663, 912 Nutrition, 912; aging and, 586, 649, 663-666; children and, 367, 580, 666-673; pregnancy and, 129, 675, 745; women and, 673-675 Oat cell carcinoma, 569 Obesity, 85, 309-310, 675-681, 684; aging and, 681-684, 920; children and, 684-689; diabetes mellitus and, 270; weight loss medications and, 921; women and, 673 Obsessive-compulsive disorder, 83, 952 Obturator, 220 Occupational health, 101, 657, 689-692, 723, 748, 802 Offgassing, 814 Omega-3 fatty acids, 92 Oncogenes, 153, 952 Oophorectomy, 490 Opiates, 729 Opioids, 887 Orchiectomy, 753 Orchitis, 189, 952 Organic disease, 952 Orthotic devices, 393 Orton-Gillingham-Stillman method, 303 Osgood-Schlatter disease, 845 Ossicles, 952
Narcolepsy, 826, 828, 952 Narcotics, 474, 698, 701 Narcotics Anonymous, 761-762 National Institutes of Health, 410 Natural childbirth, 651-654 Nearsightedness, 542, 909 Necrosis, 952 Necrotizing fasciitis, 654-655 Neglect, 179, 281, 285, 311-312 Negligence, 590 Nematodes, 705 Neonatal, 952 Neoplasm, 952 Nerve deafness, 433 Nerves, 165, 820 Nervous system, 27, 361, 841, 952 Neural therapy, 67 Neural tube, 841 Neuromas, 391 Neurons, 72, 708 Neuropathy, 952 Neurotransmitters, 259, 952 Neutrophils, 322
982
Index Osteoarthritis, 94, 97, 503, 698 Osteopenia, 650 Osteoporosis, 23, 96, 147, 149, 370, 503, 587, 674, 692-697, 953; children and, 582; exercise and, 361; fractures and, 147 Otitis media, 436 Otosclerosis, 433, 436 Ovarian cancer, 167-172 Ovariectomy, 849 Ovaries, 490, 525, 621, 849, 953 Over-the-counter medications, 607 Overbite, 254 Overdoses, 296, 728 Overeaters Anonymous (O-Anon), 762 Overflow incontinence, 516, 518 Overmedication, 604, 697-700 Oviducts, 526, 953 Ovulation, 525, 621, 953 Ovum, 953 Oxygen, 321, 356 Oxygen therapy, 65 Oxytocin, 138, 632, 953 Ozone, 818, 831, 917
PCBs, 142, 327, 915 Peak flow meter, 106 Pedestrians, 780 Pellagra, 582 Pelvic inflammatory disease (PID), 526, 810 Pelvic prolapse, 518 PEM. See Protein energy malnutrition (PEM) Penicillin, 811 Penile clamp, 518 Penis, 209 Pepsin, 905 Peptic ulcers, 904 Perforated eardrum, 436 Perimenopause, 616 Periodic leg movement during sleep, 823 Periodontal disease, 254 Peripheral vision, 24, 908 Personality changes, 71 Perspiration, 450 Pertussis, 190 Pessary, 518 Pesticides, 327, 413, 643, 711-715, 915 Pets, 938 Pharmacists, 55, 608 Pharmacodynamics, 14 Pharmacokinetics, 14 Pharmacology, 953 Pharynx, 953 Phenol, 801 Phenylketonuria (PKU), 142, 401, 626, 715-717 Photochemical smog, 831 Photodynamic therapy, 543 Photonutrients, 912 Photoreceptors, 908 Photosensitivity, 820 Phototherapy, 65, 261, 563, 799 Physical fitness tests for children, 718-720 Physical rehabilitation, 720-724 Physician-assisted suicide, 877 Phytochemicals, 913 Pica, 113, 953 Pick’s disease, 240
Pacemakers, 440, 446, 769 Pain, 701 Pain management, 12, 488, 700-702, 886 Painkillers, 97, 474, 606, 701; terminal illnesses and, 887 Palate, 216 Pancreas, 272, 500, 895 Pancreas transplantation, 897 Pandemics, 331, 531 Pap smears, 168, 171, 702-703 Paralysis, 860; sleep, 826 Paranoia, 72-73, 783 Parasites, 558, 703-708, 933 Parasympathetic nervous system, 359 Parents Anonymous (PA), 762 Parkinson’s disease, 708-711, 953; fetal tissue transplants and, 374 Partial dentures, 253 Partner abuse, 283 Passive immunity, 953 Pathogen, 953 Patient Self-Determination Act, 888
983
Index PID. See Pelvic inflammatory disease (PID) Piercing, 880 Pill, birth control, 125, 617 Pink puffers, 319 Pink Ribbon Campaign, 136 Pinworm, 705 PKU. See Phenylketonuria (PKU) Placebo, 953 Placenta, 953 Placenta abruptio, 185, 742 Placenta previa, 185, 742 Plague, 331, 725-727, 941 Plantar fascitis, 391 Plants, poisonous, 387, 731-734, 777 Plaque, 953; arterial, 91, 443, 499, dental, 248, 254 Plastic surgery, 229 Platinum analogues, 175 Playgrounds, 774 Playpens, 773 PMS, 623 Pneumocystis carinii pneumonia, 30, 39 Pneumonia, 478, 498, 509, 532, 725, 953 Pneumonic plague, 725 Point-of-service plans, 428-429, 463 Poison ivy, 732 Poison oak, 732 Poison sumac, 732 Poisoning, 195, 535, 604, 727-731, 777; food, 385-390; lead, 327, 550-552, 555, 626, 729, 778; mercury, 327, 629-631 Poisonous plants, 387, 731-734, 777 Polio, 189, 505 Poliomyelitis, 189 Pollen, 57 Pollution; air, 326, 814, 830; noise, 656-657; water, 327 Polychlorinated biphenyls. See PCBs Polyps, 224, 501 Polyspermy, 512 Port-wine stains, 543 Postmaturity, 186 Postpartum depression, 735-736 PPOs, 427 Prader-Willi syndrome, 404
Prednisone, 698 Preferred provider organizations. See PPOs Preferred providers, 428 Pregnancy, 192, 632, 745; AIDS and, 38, 42; alcohol and, 50, 372; caffeine and, 193; cancer and, 168; drug abuse and, 193; ectopic, 850; exercise and, 746; lead poisoning and, 551; nutrition and, 129, 675, 745; smoking and, 193, 745; teenage, 7, 192, 736-741 Premature birth, 186, 741-744 Premenstrual syndrome. See PMS Prenatal care, 192, 744-747, 953 Presbycusis, 24, 433 Presbyopia, 24, 908 Pressure ulcers, 480, 820 Prevalence, 953 Preventive medicine, 378, 440, 747-751, 769 Primary infection, 953 Prions, 578 Progesterone, 170, 525, 617, 621, 953 Prolactin, 138 Pronation, 391 Prone, 953 Prophylactic treatment, 954 Prostaglandins, 4, 622, 905, 954 Prostate cancer, 501, 751-754 Prostate enlargement, 501, 755-756 Prostate gland, 755 Prostatectomy, 753 Prostatitis, 755 Protease inhibitors, 34 Proteases, 322 Protein, 580, 649, 663, 670, 919 Protein energy malnutrition (PEM), 580, 586 Proteins, 954 Protozoa, 706, 954 Pseudodementia, 267 Psychiatric evaluation, 546 Psychoanalysis, 489 Psychosis, 72, 735, 954 Psychosurgery, 261 Psychotherapy, 260, 954 Ptosis, 954
984
Index Public health, 333 Public transportation, 635 Pulmonary edema, 445 Pulmonary function, 320 Pulmonary function tests, 321 Pupil, 909 Purging, 308 Pyelonephritis, 502 Pyorrhea, 254
Respiratory system, 28, 54, 357, 501 Resuscitation, 293, 766-771 Retin A, 822 Retina, 574, 576, 908, 910 Retinal detachment, 909, 911 Retroviruses, 203, 396, 954 Revascularization, 807 Reye’s syndrome, 455, 532, 771-772 Rh incompatibility, 59, 80 Rheumatoid arthritis, 94, 98 Rhinitis, 58, 954 Rhythm method, 122 Rhytidectomy, 229 Riboflavin, 582 Ribonucleic acid (RNA), 954 Rickets, 582 Right to die, 567 Ritalin, 111 Rocky Mountain spotted fever, 560, 941 Root canal, 254 Roundworm, 705, 934, 939 RU-486, 5, 125, 638, 765 Rubella, 188, 625 Rubeola, 187
Qi gong, 63 Quickening, 954 Quicksilver, 630 Quinsy, 893 Quintuplets, 642 Rabies, 939, 954 Radiation, 134, 156, 328, 382, 600, 753, 756-758; birth defects and, 129 Radiation sickness, 756 Radical mastectomy, 135 Radium, 758 Radon, 326, 757-759 Rapid eye movement sleep. See REM sleep Rashes, 187, 571, 733 Reaction time, 361; aging and, 27, 759-760 Reading glasses, 908 Reading problems, 301 Recessive gene, 954 Recombinant DNA, 954 Reconstructive surgery, 136, 229 Recovery programs, 47, 297, 760-764 Red blood cells, 409 Redux, 921 Rehabilitation, 658, 954 Rejection, 894 REM sleep, 825, 954 Renal failure, 895 Repetitive motion injuries, 165, 690 Reproductive system, 755; aging and, 27 Reproductive technologies, 764-766 Resistance, 902 Resistance training, 634, 650 Respiration, 322 Respiratory distress syndrome, 81, 954
Safety issues, 317; children and, 200, 369, 772-779; elderly and, 149, 370, 779-782; sports and, 846 Sagging skin, 819 Saliva, 253 Salmonella, 383, 385, 388, 939 Salt, 485 Sanatorium, 954 Sanger, Margaret, 124 Sarcopenia, 361, 648 Saturated fat, 201, 575, 673 Scabies, 560 Scalds, 149-152, 535, 776 Scalp reduction, 416 Schistosomiasis, 706, 933 Schizophrenia, 782-786, 872 Scoliosis, 786-790 Scrapie, 578 Screening, 80, 401, 596, 702, 747, 790-795 Scurvy, 582
985
Index Seasonal affective disorder (SAD), 261, 563, 796-800, 954 Sebaceous glands, 819, 821 Seborrheic keratoses, 821 Secondhand smoke, 194, 326, 800-803, 814, 954 Sedation, 699, 823 Seizures, 116 Semen, 521, 755 Senile purpura, 819 Sensorineural hearing loss, 432, 436 Sensory changes, 24, 536, 589 Sepsis, 954 Septic meningitis, 614 Septuplets, 642 Serotonin, 678, 824, 868, 872 Serotonin reuptake inhibitors, 874 Set point theory, 686 Sex Addicts Anonymous, 762 Sex determination, 79 Sextuplets, 642 Sexual dysfunction, 803-808 Sexually transmitted diseases (STDs), 42, 227, 809-813; child abuse and, 180 Shaken infant syndrome, 177 Shingles, 190, 454, 822 Shinsplints, 846 Shivering, 884 Shock, 148, 451 Shock therapy, 260 Shoes, 392 Shortness of breath, 319, 321 Shunts, 482, 955 Sick building syndrome, 326, 643, 814-816 Sickle-cell disease, 401, 406 SIDS. See Sudden infant death syndrome (SIDS) Sigmoidoscopy, 225 Silicone, 145, 232 Silicosis, 327, 899 Sinoatrial node, 955 Skeletal muscle, 347 Skilled nursing facility, 658 Skin, 818 Skin cancer, 23, 816-818, 822
Skin disorders, 816; aging and, 23, 818-823, 884 Skin tags, 821 Sleep, 825 Sleep apnea, 823, 826, 955 Sleep changes with aging, 25, 823-825 Sleep disorders, 73, 825-829 Sleep paralysis, 826 Sleepiness, 826, 828 Sleeping pills, 698, 827 Sleepwalking, 827 Small intestine, 501 Smallpox, 335 Smegma, 209 Smell, 25, 535 Smog, 829-832 Smokers Anonymous, 762 Smoking, 16, 334, 486, 501, 800, 832-835, 890; asthma and, 105, 195, 802; cancer and, 801; effects on children, 194, 802; emphysema and, 322; heart disease and, 443; lung cancer and, 569; macular degeneration and, 575; osteoporosis and, 693; pregnancy and, 193, 745; pulmonary function and, 320; ulcers and, 906; wrinkles and, 23 Snakebites, 835-837 Snoring, 826 Sodium, 485 Solar keratoses, 821 Sore throat, 892 Sound therapy, 65 Spasm, 955 Special education, 627, 840 Speech disorders, 220, 837-841; strokes and, 860 Sperm, 512, 520-521 Sphingomyelins, 78 Spiders, 941 Spina bifida, 130, 193, 841-842, 955 Spinal cord, 841 Spinal tap, 614 Spine, 96 Sporotrichosis, 938 Sports injuries; children and, 355, 843-848
986
Index Sports medicine, 120, 350 Sprains, 843, 955 Squamous cell carcinoma, 569, 817 Stained teeth, 254 Staphylococcal infections, 87, 385 Statins, 93 STDs. See Sexually transmitted diseases (STDs) Stereotypies, 113 Sterilization, 123, 539, 848-852 Steroid abuse, 853-854 Steroids, 155, 894 Stillbirth, 632 Stimulants, 111, 115, 303 Stones, 25, 500, 502, 542 Strain, 955 Strength, 361 Strength training, 363, 633, 650, 920; children and, 353 Streptococcal infections, 654 Stress, 119, 265, 622, 855-858; suicide and, 872 Stress fractures, 846 Stress incontinence, 516 Stress reduction, 610, 857, 937 Stretching, 723 Strokes, 25, 91, 241, 478, 483, 499, 503, 612, 749, 858-862 Stuttering, 839 Subcutaneous, 955 Substance abuse, 955. See also Addiction; Alcoholism; Drug abuse; Steroid abuse; Tobacco use Suction curettage, 3 Sudden infant death syndrome (SIDS), 862-866 Suicide, 342, 728, 866-871, 886; assisted, 343, 878; children and teenagers, 871-875; depression and, 261; elderly and, 875-878; postpartum depression and, 735; survivors of, 869 Sulfur oxide, 830 Summer depression, 796 Sun exposure, 23 Sunburns, 817, 879-880 Sundowner’s syndrome, 563 Superfecundation, 639
Supine, 955 Supplements, 607, 912 Surfactant, 642 Surgery, 496; laser use in, 541-544 Surrogate motherhood, 529 Sweat glands, 819 Sweating, 450, 884 Swimming, 686 Swine flu, 531 Sympathetic nervous system, 359 Synovial membrane, 94 Syphilis, 625, 809, 811 Syrup of ipecac, 777, 955 Systemic lupus erythematosus, 96, 928 Systolic pressure, 484 T lymphocytes, 270, 894 Tachycardia, 444, 955 Tai Chi Chuan, 63 Tanning, 817 Tapeworms, 706, 934 Tar, 801 Tardive dyskinesia, 784 Tartar, 254 Taste, 24, 535 Tattoos, 880-881 Tay-Sachs disease, 401 Teenagers; abortion and, 7-9; alcoholism and, 48-53, 295; condoms and, 228; drug abuse by, 295-300; pregnancy among, 7, 192, 736-741; suicide among, 871-875; tobacco use by, 295, 890-891 Teeth, 218, 244, 252, 882 Teething, 245, 882-883 Telangiectasias, 820 Temperature, 450, 922 Temperature inversions, 830 Temperature regulation; aging and, 28, 535, 820, 824, 884-885 Tendinitis, 392 Tendons, 94, 392, 955 Tension headaches, 422, 424 Teratogens, 128, 955 Terminal illnesses, 234, 342, 473, 567, 885-890; suicide and, 878 Test-tube babies, 528, 765 Testes, 189, 955
987
Index Testosterone, 415, 618, 805, 918; learning disabilities and, 555 Tetanus, 189, 506, 510 Tetracycline, 248 Thermoregulation, 884 Thiamine, 582 Thymus gland, 27 Thyroid disorders, 582 Thyroid hormone, 687 Thyroxine, 855 Ticks, 558-563, 571, 940 Tics, 839 Tincture, 469 Tissue plasminogen activator. See TPA Tobacco use, 255; pregnancy and, 193; teenagers and, 295, 890-891 Tolerance, 14, 955 Tonsillectomy, 891-893 Tonsillitis, 892 Tonsils, 891 Tooth decay, 248, 254, 379, 381, 883 Tooth loss, 23, 253; smoking and, 833 Touch, 25 Toupees, 416 Tourniquet, 955 Toxemia, 738, 742, 955 Toxic chemicals, 195, 327, 712 Toxicology, 955 Toxins, 955; learning disabilities and, 554 Toxoplasmosis, 386, 707, 938, 955 TPA, 770, 861 Traffic accidents, 536, 636, 780 Trance, 487 Transfatty acids, 201 Transient ischemic attack, 858 Transplantation, 893-898; hair, 230, 416; kidney, 895; liver, 896; pancreas, 897 Transportation issues, 635 Tremors, 55, 709 Triage, 955 Trichinosis, 706 Trichomoniasis, 810, 812 Trihalo-methanes (THMs), 197 Trimester, 955 Triplets, 640, 642 Tubal ligation, 849
Tubercles, 899 Tuberculin skin test, 901 Tuberculosis, 87, 194, 793, 899-904, 939, 955; AIDS and, 30 Tuberculous meningitis, 614 Tummy tucks, 565 Tumors, 153, 224, 226, 956 Turtles, 939 Twelve-step programs, 761 Twin, 639 Tylenol, 97, 606 Typhus, 559 Ulcerative colitis, 501 Ulcers, 500, 543, 856, 904-908 Ultrasonography, 130, 956 Ultraviolet light, 817, 819, 879 Ultraviolet rays, 909 Underbite, 254 Undernutrition, 586 Uranium, 758 Urethritis, 810 Urge incontinence, 516 Uric acid, 96 Urinary disorders, 28, 501, 515, 755 Urinary tract infections, 210, 956 Uterine cancer, 167-172, 618, 702 Uterine fibroids, 491 Uterine prolapse, 492 Utero placental insufficiency, 738 Uterus, 490, 525, 956 Vaccines, 409, 498, 504-505, 508, 510, 533, 956 Vacuum aspiration, 3 Vacuum tumescence therapy, 807 Vaginitis, 810 Valium, 698 Varicella, 190, 453, 455 Varicoceles, 520, 956 Vas deferens, 850 Vascular, 956 Vascular dementia, 240, 242 Vasectomy, 850 Vegans, 582 Vegetarians, 671 Venereal diseases. See Sexually transmitted diseases (STDs)
988
Index Water quality, 914-917 Water-soluble medications, 606 Water treatment, 197, 378 Wear-and-tear theory of aging, 22 Weight, 676 Weight changes with aging, 23, 649, 682, 917-920 Weight loss, 586, 677 Weight loss medications, 678, 687, 920-922 Well-baby examinations, 922-924 Wheelchair use among the elderly, 781, 924-926 Whipworm, 705 Whooping cough, 190 Widows and widowers, 266; suicide and, 877 Wild animals, 939 Wills, 567 Winter depression, 796 Wisdom teeth, 245 Withdrawal, 15, 956 Women; AIDS and, 41-43; cancer and, 930; cosmetic surgery and, 231233; depression and, 931; diabetes mellitus and, 930; headaches and, 931; health issues and, 490, 616, 926-932; heart disease and, 447-450, 617, 673, 927; infertility in, 525-530; lupus and, 928; malnutrition and, 622; nutrition and, 673-675; obesity and, 673 Workplace safety, 691 Worms, 703, 933-935, 939 Wounds, 26, 820 Wrinkles, 23, 819; smoking and, 833 Wrists, 165
Venom, 835 Venous insufficiency, 822 Ventricles, 956 Ventricular fibrillation, 444, 768 Vertebrae, 96, 956 Very low-density lipoproteins (VLDLs), 91, 201 Viability, 547 Viagra, 806 Vinka alkaloids, 174 Violent crime against the elderly, 314, 536 Violin spider, 941 Viral infections, 189 Virulence, 956 Viruses, 396, 956; antibiotics and, 86 Vision problems; aging and, 24, 574, 908-912; strokes and, 860 Visual dyslexia, 301 Vitamin A, 581, 665 Vitamin B6, 665 Vitamin B12, 582, 587, 664 Vitamin C, 582 Vitamin D, 582, 587, 664-665 Vitamin deficiencies, 72, 581, 586 Vitamin supplements, 607, 912-914 Vitamins, 587, 663, 671, 956; fatsoluble medications and, 606 Vitreous humor, 909 Vitrification, 522 VLDLs. See Very low-density lipoproteins (VLDLs) Voice disorders, 838 Voluntary Motherhood movement, 123 Waist-hip ratio, 682 Walkers, 157-159, 781; infant, 369, 773 Walking, 391, 635 Warfarin, 605 Warts, genital, 811-812 Wasting, 586, 648, 918 Water, 914; asbestos in, 100; chlorination of, 197-198, 327, 917; fluoridation of, 249, 254, 327, 378-381; therapeutic use of, 722 Water on the brain, 481 Water pills, 606 Water pollution, 327
X rays, 156, 595 Xenotransplantation, 956 Xerosis, 819 Yeast infections, 930, 935-936 Yoga, 63, 936-937 Zinc, 575, 588, 665 Zoonoses, 938-942 Zygote, 956
989
