Complications of renal transplants

-Delayed graft function.
This is usually rare in living donor transplants. In cadaveric tranplants, cold ischemia time remains the best predictor of delayed graft function. While most delayed-graft-function kidneys eventually function, they do have a somewhat diminished lifespan compared with kidneys that function immediately.

-Vascular-related and ureter-related complications.
1. Arterial stenosis associated with the abrupt onset of hypertension.
Management includes percutaneous techniques such as angioplasty or placing of stents.
2. Venous thrombosis associated wit graft infarction.
Management includes thrombolytic agents and in cases of graft infarction, prompt nephrectomy as it leads to sepsis.
3.Ureteral obstruction due to distal obstruction, clot, edema, or technical problems associated with the ureteroneocystostomy.
Management is typically by radiologic or cystoscopic stent placement and stricture dilatation.
4. Urine leak. If small, managed by bladder decompression via Foley catheter, if large, exploration and repair.

- Perivascular lymohatic vessels leakage manifested as swelling, pain, and impaired renal function within the first year following transplantation.

-Chronic rejection has immunologic and nonimmunologic components. As a broad classification for progressive graft failure, risk factors include initial poor function of the graft and a history of acute rejection episodes.

-Cancer: Certain cancers, such as basal cell carcinoma, Kaposi sarcoma, carcinoma of the vulva and perineum, non-Hodgkin lymphoma, squamous cell carcinoma, hepatobiliary carcinoma, and carcinoma in situ of the uterine cervix, occur more frequently in people who have undergone kidney transplantation.

-Relapse: A small number of people who undergo transplantation for certain kidney disease experience a return of the original disease after the transplant.

-High blood cholesterol level

-Liver disease

-Weakening of the bones

-Women who wish to become pregnant are usually told to wait for 2 years after the operation. Many women have taken their pregnancies to term after transplantation, but there is an increased risk of kidney rejection and fetal complications.

References:
http://www.emedicinehealth.com/kidney_transplant/page5_em.htm
http://www.emedicine.com/med/topic3406.htm

Complications of post transplant treatment

Calcineurin inhibitors:
- Dose related nephrotoxicity
- Tremors
- High blood pressure (hypertension)

Corticosteroids
- Easy bruising of the skin
- Osteoporosis
- Avascular necrosis (bone death)
- High blood pressure (hypertension)
- High blood sugar because of glucose intolerance (increased risk of post transplant diabetes)
- Stomach ulcers
- Weight gain
- Acne
- Mood swings
- Round face
- Growth retardation
- Lipid abnormalities (hyperlipidemia)
-
Azathioprine
- Suppression of bone marrow
- Liver damage

Sirolimus
- Reduced wound healing
- Myelosuppression

Mycophenolic acid
- Nausea and diarrhoea

As post transplant treatment basically suppresses the immune system, the host is generally more susceptible to opportunistic infections by pathogens such as cytomegalovirus, fungi, Legionella species.

References:
http://www.emedicine.com/med/topic3406.htm
http://www.emedicinehealth.com/kidney_transplant/article_em.htm

Drugs For HIV Treatment

There are currently five categories of HIV antiviral drugs available that have FDA (U.S. Food and Drug Administration) approval. These categories are:
· nucleoside reverse transcriptase inhibitors (NRTIs)
· nucleotide reverse transcriptase inhibitors (NtRTIs)
· non-nucleoside reverse transcriptase inhibitors (NNRTIs)
· protease inhibitors (PIs)
· fusion inhibitors
Fusion inhibitors work outside the CD4 cell by inhibiting HIV from joining, or fusing, with the cell. Nucleosides, nucleotides and non-nucleosides all work to stop HIV from infecting CD4 cells by inhibiting conversion their RNA into DNA. Protease inhibitors stop infected cells from reproducing the virus.

NRTIs
Nucleoside reverse transcriptase inhibitors, commonly referred to as NRTIs or nukes for short, inhibit reverse transcriptase, an enzyme that HIV needs in order to infect CD4 cells. Retroviruses, such as HIV, use the enzyme reverse transcriptase to convert their RNA into DNA, the structure that contains all of a person's genes. Without the ability to create the DNA inside the nucleus of a healthy cell, HIV cannot infect that cell. The HIV DNA then integrates with the DNA of cells (the CD4 cells, also called T-cells) in the body. A category of drugs called "integrase inhibitors" are in development to work at this stage of the virus.

NRTIs are analogs because they are imitations of the body's own nucleosides, which HIV uses to infect cells. Hence, you will hear the term "nucleoside analogs" used to refer to NRTIs. The NRTIs trick the HIV reverse transcriptase into using these imitation nucleosides, incorporating the imitation nucleoside into the HIV DNA chain. The virus thinks it's inserting the cell's nucleoside into its DNA chain, but it's actually inserting the drug. This breaks the viral DNA chain.

Drugs in the NRTI category include Retrovir (AZT), Zerit (d4T), Hivid (ddC), Epivir (3TC or lamivudine), Videx (ddI), Ziagen (abacavir) and Emtriva (FTC or emtricitabine). Combinations of these drugs are also available
Side effects-to beware of with NRTIs include pancreatitis, rash, flu-like symptoms and peripheral neuropathy (a type of nerve damage).

Nucleotides
Viread (tenofovir) is the first drug (and so far, the only one) in the category of nucleotide reverse transcriptase inhibitors (NtRTIs) to be approved by the FDA. NtRTIs are very similar to the NRTIs, but are chemically pre-activated, to quickly convert to the actual form of drug in the body, allowing the NtRTIs to enter the HIV's DNA more rapidly than the drugs in the NRTI class. Viread and the NRTI Emtriva are now available in a combination once-daily tablet called Truvada.

NNRTIs
The NNRTIs attach themselves directly to reverse transcriptase so that the RNA cannot make DNA, thus preventing further replication of the virus. The downside to this class of drugs is that NNRTIs are highly cross-resistant to one another (see "Resistance to HIV Medications" below).
The NNRTIs provide a choice for people who are intolerant of protease inhibitor side effects, those who want to save the protease class for future use, or for those whose protease inhibitor therapy failed them. Drugs in the NNRTI class include Rescriptor (delavirdine), Viramune (nevirapine) and Sustiva (efavirenz). Sustiva has been placed in the "preferred" category in the current federal guidelines for those starting HIV treatment. Viramune and Sustiva are also both easy to take. Viramune requires two tablets daily (one twice a day) while Sustiva requires just one tablet daily, usually taken at bedtime.

Side effects-Rash is a side effect that all NNRTIs share in common, and is one of the more prevalent side effects in the class. Other common side effects, usually associated with Sustiva, include confusion, abnormal thoughts, vivid dreams and impaired concentration. These side effects, though, usually disappear after two to four weeks of therapy.

Protease Inhibitors
Protease inhibitors (commonly called PIs), inhibit protease, a digestive enzyme that breaks down protein. The HIV protease works by cutting up long chains of the virus' proteins into smaller pieces that go on to infect new cells. By blocking HIV protease, these drugs keep the virus from making copies that can infect cells. Thus, these drugs keep immature non-infectious virus particles from becoming mature infectious particles, which cannot infect any other cells.

There are currently nine PIs on the market, making it the largest category of HIV drugs available. Protease inhibitors are generally thought to be the most potent or the "heavy-weights" of the HIV drugs, and Kaletra is considered, so far, to be the undisputed champion of the heavy weights. Kaletra is the other drug, along with Sustiva, to be placed in the "preferred" category in the current federal guidelines for HIV treatment. It has proven to be a very durable drug and has become the most-prescribed drug in the protease inhibitor class.

Side effects- PIs can cause blood glucose levels to rise in people with diabetes and can even bring on new cases of the disease. PIs can also increase the levels of cholesterol and triglycerides in the blood, putting you at risk for a heart attack. Other side effects include: kidney stones with Crixivan, diarrhea with Viracept, hyperbilirubinemia with Reyataz, and all of them can cause nausea and diarrhea.

Fusion Inhibitors
While the NRTIs, NtRTIs, NNRTIs and PIs are all working inside the infected CD4 cell to treat HIV, fusion inhibitors fight HIV outside the CD4 cell by blocking fusion of HIV before the virus enters the cell and begins its replication process. Fuzeon is the first (and thus far the only) in this class of drugs to be FDA approved. Administration by twice daily subcutaneous injection and its high cost have limited the use of this drug.

Side Effects- due to its route of administration, is injection site reactions. To help avoid this side effect, rotation of injection sites is recommended.

http://www.thebody.com/content/treat/art968.html

Signs and Symptoms of HIV

Early symptoms:

Flu-like illness within three to six weeks after exposure to the virus. This illness, called Acute HIV Syndrome, may include fever, headache, tiredness, nausea, diarrhoea and enlarged lymph nodes (organs of the immune system that can be felt in the neck, armpits and groin). These symptoms usually disappear within a week to a month and are often mistaken for another viral infection.

More persistent or severe symptoms may not surface for several years, even a decade or more, after HIV first enters the body in adults, or within two years in children born with the virus. This period of "asymptomatic" infection varies from individual to individual. Some people may begin to have symptoms as soon as a few months, while others may be symptom-free for more than 10 years. However, during the "asymptomatic" period, the virus will be actively multiplying, infecting, and killing cells of the immune system.

Lack of energy
Weight loss
Frequent fevers and sweats
A thick, whitish coating of the tongue or mouth (thrush) that is caused by a yeast infection and sometimes accompanied by a sore throat
Severe or recurring vaginal yeast infections
Chronic pelvic inflammatory disease or severe and frequent infections like herpes zoster
Periods of extreme and unexplained fatigue that may be combined with headaches, lightheadedness, and/or dizziness
Rapid loss of more than 10 pounds of weight that is not due to increased physical exercise or dieting
Bruising more easily than normal
Long-lasting bouts of diarrhoea
Swelling or hardening of glands located in the throat, armpit, or groin
Periods of continued, deep, dry coughing
Increasing shortness of breath
The appearance of discoloured or purplish growths on the skin or inside the mouth
Unexplained bleeding from growths on the skin, from mucous membranes, or from any opening in the body
Recurring or unusual skin rashes
Severe numbness or pain in the hands or feet, the loss of muscle control and reflex, paralysis or loss of muscular strength
An altered state of consciousness, personality change, or mental deterioration

http://www.youandaids.org/About%20HIVAIDS/Symptoms/index.asp


You may remain symptom-free for eight or nine years or more. But as the virus continues to multiply and destroy immune cells, you may develop mild infections or chronic symptoms such as:
Swollen lymph nodes — often one of the first signs of HIV infection
Diarrhea
Weight loss
Fever
Cough and shortness of breath

During the last phase of HIV — which occurs approximately 10 or more years after the initial infection — more serious symptoms may begin to appear, and the infection may then meet the official definition of AIDS.

In 1993, the Centers for Disease Control and Prevention (CDC) redefined AIDS to mean the presence of HIV infection as shown by a positive HIV-antibody test plus at least one of the following:
1. The development of an opportunistic infection — an infection that occurs when your immune system is impaired — such as Pneumocystis carinii pneumonia (PCP)
2. A CD4 lymphocyte count of 200 or less — a normal count ranges from 600 to 1,000

By the time AIDS develops, your immune system has been severely damaged, making you susceptible to opportunistic infections. The signs and symptoms of some of these infections may include:
Soaking night sweats
Shaking chills or fever higher than 100 F for several weeks
Dry cough and shortness of breath
Chronic diarrhea
Persistent white spots or unusual lesions on your tongue or in your mouth
Headaches
Blurred and distorted vision
Weight loss

You may also begin to experience signs and symptoms of later stage HIV infection itself, such as:
Persistent, unexplained fatigue
Soaking night sweats
Shaking chills or fever higher than 100 F for several weeks
Swelling of lymph nodes for more than three months
Chronic diarrhea
Persistent headaches

If you're infected with HIV, you're also more likely to develop certain cancers, especially Kaposi's sarcoma, cervical cancer and lymphoma, although improved treatments have reduced the risk of these illnesses.

Symptoms of HIV in children
Children who are HIV-positive often fail to gain weight or grow normally. As the disease progresses, they may have difficulty walking or delayed mental development. In addition to being susceptible to the same opportunistic infections that adults are, children may have severe forms of common childhood illnesses such as ear infections (otitis media), pneumonia and tonsillitis.

http://www.mayoclinic.com/health/hiv-aids/DS00005/DSECTION=2

PEP

PEP stands for Post-Exposure Prophylaxis. It is a four week long course of antiretroviral drugs. The sooner after exposure to a possible HIV incident the better, and after 72 hours it is unlikely to be effective. The evidence that it works is "non-conclusive" but it appears it does work some of the time and is usually used as a last resort, so safe sex is best sex. PEP can be obtained from any doctor that specialises in the area of HIV/AIDS and some GPs, as well as the emergency department of a hospital and sexual health clinics.
It comes with a variety of side effects depending on what drugs are used, but the general lot of rash, nausea, vomiting, fatigue and diarrhoea are common, then again some people don’t experience any side affects.
Each drug costs about $22.40 for the four week course, and usually at least two drugs are used. All the drugs must be completed for the 4 week course and then the patient must return to get testing on the effects of the PEP at intervals of approximately 3 months for a year, and a month after the course. This is both to check whether the person has it and to also collect data on the effectiveness of PEP.
http://www.health.nsw.gov.au/sexualhealth/pep.html

The classification of burns, treatment of infected burns and its complications.

In medicine, a burn is a type of injury caused by heat, cold, electricity, chemicals or radiation (e.g. sunburn).

Classification of Burns:

1^st Degree Burn: Limited to redness (erythema), a white plaque and minor pain at site of injury. Only extend into the epidermis.

2^nd Degree Burn: Superficial blistering of the skin, filled with clear fluid. Involve superficial (papillary) dermis & may involve deep (reticular) dermis layer.

3^rd Degree Burn: Charring of the skin & produce hard, leather-like eschars (scabs that has separated from the unaffected part of the body. May contain purple fluid. Painless as nerve endings have been destroyed

Burns that injure the tissues underlying the skin, such as the muscles or bones, are sometimes categorized as fourth-degree burns. These burns are additionally broken down into three additional degrees: fourth-degree burns result in the skin being irretrievably lost, fifth-degree burns result in muscle being irretrievably lost, and sixth-degree burns result in bone being charred.

A newer classification of "Superficial Thickness", "Partial Thickness" (which is divided into superficial and deep categories) and "Full Thickness" relates more precisely to the epidermis, dermis and subcutaneous layers of skin.

Nomenclature	Traditional Nomenclature	Depth	Clinical Findings
Superficial Thickness	1st Degree	Epidermis involvement	Erythema, minor pain, lack of blisters
Partial Thickness – Superficial	2nd Degree	Superficial (papillary) dermis	Blisters, clear fluid & pain
Partial Thickness – Deep	2nd Degree	Deep (reticular) dermis	Whiter appearance, with decreased pain. Difficult to distinguish from full thickness
Full Thickness	3rd or 4th Degree	Dermis & underlying tissue & possibly fascia, bone or muscle	Hard, leather-like eschar, purple fluid, no sensation

Treatment of Infected Burns:

Medical Care:

• Bacterial infection

• Cellulitis: Apply topical mafenide acetate burn cream twice daily, and administer systemic antibiotic therapy until the infection resolves. Most cases of burn wound cellulitis are caused by group A beta-hemolytic streptococci, which can be treated with penicillin. If specific cultures and sensitivities are not known, a broad-spectrum beta-lactam antibiotic should be administered.

• Colonization of nonviable tissue: The wound should be debrided, followed by the application of silver sulfadiazine cream every 12 hours. Wounds that are colonized more heavily or those that deteriorate should be treated with mafenide acetate. The topical creams should be removed daily, and the wound should be cleansed with a surgical detergent.

• Invasion of viable tissue: The infected wound should be excised surgically. Antimicrobial coverage should be started prior to excision to prevent hematogenous spread and organ seeding.
• Gram-negative infections: Invasive infections caused by gram-negative organisms should be treated with topical mafenide acetate to ensure penetration of the burn eschar. Subeschar clysis with an antibiotic solution prior to surgical excision may be helpful. The antibiotic solution is injected below the eschar 6-12 hours before surgery and again immediately prior to the procedure.
• Gram-positive infections: Invasive gram-positive infections are characterized by suppurative foci in the burned tissue. These infections require administration of appropriate systemic antibiotics and debridement, followed by a topical application of mupirocin, mafenide acetate, or silver sulfadiazine.

• Fungal infection

• Colonization of nonviable tissue: Candidal species rarely invade tissue and, therefore, do not require surgical excision. Wounds colonized with candidal species are treated with a twice-daily application of a topical antifungal cream, such as clotrimazole or ciclopirox olamine. Alternatively, mafenide acetate mixed with nystatin powder is effective for topical treatment of superficial fungal infections.
• Invasion of viable tissue: Filamentous fungi, including Aspergillus and the agents associated with mucormycosis, are responsible for most invasive fungal burn wound infections. The treatment of invasive fungal infection is analogous to invasive bacterial infection, ie, surgical excision of the infected burn wound followed by application of topical antimicrobial therapy (clotrimazole or ciclopirox olamine). Systemic dissemination or extensive tissue involvement necessitates administration of systemic amphotericin B.

Surgical Care:

• Invasive bacterial or fungal burn wound infections are treated with surgical excision to the level of viable tissue.

• Wounds that can be excised completely should be covered with an allograft (transplanted cells, tissues or organs are sourced from a genetically non-identical member of the same species) or autograft (Tissue transplanted from one part of the body to another in the same individual).

• If complete removal of the infected tissue is not possible, 5% mafenide acetate should be applied, and the wound should be reexamined in 24 hours for possible repeat excision.

• With aggressive fungal infections, particularly mucormycosis, radical debridement of muscle, including limb amputation may be necessary to control infection.

Diet: The basal metabolic rate is increased 100% above the reference range in patients with burns of greater than 40% TBSA.

• Enteral feeding of a high-caloric diet through a nasogastric tube should be instituted within the first 12 hours after injury. The feedings should include a high-protein component (2 g/kg/d) and 3-10 times the recommended daily allowance of vitamins and minerals, particularly zinc (7 mg/d).

• In severely injured patients, supplementation with omega-3 fatty acids and arginine has been shown to decrease sepsis.

Activity: Patients may be as active as they can tolerate. Aggressive physical therapy of extremity injuries is paramount.

Complications:

• Systemic spread and seeding of distant organs or invasion of muscle may occur; limb amputation may be required.

• Sepsis can contribute to multisystem organ failure and death.

• Methicillin-resistant S aureus infection

• Methicillin-resistant S aureus (MRSA) infection is a serious and increasingly common cause of nosocomial infection in patients with large burn wounds.

• The incidence of MRSA colonization and subsequent infection has increased dramatically in the last decade, primarily because of antibiotic selective pressure in critically ill hospitalized patients.

• Risk factors that have been associated with MRSA colonization or infection include age, coma, invasive procedures, and extended hospitalization.

• MRSA colonization/infection rates may be reduced by early eschar excision, wound closure, bacterial wound surveillance, and strict enforcement of infection control procedures.

• Systemic vancomycin therapy and topical application of mupirocin cream are indicated for burn wounds infected with MRSA.

• Hospital personnel who have been demonstrated to harbor MRSA should receive mupirocin nasal ointment until surveillance culture results are negative.

References: Burn Wound Infections 'http://www.emedicine.com/med/topic258.htm'
Burn (Injury) 'http://en.wikipedia.org/wiki/Burn_%28injury%29'

New treatments of Burns

1. Foetal skin cells
Doctor in the University Hospital of Lausanne treated 8 children using skin cells from foetuses, but there are doubts from the British Association of Plastic Surgeons as to the veracity of this claim. They are not sure if the wounds would not have healed by themselves.
http://news.bbc.co.uk/2/low/health/4159592.stm

2. 'Skin Cell' Bandages
These are living' bandages of the patient's own skin cells. There is a product called 'Myskin' which involvesgrowing healthy skin cells on small discs which are applied to the skin wound, helping the new skin grow. The skin cells are taken from the thigh, under a local anaesthetic and takes 5 to 7 days to grow in a lab. The disc is placed on the wound and the area wrapped in bandages. The discs release the cells and helps new layers to grow.
http://news.bbc.co.uk/2/low/health/3660533.stm

3. Growing skin from hair follicles
Researchers from the Swiss biotechnology company Modex Therapeutics, based in Lausanne, said they can use the stem cells found in hair follicles to grow new skin. They are hopeful this technique, called Epidex, could soon mean an end to the painful process of taking skin from other parts of the body for grafts. Doctors can pluck hairs from any points in the body.
The stem cells are put onto trays which are then placed above a layer of completely unrelated human skin cells. These then secrete growth factors that transform the stem cells into basic skin cells called primary keratinocytes. The cells are then exposed to the air and this turns it into proper skin, with a horny layer on top.
http://news.bbc.co.uk/2/low/health/1399252.stm

Significance of Betty's job

The burn on her hand has caused Betty pain and loss of function. As her job at the delicatessen requires cooking, cutting and chopping ingredients and possibly moving pots and pans around the stove, the loss of function of her right hand will impact her ability to do her job well. As stated in Part A of the PCL, she made it through the busiest time of the week only with a lot of help. She may feel a loss of independence in this situation and this may have a negative impact on her rate of recovery by affecting her outlook.
The work situation in the kitchen of her delicatessen also harbours lots of microorganisms as she will deal with lots of raw and uncooked food. This increases likelihood of Betty's burn getting infected. The fact that she was busy at work made her delay treatment and only applied a dresseing herself which again exposes her to the possibility of infection.

Signs & Symptoms of an Infected Wound and Why

Signs
Inflammation
• Pus
• Swelling
• Redness
• Heat in area around wound
• Fever (pyrexia)

• Swelling or tenderness in the lymph nodes (located under armpits, in groin, neck areas and behind ears)
• Odour

Symptoms
• Pain

Why
Inflammation:
• Pus: large numbers of neutrophils, tissue cells and dead pathogens
• Swelling: increased permeability of the blood vessels and migration of leukocytes
• Redness: increased blood volume (due to vasodilation, where blood vessels become wider)
• Heat: increased blood volume and endogenous pyrogens
• Fever: endogenous pyrogens are cytokines (chemical signals) produced by macrophages, skin, endothelial (inside blood vessels), epithelial and glial (CNS) cells. Pyrogens signal to the hypothalamus to increase the temperature of the body. This allows infection to recover quicker because immunological reactions are sped up.
• Swelling in lymph nodes:
-Lymph nodes filter the lymphatic fluid and have special cells that can trap bacteria that are traveling through the body via the lymph fluid.
-Swelling of the lymph nodes may be due to the increased number of lymphocytes in the region as a response to the presence of an antigen or the large number of inflammatory cells filtering/passing through the lymph nodes.
• Odour: is due to organic acids secreted by anaerobic bacteria or necrotic tissue (which can be the home to pathogenic organisms)

• Pain: stimulation of neuronal pathways

Also, here's some background info about lymph nodes (just in case):

Lymph Nodes
Lymph nodes are a part of your lymphatic system, which is one of the body's barriers to infection and plays a role in the immune responses. When lymph nodes become swollen, it may signal an infection.
There are several groups of lymph nodes. The ones most frequently enlarged or swollen are in the neck, under the chin, in the armpits, and in the groin.
• The lymphatic system consists of nodes and ducts spread throughout the body. They bring the lymph (tissue fluids surrounding the cells) back into the circulation by way of the venous system. In the lymph, there is a concentration of infectious and other foreign substances (antigens).
• Lymph nodes are small clusters of cells, surrounded by a capsule. Ducts go in and out of them. The cells in lymph nodes are lymphocytes and macrophages (lymphocytes produce antibodies—protein particles that bind foreign substances including infectious particles—and macrophages digest the debris). They act as the "cleaner" cells of the body.
• The lymph nodes are a major site where foreign substances and infections interact with the cells of the immune system. A major cluster of the lymph nodes is the spleen, which, apart from other functions, also helps fight infections and responds to foreign substances.


http://www.emedicinehealth.com/swollen_lymph_glands/article_em.htm
http://www.worldwidewounds.com/1998/march/Odour-Absorbing-Dressings/odour-absorbing-dressings.html
http://www.bmj.com/cgi/reprint/332/7536/285.pdf

First Aid for Burns

For minor burns:
- Cool the burn. Hold the burned area under cold running water for at least 5 minutes, or until the pain subsides. If this is impractical, immerse the burn in cold water or cool it with cold compresses. Cooling the burn reduces swelling by conducting heat away from the skin. Don't put ice on the burn. Other sources say ten to fifteen minutes, or until the burned area is back to a normal skin temperature.
- Cover the burn with a dressing
- Don't use ice. Putting ice directly on a burn can cause frostbite, further damaging your skin.


For major burns, call for emergency medical assistance. Until an ambulance arrives, follow these steps:
1. Don't remove burnt clothing. However, do make sure the victim is no longer in contact with smouldering materials or exposed to smoke or heat.
2. Don't immerse severe large burns in cold water. Doing so could cause shock.
3. Check for signs of circulation (breathing, coughing or movement). If there is no breathing or other sign of circulation, begin CPR.
4. Cover the area of the burn. Use a cool, moist, sterile bandage; clean, moist cloth; or moist towels. If the burn is greater than 10% of the total body surface area, a dry dressing may be more appropriate. Only use a wet dressing if the patient’s core body temperature can be maintained.

Effect of Mental Health on Heart Disease

Attaining and sustaining good mental health is just as vital as other factors, such as exercise and diet, in the prevention of cardiovascular disease

Medical researchers aren't sure exactly how stress increases the risk of heart disease. Stress itself might be a risk factor, or it could be that high levels of stress make other risk factors (such as high cholesterol or high blood pressure) worse. For example, if you are under stress, your blood pressure goes up, you may overeat, you may exercise less and you may be more likely to smoke.

If stress itself is a risk factor for heart disease, it could be because chronic stress exposes your body to unhealthy, persistently elevated levels of stress hormones like adrenaline and cortisol.

Also, depression can have an effect on your susceptibility to heart disease. Physical signs of depression, such as fatigue and loss of appetite, may contribute to thickening arteries, an early sign of cardiovascular disease.

Being stressed or depressed doesn’t directly cause heart disease, but these can lead to a person adopting an unhealthy lifestyle which can increase the risk of heart disease.

BMI, Skinfold test

Body Mass Index (BMI)
· Body Mass Index (BMI) is a number calculated from a person’s weight and height.
· BMI is a reliable indicator of body fatness for people.
· BMI does not measure body fat directly, but research has shown that BMI correlates to direct measures of body fat, such as underwater weighing and dual energy x-ray absorptiometry (DXA).
· BMI is an inexpensive and easy-to-perform method of screening for weight categories that may lead to health problems.
· At the same BMI, women tend to have more body fat than men.
· At the same BMI, older people, on average, tend to have more body fat than younger adults.
· Highly trained athletes may have a high BMI because of increased muscularity rather than increased body fatness.
· Formula: weight (kg) / [height (m)]2
· Adult:
BMI..........................Weight Status
Underweight...........Below 18.5
Normal.....................18.5 – 24.9
Overweight..............25.0 – 29.9
Obese.......................30.0 and Above
Child (refer to charts for percentiles)
Weight Status ......................Category Percentile Range
Underweight .......................Less than the 5th percentile
Healthy weight................... 5th percentile to less than the 85th percentile
At risk of overweight......... 85th to less than the 95th percentile
Overweight .........................Equal to or greater than the 95th percentile

http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/charts.htm
http://www.cdc.gov/nccdphp/dnpa/bmi/index.htm

Skinfold test
· Estimation of body fat by skinfold thickness measurement
· Can use from 3 to 9 different standard anatomical sites around the body
· The tester pinches the skin at the appropriate site to raise a double layer of skin and the underlying adipose tissue, but not the muscle.
· The calipers are then applied 1 cm below and at right angles to the pinch, and a reading taken two seconds later. The mean of two measurements should be taken.
· is best to use the sum of several sites to monitor and compare body fat measures.
· Below is a table of general guidelines for using total sum of the seven main skinfold sites (tricep, bicep, subscap, supraspinale, abdominal, thigh, calf)

Rating for NORMAL...........Male ...............Female
excellent .............................60-80 .............70-90
good ....................................81-90...............91-100
average ..............................91-110 .............101-120
below average ...................111-150 ...........121-150
poor.................................... 150+ .................150+
(Athletic scores are about 20 lower)
· Example of equations for
Males: %BF = (0.1051 x sum of triceps, subscapular, supraspinale, abdominal, thigh, calf) + 2.585, based on a sample of college students.
Females: %BF = (0.1548 x sum of triceps, subscapular, supraspinale, abdominal, thigh, calf) + 3.580, based on a sample of college students.
http://www.topendsports.com/testing/tests/skinfolds.htm

Features of Malignant Tumours

Cells in malignant tumours:
-are poorly differentiated (anaplasia) and do not resemble the cell of origin either physically when viewed under the microscope or genetically.
-are poorly circumscribed.
-have higher nuclear to cytoplasmic ratio.
-exhibit nuclear pleomorphism, ie enlarged, irregular and variable nucleus which shows up under the microscope as being stained darker than the normal cells.
-darker stains due to excessive chromatin in nucleus.
-macroscopically, one would notice that the cells have an invasive edge and tumour would tend to ulcerate if it's on a surface.
-diagnosis of malignant neoplasm would be made on presence of invasion and metastasis is pathognomic of malignancy.

Spread of malignant tumours:
-direct spread
-local invasion
-permeation or infiltration of lymphatics
-perineural invasion
-vessel invasion

How Sunscreen works and more

Sunscreen (also known as sunblock, suntan lotion) is a lotion, spray or other topical product that helps protect the skin from the sun's ultraviolet (UV) radiation, and which reduces sunburn and other skin damage, ultimately leading to a lower risk of skin cancer.

Most sunscreens work by containing
1.an organic chemical compound that absorbs ultraviolet light (such as oxybenzone) or

2.an opaque material that reflects light (such as titanium dioxide, zinc oxide), or

3.a combination of both. Typically, absorptive materials are referred to as chemical blocks, whereas opaque materials are mineral or physical blocks.

The best sunscreens!-protect against both UVB (ultraviolet radiation with wavelength between 290 and 320 nanometres), which can cause sunburn, and UVA (between 320 and 400 nanometres), which damages the skin with more long-term effects, such as premature skin aging.

How much sunscreen is enough?
Dosing for sunscreen can be calculated using the formula for body surface area and subsequently subtracting the area covered by clothing that provides effective UV protection. The dose used in FDA sunscreen testing is 2 mg:/cm².

Example:Provided one assumes an "average" adult build of height 5 ft 4 in (163 cm) and weight 150 lb (68 kg) with a 32 in (82 cm) waist, that adult wearing a bathing suit covering the groin area should apply 29 g (approximately 1 oz) evenly to the uncovered body area. Considering only the face, this translates to about 1/4 to 1/3 of a teaspoon for the average adult face.

Is one application enough?
Contrary to the common advice that sunscreen should be reapplied every 2–3 hours, research has shown that the best protection is achieved by application 15–30 minutes before exposure, followed by one reapplication 15–30 minutes after the sun exposure begins. Further reapplication is only necessary after activities such as swimming, sweating, and rubbing.[2]
However, more recent research at the University of California indicates that sunscreen needs to be reapplied within 2 hours in order to remain effective. Not reapplying could even cause more cell damage than not using sunscreen at all, due to the release of extra free radicals from absorbed chemicals.

Note:Suntan lotion is an incorrect term for sunscreen as it is something entirely different. Suntan lotion is used to moisturize and maximize UV exposure and tanning, rather than block it. These are commonly called indoor tanning lotions when designed for use with tanning beds or just suntan lotion if designed for outdoor use and may or may not have SPF protection in them.

New and Improved!! In July 2006, the Food and Drug Administration (FDA) approved a new over-the-counter sunscreen that will be marketed in the United States as Anthelios SX. The new sunscreen offers better protection from UVA rays than do traditional broad-spectrum sunscreens, according to the manufacturer. This may help reduce the risk of various types of skin cancer — including melanoma and basal and squamous cell carcinomas. Better UVA protection also may reduce sun-related skin wrinkling. But the added protection may come at a cost. Although U.S. prices aren't yet available, similar products sold in Canada cost about twice as much as traditional sunscreens — or even more.

Prevention of Melanoma

Prevention

§ Avoid the sun between 10 a.m. and 4 p.m. Because the sun's rays are strongest during this period, try to schedule outdoor activities for other times of the day, even in winter or when the sky is cloudy. You absorb UV radiation year-round, and clouds offer little protection from damaging rays.

§ Wear sunscreen year-round. Sunscreens don't filter out all harmful UV radiation, especially the radiation that can lead to melanoma. But they play a major role in an overall sun-protection program. Be sure to use a broad-spectrum sunscreen with a sun protection factor (SPF) of at least 15 when you go outside, year-round. Use a generous amount of sunscreen on all exposed skin, including your lips, the tips of your ears, and the backs of your hands and neck. More on SUNSCREEN refer below.

§ Wear protective clothing. Sunscreens don't provide complete protection from UV rays. That's why it's a good idea to also wear dark, tightly woven clothing that covers your arms and legs, and a broad-brimmed hat, which provides more protection than a baseball cap or visor does. Some companies also sell photoprotective clothing. Your dermatologist can recommend an appropriate brand. Don't forget sunglasses. Look for those that block both UVA and UVB rays.

§ Avoid tanning beds and tan-accelerating agents. Tanning beds emit UVA rays, which may be as dangerous as UVB rays — especially since UVA light penetrates deeper into your skin and causes precancerous skin lesions.

§ Be aware of sun-sensitizing medications. Some common prescription and over-the-counter drugs — including antibiotics; certain cholesterol, high blood pressure and diabetes medications; birth control pills; nonsteroidal anti-inflammatories such as ibuprofen (Advil, Motrin, others); and the acne medicine isotretinoin (Accutane) — can make your skin more sensitive to sunlight. Ask your doctor or pharmacist about the side effects of any medications you take. If they increase your sensitivity to sunlight, be sure to take extra precautions.

§ Check your skin regularly and report changes to your doctor. Examine your skin often for new skin growths or changes in existing moles, freckles, bumps and birthmarks. With the help of mirrors, check your face, neck, ears and scalp. Examine your chest and trunk, and the tops and undersides of your arms and hands. Examine both the front and back of your legs, and your feet, including the soles and the spaces between your toes. Also check your genital area, including between your buttocks.

§ Have regular skin exams. Consult your doctor for a complete skin exam every year if you're older than 40, or more often if you're at high risk of developing melanoma

Psychological factors involved with cancer sufferers and psychological treatments that are possible and if other things like laughter can help.

Well first of all, a happier person with a more positive out look would have the better chance of getting through cancer than a pessimist, as they would be more open to a range of treatments and would be involved in things such as exercise, which as Craig has said, can improve a person’s chances of making it through cancer by two fold (I’m still suss on that). Also, according to RW Trijsburg, FC van Knippenberg and SE Rijpma at the Department of Medical Psychology and Psychotherapy, Erasmus University, Rotterdam, The Netherlands; behavioural interventions and counselling were effective with treating the symptoms of cancer treatment such as pain, nausea, anxiety, and vomiting. So behavioural intervention and psychological treatments have been shown to help with the side effects of cancer treatment. The greatest methods for these, involve relaxation, suggestion, and distracting imagery.
The stress management part of the psychological treatment has had the greatest success in helping the patient as their mood towards the whole situation improves and are able to deal with it, they are able to get better sleep and have improved immune system functioning. So far, it appears the administering of stress management techniques in therapy groups has the best affect on the patient, but these are not self-help groups as such, the patients are taught things.
PeterMac offers psychological treatments free of charge and via the Pratt foundation are at present running a further research into it.
Psychological treatments help as they improve the mental state of the individual undergoing the treatment, and are able to put them in a better frame of mind when making decisions about treatments and also feel in more control of their life, reducing secondary risks such as depression.
Research, particularly in the US (Seattle) is suggesting that laughing, no matter what causes it, can boost your immune system, ease muscle tension and generally make you feel better. It appears this can occur as it brings about an increase in brain activity particularly in the frontal lobe, which is associated with emotional responses, and stimulation of the motor sections evokes physical responses to the joke. There is a real organisation called the World Laughter Tour, which promotes this involvement in treatment. Laughter helps with stress management, and also can take a patient’s mind off what they are going through.
So seen how laughter helps here are some jokes off a legitimised website in which cancer sufferers write in jokes: the website is: http://www.learningplaceonline.com/illness/humor/jokes-intro.htm and worth a looksee.
Doctor: "I'm sorry to be the one to tell you, but this is your last day to live.
Cancer patient: "Then I'll ask my friends to come here for a final party. We'll have a gourmet dinner, champagne and dancing girls! We'll party 'till dawn. Come and join us doc."
Doctor: "That's easy for you to say. You don't have to get up in the morning."
A woman with terminal cancer returns to religion with fervor. She knows that God will help her get better.
Early in her sickness, a surgeon proposes radical surgery.
"No", she says, "I don't want to get mutilated and suffer pain. It's not necessary, God will help me".
A while later, she sees a radiologist and he proposes radiation to treat the tumour, which by now is uncomfortably large. "No", she says, "I don't want radiation burns inside and out. It's not necessary. God will help me."
A year later, the cancer has metastasised. It's painful and she is referred to an oncologist. Chemotherapy is advised. "No", she says, "I don't want to be sick all the time and lose my hair as well. It's not necessary. God will help me".
Soon after, she dies. She goes to Heaven and demands an audience with God. "Why didn't you help me?," she whines.
"What do you mean? I sent you help three times: a surgeon, a radiologist and an oncologist. What more did you want?"

http://seattlepi.nwsource.com/health/262840_laughter14.html
http://www.psychosomaticmedicine.org/cgi/content/abstract/54/4/489
http://www.psychologyhelps.org/id27.html
http://www.petermac.unimelb.edu.au/dept/clipsy

Melanoma Treatment Options

SURGERY
Treatment consists of urgent local or wide local excision, with a 2cm margin. The amount of normal skin removed from around the tumour is between 5mm to 2cm. The wound is stitched and heals as a straight scar. Histological analysis will determine the depth of invasion using Clark’s level and thickness of the tumour using Breslow thickness.

- If the melanoma is at an early enough stage, the removal will be enough and no further treatment is necessary, although follow ups are necessary to make sure it has not spread.
- For a larger tumour, a larger amount of skin is cut out to make sure as many cancer cells as possible are removed. This usually requires general anaesthetic, and potentially a brief stay in hospital.

If the wound is large enough, a skin graft may be put over it. Alternatively, a ‘flap’ which is a section of nearby skin which is still attached can be placed over the wound. Regardless, the wound is dressed and left undisturbed for several days. After the removal, the patient may be in pain and require painkillers. Risks include infection, haemotoma (bruising) and scarring, or the skin graft failing. Recovery time varies although most people are back to normal after two weeks.

TESTING
Sentinel node biopsy or fine needle aspiration of lymph nodes is necessary for patients with thicker lesions for predicting prognosis. Sentinel node biopsy involves injection of a harmless dye or radioactive chemical into where the melanoma developed. The sentinel nodes drained the fluid from around the site. After about an hour, a ‘counter’ is passed over the area and the sentinel nodes are identified and then removed and checked for cancer. Fine needle aspiration draws fluid from a lymph node and examined. If cancer cells are found, the lymph nodes may be surgically removed. Metastatic disease treatment can involve surgery to lymph nodes, radiotherapy, immunotherapy and chemotherapy.

RADIOTHERAPY
Radiotherapy uses radiation to kill or injure cancer cells. It can be used to eliminate, control or relieve symptoms. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. It precisely targets cancer sites, which means as little harm to normal tissues as possible. Side effects of melanoma radiotherapy may involve reddening or burning of the skin. Others may occur depending on where the treatment is.

CHEMOTHERAPY
Chemotherapy is not often able to cure melanoma and may sometimes be used as palliative care (pain relieving). Chemotherapy given after surgery to kill remaining cancer cells to increase the chance of a cure is called adjuvant therapy. In treating melanoma, anticancer drugs may be given as a hyperthermic isolated limb perfusion, which is a regional treatment as opposed to a systemic treatment. The flow of blood to and from the limb is temporarily stopped with a tourniquet, and a warm solution containing anticancer drugs is put directly into the blood of the limb. This allows the patient to receive a high dose of drugs in the area where the cancer occurred.
Alternatively, normal chemotherapy can be given. The cytotoxic drugs cannot distinguish between cancer and other fast-growing cells healthy cells eg. hair and blood cells, which are also eliminated, causing side effects. Though, these cells usually repair themselves after chemotherapy.

Side effects: some may cause dose reductions, treatment delays or be life-threatening: Feeling sick, nausea, vomiting, depression, fatigue, thinning or loss of hair, low white and red blood cell count, low platelet count. Neutropenia: low count of infection-fighting white blood cells causing severe immunosuppression.

Course usually 6-12 months, drugs injected into a body cavity, intravenously, or delivered orally as a pill, depending on which drug is used.

BIOLOGIC THERAPY
Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defences against cancer. This type of cancer treatment is also called biotherapy or immunotherapy. Types include: interferon, interleukin, monoclonal antibodies, colony-stimulating factors, cytokines and vaccines.


New types of treatment are being tested in clinical trials. These include the following:

CHEMOIMMUNOTHERAPY
Chemoimmunotherapy is the use of anticancer drugs combined with biologic therapy to boost the immune system to kill cancer cells.

COMPLEMETARY AND ALTERNATIVE THERAPIES
The following therapies have been shown to be helpful in dealing with the side effects of cancer treatment in some clinical trials:

psychotherapy, counselling, relaxation, support groups: help reduce stress
meditation: improves sleep and reduces stress
yoga: improves sleep and reduces stress
massage: helps reduce pain and fatigue, and improves sleep
tai chi: relieves pain, improves flexibility and strength, and reduces stress
reflexology: reduces anxiety
spiritual practices: help reduce stress
acupuncture: reduces nausea, vomiting and fatigue from chemotherapy and radiotherapy
aromatherapy: improves sleep
art and music therapy: provide distraction from pain and aid relaxation.

http://www.cancervic.org.au
http://www.cancercouncil.com.au/