 1 DISEASE PATHOLOGY
 2 BACTERIAL DISEASES (incl. Syphilis)
 3 DISEASES to watch out for while TRAVELLING (incl. V.D., S.T.D.)
 4 Ten Diseases on the Way Out
 5 AIDS (HIV)
 6 Alzheimer's Disease
 7 Anthrax
 8 Bacteria
 9 Campylobacter
 10 Cancer
 11 Cancer, Skin
 12 Cancer, Stomach
 13 Colon and Rectal (Colorectal) Cancer
 14 Prostatic Cancer and Diet
 15 Cancers from smoking


\1 DISEASE PATHOLOGY

Most diseases are caused by viruses or bacteria. Disease is a harmful deviation from the normal structural or functional state of an organism. A diseased organism commonly exhibits signs or symptoms indicative of its abnormal state. Thus, the normal condition of an organism must be understood in order to recognize the hallmarks of disease. Nevertheless, a sharp demarcation between disease and health is not always apparent. Disease is called pathology. It involves the determination of the cause (etiology) of the disease, the understanding of the mechanisms of its development (pathogenesis), the structural changes associated with the disease process (morphological changes), and the functional consequences of these changes. Correctly iden- tifying the cause of a disease is necessary to determine the proper course of treatment. Humans, and animals are all susceptible to diseases of some sort. However, that which disrupts the normal functioning of one type of organism may have no effect on the other types. Major distinctions - The normal state of an organism represents a condition of delicate physiological balance, or homeostasis, in terms of chemical, physical, and functional processes, maintained by a complex of mechan- isms that are not fully understood. In a fundamental sense, therefore, disease represents the consequences of a breakdown of the homeostatic control mechanisms. In some instances the affected mechanisms are clearly indicated, but in most cases a complex of mechanisms is disturbed, initially or sequentially, and precise defi- nition of the pathogenesis of the ensuing disease is elusive. Death in human beings and other mammals, for example, often results directly from heart or lung failure, but the preceding sequence of events may be highly complex, involving disturbances of other organ systems and derangement of other control mechanisms. The initial cause of the diseased state may lie within the individual organism itself, and the disease is then said to be idiopathic, innate, primary, or "essential." It may result from a course of medical treatment, either as an unavoidable side effect or because the treatment itself was ill-advised; in either case the disease is classed as iatrogenic. Finally, the disease may be caused by some agent external to the organism, such as a chemical that is a toxic agent. In this case the disease is noncommunicable; that is, it affects only the individual organism exposed to it. The external agent may be itself a living organism capable of multiplying within the host and subsequently infecting other organisms; in this case the disease is said to be communicable. Noncommunicable disease - Metabolic defects - arise from genetically determined metabolic abnormalities present at birth that leave the organism ill-equipped to deal with the natural materials it encounters in its daily life. In human beings, for example, the lack of a certain enzyme necessary for the metabolism of the common amino acid phenylalanine leads to the disease phenylketonuria (or PKU), which appears at a few weeks of age and, if not treated, is often associated with mental retardation. Other metabolic defects may make their appearance only relatively late in life. Examples of this situation are the diseases gout and late-onset, or adult-type, diabetes. Gout results from an accumulation within the tissues of uric acid, an end product of nucleic acid metabolism. Late-onset diabetes results from an impaired release of insulin by the pancreas and a reduction in responsiveness of body tissues to insulin that lead to the inability to metabolize sugars and fats properly. Alternatively, the metabolic fault may be associated with aging and the concomitant deterioration of control mecha- nisms, as in the loss of calcium from bone in the condi- tion known as osteoporosis. That these late developing metabolic diseases also have a genetic basis--that is, that there is an inherited tendency for the development of the metabolic faults involved--seems to be definitely the case in some instances but remains either incomple- tely understood or uncertain in others.


\2 BACTERIAL DISEASES

Diphtheria (pp. 634- 635) Diphtheria is caused by exotoxin-producing Corynebacterium diphtheriae. (a gram+ rod related to the bacteria that cause acne) Sometimes these bacteria are symbiotic with humans. Exotoxin is produced when the bacteria are lysogenized by a phage. It is theis toxin and not direct damage by the Corynebacterium diphtheriae itself that produces the symptoms. A membrane, containing fibrin and dead human and bacterial cells, which is diagnostic for the disease, forms in the throat and can block the passage of air. The exotoxin inhibits protein synthesis, and heart, kidney, or nerve damage may result. Antitoxin must be administered to neutralize the toxin, and antibiotics (penicillin and erythromycin) can then stop growth of the bacteria. Routine immunization in the U.S. includes diphtheria toxoid in the DTP vaccine. 

Otitis Media (p. 635) Ear-ache, or otitis media, can occur as a complication of nose and throat infections. Bacteria enter the ear canal through the eustacian tube. Pus accumulation causes pressure on the eardrum. Bacterial causes include Streptococcus pneumoniae, nonencapsulated Hemophilus influenzae, Moraxella (Branhamella) catarrhalis, Streptococcus pyogenes, and Staphylococcus aureus. The most common causes of antibiotic resistant ear infections are Streptococci Treatment, when feasible, involves broad spectrum pennicillins. 

Pertussis (Whooping Cough) (pp. 636- 637) Pertussis is caused by Bordetella pertussis. (gram-, Proteobacteria) the bacteria degrade the cilliary elevator, so mucus gets stuck in the lungs. Virulence factors include capsules, adherance molecules, exotoxins that damage tissues and retard the immune response, and endotoxins as well. The initial stage of pertussis resembles a cold and is called the catarrhal stage. The accumulation of mucus in the trachea and bronchi causes deep coughs characteristic of the paroxysmal (second) stage. The convalescence (third) stage can last for months. Regular immunization for children has decreased the incidence of pertussis. In areas where vaccination programs have broken down, epidemics have occured. It can be treated with erythromycin but this does not guarantee a cure. 

Tuberculosis (pp. 637- 641) Tuberculosis (aka "consumption" and "TB") is caused by Mycobacterium tuberculosis. (A mycobacteria). Large amounts of lipids in the cell wall account for the bacterium' s acid-fast characteristic as well as its resistance to drying and disinfectants. Up to one third of the world's population have been infected with TB. It is still a serious illness. Its hard to catch TB, and not everyone exposed to it developes disease. People with healthy immune systems can generally thwart infection. M. tuberculosis may be ingested by alveolar macrophages; if not killed, the bacteria reproduce in the macrophages. If this happens and disease progresses. It goes through several stages. The bacteria grow inside of macrophages and a delayed hypersensivity reaction causes lesions to form called tubercles As it progresses further these become caseous lesions, which have a cottage cheese like consistancy. The disease can become dormant at this stage. If the body's defenses permanently arrest the disease they heal and calcify and become Ghon complexes. If not, a caseous lesion becomes enlarged and full of liquid the bacteria can start to grow again. A caseous lesion can rupture and release bacteria into blood or lymph vessels; and cause a disseminated infection, this is called miliary tuberculosis. Miliary tuberculosis is characterized by weight loss, coughing, and loss of vigor. (consumption) Treatment usually involves multiple drugs taken for 1- 2 years (drugs are effective only against growing bacteria and these bacteria grow very slowly). These drugs are isoniazid, rifampin, pyrazinamide and ethmbutol. Many patients do not take their medication so DOT (direct observed therapy) is indicated. Multidrug-resistant M. tuberculosis is becoming prevalent and TB is now considered a re-emerging infectious disease. Social conditions and lax public health policies also contribute to the spread of TB. A positive tuberculin skin test can indicate either an active case of TB, or prior infection, or vaccination and immunity to the disease. It is an indication that cell mediated immunity has developed. It is similar to the lepromin test for leprosy. Laboratory diagnosis is based on the presence of acid-fast bacilli and isolation of the bacteria, which requires incubation of up to 8 weeks. Bacterial Pneumonias (p. 642) Pneumonia is a general term for lung infection. Typical pneumonia is caused by Streptococcus pneumoniae. Atypical pneumonias are caused by other microorganisms. Pneumococcal Pneumonia (p. 642) Pneumococcal pneumonia is caused by encapsulated Streptococcus pneumoniae. (gram+) Symptoms are fever, breathing difficulty, chest pain, and rust-colored sputum. The bacteria can be identified by the production of a-hemolysins, inhibition by optochin, bile solubility, and through serological tests. A vaccine consists of purified capsular material from 23 serotypes of S. pneumoniae is available and conjugated vaccines for children are being developed. Penicillin is used to treat. Hemophilus influenzae Pneumonia (pp. 642- 643) Alcoholism, poor nutrition, cancer, and diabetes are predisposing factors for Hemophilus influenzae pneumonia. (Hemophilus is a gram- facultatively aerobic encapsulated rod in the Proteobacteria.) Hemophilus is resisitant to many ?-lactam drugs so second generation cephalosporinsare used to treat. It can easily be differentiated from pneumococcal pneumonia by the gram stain. Mycoplasmal Pneumonia ("walking pneumonia") (p. 643) Mycoplasma pneumoniae (a wall-less bacteria) causes mycoplasmal pneumonia; it is an endemic disease, and symptoms are usually mild. It is often confused with viral pneumonia. Mycoplasmas are the smallest-known organisms capable of growth and reproduction outside living host cells M. pneumoniae produces small "fried-egg" colonies after 2 weeks' incubation on enriched media containing horse serum and yeast extract. A complement-fixation test, used to diagnose the disease, is based on the rising of antibody titer. Antibiotics, either erythromycin or tetracycline, are the usual form of treatment for a M.      pneumoniae infection. The antibiotics help the infected person feel better faster but they do    not remove the bacteria from the throat. M. pneumoniae can remain in the throat for up to      13 weeks Legionellosis (Legionnaires disease) (pp. 643- 644) The disease is caused by the aerobic gram-negative rod Legionella pneumophila (a gram- rod in Proteobacteria) The disease emerged in 1976. The bacterium can grow in water, such as air-conditioning cooling towers, and fountains, and then be disseminated in the air. It is highly resistant to disinfectants like chlorine, and this may be due to its relationship with chlorine resistant waterborne amoebae. It does not appear to be transmitted from person to person. Bacterial culture, FA tests, and DNA probes are used for laboratory diagnosis. Treatment involves erythromycin and rifampin. Psittacosis (Ornithosis) (p. 644) Psittacosis is a zoonosis caused by the obligate intracellular bacteria Chlamydia psittaci (gram- obligately intracelluar bacteria related to gram+'s) and is transmitted by contact with contaminated droppings and exudates of fowl. (pigeons, parakeets, ducks, chickens, turkeys) Elementary bodies allow the bacteria to survive outside a host. Commercial bird handlers are most susceptible to this disease. The bacteria are isolated in embryonated eggs, mice, or cell culture; identification is based on FA staining. No vaccine is available, but it can be treated with tetracycline. Chlamydial Pneumonia (p. 644) Chlamydia pneumoniae (another gram- intracellular bacteria) was recently identified as a cause of pneumonia; it is transmitted from person to person. Most people in the US have been found to have been exposed to it. May be implicated in atherosclerosis. Chlamydia have a tendency to mimic host self antigens so this isnnot surprising. can be treated with tetracycline. Q Fever (pp. 644- 645) Another obligately parasitic, intracellular bacteria, Coxiella burnetii (a gram- rickettsia in proteobacteria) causes the zoonosis Q fever, which emerged in the 1930's.

The disease is usually transmitted to humans from cattle (the reservoirs) through unpasteurized milk or inhalation of aerosols in dairy barns. The bacteria can probebly form endospores. Endocarditis can result. A vaccine is available, and it can be treated with tetracycline Other Bacterial Pneumonias (p.645) Gram-positive bacteria that cause pneumonia include Staphylococcus aureus and Streptococcus pyogenes. Gram-negative bacteria that cause pneumonia include Moraxella catarrhalis, Klebsiella pneumoniae, and Pseudomonas species Dental Caries (Tooth Decay) (pp. 659- 661) Dental caries (cavities) begin when tooth enamel and dentin are eroded and the pulp is exposed to bacterial infection. Around 300 species of bacteria have been found in the normal flora of the mouth. Streptococcus mutans, uses sucrose (table sugar) to form dextran from glucose and lactic acid from fructose. Bacteria adhere to teeth and produce sticky dextran, forming dental plaque. Acid produced during carbohydrate fermentation destroys tooth enamel at the site of the plaque  Gram-positive rods and filamentous bacteria (Actinomyces) can then penetrate into dentin and pulp. Caries are prevented by restricting the ingestion of sucrose (since carbohydrates such as starch, mannitol, & sorbitol are not used by cariogenic bacteria to produce dextran an  thus do not promote tooth decay) and by the physical removal of plaque. (so cut out sweets and brush your teeth) Periodontal Disease (pp. 661- 662) Disease of the support structures of the teeth (gums and bones) is called periodontal disease. Cavities of the cementum (roots of the teeth) and gingivitis (disease of the gums) are caused by streptococci, actinomycetes, and anaerobic gram-negative bacteria. Chronic gum disease (periodontitis) can cause bone destruction and tooth loss; periodontitis is due to an inflammatory response to a variety of bacteria growing on the gums. Acute necrotizing ulcerative gingivitis is caused by Prevotella intermedia (gram-, rods) and spirochetes. Staphylococcal Food Poisoning (Staphylococcal Enterotoxicosis) (pp.663- 664) Staphylococcal food poisoning is caused by the ingestion of an enterotoxin produced in improperly stored foods. Staphylococcus aureus (common gram+ symbiotic bacteria found on skin) is inoculated into foods during improper food preparation. The bacteria grow and produce enterotoxin in food stored at room temperature. The exotoxin is not denatured by boiling for 30 minutes. Foods with high osmotic pressure and those not cooked immediately before consumption are most often the source of staphylococcal enterotoxicosis. Diagnosis is based on symptoms. Nausea, vomiting, and diarrhea begin 1- 6 hours after eating and last about 24 hours. Shigellosis (Bacillary Dysentery) (p. 664) Shigellosis is caused by four species of Shigella. (gram-, Proteobacteria) close relatives of E. coli. Anal to oral transmission via contaminated water. S ymptoms include blood and mucus in stools, abdominal cramps, and fever. These bacteria are resistant to stomach acids. Infections by S. dysenteriae result in ulceration of the intestinal mucosa. Some virulent strains release exotoxins (yes, rare for a gram- bacteria) Unlike Salmonella, Shigella does not get into the blood and cause septicemia. Isolation and identification of the bacteria from rectal swabs are used for diagnosis. It can be treated with floroquinone antibiotics. Rehydration therapy (due to the loss of body fluid with diarrhea) is also indicated. Salmonellosis (Salmonella Gastroenteritis) (pp. 664- 666)

Salmonellosis, or Salmonella gastroenteritis, is caused by many Salmonella species. (gram-Proteobacteria) Transmitted through contaminated food (they are part of the normal flora of birds and reptiles) They are also resistant to stomach acids. Symptoms include nausea, abdominal pain, and diarrhea and begin 12- 36 hours after eating large numbers of Salmonella. Septicemia can occur in infants and in the elderly. Symptoms are due to direct damage by the bacteria. Virulence factors include invasins which enable the bacteria to penetrate host cells. Fever might be caused by endotoxin. Mortality is lower than 1%, and recovery can result in a carrier state. Disease is usually self limiting so antibiotics are not generally given, treatment (like for most diarrheal diseases) involves rehydration Heating food to 68? C (154? F) will usually kill Salmonella. Typhoid Fever (pp. 666- 668) Salmonella typhi causes typhoid fever (not to be confused with typhus, which is athropod transmitted and caused by Rickettsia); the bacteria are transmitted by contact with human feces or food contaminated with human feces. Fever and malaise occur after a 2-week incubation period. Symptoms last 2- 3 weeks. S. typhi is harbored in the gallbladder of carriers. Vaccines are available for high-risk people. Antibiotic treatments include cephalosporins. We saw an outbreak of this in South Florida due to contaminated frozen fruit imported from Central America. Cholera (pp. 668- 669) Cholera is one of those diseases like pague and tuberculosis, where there have been huge epidemics, and large ccale public health responses to bring them under control. Vibrio cholerae (a curved gram- proteobacteria) causes cholera It produces an exotoxin that alters the membrane permeability of the intestinal mucosa; the resulting vomiting and diarrhea cause a loss of body fluids. The incubation period is approximately 3 days. The symptoms last for a few days. Untreated cholera has a 50% mortality rate. Diagnosis is based on the isolation of Vibriofrom feces. There are several serovars of Vibrio cholerae, non-O:1 causes gastroenteritis in the United States. V. cholerae grows in seaweed, it is usually transmitted via contaminated seafood. In crowded unsanitary conditions anal to oral transmission (via contaminated water) can occur. As w/Salmonella treatment involves tetracycline and rehydration. Vibrio Gastroenteritis (p. 669) Vibrio gastroenteritis can be caused by V. parahaemolyticus and V. vulnificus. The onset of symptoms begins within 24 hours after eating contaminated foods. Recovery occurs within a few days. The disease is contracted by eating contaminated crustaceans or contaminated mollusks. Escherichia coli Gastroenteritis (pp. 669- 670) Most strains of E.coli are harmless, but some are not. E. coli gastroenteritis may be caused by enterotoxigenic, enteroinvasive, or enterohemorrhagic strains of E. coli. The disease occurs as epidemic diarrhea in nurseries, as traveler's diarrhea, as endemic diarrhea in less developed countries, and as hemorrhagic colitis. In adults, the disease is usually self-limiting and does not require antibiotics. Enterohemorrhagic E. coli, such as E. coli O157:H7, (which is an inhabitant of cattle intestines) produces Shigella-like exotoxins that cause inflammation and bleeding of the colon. These toxins can affect the kidneys to cause hemolytic uremic syndrome. This is the E coli you read about that has killed people. The best prevention of course is thorough cooking to kill the E. coli bacteria. Campylobacter Gastroenteritis (p. 670) Campylobacter jejuni (gram- proteobacteria) is the second most common cause of diarrhea in the U.S. The infective dose is even lower than Salmonella. These bacteria are part of the normal flora in cattle and poultry. Campylobacter is often transmitted in cow's milk. It is usually self limiting but in rare cases the paralytic Guillain-Barre disease may result due to misdirected cell mediated immune response which causes inflammation of the nerves. Early treatment with erythromycin may shorten the disease Yersinia Gastroenteritis (pp. 670- 671) Y. enterocolitica and Y. pseudotuberculosis can also be transmitted in meat and milk. They are symbiotic bacteria found in domestic animals. Yersinia can grow at refrigeration temperatures. Clostridium perfringens Gastroenteritis (p. 671) A self-limiting gastroenteritis is caused by Clostridium perfringens. (the causative agent of gas gangrene) Endospores survive heating and germinate when foods (usually meats) are stored at room temperature. Exotoxin produced when the bacteria grow in the intestines is responsible for the symptoms. Diagnosis is based on isolation and identification of the bacteria in stool samples. The illness is usually self limiting Bacillus cereus Gastroenteritis (pp. 671- 672) Ingesting food contaminated with the soil saprophyte Bacillus cereus (gram+endospore forming) can result in diarrhea, nausea, and vomiting. As with Clostridium perfringens the illness is usually self limiting Helicobacter Peptic Ulcer Disease (p. 670) We now know that ulcers are not caused by stress, but by bacteria. Helicobacter pylori produces ammonia, which neutralizes stomach acid; the bacteria colonize the stomach mucosa, and this causes an inflammatory response that causes peptic ulcer disease. (so it is our own immune response to the bacteria not direct damage by the bacteria that ulcerates the stomach) The mode of transmission has not been established Bismuth and several antibiotics (tetracycline and metranidazole) may be useful in treating peptic ulcer disease. Cystitis (p. 695) Inflammation of the urinary bladder, is called UTI or cystitis. Cystitis results when intestinal bacteria oppurtunistically invade the bladder. Microorganisms at the opening of the urethra and along the length of the urethra, careless personal hygiene, and sexual intercoursecontribute to the high incidence of cystitis in females. (UTI is sometimes called "honeymoon disease") It can also occur as a nosocomial infection from catheterization. The most common pathogen is E. coli and less commonly, Staphylococcus saprophyticus. Treatment includes trimethoprim-sulfamethoxazole, quinolone and ampicillin. It can often be prevented in the first place by proper hygiene (and refusal to be catheterized) Pyelonephritis (p. 695) Inflammation of the kidneys, or pyelonephritis, is usually a complication of lower urinary tract infections. About 75% of pyelonephritis cases are caused by E. coli. Proteus can also cause it. Low grade kidney infections may also be contributory to the formation of kidney stones. These may involve newly discovered nanobacteria. Treatment is long term intravenous cephalosporins. 

Leptospirosis (pp. 695- 696) 

Leptospirosis is a zoonosis caused by the gram- spirocheteLeptospira interrogans. The disease is transmitted to humans by urine-contaminated water, or cuts an abrasions that come in contact with infected animals. Transmission has also been documented from pet urine in backyard gardens. Domestic dogs are often infected. Like many spirochetes some species of Leptospira can shift antigenicity. Leptospirosis is characterized by chills, fever, headache, and muscle aches. Immune complications may arise. In some patients kidney and liver infections develop. Diagnosis is made by isolation of pathogen from CSF. Recovery confers immunity. Antibiotic treatment includes penicillin, cephalosporinslicomycin or erythromycin. Gonorrhea (pp. 697- 700) Neisseria gonorrhoeae (gram- proteobacteria) causes gonorrhea. Gonorrhea is a common reportable communicable disease in the United States. N. gonorrhoeae attaches to mucosal cells of the oral-pharyngeal area, genitals, eyes, and rectum by means of fimbriae. Inflammation sets in and the familiar symptoms develop. Symptoms in males are painful urination and pus discharge. Blockage of the urethra and sterility are complications of untreated cases. Females might be asymptomatic unless the infection spreads to the uterus and uterine tubes (see pelvic inflammatory disease). Gonorrheal endocarditis, gonorrheal meningitis, and gonorrheal arthritis are complications that can affect both sexes if gonorrheal infections are untreated. Ophthalmia neonatorum is an eye infection acquired by infants during passage through the birth canal of an infected mother. Treatment involves cephalosporins and tetracyclines, since most strains are reistant to penicllin now. Recovery from infection does not give immunity, due to Neisseria gonorrhoeae ability shift antigenicity. Nongonococcal Urethritis (NGU)(pp. 700- 701) Nongonococcal urethritis (NGU), or nonspecific urethritis (NSU), is any inflammation of the urethra not caused by N. gonorrhoeae. Most cases of NGU are caused by Chlamydia trachomatis, which is the most common STD in the United States. Symptoms of NGU are often mild or lacking, although uterine tube inflammation and sterility may occur. C. trachomatis can be transmitted to infants' eyes at birth. Diagnosis is based on detection of chlamydial DNA in urine. Remember Chlamydia mimics host self antigens. We now have eveidence of evidence of heart disease from immune complex deposition that may have been triggered by Chlamydial infection. 2 Mycoplasmas, Ureaplasma urealyticum and Mycoplasma hominis also cause NGU. Tetracyclines and macrolide anitbiotics are used to treat NGU. Pelvic Inflammatory Disease (PID)(p. 701) Extensive bacterial infection of the female pelvic organs, especially of the reproductive system, is called pelvic inflammatory disease (PID). PID is caused by N. gonorrhoeae, Chlamydia trachomatis, and other bacteria that gain access to the uterine tubes.

1 in 10 women will suffer from it. Infection of the uterine tubes is called salpingitis. PID can result in blockage of the uterine tubes ectopic pregnance or even sterility. doxycycline and cefoxitin (a cephalosporin) are used to treat PID. Syphilis (pp. 701- 704) Syphilis is caused by Treponema pallidum, a spirochete (gram-) that has not been cultured in vitro. Laboratory cultures are grown in cell cultures. Syphillis may have evolved int he New World and been brought back to Europe as a "Montezuma's revenge" at the time of contact and conquest after 1492. Many famous people (including Isak Dinesen, the Danish writer, had it) This disease was also made infamous by a very unethical study done on African American men in Tuskeegee from 1928-1972 where the men were left intentionally untreated. T. pallidum is transmitted by direct contact (usually sexual) and can invade intact mucous membranes or penetrate through breaks in the skin. T. pallidum does not have good antigenicity and therefore can evade the immune response. The disease progresses through 3 stages The primary lesion is a small, hard-based chancre at the site of infection. The bacteria then invade the blood and lymphatic system, and the chancre spontaneously heals. The appearance of a widely disseminated rash on the skin and mucous membranes marks the secondary stage. Spirochetes are present in the lesions of the rash. The patient enters a latent period after the secondary lesions spontaneously heal. At least 10 years after the secondary lesion, tertiary lesions called gummas can appear on many organs. It is rare today to see tertiary progression. Congenital syphilis, resulting from T. pallidum crossing the placenta during the latent period, can cause neurological damage in the newborn. Benzathine penicillin is used to treat. Lymphogranuloma Venereum (LGV)(p. 704) LGV is caused by an invasive strain of Chlamydia trachomatis (primarily in tropical and subtropical regions, but also in the US) that infects lymph tissue. The initial lesion appears on the genitals and heals without scarring. The bacteria are spread in the lymph system and cause enlargement of the lymph nodes, obstruction of lymph vessels, and swelling of the external genitals. The bacteria are isolated and identified from pus taken from infected lymph nodes. Doxcycline is used to treat. Chancroid (Soft Chancre) (p. 704) Chancroid, a swollen, painful ulcer on the mucous membranes of the genitals or mouth, is caused by Hemophilus ducreyi. (Hemophilus is a gram- facultatively aerobic encapsulated rod in the Proteobacteria.) This disease occurs most often in the tropics, where it is implicated as a coinfection factor with HIV. When seen in the US, it is strongly correlated with drug use. Erythromycin and ceftriaxone are used to treat. Gardnerella Vaginosis (pp. 704-705) Vaginitis is infection and inflammation of the vagina. Vaginosis is infection without inflammation. They can be caused by Candida albicans (a yeast fungus), Trichomonas vaginalis (a flagellated protozoan), or Gardnerella vaginalis (a gram+ bacteria) Diagnosis of G. vaginalis is based on increased vaginal pH, fishy odor, and the presence of clue cells. Many women are (sadly) unaware they are infected, and seem to think that vaginal odor is "normal". It is not. G. vaginalis is sexually transmitted but it causes no disease in men. Women who routinely get reinfected are advised to have their partners tested for G. vaginalis and treated. It can be treated successfully with metronidazole (an antibiotic that does not kill the beneficial Lactobacilli that are part of the normal vaginal flora.)


\3 DISEASES TO WATCH OUT FOR WHILE TRAVELLING

Cholera

This bacterial infection causes severe painless watery  diarrhoea of sudden onset, occasionally accompanied by vomiting, which rapidly leads to dehydration. Symptoms range from mildto the severe which may be fatal. The bacteria are transmitted in water or food contaminated with infected faeces and the disease can occur in large-scale epidemics where sanitary conditions have broken down. Raw or undercooked seafood from polluted water can cause outbreaks. The incubation period is usually 2-3 days but may only be a few hours. Cholera is rare in travellers as they tend to avoid the unsanitary conditions which would put them at risk.

Treatment Fluid replacement is essential and should be started as soon as symptoms occur. You should aim to drink as much non-alcoholic fluid as it takes to maintain a good output of normal looking urine (this may be as much as 6 or 7 litres a day). Tetracycline antibiotics (250mg four times daily)may be of some benefit. Seek medical help without delay.

Prevention Avoid contaminated food and water. Immunisation is not recommended by the WHO as ameans  of personal protection.


Dengue Fever (break-bone fever)

This is a viral disease causing a severe flu-like illness. Symptoms include fever, intense headache, pain behind theeyes,  in joints and muscles and a rash (usually 3-4 days after onset).The  fever usually settles in 5-7 days although full recovery maybe  delayed by fatigue and depression. The disease often occurs in epidemics.The  virus is transmitted by infected mosquitoes that bite inthe  day. The incubation period is usually 5-7 days. It is not transmitted directly from person-to-person.

Occasionally a more severe and life-threateningform  of dengue fever may occur (more commonly in children) with the development of either a bleeding tendency or a confused state.

Treatment Symptoms can be controlled with simple analgesicssuch  as paracetamol or aspirin, plentiful non-alcoholicfluids  and bedrest. Aspirin, however, should not be taken if bleeding tendencyis  suspected. If confusion, bleeding tendency or shock developsurgent  medical advice should be sought.

Prevention Avoid mosquito bites. There is no vaccine.

Diphtheria

This bacterial infection causes a moderately sore throat with a greyish membrane over the infected area. In severe casesthe  neck tissue may become very swollen. In tropical countries the infection may occur in skin ulcers. After 2-6 weeks, the effects of toxin produced by the bacteria become apparent with severe muscle weakness, mainly affecting the muscles of the head and neck.  Inflammation of the heart muscle may cause heart failure.

Treatment This is specialised and requires medical supervision in hospital.

Prevention Immunisation is very effective and UK childrenare  immunised within their first year. Boosters are required every 10 yearsfor  those at high risk. Avoid too close contact with people in crowdedplaces  (particularly kissing and sharing bottles or glasses).

Hepatitis A

This is a viral disease of the liver. Symptomsinclude  fever, chills, weakness, loss of appetite, nausea and abdominal discomfort, followed within a few days by jaundice (yellowing of theskin  and eyes). Urine becomes dark and stools pale. Many infections, particularly in children, are often without specific symptoms. In others, jaundice may be severe and prolonged and complete liver failure may occur. Past infection with hepatitis A virus gives life-long immunity.

The virus is transmitted person-to-person by the faecal-oral route particularly in areas with poor sanitation and overcrowding. This is commonly associated with eating and drinking  contaminated food and water. Food outbreaks are often linked to raw or undercooked shellfish and raw vegetables.

Prevention Avoid contaminated food and water.

For those who do not have antibodies in their blood (this may be checked by your doctor if appropriate), there isa  vaccine available for regular or long-term travellers/residents. Good protection is afforded by human immunoglobulin (gammaglobulin) for intermittent or short-term travellers.

Hepatitis B

This viral infection affecting the liver usuallyhas  an insidious onset of vague abdominal pain, nausea, vomiting and lossof  appetite which often progresses to jaundice (yellowing of the skin and eyes). The urine is dark. Recovery takes about 28 days but may sometimes be more prolonged.

The virus is transmitted through contaminated blood and body fluids thus it may be acquired by contact with blood e.g. from transfusion with infected blood and the use of unsterilised needlesand  syringes (particularly by drug addicts and tattooists) andby  unprotected sexual intercourse.

The incubation period is 2 weeks to 6 months.

Treatment Specialist medical supervision may be required dependent upon the severity of the illness. Follow-up of liver function and viral markers by blood test is essential.

Prevention Where possible ensure blood for transfusion is screened for hepatitis B infection. Consider joining the Blood Care Foundation. Check sterile needles and syringes are being used. Avoid sharing needles with others if using intravenous drugs. Avoid having a tattoo or acupuncture. Avoid casual unprotected sexual intercourse. Theuse  of a condom will reduce but not eliminate the risk of exposure. There is a vaccine which should be considered for long-stay travellers/residents to areas where hepatitis Bis  endemic.

HIV/AIDS

AIDS is a condition caused by the gradual disablement of the body's defensive immune system by a virus (HIV). Thosewho  acquire the virus may go on to develop the invariably fatal conditionof  AIDS and may pass on the infection even before AIDS becomes manifest. Transmission is through unprotected sexual intercourse and contact with infected blood. It is not spread by casual contact, sharing cutleryor  crockery, using public toilets or telephones swimming pools orfrom  mosquito or insect bites. There is no curative treatment as yet.

Prevention Avoid casual unprotected sexual intercourse. Theuse  of a condom can reduce but not eliminate the risk. Avoid sharing unsterilised needles and syringesor  allow yourself to be given an injection with them. Consider taking a sterile needle and syringe pack with a note from your doctor for customs  explaining why. For long-stay travellers/residents where thereis a  high risk of requiring a blood transfusion in the event of accident or other medical emergency, consider joining the Blood Care Programme. There is no vaccine.

Japanese Encephalitis

This is a viral disease which causes a severe flu-like illness with headache, neck stiffness, confusion and coma.  Mortality may be greater than 30% and long-term effects on the nervous system are common. It is spread by night time biting, rural area mosquitoes and  the chance of developing the disease is about 1 in 200 bites.

The incubation period is usually 5-15 days.

Treatment There is no specific treatment but medical support is necessary. Aspirin and paracetamol help to reduce temperature andrelieve  pain.

Prevention Avoid mosquito bites. These mosquitoes usuallybreed  in rice fields and are mainly animal- biters. They tend to feed outside rather than indoors so any type of accommodation offers protection.Avoid  sleeping outdoors near large concentrations of animals. There is a vaccine which may be considered wherethe  risk is assessed as significant.

Malaria

Malaria is a parasitic disease spread by the biteof a  female anopheline mosquito. The principal symptoms are fever, malaise, chills with sweating and fever and headache. Malaria is either malignant (falciparum malaria) or benign (vivax, ovale or malariae).

The incubation period until symptoms occur is usually 12 days for malignant malaria but up to 30 days for the benign form. Malignant malaria may progress to life-threatening coma or severe state of shock. Benign malaria may produce recurrent episodes of fever, sometimes over many years. Malaria is diagnosed at the time by microscopic examination of a blood film or it can be confirmed after recovery by a special antibody blood test.

Treatment If chloroquine resistance is present in the area visited then treatment is either with halofantrine (only under medical  supervision) or quinine plus Fansidar. Where chloroquine resistance is not present then chloroquine is used (4 tablets followed by 2 tablets 6 hourslater  and 2 tablets daily for 2 days).

Prevention Take precautions to avoid mosquito bites. Ensure strict compliance with the recommended  anti-malarials for your destination. Pregnant women, former residents of endemic areasand  those who have undergone splenectomy are at particularly highrisk of  serious illness associated with malaria. There is an experimental vaccine but it seems unlikely that it will be suitable for travellers and is not available.

Meningitis (Meningococcal)

Meningitis is the infection of the membrane liningof  the brain and spinal cord. Many different bacteria and viruses can cause infection but the meningococcal type can pose a hazard to travellers.It  can occur in epidemics, especially where large crowds are gathered, as it is acquired through inhalation of bacteria in droplets coughedor  sneezed into the air. The principal symptoms are fever with severe headache, neck stiffness, photophobia and a blotchy rash is common. The onsetis  usually sudden and progression to coma is often rapid if treatmentis  not started. The incubation period is usually 3-4 days.

Treatment Large doses of penicillin are effective given intothe  vein and medical supervision is required. Chloramphenicol tablets1  gram (tablets) 8 hourly is an alternative in an emergency and should be started without delay if medical help cannot be obtained.

Prevention Avoid overcrowded places and close contact withthe  local population. Vaccination is effective against two of the three types of the disease (A and C) and is recommended for those at high risk.

Poliomyelitis (polio)

It is caused by a virus which is spread from  person-to-person through either mucous from the nose and throat or by  contamination of food and drink with infected faeces. The initial symptomsare  fever, headache, nausea and vomiting as the virus multiplies inthe  gut. The virus then invades the blood stream and nervous system. Paralysis occurs in less than 1 in 100 cases of infection. This risk increases with age. A blood test for antibodies will confirm the diagnosis, although this is not always available abroad. The incubation period is 7-14 days. Patients are infectious by close contact and should be isolated for at least a week.

Treatment - The development of paralysis is clearly an emergency and medical help should be sought without delay. If the paralysis affects the breathing muscles, artificial means of respiration may be required. Extreme care should be taken when disposing of excreta for up to 6 weeks.

Prevention - As the disease is usually spread through close contact, avoid crowded places (buses, public swimming pools). There is an effective vaccine. Past infection with polio does not always give complete protection as there are three strains of the virus. 10 year boosters should be given to ensure maximum immunity and travellers should ensure they are in date for polio immunisation. There is a World Health Org program aiming to achieve global polio eradication by the year 2000. By 1994, the Americas were certified as polio-free.

Rabies

This viral infection is acquired from the saliva of an infected or rabid animal, usually a dog or cat. In most cases infection results from a bite but even a lick on an open cut or sore may be enough. 

Symptoms start with itching and tingling at the site of the healed bite and then rapidly progresses to include headache, fever, spreading paralysis, confusion and aggression and hydrophobia (fear of water). It may take many weeks or months for symptoms to develop although it is usually 2-8 weeks. Animals may be infectious for five days before they develop symptoms.

Treatment - Thoroughly cleanse all bites with soap and water and do not allow the wound to be stitched. Limited bleeding should be encouraged. Apply alcohol if poss. If available human immunoglobulin (HRIG) should be given especially for bites to the head/face.

The disease can almost always be prevented, even after  exposure, if vaccine is administered without delay. You should therefore seek medical advice immediately and have a course of 5 injections of Purified Chick Embryo Cell Vaccine (PCEC) or Human Diploid Cell Vaccine (HDCV). This can be difficult to obtain abroad and if necessary the British Embassy or consulate should be contacted for a supply.

If you have had a pre-exposure course of vaccine you should still have a 'booster' course of 2 doses of vaccine without delay. Try to get the owner's name and address if a domestic animal and ask him to contact you if the animal gets sick or dies within 2 weeks. Ask if the animal has had rabies vaccine and ask to see the certificate.

Prevention - Never approach or handle animals you don't know, particularly if they are acting strangely. Pre- exposure immunisation against rabies is recommended for long-stay travellers/residents and those who intend to travel to rural and remote areas. In the event of a bite, your body's responses could be quickly activated by booster doses of vaccine. There are rarely any side effects or discomfort from the new type of vaccine unlike the old types.

Tetanus

This bacterial infection produces a toxin which circulates in the body to cause severe and painful muscular contractions and spasms which often lead to death through respiratory problems and exhaustion. Tetanus spores are present in soil and may be introduced into the body during injury through a puncture wound, burn or trivial, unnoticed wounds. The incubation period is 4-21 days, commonly about 10 days.

Treatment - Requires medical supervision in hospital.

Prevention - Immunisation is highly protective and adults and children should ensure they are in date for it. Human tetanus immunoglobulin (HTIG) may be given in circumstances where injured persons are unsure of their tetanus status and a primary course commenced. Clean all wounds thoroughly with clean water and soap taking particular care to remove all dead tissue.

Tuberculosis (TB)

This bacterial disease usually affects the lungs causing persistent cough with fever and sweating. The disease is slow to establish itself and general malaise, weakness and weight loss are characteristic during its incubation of up to 12 wks. Sometimes the disease can be overwhelming; producing meningitis and coma; this particularly dangerous form is usually found in children and those who have not previously been vaccinated or exposed to the disease. Spread is usually through infected sputum but there is a form spread through milk from infected cows.

Treatment - with antimicrobial drugs is effective but is prolonged and requires medical supervision. It is also expensive and not always available abroad.

Prevention - Avoid overcrowded places, particularly where spitting is common. Never drink unpasteurised milk. If in doubt, boil before drinking.

There is a vaccination which can give a valuable degree of protection, particularly in children. Those who have not received BCG immunisation are advised to do so and if for travel purposes, at least 6 weeks before departure to ensure a protective level of immunity.

Tick Encephalitis (European)

This viral illness is transmitted to man by the bite of an infected tick, mainly during the spring and summer months, inparts of Europe and Scandinavia. Symptoms include headache, neck stiffness, confusion and occasionally coma. Ticks are usually foundon the edge of forests and in clearings, long grass and hedgerows and often the bite goes unnoticed. The incubation period is 7-14 days when fever is first noticed and the diagnosis can later be confirmed by blood test.

Treatment - There is no specific treatment but the outlook is usually good with proper hosp care. Aspirin or paracetamol help to reduce fever and relieve pain.

Prevention - Avoid tick bites. A vaccine against the European form is available in the UK. Walkers, hikers and campers in affected countries should consider having this immunisation.

Traveller's Diarrhoea

Travellers commonly suffer attacks of diarrhoea particularly during the first week or two of a stay in a foreign environment. The commonest causes are bacteria and viruses in contaminated food and water. Symptoms are usually those of abdominal cramps, vomiting and fever followed by diarrhoea lasting for about 2-3 days. In warm climates dehydration can lead to rapid prostration, particularly in children.

Treatment - Children should continue to eat and babies continue to be breastfed otherwise they quickly lose weight and energy. Fluid replacement is essential and should be started early. Sugar/salt rehydration solution may either be made up from commercially available mixtures or as follows: To 1 litre of clean water (boiled, bottled or from a purifier) add 1 level teaspoon of salt and 8 level teaspoons of sugar.

For each loose stool passed give: Small infants - ¼ glass of solution and one volume of plain water for every two volumes. Small children - ½ glass of solution Older children - 1 glass of solution. Sufficient fluid should given to ensure a good output of normal looking urine.

Adults - Continue to eat but stick to a bland diet and avoid alcohol and dairy products until 12 hours after the last loose stool. Fluid replacement - 2 glasses of solution per loose stool. Total fluid intake should be about 3 litres per 24 hours. Loperamide (Imodium) is an effective anti-diarrhoeal agent. Take in accordance with manufacturer's instructions. Two tablets may be taken in advance of important meetings.

Antibiotics have been shown to shorten the duration of traveller's diarrhoea. A single dose of 500mg of ciprofloxacin taken after passing the first loose stool should reduce the duration of uncomplicated watery diarrhoea to about one day. If diarrhoea lasts longer than 4 days or there is a fever of 38 degrees C or greater or there is blood in the stool then medical attention should be sought.

Prevention - It is very difficult to avoid traveller's diarrhoea but the risk may be reduced by avoiding contaminated food and water. The prophylactic value of antibiotics is debatable. For very short periods (less than 10 days) and where it is very important to reduce the risk of diarrhoea, an antibiotic (such as ciproflox- acin, trimethoprim or pivmecillinam) may be taken daily. You should discuss your specific situation with your doctor (as a prescription is required) who will advise you of the relative risk of side effects.

Traveler's diarrhea is a problem that mainly affects people who travelto developing countries. Diarrhea-causing bacteria livein  the water in many developing countries. Visitors often experience diarrhea when they drink tap water, use ice cubes, or eat fruits and vegetables washed in tap water. Less common causes of traveler's diarrheaare jet  lag, altitude changes, medicines, or changes in diet and eating pattern.

Symptoms are three or more loose stools in 24 hours. More severe cases will have blood in the stool, vomiting, cramps, fever, or nausea. The diarrhea usually lasts 3 to 4 days. It is not  life-threatening except for infants, who may become dehydrated.

A doctor may prescribe medicine to kill the bacteriaor  to relieve symptoms. The most important part of treatment isto  drink lots of fluids to prevent dehydration. Travelers can drink bottled water, fruit juice, or caffeine-free soda (caffeine can worsen diarrhea).If  dehydration does occur, the person must drink a special rehydration solution that contains the right mix of sodium, potassium, chloride, sugar,and  water.


Typhoid Fever

This bacterial infection causes a pro- longed feverish illness with loss of appetite, lethargy and constipation. The bacteria enter the blood stream from the gut after ingestion of contaminated food and water. Without treatment the illness can be fatal, with perforation of the gut producing peritonitis or severe haemorrhage. Paratyphoid fever is a similar but less severe variant. 

Transmission of both diseases is by consumption of contaminated food or water; contamination is most likely when cooked food is handled or left un-refridgerated. The incubation period is from 1-3 weeks.

Diagnosis needs expert medical opinion and examination of the blood.

Treatment - is with antibiotics and is very effective but should be given under medical supervision. Hosp admission may be more appropriate abroad. Relapse is not uncommon and patients may develop the carrier state after treatment. It is therefore very important to have your stools examined on your return if you have been treated abroad.

Prevention - Avoid contaminated food and water. There are effective typhoid vaccines which are strongly recommended.

Yellow Fever

This viral disease is characterised by a severe flu-like illness in which a bleeding tendency and jaundice may develop. Itis  principally a disease of jungle areas but there are occasional small outbreaks in towns and cities. Monkeys are the principal animal reservoirin  the jungle. The disease must be reported to the World Health  Organisation and there are various obligatory vaccination requirements for travellers. Diagnosis is made by special blood test. The disease is transmitted by the bite of infected mosquitoes. Incubation period is 3-6 days.It  is not transmitted from person-to-person expect by mosquito.

Treatment Good nursing care is the mainstay of treatmentand  hospital admission with isolation is essential.

Prevention Avoid mosquito bites. Vaccination is highly effective in conferring immunity and lasts 10 years. The initial vaccination must be given 10 days before travel if the international certificate is to be valid, but  re-vaccination may be given at any time before expiry of the certificate and is effective immediately.


\4 Ten Diseases on the Way Out

Smallpox: The Once and Future Scourge? (June 15, 1999);  Killer Smallpox Gets a New Lease on Life (May 25, 1999);  ith all the high-tech medical research currently under way, new cures  for disease seem to roll out of the laboratory at an ever-faster pace.  But actually eliminating diseases -- getting the proper cure or  prevention to every last person who needs it -- is a slow, low-tech  business. To date, only one disease, smallpox, has been completely  removed from nature. There are many others, however, for which the  necessary treatments are widely available and for which a plan of attack has already been drawn.
 With the right financing, the following  illnesses could soon be consigned to history.  1. POLIO  What it is: A virus that attacks the central nervous system  Where it's found: Africa and Asia  When it could be conquered: 2005  Projected cost: $1 billion  Status report: In 1988, the World Health Organization began a  coordinated campaign to administer the Sabin vaccine. Since then, the  number of cases has fallen by more than 95 percent. (In India, 134  million children were vaccinated in a single day.); But in many areas,  total vaccination has not occurred, and as long as the virus survives  anywhere -- in Chechnya, say, or Sierra Leone -- it can spread anywhere  else on the globe. Human beings are the only creatures affected by  polio, however, so scientists believe that once the virus is eliminated  from every community, the disease will disappear, and vaccination will  no longer be necessary. The vaccine costs 20 cents; administering it can  cost up to $3.  2. GUINEA-WORM DISEASE  What it is: A parasitic worm that grows to 3 feet  Where it's found: Africa and Yemen  When it could be conquered: 2005  Projected cost: $40 million  Status report: Since there is no vaccine against this disease, and no  safe way to kill the worm during the year that it inhabits its host, the  goal is to disinfect the drinking water in which it's transmitted. In  remote African villages, where even boiling the water is too expensive a  solution, international agencies are handing out low-tech filters (made  of finely woven nylon); and educating people who are already infected on  sanitary procedures. As a result of these efforts, the number of  reported cases since 1986 has fallen by 97 percent to fewer than  100,000. Most of the remaining cases are concentrated in Sudan, where  the protracted civil war has hampered the eradication campaign.  3. MEASLES  What it is: A virus that causes rash and high fever  Where it's found: Everywhere, though now rare in the Americas  When it could be conquered: 2010  Projected cost: $3 billion  Status report: Each year 30 million children -- the vast majority of  them in developing nations -- contract the disease; about 900,000 of  them die. It is biologically possible, using existing technology, to  wipe out measles entirely. But it would be difficult: since the virus is  so highly infectious, it would be necessary to achieve high levels of  immunity in almost the entire world population at the same time. And the  regions where that would be most difficult -- urban slums -- are those  that are most conducive to outbreaks. The World Health Organization has  not yet targeted measles for eradication, but it hopes to cut infections  in half by 2005 and to cut the rest thereafter.  4. LYMPHATIC FILARIASIS  What it is: A parasitic disease of the lymphatic system  Where it's found: Africa, Asia, South America  When it could be conquered: 2020  Projected cost: $800 million  Status report: According to the W.H.O., 120 million people in tropical  areas of the world are currently infected with the mosquito-borne  parasite; as many as one billion are at risk. Many who are infected  suffer a terrible secondary effect: grotesque enlargement of arms, legs,  breasts or genitals, known as elephantiasis. The pharmaceutical  companies GlaxoSmithKline and Merck actually give away effective  anti-parasite drugs, but the end of the disease is still years away,  since many people who are infected are not yet aware that they have  contracted the disease. An additional challenge is getting people to  keep taking the drugs year after year even when they have no obvious  signs of illness.  5. RIVER BLINDNESS  What it is: A parasitic infection that causes blindness  Where it's found: Sub-Saharan Africa, Latin America, Yemen  When it could be conquered: 2010  How much it would cost: $135 million  Status report: Onchocerciasis, which affects more than 17 million  people, is caused by a worm and spread by black flies that bite humans.  Previous containment efforts relied on spraying larvicide, which had  qualified success in reducing the fly population. In 1987 Merck  introduced a new drug, Mectizan, that attacks the young parasite  directly. Although the drug does not kill the adult worms already inside  victims, it can prevent blindness and alleviate skin disease. Merck has  agreed to give away whatever quantity of the drug is needed. Using these  donated supplies, and the services of groups like the Carter Center, the  W.H.O. estimates that onchocerciasis can be so severely reduced that it  will be "eliminated as a public health problem."  6. BLINDING TRACHOMA  What it is: A bacterial disease that can lead to blindness  Where it's found: Africa, Asia, South America, Australia  When it could be conquered: 2020 for blindness  Projected cost: $4 billion to $28 billion  Status report: According to the W.H.O., more than 15 percent of people  who are blind today could have kept their sight if their trachoma  infections had been treated with antibiotics in time. At present 146  million people -- concentrated in areas with scarce water and poor  hygiene -- are affected. The bacteria will never be completely  eradicated, but their dangerous effects can be eliminated with the use  of antibiotics like tetracycline or azithromycin, the latter of which is  being donated by Pfizer. A 10-minute surgical technique can save the  sight of those already infected but not yet blind.  7. LEPROSY  What it is: A chronic bacterial infection  Where it's found: Asia, Africa, South America  When it could be conquered: 2005  Projected cost: $250 million  Status report: A new multidrug antibiotic therapy is highly effective  against this disfiguring disease, but there are still 500,000 new cases  per year -- in part because its years-long incubation period stymies  efforts at early detection and treatment. Seventy percent of these cases  are in India, Myanmar and Nepal. With drugs donated by Novartis, the  W.H.O. hopes to reduce the disease to obscurity. But because some other  species (including armadillos); can carry the bacteria, the disease will  probably never truly be eradicated.  8. HEPATITIS B  What it is: A virus that can lead to liver cancer and other diseases  Where it's found: Everywhere, but mainly in Asia and Africa  When it could be conquered: 2010  Projected cost: $3 billion to $5 billion  Status report: As many as 360 million people are chronic carriers of the  hepatitis B virus, which is transmitted from mothers to infants at  birth, between young children and via unsafe sex or unclean needles. The  great majority of those cases are in Asia. There is no cure, but there  is a vaccine, which costs just $1.50. Even that, however, is too  expensive for the countries worst affected. As a result, eradication is  possible, but particularly difficult, since many carriers remain  infectious for life.  9. MATERNAL/NEONATAL TETANUS  What it is: A bacterial infection that causes muscle seizures  Where it's found: Everywhere  When it could be conquered: 2005  Projected cost: $130 million  Status report: Unicef estimates that 215,000 deaths are caused by  neonatal tetanus every year, and the infection also leads to an  additional 30,000 deaths in mothers. Since the bacteria will always  exist in the soil, tetanus can never be completely wiped out. But  vaccinating women of childbearing age and keeping newborns' umbilical  cords clean will all but eliminate the disease.  10. IODINE DEFICIENCY DISORDERS  What it is: A deficiency that affects the central nervous system  Where it's found: Every continent  Whe  it could be conquered: 2010  Projected cost: $75 million  Status report: Close to 1.5 billion people have iodine-poor diets, which can afflict entire populations with reduced intellectual capacity, impaired motor functions or goiter. The strategy for conquering this disease is relatively simple: add iodine to salt and get people to use it. The iodization program is relatively inexpensive but must be maintained permanently.
	--
Anthrax (1997);  Aujesky's Disease (1989);  Avian Influenza (1992);  Brucellosis (1993);  Classical Swine Fever (2000);  Contagious Equine Metritis (1997);  Enzootic Bovine Leukosis (1996);  Equine Viral Arteritis (1998);  Foot and Mouth Disease (1981);  Swine Vesicular Disease (1982);  Warble Fly (1994)
Campylobacteriosis - Chlamydia psittaci - Erysipelothrix rhusiopathiae - Newcastle disease virus - Pasteurella multocida - Histoplasma capsulatum - Salmonellosis - Yersinia pseudotuberculosis -


\5 AIDS

The human immunodeficiency viruses (HIV) assoc with the Acquired Immunodeficiency Syndrome (AIDS) have become widespread in developing nations. By 2000, over 25 million blacks were living with HIV in black africa, representing about 70% of the global number of infected. 

The spread of HIV in this region has been exacerbated by area crises, such as natural disasters and armed conflict, with resulting mass population movements. The number of infected individuals in Asia is also rapidly rising; it is currently estimated that over 5 million people are living with HIV/AIDS in South and SE Asia. 

The progressive erosion of the immune system suffered by HIV-infected individuals renders them more susceptible to other infections. Often these secondary (or "opportu- nistic") infections are atypical or more severe than they would appear in an immunocompetent person. Since diff diseases are prominent in tropical regions, patterns of the HIV-associated infections may diverge significantly from those seen in the developed nations. 

Moreover, it is thought that being infected with one or more tropical diseases may affect the course of AIDS upon subsequent HIV infection.
  --------------------------------------------------------- Intensive Effort Helps Contain Thai HIV-1 Spread. WESTPORT, CT (Reuters Health) Dec 25 00 - An aggressive prevention campaign has helped control HIV-1 infection in Chiang Rai, Thailand's northernmost province, according to a report in the December 1st issue of AIDS. 

Dr. Peter H. Kilmarx, of the Thai Ministry of Public Health, Nonthaburi, and colleagues note that although HIV-1 infection began relatively late in Asia, it spread very rapidly. Chiang Rai, in the Golden Triangle bordered by Laos and Burma, was among areas with the highest infection rates in Asia. 

The first reports of HIV-1 infection in the province appeared in 1988, but by 1991, seroprevalence in brothel- based female sex workers was 62%. In the same year, as many as 81% of young male military recruits reported having had sex with such workers, and by 1992 the HIV-1 prevalence in 21-year-old male conscripts was 17.3%. 

In response to the HIV-1 epidemic in Chang Rai and elsewhere, the Thai government promoted condom use and sanctioned police action against sex establishments with infected workers or customers. As part of the effort, the provincial government distributed 1.2 million free condoms annually. 

Most brothels closed, and although the number of sex workers remained constant, a shift in favor of nonbrothel settings such as massage parlors, was helpful, say the authors. The women had fewer sex partners and thus had less chance of acquiring and transmitting HIV-1. 

These declines, the investigators conclude, "are believed to be real, and are perhaps the strongest examples in the world of a societywide, successful response to the HIV/AIDS epidemic." Nevertheless, they add, "the number of AIDS cases continues to mount, along with profound demographic social and economic effects." 

--------------------------------------------------------- FDA Warns of Stolen AIDS 'Treatment' Serum By REUTERS  WASHINGTON 12/2000 - Someone stole a batch of an unappro- ved goat serum treatment for HIV infection and might try to sell it, but it could be extremely dangerous, the Food and Drug Administration (FDA) warned.

It said Dr. Gary Davis reported the serum was stolen from a storage facility in Raleigh, North Carolina and that he said it could be contaminated and dangerous.

``The FDA is advising health care providers and patients that goat antiserum to treat HIV/AIDS is not currently approved for the treatment of HIV/AIDS or for any human clinical study,'' the FDA said in a statement.

``This unapproved product, produced in goats as an antiserum against HIV/AIDS, was already the subject of a 'clinical hold' by the FDA, prohibiting its use until previously existing safety questions are resolved.''

--------------------------------------------------------- NYT 1/2001 The AIDS Epidemic.  Over 10,000 leaders, scientists and journalists gathered recently for an AIDS conference, particularly to address the crisis in Africa. Nearly 34 million people are infected with HIV or have AIDS, and approximately 25 million are estimated to be in the African continent. While much progress is being made in awareness and education, many pivotal issues remain contentious: Does HIV cause AIDS? Are the African numbers correct? Is the Bangui definition useful? Is circumcision really a factor?http://www.trimeris.com/t-20Model.htm 

Q: Why does undiluted blood test positive for HIV on the ELISA when that blood comes from a presumably seronegative person? Why is sera diluted as heavily as it is when running the ELISA? 

I have not studied the ELISA test for HIV. My guess, and it is only a pure guess at present, is that the enzyme used for the test is not absolutely specific to the HIV antibody. The enzyme will react also to some other antibodies in the blood, but in a much weaker reaction. In an undiluted sample, these weaker reactions may still cause an observable reaction like a slight color change, but in a heavily diluted sample, these weaker reactions will be so small that no observable indication will be produced. However, this is only a guess at present, until I have a chance to research the matter. 


"I have not studied the ELISA test for HIV. My guess, and it is only a pure guess at present, is that the enzyme used for the test is not absolutely specific to the HIV antibody." 

This makes sense. Take it one step farther and one could surmise that the antibody detected is not specific to HIV. (If you see how incomplete the so-called isolation of HIV is (was), this makes even MORE sense.) 

"The enzyme will react also to some other antibodies in the blood, but in a much weaker reaction." 

Bingo. "In an undiluted sample, these weaker reactions may still cause an observable reaction like a slight color change, but in a heavily diluted sample, these weaker reactions will be so small that no observable indication will be produced." 

People I've contacted who are involved in various ELISA's claim that pure sera it the norm. 

"However, this is only a guess at present, until I have a chance to research the matter." 

Good luck. I wrote to the Pasteur Institute, the FDA, the CDC, the International AIDS Vaccine Initiative, the World Health Organization and a half dozen or so HIV testing facilities. The only response I ever got was from one of the testing labs and they said "That's a good question. When we find out we'll let you know." Never heard from them again. 

The cynical answer is that Gallo figured out that people in high risk groups would still test positive with blood diluted 400 times, and so he schemed to use diluted sera to screen out everyone else. Others imply that this is giving Gallo *way* too much credit, intelligence-wise. 

Well, here is a link which gives one possible hypothetical explaination for false positives:  http://www.supercolostrum.com/colostrum/Information/ information9.htm 

The Elisa test uses an inert extract of proteins from HIV virus fragments, and places this mishmesh of different HIV virus capsule proteins on the test plate for reaction with the sample blood. However, this extract is not purified absolutely. According to the link, even if the extract is purified perfectly, the HIV virus can incorporate host cell proteins on its coat when it buds out of the cell where it was created. Some of this host protein according to the link can cause false positive readings. 

Some other links state the Elisa test gives false positive readings in one out of five hundred tests. False positive results also increase if flu shots were taken within three months of the Elisa test. Positive results should be following up with a more accurate test call the Western Blott test, which separates out the HIV virus proteins in a visible band by the length of the different HIV virus proteins. These proteins are known because the HIV virus genome had been sequenced, and the proteins the virus genome codes for had been identified from the virus gene sequences. 

Color changes on specific HIV virus protein bands from Western Blott test indicate antibodies to specific HIV virus proteins are present, thus this test is considered more accurate than the Elisa test. 

"The Elisa test uses an inert extract of proteins from HIV virus fragments, and places this mishmesh of different HIV virus capsule proteins on the test plate for reaction with the sample blood." 

This is the key: an "...extract of proteins from HIV virus fragments..." 

This is exactly how antibodies to viruses are obtained. For the antibodies to be specific it is of course necessary to isolate the virus. This *can* be a one stop process: you put the sample of blood or tissue which contains the virus and put it through a centrifuge. Viral particles will band together at a very specific density. If all you have at that density are viral particles, isolation is assumed. 

In the case of HIV, Luc Montagnier has admitted that there were distinctly non viral particles at the designated density. Not only that but he admitted they could not detect viral particles even after exerting what he referred to as "Roman effort." What you are supposed to do at that point if purify the isolates, by using something other than density as the guideline, such as for instance, electrical properties. This was never done, by Montagnier or Gallo. 

This would explain why pure blood gives 100% positive response to the HIV ELISA; it is very likely that the proteins that are assumed to be from HIV are proteins we all have in our systems. If this is the case, the HIV ELISA and the Western Blot are just about meaningless. 

accusystems - 10:37pm Dec 16, 2000 EST (#1043 of 1044) Newly Discovered Molecule Is a Clue to the Spread of AIDS By LAWRENCE K. ALTMAN  Feb 9, 2001 
CHICAGO, Feb. 8 — Researchers expressed hope today, at the end of a major AIDS meeting, that a recently discovered molecule might eventually lead to new ways to prevent the infection.

The molecule, which was discovered in the Netherlands with the aid of researchers in New York, is on the fingerlike dendritic cells that lie just beneath the skin and beneath moist mucosal tissue on surfaces like those of the vagina, urethra and penis. 

Dendritic cells lie in wait, ready to greet and capture invading microbes like H.I.V., the AIDS virus, that enter through the mucosa. The dendritic cells carry the invaders to lymph nodes throughout the body so they can be attacked by CD-4 and other immune cells.

But H.I.V. attacks and replicates in the very CD-4 cells that are sent to attack it. And as H.I.V.'s navigational guide, the dendritic cells turn into Trojan horses. The newly detected molecule binds to H.I.V., allowing the virus to survive for four days. Otherwise, H.I.V. would die much sooner.

Dr. Yvette van Kooyk of the University of Nijmegen, described her research in a talk at the eighth annual retrovirus meeting here. In introducing her, Dr. Douglas D. Richman, of the University of California at San Diego, called her work "one of the most exciting discoveries in the past year relating to AIDS research."

One of the enduring mysteries of AIDS is that it takes such a small amount of virus to establish an H.I.V. infection. Dr. van Kooyk's work suggests that the newly detected molecule's protection provides an efficient mechanism for a small amount of H.I.V. to enter, survive and then amplify in large amounts to damage the immune system and create AIDS.

The findings offer potential practical applications. One is in developing a chemical that when inserted in the vagina could act as a microbicide, preventing H.I.V.'s entry into the body. With further research, the molecule might become a target in developing a vaccine or drugs for treating infected people. Development of such a microbicide is considered an important public health goal.

Although Dr. van Kooyk's route to her findings was unusual, it illustrates the unpredictable nature of scientific discoveries and how a fresh look from scientists outside a field can contribute to the process.

Dr. van Kooyk is a cancer immunologist, and her team was studying how dendritic cells interact with certain immune cells, T lymphocytes, through attachments known as adhesion molecules. In doing so, she built on dendritic cell research by Dr. Ralph Steinman's team at Rockefeller University in New York.

The Dutch team focused on one adhesion molecule known as an icam and identified a dendritic protein that strongly bound the icam. In her work, Dr. van Kooyk's group teamed with another headed by Dr. Dan Littman of New York University. The researchers gave the molecule the acronym DC-SIGN to avoid using its tongue-twisting formal name: dendritic-cell-specific, icam-grabbing nonintegrin.

Later, Dr. van Kooyk's team learned that scientists from Bristol- Myers had found what was apparently the same protein bound to a protein on the surface of H.I.V. but had not linked it to dendritic cells.

Dr. van Kooyk suggested that scientists might find a way to use the molecule to develop a vaccine. If further research shows that dendritic cells play an important part in perpetuating replication of H.I.V., then scientists might also try to develop a drug that blocks such action.

Dr. Preston Marx of the Aaron Diamond AIDS Research Center in New York was among the scientists who said they planned to pursue Dr. van Kooyk's findings.

At this meeting last year, Dr. Marx reported that injections of estrogen into female monkeys strongly protected against infection by the simian AIDS virus. The injected estrogen led to a thicker layer of cells that acted as a protective barrier against infection when S.I.V., the simian AIDS virus, was squirted into the vaginas of female monkeys to test the effectiveness of the therapy.

Dr. Marx said in an interview here that he planned to explore how DC- SIGN might relate to the estrogen effects, in his efforts to develop estrogen or another drug as a protective microbicide.


\6 Alzheimer's Disease

A common degenerative brain disease that impairs mental and emotional function in older adults, causing them to lose their memory and ability to care for themselves. Although there is extensive ongoing research, no cure has yet been found for Alzheimer's.

A brain disorder marked by a slowly deterioration of brain tissue and therefore, of brain function as well. This gradual decline in mental capacity affects memory and reasoning abilities in about 6% of people over the age of 65, in more than 10% of those between 75-85, and in about 20% of those over 85.

The disease is the most common form of dementia (a general term for mental decline, especially in memory and thought processes) among the elderly. It was first described early in the twentieth century by German neurologist Alois Alzheimer. The disease causes irreversible changes in nerve cells in certain vulnerable areas of the brain, including nerve cell loss, abnormal tangles within nerve cells, and deficiencies of several chemicals in the brain.

The disease starts slowly, usually with forgetfulness and personality changes, but daily activities soon become impossible, leaving the patient bewildered and frustrated. Eventually, he or she loses control of mental and bodily functions and becomes completely dependent on others for all care. Most patients die within 5 to 10 years after diagnosis, often from infections such as pneumonia. Among American adults, Alzheimer’s disease is the fourth leading cause of death.

No single cause of Alzheimer's disease has been found, but the following have been strongly associated with its development: genetic factors, such as inheriting an abnormal gene 

neurochemical factors, such as a deficiency of several neurotransmitters (chemicals essential for transmitting nerve messages)

environmental factors, such as exposure to excess aluminum and manganese

viral factors, such as exposure to a slow-acting virus

immunological factors, such as a malfunction of the immune system whereby the body begins to attack its own tissues, producing antibodies to its own cells.

The only identified risk factors for Alzheimer’s disease are advancing age and family history of dementia, Alzheimer’s disease, or Down syndrome.

SIGNS AND SYMPTOMS of Alzheimer's disease vary with the stage of the disease, as outlined below:

Stage 1 forgetfulness poor insight problems finding the right word to say personality changes problems with calculations losing or misplacing things repeating questions or statements a minor degree of disorientation

Stage 2 worsening memory using words less and less appropriately loss of basic self-care skills further personality changes agitation inability to recognize distant family or friends difficulty communicating wandering off having delusions and hallucinations

Stage 3 total helplessness hostility complete loss of memory loss of bladder and bowel control total lack of comprehension loss of motor skills inability to communicate

DETECTION AND DIAGNOSIS Since some cases of mental decline in elderly people can be reversed once the cause is found, the doctor will screen the patient for many other problems, such as heart disease, anemia, side effects of medications, and depression. The doctor will take a detailed medical history, including a complete inventory of any prescription and over-the-counter drugs the patient is taking, and do a physical and a neurological examination, including a functional and mental status assessment test. A variety of laboratory examinations will also help with the diagnosis, such as blood and urine tests, a computed tomography (CT) scan to get clear cross-sectional images of the brain, and magnetic resonance imaging (MRI) for an even more detailed view of the soft tissues inside the skull. The doctor might also request positron emission tomography (PET) to detect structural problems of the head and the brain.

TREATMENT Alzheimer’s disease cannot be cured, but drug therapy can help slow its progress in the early stages. Some improvement in memory and mental functioning is possible with tacrine (Cognex), a drug that slows the breakdown of a neurotransmitter that helps coordinate memory and learning. The drug’s effect is temporary, but it might help for as long as 6 months. Doctors might also prescribe a wide variety of other types of drugs to help control the agitation, mental problems, depression, anxiety, apathy, hostility, and sleep and appetite disturbances common in Alzheimer’s patients.

To help keep the patient functioning as well as possible for as long as possible, the following measures might also help:

eating a proper diet getting daily exercise, including walking keeping the home environment safe and stable sticking to familiar routines

writing down simple instructions and reminders, such as lists of daily activities, labels on frequently used items, and notes on a prominently displayed calendar

continuing intellectual stimulation and social contact having the patient wear an identification bracelet

distracting the patient when he is frustrated or agitated

encouraging the patient to reminisce, as long-term memory is usually less impaired

participating in support groups (for the patient as well as for the family and caregivers)

The physical, emotional and financial burdens of caring for a person with Alzheimer’s disease can be enormous. Family members and other caregivers can become exhausted and demoralized by the all-consuming task. They lose freedom and privacy and sacrifice their own needs, often without getting any thanks in return. Any resentment they feel builds as they worry about inheriting the disease and feel guilty about their anger, about past mistakes, about lying to the patient in small ways, or about denying the patient’s wishes.

Existing family problems may worsen as the patient becomes more dependent. A formerly passive spouse might find it difficult to make decisions for the patient. It is not surprising that caregivers have a higher rate of depression than the actual patients with Alzheimer’s disease do. Some caregivers join support groups to help deal with the isolation they feel, to comfort one another, and to exchange advice. Such groups are available through local chapters of the Alzheimer’s Association, and can help caregivers realize that they need time to lead their own lives. That’s where respite care can help, with services like housekeepers, home attendants, visiting nurses, day care centers, senior citizen programs, and day hospitals, not to mention case managers to coordinate such services. Sadly, many families know too little about these services or are too shy or too proud to seek help.

Although family members are the usual caregivers for people with Alzheimer’s disease in the earlier stages, the demands eventually become too great even for the most devoted wife, daughter, husband, or son. Most Americans with the disease ultimately wind up in nursing homes or long-term care facilities. Many families take this step only after their resources are exhausted and the patient is already near death. Families sometimes wait too long and have to be persuaded by outsiders to do what is best for all involved. To avoid having to make a hasty decision during a crisis, it is best to start exploring the options as soon as the patient begins to need supervision.

PREVENTION Although Alzheimer’s disease cannot be prevented, early detection and appropriate treatment might help slow its progress. Toward that end, the Agency for Health Care Policy Research, part of the U.S. Department of Health and Human Services, suggests the following series of questions to ask to help recognize the condition:

Does the person have problems with any of these activities?

Learning and remembering new info. Does he repeat things he says or does? Forget conversations or appts? Forget where he put things? •Handling complex tasks. Does he have trouble performing tasks that require many steps, such as balancing a checkbook or cooking a meal? •Reasoning ability. Does he have trouble solving everyday problems at work or at home, such as knowing what to do if the bathroom is flooded? •Spatial ability and orientation. Does he have trouble driving or finding his way around familiar places? •Language. Does he have trouble finding the words to express what he wants to say? •Behavior. Does he have trouble paying attention? Is he more irritable or less trusting than usual?

GLOSSARY OF MEDICAL TERMS

anemia: condition of having too few or inadequate red blood cells

antibodies: drugs that block the action of histamine, a compound that expands blood vessels and constricts breathing passages

Down syndrome: a combination of physical abnormalities and mental retardation caused by a defective gene

gene: basic unit of protein molecules that transmits inherited traits, like eye color or blood type

immune system: the sum total of the body's response to foreign invaders, such as bacteria or transplanted tissue

neurological: pertaining to the brain and spinal cord, the body’s main coordinating and controlling center

In Struggle Against Alzheimer's, Hope May Be Over the Counter
 By DENISE GRADY Jan 22 02.

For people worried about developing Alzheimer's disease, a recent study seemed to offer a rare hint of good news. Dutch researchers found that people who took anti-inflammatory drugs like ibuprofen or naproxen for at least two years were only one-sixth as likely to get Alzheimer's as people who did not take the drugs. The medicines are widely used: ibuprofen is the main ingredient in Advil and Motrin, and naproxen is found in Aleve.

The study, published in November in The New England Journal of Medicine, was not considered definitive, but several other trials are under way, also testing anti-inflammatory drugs in people with Alzheimer's disease or at high risk of developing it. The newer trials, more rigorously designed than the Dutch one, are expected to provide clearer answers about whether the drugs can ward off Alzheimer's.

The studies reflect scientists' growing interest in the idea that a common condition, inflammation, may underlie many chronic and debilitating diseases — like Alzheimer's, heart disease, osteoporosis and diabetes — and that drugs that fight inflammation may have a role in preventing or delaying those diseases, or at least slowing them down.

The drugs being studied belong to the class known as Nsaids (pronounced EN- seds) — nonsteroidal anti-inflammatory drugs. In addition to ibuprofen and naproxen, the class includes aspirin and the prescription drugs known as cox-2 inhibitors, celecoxib (Celebrex) and rofecoxib (Vioxx). Prescription anti-inflammatory drugs also include diclofenac (Voltaren), indomethacin (Indocin) and other less commonly used drugs. 

Acetaminophen (Tylenol) is not part of the group; it treats pain and fever, but does not have the same anti-inflammatory properties as the other drugs.

Nonsteroidal anti-inflammatories are among the most popular medicines in America. They ease pain and fever, and millions of people take them for headaches, backaches, arthritis, colds and the flu. Millions with risk factors for cardiovascular disease have also been advised to take an aspirin a day to lower the risk of a heart attack or the most common type of stroke, which occurs when an artery supplying blood to the brain is blocked. Aspirin is the only anti-inflammatory drug that has been proved to have this benefit. Originally, the effect was attributed to aspirin's ability to prevent blood clots, which can cause heart attacks or strokes. But now, researchers think part of the protective effect may come from aspirin's ability to quell inflammation in the arteries, helping to prevent blockages.

But apart from recommending an aspirin a day, or a baby aspirin, to patients at risk for heart disease, doctors are not encouraging people to take other anti-inflammatory drugs to prevent Alzheimer's or any other chronic illnesses. They say it is too soon: there is no definitive evidence that the drugs will work. And regular use is not safe for everyone. 

Side effects can include stomachache or nausea in up to 20 percent of patients, and stomach or intestinal ulcers and bleeding in 2 percent to 4 percent of those who take the drugs for a year, especially people over 60. The stomach bleeding can occur with little warning, and it can be fatal. Even low doses of aspirin can cause stomach bleeding in some people. (Cox-2 drugs are thought less likely to cause stomach bleeding.) 

Aspirin can also cause a slight increase in the risk of a less common type of stroke, one brought on by bleeding in the brain.  In people with kidney disease, anti-inflammatory drugs may make the problem worse.  A study has suggested — though it is not definitive — that cox-2 drugs may cause a slight increase in heart attack risk. Finally, researchers say that the anti- inflammatory drugs' interactions with other drugs, including aspirin, need further study. 

Recent studies have highlighted some of the uncertainty about the effects of long- term use of Nsaids. Last month, a study suggested that if aspirin users took ibuprofen, too, it might cancel out aspirin's cardiovascular benefit. The researchers, led by Dr. Garret A. FitzGerald at the University of Pennsylvania, did the study because they knew that many people took more than one anti-inflammatory drug at a time.

Aspirin helps prevent heart attacks by acting on blood cells known as platelets, which play a major role in clotting. Aspirin prevents platelets from sticking to each other; it does so by blocking the enzyme cyclooxygenase, or cox, and stopping production of a substance called thromboxane, which makes platelets sticky. Aspirin's effect on platelets is irreversible and lasts for as long as the cells live. But the body is constantly making new platelets.

The researchers found that if people took aspirin first, and took one dose of ibuprofen two hours later, the aspirin still prevented their platelets from clumping. But if for six days they took ibuprofen first, or took several doses a day after taking aspirin, the effect of aspirin was blunted, and the platelets became sticky. Ibuprofen temporarily attaches itself to the same part of the enzyme as aspirin, interfering with its action.

Unlike ibuprofen, other painkillers — acetaminophen, rofecoxib, diclofenac — did not interfere with aspirin because the molecules have a different structure. But indomethacin might act like ibuprofen, the researchers said. The study, published in The New England Journal of Medicine, was widely reported, and the findings worried many people who take aspirin in hope of preventing a heart attack.

Dr Leslie J. Crofford, a rheumatologist and assoc prof of internal medicine at the Univ of Michigan, said some of her patients called to ask, "Will I have a heart attack if I take an Advil?"  Dr Crofford has been telling them that occasional use is of no concern, especially since most people take their aspirin in the morning.

"This idea — that if you take Advil for a headache, it will interfere with aspirin's work — is nonsense," she said. But she and other experts cautioned that the Pennsylvania study did suggest that steady use of ibuprofen — several doses a day for weeks or months at a time — might interfere with aspirin.

For patients who take aspirin to lower the risk of heart attacks but also need regular doses of an anti-inflammatory drug, Dr. Crofford said that she would recommend an anti-inflammatory other than ibuprofen. 

For those who like ibuprofen best for chronic pain but also have a risk of heart attack, Dr. David P. Faxon, chief of cardiology at the University of Chicago and president of the American heart association, said: "They need to consult physicians. If they need to be on a blood thinner like aspirin, they may need to switch to another blood thinner like Plavix." Plavix is a prescription drug that makes platelets less sticky, but it is not an anti-inflammatory. 

Another article in the same issue of The New England Journal as Dr. FitzGerald's study suggested that in people who already had chronic kidney failure, aspirin and acetaminophen might make the condition worse, with a slightly higher risk from acetaminophen. The drugs may block the production of substances that are needed by the kidney.

But the researchers said that they could not be sure whether the patients' use of anti- inflammatory drugs was a cause of kidney disease, or an effect of it. In some of the patients, conditions that caused their kidney problems may also have caused pain, prompting them to use painkillers more often than healthy people.

Despite the uncertainty, though, Dr. Faxon and Dr. Crofford warned that people with kidney failure, which in its early stages often has no symptoms, had to be very careful in using anti-inflammatory drugs.

But, Dr Faxon said, "A lot of people with kidney disease also have heart disease, and we keep them on aspirin because the heart disease risk is worse. It's always a balancing of risks with medicines."


\7 Anthrax

Bacteria in contaminated meat Red/brown skin boil, fever Disease of farm animals. Travelers are at low risk except in epidemic areas as eastern Europe and rural Russia. Treatable with antibiotic or vaccine. At high risk are vets, lab techs, tanners, abutuars workers who often come in contact with spores of contaminated animals or hides. Eating infected meat in rueal areas is a danger. 

severe disease of sheep, cattle, horses, goats, & pigs occasionally transmitted to man by contact with these animals or their products. Infection is by handling (cutaneous form), by inhaling the infective spores (respiratory/pulmonary form), or by eating contaminated uncooked or inadequately cooked meat (intestinal form). The causative organism is Bacillus anthracis which exists in a vegetative state in animals and man. Spores that are extremely resistant to disinfection or physical destruction form when the organism contacts oxygen.

Cutaneous anthrax or malignant pustule, theusual form of the disease, results from direct infection of a cut, an abrasion or, at times, intact skin. Two-five days after being infected, a raised area with a purple to black ctr appears on the exposed area of skin. After a few days, the usually painless lesion ruptures and dries to a thick black crusty scab. Fever and general tiredness may also be present. Prognosis is good if the treatment is started early (5-20% of untreated cases result in death).

Pulmonary anthrax or woolsorter's disease is the result of inhalation of infective spores from hides, bristles or wool. Pulmonary anthrax begins as a flu-like infection with fever, general tiredness, headache, shortness of breath, cough and upper respiratory congestion. This form of the disease can develop into severe respiratory distress and death can occur.

Intestinal anthrax is uncommon but severe. It is the result of eating the meat of animals infected with anthrax. Immediate symptoms are aggravated gastroenteritis including bloody stools and vomiting, fever and septicemia (generalized infection of the blood). Death is common (25 - 75% of cases).

Risk -Anthrax occurs globally, but it is most often a risk in countries with weak public health regulations. Areas of highest risk are countries in Africa, Asia and the Middle East, although epidemics have been recorded in Haiti and Mexico. Farmers, veterinarians, tannery workers and wool workers are most at risk. Travelers do not appear to be at great risk for this disease; however, they should be aware of the potentially contaminated raw materials and foods and take necessary precautions against exposure.

Prevention - For those at high risk, a cell-free vaccine is available (through the CDC drug service in the United States). Otherwise, travelers should avoid contact with livestock (and especially livestock remains) in areas where vaccination of herds is questionable. Travelers should also, where possible, make sure that meat has been properly slaughtered and cooked well-done prior to eating (since intestinal anthrax is generally caused by eating meat of animals that died from anthrax).

Treatment - Treatment with penicillin is preferred, but tetracycline or broad based antibiotics such as erythromycin and chloramphenicol can also be used.

One of the biological warfare agents is the spore-forming bacterium that causes Anthrax, an acute infectious disease. 

--An Anthrax vaccine that confers protective immunity does exist, but is not readily available to private parties.(Please see the Department's Fact Sheet on the Anthrax Vaccine.)Efficacy and safety of use of this vaccine for persons under 18 or over 65 and pregnant women have not been determined. 

--Anthrax is susceptible to treatment if that treatment is initiated promptly after exposure.The post-exposure treatment consists of certain anti-biotics administered in combination with the vaccine.For Anthrax as a Biological Warfare Agent

Anthrax is the preferred biological warfare agent because: It is highly lethal. 100 million lethal doses per gram of anthrax material (100,000 times deadlier than the deadliest chemical warfare agent). Silent, invisible killer. Inhalational anthrax is virtually always fatal. There are low barriers to production. Low cost of producing the anthrax material. Not high-technology. Knowledge is widely available. Easy to produce in large quantities. It is easy to weaponize. It is extremely stable. It can be stored almost indefinitely as a dry powder. It can be loaded, in a freeze-dried condition, in munitions or disseminated as an aerosol with crude sprayers. Currently, we have a limited detection capability. 

What is Anthrax? Anthrax is a naturally occurring disease of plant eating animals (goats, sheep, cattle, wine, etc.) caused by the bacterium Bacillus anthracis. 

It is an illness which has been recognized since antiquity. Anthrax was common in essentially all areas where livestock are raised. Intensive livestock immunization programs have greatly reduced the occurrence of the disease among both animals and humans in much of the world, an most outbreaks occur in areas where immunization programs have not been implemented or have become compromised (primarily Africa and Asia; however, outbreaks occurred during the mid- I 990's in Haiti and the former Soviet Union). 

Anthrax spores can remain viable for several decades under suitable environmental conditions; thus, absence of cases does not equate to absence of risk. Humans can contract anthrax in three ways: Through cuts or breaks in the skin resulting from contact with an infected animal (cutaneous anthrax), resulting in local and possibly systemic (bloodstream) infection. 

From breathing anthrax spores (termed "woolsorters" disease) resulting in an infection of the lungs (inhalational anthrax). 

From eating infected meat, resulting in gastrointestinal infection (gastrointestinal anthrax). Gastrointestinal anthrax is generally not considered a threat to U.S. forces. 

What are the symptoms? Symptoms of anthrax begin after a 1 to 6 day incubation period following exposure. For contact or cutaneous anthrax, itching will occur at the site of exposure followed by the formation of a lesion. Untreated contact anthrax has a fatality rate of 5-20 percent, but with effective antibiotic treatment, few deaths occur. 

Initial symptoms for inhalational anthrax are generally non-specific: low grade fever, a dry hacking cough, and weakness. The person may briefly improve after 2 to 4 days; however within 24 hrs after this brief improvement, respiratory distress occurs with shock and death follow- ing shortly thereafter. Almost all cases of inhalational anthrax, in which treatment was begun after patients have exhibited symptoms, have resulted in death, regardless of post-exposure treatment. 

What is the medical countermeasure? Prior to exposure, prevention through vaccination, using the FDA-licensed vaccine. Otherwise, antibiotics such as penicillin, ciprofloxacin, and doxycycline are the drugs of choice for treatment of anthrax. 

Treatment with antibiotics must begin prior to the onset of symptoms and must include vaccination prior to discontinuing their use. The use of antibiotics keep the patient alive until their body can build an immunity to anthrax via vaccination. After symptoms appear however, inhalational anthrax is almost always fatal, regardless of treatment.10 Jun 1998

  Bacillus anthracis. Causes anthrax. If bacteria are inhaled, symptoms may develop in two to three days. Initial symptoms resembling common respiratory infection are followed by high fever, vomiting, joint ache and labored breathing, and internal and external bleeding lesions. Exposure may be fatal. Vaccine and antibiotics provide protection unless exposure is very high. 

Excruciating Lessons in the Ways of a Disease Oct 31, 2001
 By THE NEW YORK TIMES

This article was reported and written by William J. Broad, Stephen Engelberg, Judith Miller and Sheryl Gay Stolberg.

The diagnosis of inhalation anthrax in a New York hospital worker throws into question many of the assumptions about an outbreak for which the scientific and medical wisdom was already being revised daily, sometimes hourly.

Just a few days ago, it seemed possible that the spate of infections could be traced to a handful of anthrax-laced letters, in particular a remarkably potent one that wound its way from New Jersey to a Washington mail collection center and then, finally, to the office of Tom Daschle, the Senate Democratic leader.

That now seems increasingly unlikely. And what was striking yesterday as officials struggled to explain the latest twist - the infection in the hospital employee, who works in a basement stockroom and neither handles the mail for a living nor appears to have been the target of an anthrax-tainted letter - was their acknowledgement of how much they do not know.

"It is unclear whether this particular instance is part of a pattern of other cases or whether it represents something different," said Dr. Jeffrey Koplan, head of the Centers for Disease Control and Prevention. "We are making no assumptions as to where this exposure occurred."

Since the first case was diagnosed in Florida a month ago, almost every assumption about anthrax has been challenged, if not disproven outright. Finely ground anthrax, it now seems, can form a lethal mist with no more sophisticated a delivery system than an envelope in the mail. Powerful antibiotics, doctors have learned, can offer a fighting chance of survival even after symptoms have appeared. Yet the amount of spores needed to produce inhalation anthrax, the deadliest form of the disease, could be far smaller than previously believed.

The most recent case is even more confounding. Could a wisp of the anthrax mailed to Washington have found its way to the basement of a Manhattan hospital before settling in the lungs of the worker? Were there other letters and, if so, where are they? Or is this latest infection a harbinger that something worse is to come - an anthrax outbreak in which the spores are being spread in some way other than the mail?

The inability of scientists to answer these questions points up how little experience they have with the illness.

Anthrax is an ancient disease, refined in the 20th century into a weapon of war. But there is little human data on how the infection takes hold in individuals or how an outbreak moves through populations.

There is also enormous uncertainty over who might have the capability to produce such a weapon. While only a few nations are known to have made anthrax in the form found in the letter to Senator Daschle, the technology for producing such finely ground particles is now widely available. While it might take more than a Ph.D. in microbiology to make the weapon, it is not beyond the ability of a terrorist group or even a lone individual trained in the arts of pharmacology.

"This is a classic who, what, when, where and why," said Dr. Michael T. Osterholm, director of the Center for Infectious Disease Research at the University of Minnesota. He added: "We are going to have to start getting used to this uncertainty in the short term, because it is going to take a while for these cases to be fully investigated."

A Public Health Puzzle

From a public health standpoint, the troubling, unanswered question about the 61-year-old New York hospital worker, who has been identified as Kathy T. Nguyen, a Vietnamese immigrant, is whether she is what epidemiologists term an outlier - someone who fails to fit the pattern of an outbreak and therefore represents a harbinger that an epidemic is about to grow more dire.

"The obvious thing here is, it is not clear what her source of exposure would be," said Stephen S. Morse, director of the Center for Public Health Preparedness at Columbia University. "She doesn't fit the normal pattern. She's not a mail handler who was working in a facility where there was a lot of mail going to the media, or government offices, or an obvious target."

Before the outlier question can be settled, some old-fashioned disease detective work must be done. Authorities must track Ms. Nguyen's habits and whereabouts in the weeks before she became ill - all without her help, since she is too ill to talk. They must test for anthrax in her home and workplace; the stockroom where she worked shared space with the hospital mailroom until recently. Some tests have already been conducted, and the few results that have come back so far have been negative.

"We are making no assumptions as to where this exposure occurred," Dr. Koplan said today, "and we have to both investigate and rule out where she worked, did she have other jobs and where else she might have been exposed, what were her patterns of activity."

He added, "And we don't have answers on all of those yet."

In any public health investigation, authorities zero in on the "mode of transmission" - the way a disease is spread. In the case of anthrax, the mode of transmission so far has been the mail. But anthrax germs are being spread intentionally, not naturally, so officials must be open to the possibility that the mode of transmission may have changed.

One important clue is that the woman has developed inhalation anthrax, which occurs when microscopic spores lodge in a person's lungs. Although experts have theorized in recent weeks that anthrax might be spread when letters cross- contaminate one another in postal facilities, many are skeptical that the woman got infected this way.

One comforting sign, experts say, is that so far, no one else has gotten sick. If someone intentionally released anthrax spores in the hospital or some other place the woman visited, "you would probably see an epicenter of several people being infected," said Dr. Irwin Gelman, an infectious disease expert at Mount Sinai School of Medicine in Manhattan.

So it may take additional anthrax cases - if any emerge - before authorities can determine whether the woman's infection is the result of exposure in the mail, or whether anthrax is being disseminated in a different way. That will help experts determine who else may be at risk.

"If you're investigating a serial killer, it's very hard to know the pattern of that serial killer after one or two murders," said Dr. Osterholm, of the University of Minnesota. "By the seventh or eighth murder, things start to appear in a particular way. As more cases come in, we will learn a lot about the epidemiologic pattern, and the risk factors for developing this infection."

Today, New York City public health officials urged doctors and hospitals to be alert for additional cases of inhalation anthrax. "You need to be watchful for those first cases that don't fit any established pattern," said Dr. Morse, of Columbia, "because they may tell you that there is another pattern that you need to be looking for."

The Contamination Chain

In theory, a single letter containing anthrax, like the letter sent to Mr. Daschle, could contaminate other letters moving with it through the postal system with enough anthrax to infect a person.

To some, that situation seems unlikely.

"The whole secondary spread is very dubious to me," said Dr. Philip S. Brachman, the researcher who did the pioneering studies of anthrax in the United States in the 1950's following an outbreak at a textile mill in New Hampshire. "If you did have an envelope that had spores in it and some of the powder gets out and lands on something else, I'm not sure it becomes aerosolizable. I can envisage large particles coming out, but for them to re-aerosolize in a manner in which they would be inhalable, that would take a tremendous amount of energy. I don't know if that's aerodynamically possible."

But other experts said that, given recent events, spreading of the spores in this way could not be ruled out.

The issue arises because anthrax spores, if properly grown and processed, are incredibly potent. Federal officials have disclosed that the powder in the Daschle letter was an advanced formulation, with a compound added to keep the anthrax spores from sticking together, enabling them to float more freely, spread more widely and potentially infect more people.

One gram, or one twenty-eighth of an ounce, of such high-grade anthrax can hold up to 100 billion spores, said Ken Alibek, a former top official of the Soviet germ weapons program who is now president of Advanced Biosystems Inc., a consulting company in Manassas, Va. Estimated conservatively, at 10,000 spores to a lethal dose, one gram in theory could cause about 10 million deaths.

Representative Mike Pence, an Indiana Republican whose office last week was found to be contaminated with a few spores, said in an interview that he had been told by federal investigators that the letter sent to Mr. Daschle contained two grams of anthrax - enough to make about 20 million lethal doses, assuming it could be distributed with perfect efficiency.

But this letter caused only minor problems in the Senate office building itself, because most of the spores probably stayed put and only a fraction rose into the air, weapons experts said. Moreover, only a tiny fraction of the floating particles were inhaled.

The anthrax in the Daschle letter was found to have contaminated 28 people. None of these people became sick. But federal investigators said the Senate letter may have leaked anthrax in transit from New Jersey and infected postal workers there and in Washington. And perhaps it could even have tainted other letters, spreading the germs to other buildings in Washington.

"If you shake it somehow," Dr. Alibek said, a contaminated letter might let loose a lethal puff of anthrax spores. "It's possible to re- aerosolize enough to become infected," he said. "The probability is low but you cannot rule it out."

Another possibility, he said, was that a poisoned letter could hold so little anthrax that the spores would be essentially imperceptible. "It might be that you wouldn't see the actual product," Dr. Alibek said.

"It could be a very tiny amount," he said, but still harbor enough spores so more than one person would come down with the disease.

Dr. Alibek said that when he directed the production of mass quantities of anthrax in the Soviet Union, scientists were amazed at its ability to spread. The anthrax he perfected at the Stepnogorsk plant in remote Kazakhstan, he noted, was found in many unlikely places.

"We found them in zones of our production building where they were never supposed to be," he said. "But you can't control wind direction, and you really can't control their movement."

The scientists did not fall ill, however, "because we had a very powerful vaccine, and we were all vaccinated, repeatedly."

Other Means to an End

As investigators and scientists study the question of whether tainted letters alone could have caused all of the cases of infection and contamination, they find themselves confronting an array of other possibilities, some more likely than others.

The most improbable would be a large-scale outdoor release of spores by an airplane or sprayer driven around by car or van, experts agreed. Such attacks are hard to pull off successfully, especially in urban areas, because fickle winds, heat effects and other meteorological variables would tend to disperse spores harmlessly. Also, they said, such an attack might produce more cases of anthrax than have been reported so far.

"You'd think there would be more cases by now, because people are so vigilant," said Jonathan B. Tucker, a germ-weapons expert in the Washington office of the Monterey Institute of International Studies. "It seems unlikely that this is the first of a wave of new cases."

But strikes in indoor spaces, like buildings and subways, would be easier, experts said, though they agreed that medical evidence for such attacks is so far lacking.

Moreover, hitting a building through its ventilation system can be risky and highly unreliable, said Ashok Gadgil, a senior scientist at the Lawrence Berkeley National Laboratory in Berkeley, Calif., who studies germ terrorism.

For instance, he said, if the two grams of anthrax powder sent to the Senate in a letter had instead been scattered at the building's air intake, the results could have ranged from catastrophic to nothing at all. The outcome, he said, would depend on the quality of the air system.

"If the filters were good - and that's a big if - two grams of the stuff going into the air intake wouldn't have killed anybody," Dr. Gadgil said. "But if they were lousy, it would have killed everyone." (This, of course, assumes that the attack went undetected and that no one received treatment.)

Dr. Alibek, the former Soviet germ official, said that medical evidence of a large strike, if it occurred, would emerge within days as patients began streaming into hospital emergency rooms.

"If not, if we see nothing in two or three days, it means the attack was maybe small" and most probably the result of mail contamination, he said, referring to the most recent case of the New York hospital worker.

Steven M. Block, a germ-terror expert at Stanford University, noted that science rests on the philosophical view known as Occam's razor, which holds that the simplest explanation of an event is usually the best and most likely to be correct.

By that logic, he said, it is only after the mails have been ruled out in the New York case as a source of contamination that "we'll have to look for a second source."

A Question of Numbers

Much of what is known about anthrax has been drawn from studies of monkeys by the United States and other nations that developed germ weapons. There has been little research on the effect of the disease on people since it is unethical to perform human experiments with a germ that is fatal if left untreated.

Dr. Brachman, the scientist who closely studied the pattern of anthrax infections among millworkers in New Hampshire and elsewhere, is one of the few researchers to have ever looked closely at inhalation anthrax. He said in an interview that the recent outbreak offered important insights on both the course of the disease and its treatment.

The victims of inhalation anthrax, he said, appear to be faring far better than similar patients a half-century ago. Modern intensive-care units, with respirators, intravenous antibiotics and fluids, have allowed several people to survive the sort of massive infections that killed millworkers.

One of the key uncertainties that remains about anthrax is the dose of spores necessary to cause the disease. At the mills he studied in the 1950's, Dr. Brachman found that workers were exposed to approximately 500 spores each eight-hour day. It is not clear how many of these reached the lungs, or how few spores could cause inhalation anthrax.

The monkey studies suggest concentrations of 8,000 to 10,000 spores will kill half of those exposed. Experts note that this finding means some of the animals were susceptible to far smaller concentrations of spores.

Dr. Matthew Meselson, a Harvard University biologist who has studied biological warfare, said some monkey experiments suggested that a single spore would be enough to infect and kill particularly vulnerable animals.

This may be relevant to people. For every case of inhalation anthrax, many more people breathe spores and fight off the infection, Dr. Meselson said. But the spores can remain suspended in the air for a considerable time, and a susceptible person distant from any known source of anthrax could inhale a single spore and become sick, he said.

Dr. Bradley Perkins, a leading anthrax expert at the Centers for Disease Control and Prevention who directed the investigation of the Florida cases, told reporters today that "we can be pretty assured that if you have 1 or 2 or 5 or 10 spores, that they pose very little danger."

Dr. Meselson questioned this assumption and said it might be leading authorities to assume that there may be a second letter somewhere causing further infections or that postal workers would not be harmed by tiny releases from sealed letters.

"There is no theoretical justification for assuming there is any threshold at all," Dr. Meselson said. "A single organism has a chance of initiating infection, although in monkeys that chance seems to be very small," he said.

The issue could be significant in understanding the recent progression of cases. If relatively small amounts of anthrax can be lethal for some people, it might explain how someone with a limited exposure - a recipient of a letter coated with a few hundred spores, for example - might become ill.

Dr. Martin Hugh-Jones, a microbiologist at Louisiana State University, said epidemiologists would learn much from studying the current round of cases, particularly those that proved fatal. In a 1979 accident at Sverdlovsk in the Soviet Union, when powdered anthrax was released from a weapons factory, researchers found that a disproportionate number of the 68 reported victims were older men.

Dr. Hugh-Jones said this suggested a link between susceptibility to inhalation anthrax and a compromised immune system.

Similarly, he said, the victims of the biological attack on the United States were all older, over 45. "Did they have bronchitis, a cold?" he asked. "Is the lethal dose closer to 3,000 spores for people over 60 or someone who has been smoking all their lives?"

Search for an Origin

Bush administration bioterrorism experts remain befuddled by the origin of the anthrax.

So far, all the anthrax samples discovered have characteristics of the so-called Ames strain, a variety the United States used in its germ weapons program. That suggests the possibility that the anthrax was domestically produced, the experts say. So too, they say, does the presence of silica in the anthrax sent to Mr. Daschle. Silica was the additive American bioweapons developers chose to remove electrostatic charges from anthrax spores to prevent them from sticking together. Other countries used different materials.

But those who favor the theory that the anthrax has a foreign source say that both the Ames strain and silica along with other hallmarks of the American program have become well known to foreign scientists.

While some experts initially contended that only three countries - the United States, the former Soviet Union and Iraq - were known to have made the high-grade anthrax powder that floats easily in the air, many others disagreed.

They say that the techniques used in those programs are now sufficiently common that a well-trained scientist in a private laboratory could have produced similar results, at home or abroad.

Reluctantly, White House officials have come around to that view.

Experts also agree that the list of countries that could have produced the high-quality anthrax is long and growing. A National Intelligence Council report issued last January concluded that more than a dozen states either have or are actively pursuing germ weapons capabilities.

The report identified only Iran, Iraq, Libya, North Korea and Syria, along with Russia. But the Monterey Institute of International Studies has complied a list of 13 countries, including Algeria, China, Egypt, Pakistan, Taiwan and Israel.

While a great deal is known about the former Soviet program - the world's most sophisticated - much less is known about the others. After the Gulf War, UN inspectors learned that Iraq had mastered the techniques for making a powdered form of a bacterium closely related to anthrax. But it is unclear whether Iraq ever made powdered anthrax of the sort found in the letter to Senator Daschle.

Even less is known about Iran's pgm. In the Jan report, intelligence analysts wrote that Iran had the "technical infrastructure to support a significant BW program." Iran has also hired at least four Russian scientists from inst assoc with the former Soviet Union's program. Iran and the scientists say they are pursuing peaceful research. Experts are increasingly dismayed by the growing number of possible sources of such anthrax, not just overseas but also in the US.

Richard H. Ebright, a microbiologist at Rutgers Univ, said the starter strains, chemical additives and drying and milling machines for processing spores into the small sizes needed to penetrate deep into lungs were widely available around the world.

"A disgruntled prof who didn't get tenure, he could do it," said Dr William C. Patrick 3d, a microbiologist who designed germ weapons for the US before Pres Nixon renounced them in 69. "He wouldn't provide the ultimate, like we did. But he'd do all right."


\8 Bacteria

Bacteria (singular = bacterium) are more complex than viruses, containing genetic info and much of the equip- ment necessary to produce energy and replicate independ- ently. Some bacteria, however, can only reproduce when growing inside a cell, from which they derive required nutrients. 

-- Bacterial diseases -- *note it is a good idea to review the antibiotics notes with you to class as you read these notes diseases that are reportable to the CDC are higlighted in red bacteria from the "big list" appear in green bacteria listed in your photo atlas are marked in yellow 

Intro - Most diseases that we think of as caused by "germs" are caused by bacteria. There are a HUGE number of diseases caused by bacteria. We are only going to be able to cover very few of them. Please make sure you read the book thoroughly. Be able to distinguish disease names and know if they are caused by bacteria, for some diseases you will also have to know the name of the bacteria that causes it. Also pay attention to virulence factors. Remember that many bacterial diseases are caused by the exotoxins that certain species of bacteria release. Understand why certain antibiotics are used to treat certain bacterial infections. 

Staphylococcal Skin Infections - are gram+ bacteria that often grow in clusters. The majority of skin microbiota consist of coagulase-negative Staphylococcus epidermidis.

(Coagulase is an enzyme that can clot blood - blot clots can protect bacteria from phagocytosis - the possession of coagulase is a virulence factor so coagulase negative bacteria are less virulent than coaglase pos bacteria) 

Localized infections (sties, pimples, and carbuncles) result from Staphylococcus aureus entering openings in the skin. A quote from John Makemson (My colleague on south campus)  "Pimples are Staphylococcus aureus infection of sweat glands (the pus is dead bacteria and white blood cells that came in trying to kill off the bacteria, but get nailed by the staphylococcal leuko- cidin, one of the several toxins made by these critters)"

Impetigo of the newborn is a highly contagious superficial skin infection caused by Staphylococcus aureus.  Coagulase-positive organisms can clot the blood, and walled of sites of infection called boils can occur  Toxemia occurs when exotoxins enter the bloodstream; staphylococcal toxemias include scalded skin syndrome and toxic shock syndrome.  Staphylococcus aureus isalso major cause of nosocomial infection  Streptococcal Skin Infections (pp. 563- 564) PA p 139-140

Streptococci are gram+ cocci that often grow in chains. Streptococci are classified according to their hemolytic (blood destroying) enzymes and cell wall antigens.  (remember those enzymes are virulence factors)  We can detect whether or not they have these enzymes with the blood agar plates PA page 41  Group A b ?-hemolytic streptococci (including S. pyogenes) are the pathogens most important to humans. Group A ?-hemolytic streptococci produce a number of virulence factors:  M protein, - prevents the bacteria from being phagocytized by host white blood cells  erythrogenic toxin, - destroys red blood cells and other cells in the host  deoxyribonuclease,  - destroys DNA in host cells  streptokinases, - dissolve blood clots in the host  hyaluronidase. - destroys the connections between coonective tissue cells in the host  so you can see how these virulence factors enable to the bacteria to rapidly destroy tissue  Erysipelas (reddish patches) and impetigo (isolated pustules) are skin infections caused by Streptococcus pyogenes.  Invasive group A ?-hemolytic streptococci cause severe and rapid tissue destruction (Streptococcus pyogenes is also known as the "flesh eating bacteria") due to their proteolytic exotoxins  Infections by Pseudomonads (pp.564- 565)  Pseudomonads are gram- rods. They are aerobes found primarily in soil and water that are resistant to many disinfectants and antibiotics (virulence factors!)  They are also important causes of oppurtunistic and nosocomial infections.  Pseudomonas aeruginosa is the most prominent species; it produces an endotoxin and several exotoxins. Diseases caused by  include dermititis, otitis externa (swimmer's ear), respiratory infections, burn infections, urinary tract infections, and dermatitis. Infections have a characteristic blue-green pus caused by the pigment pyocyanin. The pigment itself seems to be a virulence factor since it can damage cells. Here is a picutre of a bag of urine from a patient with a Pseudomonas urinary tract infection, turned blue by this pyocyanin pigment.   Acne (pp. 565- 567)  Propionibacterium acnes (a gram+ rod) can metabolize sebum (skin oil) trapped in hair follicles. Metabolic end-products (fatty acids) cause an inflammatory response known as acne. From John Makemson "Acne is caused by Corynebacterium acnes, a relative of propionibacteria.  This is the deep seated infection of sebaceous and sweat glands...the infection penetrates the dermis and leaves scar tissue where there should be germ cells, hence is deforming."  Cosmetics can worsen the condition. Diet appears to have no role.  Tretinoin (Retinoic acid, aka "Retin A") , benzoyl peroxide, Accutane  and the antibiotic tetracycline are used to treat acne. The mode of action of the non-antibiotic drugs that are used to treat acne is to dry up the sebaceus glands. Accutane must not be taken by pregnant women as it can damage a fetus. Also long term antibiotic use can have other side effects, for example darkending of the teeth. It usually affects children who use the antibiotic when their permanent teeth are developing. The dentin absorbs the antibiotic, leaving deep brown, orange or grayish stains that can not be removed by a professional cleaning.  Bacterial Diseases of the Eye (pp. 574-575)  Conjunctivitis is caused by several bacteria (usually Pseudomonas, Chlamydia, Staphylococcus or Streptococcus) and can be transmitted by improperly disinfected contact lenses.  (Pseudomonas occasionaly contaminate mascara as well)  Inclusion conjunctivitis is an infection of the conjunctiva caused by Chlamydia trachomatis. It is transmitted to infants during birth and is transmitted in unchlorinated swimming water.  Neonatal gonorrheal opthalmia is caused by the transmission of Neisseria gonorrhea (a gram- aerobic rod in the Proteobacteria) from an infected mother to an infant during its passage through the birth canal. At one time, all newborn infants were treated with 1% silver nitrate or an antibiotic to prevent the growth of Neisseria, and blindness  Bacterial Meningitis (pp. 581-584)  Meningitis (infection of the meninges, the membranes that protect the brain) can be caused by viruses, bacteria, fungi, and protozoa. The three major causes of bacterial meningitis are Hemophilus influenzae, Streptococcus pneumoniae, and Neisseria meningitidis. Nearly 50 species of opportunistic bacteria can cause meningitis. Symptoms include headache, nausea vomiting, and neurological damage.  Hemophilus influenzae Meningitis (Hib) (pp. 581-582)  H. influenzae is part of the normal throat microbiota. Hemophilus is a gram- facultatively aerobic encapsulated rod in the Proteobacteria. It is part of the normal flora of the throat  H. influenzae requires blood factors for growth;  there are six types of H. influenzae based on capsule differences.  A conjugated vaccine is available.  (remember conjugated vaccines work better in children than other types of vaccines)  Neisseria Meningitis (Meningococcal Meningitis) (pp. 582-583)  N. meningitidis (gram- aerobic bacteria in Proteobacteria) causes meningococcal meningitis. Like Hemophilis, this bacterium is part of normal throat flora. So infection begins in the throat. The bacteria probably gain access to the meninges through the bloodstream. The bacteria may be found in leukocytes in CSF.  Symptoms are due to endotoxin. The disease occurs most often in young children. Military recruits are vaccinated with purified capsular polysaccharide to prevent epidemics in training camps. A conjugated vaccine may be available soon.  Streptococcus pneumoniae Meningitis (Pneumococcal Meningitis) (p. 583)  S. pneumoniae (gram+ capsule forming coccus) is commonly found in the nasopharynx (nose and throat). Hospitalized patients and young children are most susceptible to S. pneumoniae meningitis. It is rare but has a high mortality rate. The vaccine for pneumococcal pneumonia (which is caused by the same organism) may provide some protection against pneumococcal meningitis. They are trying to develope a conjugated vaccine for children.  Listeria monocytogenes meningitis - Listeriosis (p. 584)  Listeria monocytogenes (a gram+ rod) causes meningitis in newborns, the immunosuppressed, pregnant women, and cancer patients.  Acquired by ingestion of contaminated food,  it may be asymptomatic in healthy adults.  L. monocytogenes can cross the placenta and cause spontaneous abortion and stillbirth. This was the bacteria found to be contaminating teh Sara Lee hotdogs.  Diagnosis and Treatment of the Most Common Types of Bacterial Meningitis (p. 583)  Cephalosporins (antibiotics that resemble penicillins, and hence are more effective against the gram positive Listeria and Streptococcus) may be administered before identification of the pathogen. Diagnosis is based on isolation and identification of the bacteria in CSF (cerebral spinal fluid - requires a spinal tap to sample). Cultures are usually made on blood agar and incubated in an atmosphere containing reduced oxygen levels. Tetanus (pp. 584-585)  Tetanus is caused by a localized infection of a wound by Clostridium tetani. (an anaerobic endospore forming gram+ bacteria)  C. tetani produces the neurotoxin tetanospasmin, (an exotoxin) which causes the symptoms of tetanus: spasms, contraction of muscles controlling the jaw, and death resulting from spasms of respiratory muscles. C. tetani is an anaerobe that will grow in deep, unclean wounds and wounds with little bleeding. This is one of the reasons we apply hydrogen peroxide to puncture wounds, the hope is the oxygen will kill any C. tetani that got in.  Recovery from exposure does not provide immunity but a toxoid vaccine is available. For emergency cases there are also antisera (gamma globulins) available.  Botulism (pp. 585-587)  Botulism  a form of "food poisoning", is caused by an exotoxin produced by C. botulinum (another endospore forming gram+ bacteria) growing in foods. You get botulism by eating foods contaminated with C. botulinum. You cannot get botulism from ingesting C. botulinum itself.  Serological types of botulinum toxin vary in virulence, with type A being the most virulent.  The exotoxin is a neurotoxin that inhibits the transmission of nerve impulses. It is one of the most lethal toxins known to science. Blurred vision occurs in 1-2 days; progressive flaccid paralysis follows for 1-10 days, possibly resulting in death from respiratory and cardiac failure. As with Tetanus recovery from exposure does not confer immunity.  C. botulinum will not grow in acidic foods or in an aerobic environment. Endospores are killed by proper canning. The addition of nitrites to foods inhibits growth after endospore germination. The toxin is heat labile and is destroyed by boiling (100? C) for 5 minutes.  Wound botulism occurs when C. botulinum grows in anaerobic wounds. (just like tetanus)  Infant botulism has been associated with honey. Infants do not always have enough intestinal bacteria (yet) to inhibit hte growth of C. botulinum if it is ingested.  Leprosy (pp. 587-588)  Mycobacterium leprae (a Mycobacteria closely related to Mycobacterium tuberculosis) causes leprosy, or Hansen's disease. M. leprae has never been cultured on artificial media. It can be cultured in armadillos. Laboratory diagnosis is based on observations of acid-fast rods in lesions or fluids and the lepromin test (a test to see if cell mediated immunity has developed, it is similar tothe TB test)  The course of leprosy can take one of 2 forms depending on the state of a person's cell mediated immunity. (not everyone who is exposed will get it, just like Tuberculosis)  The tuberculoid (or neural) form of the disease is characterized by loss of sensation in the skin surrounded by nodules. The lepromin test is positive, which means patients have good cell mediated immunity. Patients may recover spontaneously.  In the lepromatous (or progressive) form, disseminated nodules and tissue necrosis (tissue death) occur. The lepromin test is negative, which means patients have poor cell mediated immunity. This is familar form that causes the patient to become deformed due to loss of tissue.  Leprosy is not highly contagious and is spread by prolonged contact with exudates. Untreated individuals often die of secondary bacterial complications, such as tuberculosis. Patients with leprosy are made noncommunicable within 4-5 days with sulfone drugs (relatives of sulfa drugs) and then treated as outpatients. Leprosy occurs primarily in the tropics. Rifampin (also used for Tuberculosis) can be used in treatment as well.  Septicemia, Sepsis, and Septic Shock (p. 603)  The growth of microorganisms in blood is called septicemia. Signs include lymphangitis (inflamed lymph vessels). Septicemia can lead to septic shock, characterized by decreased blood pressure. Septicemia usually results from a focus of infection in the body. Gram- rods are usually implicated. Endotoxin causes the symptoms.  Puerperal Sepsis (pp. 603- 604)  Puerperal sepsis begins as a nosocomial uterine infection following childbirth or abortion; it can progress to peritonitis or septicemia. Streptococcus pyogenes (gram +) is the most frequent cause.  Oliver Wendell Holmes & Ignaz Semmelweiss demonstrated that puerperal sepsis was transmitted by the hands and instruments of midwives and physicians. Puerperal sepsis is now uncommon because of modern hygienic techniques and antibiotics.  Bacterial endocarditis (pp. 604- 605)  Endocarditis is an inflammation of the inner lining of the heart. It is usually caused by  a-hemolytic streptococci, staphylococci, or enterococci. The infection arises from a focus of infection, such as a tooth extraction. Preexisting heart abnormalities are predisposing factors. Signs include fever, anemia, and heart murmur. Studies have now shown many heart attacks are caused by long term subacute infections that weaken the heart over time. (part of the trend we are seeing in modern medicine to recognize that more and more diseases we thought were caused by environment or "lifestyle" are actually caused by pathogens)  Acute bacterial endocarditis is usually caused by Staphylococcus aureus. The bacteria cause rapid destruction of heart valves.  Rheumatic Fever (pp. 605- 606)  Rheumatic fever is an autoimmune complication of streptococcal infections.  Rheumatic fever is expressed as arthritis or inflammation of the heart. It can result in permanent heart damage. Antibodies against group A ?-hemolytic streptococci react with streptococcal antigens deposited in joints or heart valves or cross-react with the heart muscle.  Rheumatic fever can follow a streptococcal infection, such as strep throat. Streptococci might not be present at the time of rheumatic fever. Prompt treatment of streptococcal infections can reduce the incidence of rheumatic fever. Penicillin is administered as a preventive measure against subsequent streptococcal infections.  (we have seen something similar to this before with Chlamydia which has antigens that mimic the self antigens of the host. When the host makes antibodies against the Chlamydia, some of these antibodies can target the host cells as well)  Tularemia (pp. 606- 607)  Tularemia is a zoonosis caused by Francisella tularensis. (a gram- rod in the Proteobacteria) The reservoir is small wild mammals, especially rabbits. Signs include ulceration at the site of entry, followed by septicemia and pneumonia. Humans contract tularemia by handling diseased animals or animal carcasses, eating undercooked meat of diseased animals, and being bitten by certain vectors (such as deer flies).  F. tularensis is resistant to phagocytosis. Laboratory diagnosis is based on an agglutination test on isolated bacteria. Recovery from infection does seem to provide immunity from reinfection. (via naturally aquired immunity) An attenuated live vaccine is available for at risk veteranary workers. It is treated with streptomycin or gentamycin. (both antibiotics that target protein synthesis)  Brucellosis (Undulant Fever) (p. 607)  Brucellosis is a zoonosis that can be caused by three species of gram- aerobic rods in Proteobacteria: Brucella abortus, B. melitensis, and B. suis.  Domesticated animals (cattle, pigs, goats, and camels) constitute the reservoir. Wild American bison are also carriers.  The bacteria enter through minute breaks in the mucosa or skin, reproduce in macrophages, and spread via lymphatics to liver, spleen, or bone marrow. Signs include malaise and fever that spikes each evening (undulant fever).  A vaccine for cattle is available. Long courses of antibiotic treatment with tetracycline and streptomycin (again both are antibiotics that target protein synthesis) are needed for humans  Anthrax (pp. 607- 608)  Bacillus anthracis (a gram+ aerobic endospsore forming encapsulated rod) causes anthrax. In soil, endospores can survive for up to 60 years. Grazing animals acquire an infection after ingesting the endospores. Humans contract anthrax by handling hides from infected animals. The bacteria enter through cuts in the skin or through the respiratory tract.  Entry through the skin results in a pustule that can progress to fatal septicemia. Entry through the respiratory tract can result in pneumonia. It has multiple virulence factors. The bacteria is encapsulated so it resists phagocytosis. It forms endospores so it can survive outside of a host. It produces exotoxins that cauase the overt symptoms of disease.  Pencillin can be applied early after exposure, however antibiotic treatment is ineffective later on, as the exotoxins can survive the death of the bacteria.  Anthrax is used as a biological weapon.  Gangrene (pp. 608- 609)  Necrosis (soft tissue death) from ischemia (loss of blood supply) is called gangrene. Microorganisms can grow oppurtunistically on nutrients released from gangrenous cells. Gangrene is especially susceptible to the growth of anaerobic bacteria such as Clostridium perfringens, (gram+ anaerobe) the causative agent of gas gangrene. Ischemia of extremeties caused by diabetes) can also cause favorable conditions for the growth of C. perfringens.  C. perfringens releases exotoxins as it grows, which kills more tissue and alos releases CO2 gas, swelling the tissue. C. perfringens can invade the uterine wall during improperly performed abortions.  Without treatment this disease id fatal. In many more soldiers died of gangrene in previous wars than did on the battle field.  Debridement (the surgical removal of dead tissue), hyperbaric chambers (chambers w/increased oxygen), and amputation are used to treat gas gangrene. It is important to clean and treat serious wounds promptly to prevent gangrene. Application of penicillin early enough can prevent the growth of C. perfringens.  Systemic Diseases Caused by Bites and Scratches (p. 609)  When we think of risks caused by animal bites most of us think of rabies, a viral disease. But bacteria can also be passed from animal to human this way and cause disease.  Pasteurella multocida, (gram- rod in the Proteobacteria), a relative of Yersinia,  introduced by the bite of a dog or cat, can cause septicemia. Penicillin and tetracycline are used to treat.  Anaerobic bacteria such as Clostridium, Bacteroides, and Fusobacterium infect deep animal bites.  Cat-scratch disease is a zoonosis caused by Bartonella henselae. (a gram-, rickettsia like bacteria in Proteobacteria) This is a bacteria that is symbiotic with cats but pathenogenic to humans. It is an obligate intracelluar parasite, like Chlamydia and Mycobacteria. Rifampin (an mRNA blocker used to treat TB) is used to treat cat scratch fever.  Bubonic Plague (aka the Black Death) (pp. 609- 611)  In the past war and disease served to curtail human population explosions. In the 1300's the Black Death, or Bubonic Plague, killed off about 25% of Europe's population (One of those windows in time like the flu epidemic of 1918 that had a serious impact on human populations. One wonders what will be next, AIDS or WWIII)  Plague is a zoonosis caused by Yersinia pestis. (gram- encapsulated bacteria in Proteobacteria)  The vector is usually the rat flea (Xenopsylla cheopis).  Reservoirs for plague include European rats and North American rodents. (yes folks squirrels included) However in recent years domestic cats(!) also seem to be serving as resevoirs for Yersinia.  Signs of bubonic plague include bruises on the skin and enlarged lymph nodes (buboes). The bacteria can enter the lungs and cause pneumonic plague. Pneumonic plague is higly contagious.  Yersinia engulfed by macrophages survive and produce a capsule preventing further phagocytosis. They also produce endotoxins upon death that can cause septic shock.  Antibiotics (streptomycin and tetracycline - protein synthesis blockers) are effective in treating plague, but they must be administered promptly after exposure to the disease. Recovery from plague seems to provide immunity to further infection.  Lyme Disease (Lyme Borreliosis) (pp. 611- 613)  Lyme disease is a zoonosis caused by Borrelia burgdorferi (a gram- Spirochete)  The vector is a tick (Ixodes spp.). The resevoir is field mice. It is now the most common tick borne disease in the United States.  *please see figure 23.14 life cycle of Ixodes scapularis  It emerged in 1975, and the causative agent was identified in 1982. Lyme disease is prevalent on the U.S. Atlantic Coast.  Initial signs include a characteristic "target shaped" rash, and flu-like symptoms, but the disease can progress on to neurological symptoms and arthritis. Antibody complexes produced in response to the spirochetes (rather than the spirochetes themselves) cause the joints to become inflammed.  If the disease is caught early enough it can be treated with tetracycline or penicillin, later detection requires cefriaxone a ?-lactam antibiotic that can cross the brain-blood barrier.  Relapsing Fever (p. 611)  Execpt for Borrelia burgdorferi (above) all other species of Borrelia cause Relapsing fever.  The vector for this zoonosis are soft ticks. The reservoir is rodents.  Signs include fever, jaundice, and rose-colored spots. Signs recur three or four times after apparent recovery. This is because the spirochetes can change antigenicity. Laboratory diagnosis is based on the presence of spirochetes in the patient's blood. Without therapy, the death rate can be as high as 40%. With  treatment, mortality is about 5%.  The infection is treated with tetracycline or erythromycin (protein synthesis blockers)  Ehrlichiosis (p. 613)  Ehrlichosis, a mild disease with flu-like symptoms, is caused by Ehrlichiachaffeensis, Ehrlichia canis  and an Ehrlichia equi -likeorganism. (gram-, Proteobacteria) These bacteria are Rickettsia-like in that they are obligately intracellular bacteria  the vector is the Ixodes tick. The reservoirs are deer,horses and dogs  This zoonosis emerged in human in 1986. (previously it was a veterinary disease of horses) the causative agent was identified in 1994.  It can be treated with tetracycline and other tetracycline-like antibiotics. Sometimes rifampin is also used.  Typhus (pp. 613- 615)  The various Typhus diseases are caused by rickettsias, (gram-, in Proteobacteria) obligate intracellular parasites of eukaryotic cells. They are all spread by arthropod vectors.  Epidemic Typhus (p. 613)  The human body louse Pediculus humanus corporis transmits Rickettsia prowazekii in its feces, which are deposited while the louse is feeding. Epidemic typhus is prevalent in crowded and unsanitary living conditions that allow the proliferation of lice. The signs of typhus are rash, prolonged high fever, and stupor.  Tetracyclines and chloramphenicol are used in treatment. A vaccine is also available.  Endemic Murine Typhus (p. 613)  Endemic murine typhus is a less severe disease caused by Rickettsia typhi and transmitted from rodents to humans by the rat flea.  Tetracyclines and chloramphenicol are used in treatment, but it is also important to have rodent control.  Tick borne typhus (Rocky Mountain Spotted Fever) (p. 614- 615)  Rickettsia rickettsii is a parasite of ticks (Dermacentor species) in the southeastern U.S., Appalachia, and the Rocky Mountain states. (a rare case of the ticks being both the vector and the reservoir of the disease) The rickettsia may be transmitted to humans, in whom it causes tickborne typhus fever. The signs include a measles like rash.  Chloramphenicol and tetracyclines effectively treat Rocky Mountain spotted fever.  Streptococcal Pharyngitis (StrepThroat) (pp. 632- 633)  This infection is caused by group A  ?-hemolytic streptococci, the group that consists of Streptococcus pyogenes. (remember from before these are gram+'s)  Symptoms of this infection are inflammation of the mucous membrane and fever; tonsillitis, and otitis media (ear ache) may also occur. Preliminary rapid diagnosis is made by indirect agglutination tests. Definitive diagnosis is based on a rise in IgM antibodies.  Strep throat is usually transmitted by droplets but at one time was commonly associated with unpasteurized milk.

Penicillin is used to treat streptococcal pharyngitis. Immunity to streptococcal infections is type-specific.  Scarlet Fever (p. 633)  Strep throat, caused by an erythrogenic (reddening) toxin-producing S. pyogenes, results in scarlet fever. S. pyogenes produces erythrogenic toxin when lysogenized by a phage.  Symptoms include a red rash, high fever, and a red, enlarged tongue. Most of these symptoms are due to the toxin.  It is rare in modern times to see Scarlet fever since most cases of Strep throat get treated. However if the disease does progress penicillin and pencillin like antibiotics are used to treat Scarlet fever. 


\9 Campylobacter

A Gram-negative slender, curved, and motile rod. It is a microaerophilic organism, which means it has a rqmnt for reduced levels of oxygen. It is relatively fragile, and sensitive to environmental stresses (eg, 21% oxygen, drying, heating, disinfectants, acidic conditions). Because of its microaerophilic characteristics the organism requires 3 to 5% oxygen and 2-10% carbon dioxide for optimal growth conditions. This bacterium is now recognized as an important enteric pathogen. 

Before 1972, when methods were developed for its isolation from feces, it was believed to be primarily an animal pathogen causing abortion and enteritis in sheep and cattle. Surveys have shown that C. jejuni is the leading cause of bacterial diarrheal illness in the United States. It causes more disease than Shigella spp. and Salmonella spp. combined. 

Although C. jejuni is not carried by healthy individuals in the United States or Europe, it is often isolated from healthy cattle, chickens, birds and even flies. It is sometimes present in non-chlorinated water sources such as streams and ponds. 

Because the pathogenic mechanisms of C. jejuni are still being studied, it is difficult to differentiate pathogenic from nonpathogenic strains. However, it appears that many of the chicken isolates are pathogens. 
  2. Name of Disease: Campylobacteriosis is the name of the illness caused by C. jejuni. It is also often known as campylobacter enteritis or gastroenteritis. 

3. Major Symptoms: C. jejuni infection causes diarrhea, which may be watery or sticky and can contain blood (usually occult) and fecal leukocytes (white cells). Other symptoms often present are fever, abdominal pain, nausea, headache and muscle pain. The illness usually occurs 2-5 days after ingestion of the contaminated food or water. Illness generally lasts 7-10 days, but relapses are not uncommon (about 25% of cases). Most infections are self-limiting and are not treated with antibiotics. However, treatment with erythromycin does reduce the length of time that infected individuals shed the bacteria in their feces. 

The infective dose of C.jejuni is considered to be small. Human feeding studies suggest that about 400-500 bacteria may cause illness in some individuals, while in others, greater numbers are required. A conducted volunteer human feeding study suggests that host susceptibility also dictates infectious dose to some degree. The pathogenic mechanisms of C.jejuni are still not wholey understood, but it does produce a heat-labile toxin that may cause diarrhea. C.jejuni may also be an invasive organism. 
  4. Isolation Procedures: C. jejuni is usually present in high numbers in the diarrheal stools of individuals, but isolation requires special antibiotic-containing media and a special microaerophilic atmosphere (5% oxygen). However, most clinical laboratories are equipped to isolate Campylobacter spp. if requested. 

5. Associated Foods: C.jejuni frequently contaminates raw chicken. Surveys show that 20 to 100% of retail chickens are contaminated. This is not overly surprising since many healthy chickens carry these bacteria in their intestinal tracts. Raw milk is also a source of infec- tions. The bacteria are often carried by healthy cattle and by flies on farms. Non-chlorinated water may also be a source of infections. However, properly cooking chicken, pasteurizing milk, and chlorinating drinking water will kill the bacteria. 

6. Frequency of the Disease: C. jejuni is the leading cause of bacterial diarrhea in the U.S. There are probably numbers of cases in excess of the estimated cases of salmonellosis (2- to 4,000,000/year). 

7. Complications: Complications are relatively rare, but infections have been associated with reactive arthritis, hemolytic uremic syndrome, and following septicemia, infections of nearly any organ. The estimated case-fata- lity ratio for all C.jejuni infections is 0.1, meaning one death per 1,000 cases. Fatalities are rare in healthy individuals and usually occur in cancer patients or in the otherwise debilitated. Only 20 reported cases of septic abortion induced by C. jejuni have been recorded in the literature. 

Meningitis, recurrent colitis, acute cholecystitis and Guillain-Barre syndrome are very rare complications. 
  8. Target Populations: Although anyone can have a C. jejuni infection, children under 5 years and young adults (15-29) are more frequently afflicted than other age groups. Reactive arthritis, a rare complication of these infections, is strongly associated with people who have the human lymphocyte antigen B27 (HLA-B27). 

9. Recovery from Foods: Isolation of C. jejuni from food is difficult because the bacteria are usually present in very low numbers (unlike the case of diarrheal stools in which 10/6 bacteria/gram is not unusual). The methods require an enrichment broth containing antibiotics, special antibiotic-containing plates and a microaero- philic atmosphere generally a microaerophilic atmosphere with 5% oxygen and an elevated concentration of carbon dioxide (10%). Isolation can take several days to a week.
  10. Selected Outbreaks: Usually outbreaks are small (less than 50 people), but in Bennington, VT a large outbreak involving about 2,000 people occurred while the town was temporarily using an non-chlorinated water source as a water supply. Several small outbreaks have been reported among children who were taken on a class trip to a dairy and given raw milk to drink. An outbreak was also assoc with consumption of raw clams. 

However, a survey showed that about 50% of infections are associated with either eating inadequately cooked or recontaminated chicken meat or handling chickens. It is the leading bacterial cause of sporadic (non-clustered cases) diarrheal disease in the U.S. 

In Apr 86, an elementary school child was cultured for bacterial pathogens (due to bloody diarrhea), and C. jejuni was isolated. Food consumption/gastrointestinal illness questionnaires were given to other students and faculty at the school. In all, 32 of 172 students reptd symptoms of diarrhea (100%), cramps (80%), nausea (51%), fever (29%), vomiting (26%), and bloody stools (14%). The food questionnaire clearly implicated milk as the common source, and a dose/response was evident (those drinking more milk were more likely to be ill). 

Investigation of the dairy supplying the milk showed that they vat pasteurized the milk at 135°F for 25 minutes rather than the required 145°F for 30 minutes. The dairy processed surplus raw milk for the school, and this milk had a high somatic cell count. Cows from the herd supplying the dairy had C. jejuni in their feces. This outbreak points out the variation in symptoms which may occur with campylobacteriosis and the absolute need to adhere to pasteurization time/temp standards. 

Although other Campylobacter spp. have been implicated in human gastroenteritis (e.g. C. laridis, C. hyointesti- nalis), it is believed that 99% of the cases are caused by C. jejuni. 

 Low-Profile Bug Is Food Poisoning Leader When it comes to food poisoning, big outbreaks make headlines. E. coli in apple juice and alfalfa sprouts. Listeria in cheese and hot dogs. Salmonella in eggs and on poultry. But the most frequently diagnosed food-borne bacterium rarely makes the news. 

The name of thc unsung bug? Campylobacter. "Most Campylobacter infections are sporadic and not associated with an outbreak, but we know it causes up to 4 million human infections a year," says Frederick J. Angulo, D.V.M., an epidcmiologist with the national Centers for Disease Control and Prevention. Federal and state health experts have long recognized that Campylobacter causes disease in animals. 

Conclusive proof that the bacteria also causes human disease emerged in the 1970s, and by 1996, Campylobacter was sitting atop the bacterial heap as the number one cause of all domestic food-borne illness. In addition, with the emergence of antibiotic-resistant Campylobacter, "the true magnitude of the problem is becoming clearer," says Angulo, who also heads the CDC arm of the National Antimicrobial Resistance Monitoring System. 

Campylobacter is commonly found in the intestinal tracts of people or animals without causing any symptoms of illness. But eating contaminated or undercooked poultry or meat, or drinking raw milk or contaminated water, may cause Campylobacter infection, or campylobacteriosis. Symptoms of campylobacteriosis usually occur within two to 10 days of ingesting the bacteria. Children, the elderly, and people with weakened immune systems are particularly at risk. The most common symptoms include mild to severe diarrhea, fever, nausea, vomiting, and abdominal pain. 

Most people infected with Campylobacter can get well on their own without treatment, though antibiotics may be prescribed for severe cases. But complications can occur, such as urinary tract infections or meningitis. The bacteria also is now recognized as a major contributing factor to Guillain-Barre syndrome, the most common cause of acute paralysis in both children and adults. (See accompanying article.) Concerns About Chicken Although found in many farm animals, Campylobacter in poultry is causing experts the most concern. 

There have been several studies pointing to high levels of Campylobacter present on poultry at the retail level, including a recent two-year Minnesota Department of Health study that found that 88 percent of poultry sampled from local supermarkets tested positive for the bacteria. "The retail study was in collaboration with the Minnesota Department of Agriculture; their inspectors went to supermarkets throughout the St. Paul/Minneapolis Twin Cities area to cover a variety of supermarket types, from big chains to mom-and-pop stores," says Kirk E. Smith, D.V.M., a Minnesota state epidemiologist who participated in the study. 

Many prior surveys have found Campylobacter contamination rates of between 40 and 60 percent, he says. "But 88 percent--this degree [of contamination] surprised even me," he admits. In studies conducted by the U.S. Department of Agriculture's poultry microbiological safety research unit, more than 90 percent of poultry tested positive for Campylobacter, in levels ranging from one cell to over a million cells per bird. Norman J. Stern, Ph.D., research leader for the unit, says the infection of poultry broiler flocks typically occurs at week three in the six-week growing cycle. It's not unusual, he says, for Campylobacter to infect the entire flock. 

Things only get worse by the time the chickens reach the processing plant, he says. USDA studies have found a hundredfold increase in bacteria amounts on the birds' exterior from that detected on the farm. "The exterior contamination represents consumer exposure," he explains. To help reduce that exposure, Stern says the poultry industry is currently participating in a USDA-led study that will cover "every element of production where chickens can become infected, from ... shells to farmers' boots to wild bird droppings. When we're done ... we will be able to genetically fingerprint the organism so we can ascribe a relationship between various environmental sources and the spread of pathogens." 

The study was slated to end in Sep. Resistance to Antibiotics According to the Minnesota Department of Health study, the number of Campylobacter infections that are resistant to a class of antibiotics called fluoroquinolones has been on the increase since 1992. While most Americans acquired the resistant infections while on foreign travel, Kirk explains, "we have been seeing a significant increase in domestically acquired resistant cases as well." 

The Food and Drug Administration approved the use of fluoroquinolones in food animals in 1995. The study concluded that antibiotic use in U.S. poultry is contributing to antibiotic resistance. Resistance to fluoroquinolones, not only by Campylobacter but by other bacteria as well, is a concern, explains Jesse Goodman, M.D., chief of the division of infectious diseases at the University of Minnesota, "because fluoroquinolones are commonly used to treat severe infectious diarrhea, often before the specific cause has been identified. 

Fluoroquinolones are very important drugs for treating a variety of serious human infectious diseases." CDC studies also show an increase in resistance to fluoroquinolones and this can be correlated to fluoroquinolone use in poultry, according to Angulo. In addition, "We did a case control study in 1997, comparing people with [nonresistant] Campylobacter infections with fluoroquinolone-resistant infections, and found that those with resistant infections [were] more likely to have severe infections, bloody diarrhea, and be hospitalized." 

Because of the concern over antibiotic resistance, FDA is considering whether, before it reviews a new animal drug for approval, manufacturers must assess the likelihood that use of a certain drug in food animals will transfer resistance and create a public health problem. In addition, new procedures for monitoring antibiotic use and resistance after approval also are being considered. "FDA believes a new regulatory framework is needed to address resistance concerns raised by the food animal use of antibiotics," says Goodman, who also serves as a deputy medical director for FDA.

The Animal Health Inst, a national trade assoc represen- ting manufacturers of animal health products, says it also is concerned about the possibility of antibiotic use in food animals causing resistant bacteria to develop. But the organization believes that the requirements FDA is proposing may have "unintended negative consequences on animal health ... and risk sending unhealthy animals into the food chain." Hollinger says, "At this time we are not taking action toward withdrawal of these products from the market. 

We have asked the sponsors of poultry fluoroquinolone products to provide data that would describe the prevalence of resistance in poultry flocks and identify possible actions to prevent the emergence of disease in treated flocks." Calling it a "farm to plate" approach, Hollinger says that the Campylobacter problem can be addressed "at any number of points" along the food chain.

"They all need to be reviewed and evaluated for new methods to deal with the problems." USDA's Stern says he believes the poultry industry is "trying very hard" to move toward enhanced food safety for economic as well as safety benefits. For example, he explains, a company could use extensive microbiological criteria to ensure safety as a marketing tool. Just as consumers are willing to pay more for "gourmet" coffees or specialty food items, an increasingly health-conscious consumer could be wooed by a health emphasis when it comes to safer poultry products, he says. 

Vaccine on the Horizon A team of Navy, Army, and drug industry researchers is also moving ahead in the development of a prototype vaccine for Campylobacter. The vaccine has shown promise in animal models and currently is undergoing clinical trials. Capt. Louis A. Bourgeois, director of the enteric diseases program at the Naval Medical Research Center in Bethesda, Md., says the Navy has been involved in Campylobacter research since the early 1980s.

"Historically, the military has had longstanding diarrheal problems with troops deploying overseas," he explains. "Campylobacter was an emerging pathogen in the early '80s, and by the mid-1980s, we began doing more directed studies towards a vaccine development." Bourgeois and his fellow researchers say an approved vaccine is likely "several years away" but they remain optimistic. 

Bourgeois says private companies are interested in a vaccine due to its possible application in "traveler's diarrhea," a common ailment. "We know from animal model work that we can protect animals against Campylobacter colonization," says colleague Daniel Scott, M.D., deputy director of the Navy's enteric diseases program. "We have also gained an increasing amount of knowledge in the clinical and preclinical development of this product, especially in terms of what happens with the actual infection. We are already seeing some evidence that term protection can occur, which allows for a lot of optimism." The Consumer's Role While researchers, regulatory agencies, and scientists grapple with Campylobacter, what can you do to protect yourself? "Consumers go to the supermarket thinking everything [there] is clean, and that is just not true," says Donald H. Burr, Ph.D., a research microbiologist in FDA's Center for Food Safety and Applied Nutrition. "People can't assume that anymore. 

Consumers have a responsibility in food safety." Those responsibilities include prompt refrigeration, thorough cooking, avoiding cross-contamination, and washing hands and surfaces often. In addition: o Don't let raw foods such as uncooked poultry touch other food, since bacteria can spread. o Thaw raw poultry on a bottom shelf in the refrigerator so that blood or juices don't drip onto other foods. o Do not reuse marinades from raw meat or poultry. o Never put cooked poultry or meat back on the plate that held the raw product. o Wash your hands frequently, especially after handling raw meat and poultry. o Wash kitchen surfaces and cutting boards often, especially after they have come in contact with raw meat or poultry. Link To Guillain-Barre Campylobacter is not the only thing that triggers Guillain-Barre syndrome, but it is now recognized as one of the disorder's major forerunners. Guillain-Barre, which also may follow a viral illness, is an autoimmune attack on the peripheral nerves that can cause weakness and paralysis. 

Annually, about two people per 100,000 contract the syndrome. "We also know that many patients who have [campylobacteriosis] seem to have a more severe form of Guillain-Barre," Leshner says. Guillain-Barre can be difficult to diagnose in its early stages, although Leshner says clinicians often suspect anyone with "acute weakness" as having the disorder. It's usually diagnosed via clinical observation, spinal fluid analysis, and electromyogram (EMG) tests, which analyze electrical activity in muscles. "With mild cases, probably no more is needed other than supportive care. But if the person is unable to walk or has breathing problems, more dramatic treatments may be needed," Leshner says. "A small percentage of people have residual disabilities, and these people have the form linked to Campylobacter." --Audrey Hingley Tracking Down Trouble

Bacteria That Cause Food-Borne Illness Legend for Chart: A - Bacteria B - Cases of Food-Borne Illness  A B Listeria 77 Vibrio 51  Yersinia 139 E. coli O157:H7 340  Shigella1,263 Salmonella 2,207  Campylobacter 3,974 Total8,051 

Campylobacter was the culprit in an overwhelming number of cases detected by the FoodNet system in 1997. FoodNet, a joint project of FDA, the national Centers for Disease Control, and USDA's Food Safety and Inspection Service, tracks cases of food-borne infections at early-warning sites in several states. The numbers are combined totals from CA, CT, GA, MN, and OR. 

09/01/99 By Audrey Hingley: FDA Consumer, Sep-Oct 1999  Audrey Hingley is a writer in Mechanicsville, Va. 


\10 Cancer

abnormal cells that divide without control, which can invade nearby tissues or spread through the bloodstream and lymphatic system to other parts of the body.

ANTIOXIDANTS REDUCE CANCER THERAPY SIDE EFFECTS

When it comes to vitamins, most oncologist (cancer specialists) are
adamantly against using them while undergoing cancer treatment. They
mistakenly believe that anti-oxidants will protect the cancer cells
and will render chemotherapy or radiation ineffective. According  to this study, there is no reason to avoid antioxidants. In fact,  they actually improve the effectiveness of the treatment and reduce  the side effects.

Mice with colon cancer were treated with radioimmunotherapy, a form
of treatment that uses specialized antibodies to deliver radioactive
agents directly to the tumor cells. The goal is to kill the tumor  by exposing it to high amounts of radiation without harming normal  tissues. In addition to radiation, some mice also received either  vitamins (C, E and A) or bone marrow transplant or both.

All the mice in the group that received radiation alone died. But  there were many survivors in the vitamin group, even though the dose  of radiation was the same. The authors mention previous studies in  which vitamin E was shown to be deadly for malignant cells. They  also note that no study has ever demonstrated that vitamins promote  the formation of cancer.
 International Journal of Cancer 2000;86:276-280.

Thai cancer rate world's third highest Disease kills some 10,000 here yearly Sumet WannapruekNov 9 2000 

Thailand ranks third in a global survey of countries with the highest incidence of cancer cases, delegates at a seminar heard yesterday.

Health experts were also told Khon Kaen has the highest number of liver cancer patients, relative to the pop.

Mongkol na Songkhla, permanent secretary for public health, said feedback from the meeting is to be used in formulating ministry policies on cancer treatment.

Dr Mongkol said about 3,000 Thai women die of cervical cancer and between 6,000-7,000 other Thais of other forms of cancer every year.

Liver and lung cancers are more prevalent among men, and cervical and breast cancers among women, Dr Mongkol said.

Wanchai Wattanasap, an oncologist at Sri Nakharin hosp, said research had shown that electromagnetic radiation from power stations can cause leukemia among children living nearby.

"Apart from electromagnetic radiation and mobile phones, another issue being researched is the link between stress and cancer," Dr Wanchai said.

"Stress is related to cancer because several studies show that those suffering from stress have a low immunity."

A report by the Intl Agency for Research on Cancer said infection from Hepatitis B and C and cirrhosis of the liver were the main causes of liver cancer.


Linda Rosier for The New York Times  Cigarette smoking and other uses of tobacco are the leading causes of oral cancers. 

t a recent visit for a periodic dental cleaning, my periodontist took  a few extra minutes to examine the roof and floor of my mouth, upper  reaches of my gums and my tongue for white or red patches that were  possible signs of an oral cancer or precancer.  The periodontist, Dr. Stephen F. Goodman, a past president of the  American Academy of Periodontology, told me he had begun such checkups  for all his patients a few months earlier after realizing that no one  -- not primary care physicians, regular dentists or ordinary people --  has been assigned this responsibility. And in those first few months  he'd already found three cancers and several precancerous lesions.  Oral cancer is one of those diseases that should never happen. Its  leading causes -- the use of tobacco primarily and, to a lesser  extent, excessive alcohol consumption -- are totally preventable. As  with superficial skin cancers, before oral cancer becomes a  potentially deadly disease, it usually forms precancerous lesions that  can be readily seen. And outside of the skin, the mouth is probably  the easiest place to look for signs of abnormal tissue growth.  Yet, each year more than 30,000 cases of oral cancer are diagnosed in  the United States and 8,000 people die of this disease. There has of  late been a reduction in overall deaths from oral cancers, primarily  the result of the drastic decline in cigarette smoking among American  adults.  But despite notable progress made in curing several of the more hidden  cancers, once oral cancer develops, the chances of surviving it have  not improved for decades.  Dismayed experts insist that this need not be the case. Few deaths  from oral cancer would occur if dentists and physicians regularly  examined their patients' mouths. The death rate is so high "because  the early cancers are not being caught," said Dr. Arnold Rosenheck,  associate dean at the New Jersey Dental School. "If you find the oral  lesion before it metastasizes, the cancer can be cured."  Slipshod Detection  In a recent report, "Oral Health in America," the surgeon general said  that adults generally were "ill-informed regarding risk factors for  and signs and symptoms of oral cancers."  "One national survey" it continues, referring to a 1995 report, "found  that only 14 percent of adults 40 and older reported that they had  ever had an oral cancer examination. Of those, only 7 percent had had  an exam within the last year."  In a national survey of dentists three years later, 70 percent said  they provided annual oral cancer exams to patients 40 and older, a  statistic that strikes me more as wishful thinking than fact. I do not  live in the boondocks and I've been to at least four different  well-trained dentists since 40. Yet the exam this year by my  periodontist was the first such checkup I'd ever received.  So it may be up to you to ask your dentist or health care provider to  include an oral cancer exam as part of a routine checkup.  You should also know the signs and symptoms of a possible oral cancer  or precancerous lesion and make sure that any you may find are  promptly examined by a knowledgeable health professional. In a  booklet, "What You Need to Know About Oral Cancer," the National  Cancer Institute points out that while oral cancer usually occurs in  people over the age of 45, it can develop at any age. The institute  lists these symptoms to watch for:  • A sore or lump on the lip or in the mouth or throat.  • A white or red patch on the gums, tongue or lining of the mouth.  • Unusual bleeding, pain or numbness in the mouth.  • A sore throat that does not go away, or a feeling that something is  caught in the throat.  • Difficulty or pain with chewing or swallowing.  • Swelling of the jaw that causes dentures to fit poorly or become  uncomfortable.  • A change in the voice.  • Pain in the ear.  Cause and Prevention  It has been known for many decades that repeated exposure of the oral  tissues to cancer-causing substances is the primary cause of oral  cancer. Cancers were found among the peoples of the South Pacific who  regularly chewed carcinogenic betel nuts. In this country, 80 percent  to 90 percent of oral cancers result from exposure to the carcinogens  in tobacco, whether it is smoked, chewed or stuffed in a cheek pouch.  Excessive alcohol consumption is the second main risk factor, and when  alcohol and tobacco exposure are combined, the risk is especially high  since their combined effect is more than additive. Sunshine is another  factor; excessive exposure can cause cancer of the lip. So can pipe  smoking. Quitting the use of tobacco products can greatly reduce the  risk of oral cancer.  Many people who eventually develop oral cancer have a history of  forming whitish patches inside their mouths called leukoplakia,  usually in the areas that are subjected to chronic irritation, such as  the lower lip of a pipe smoker or the gums and mouth lining of people  who use smokeless tobacco.  Red patches called erythroplakia, most often found in people in their  60's, are another warning sign. Both leukoplakia and erythroplakia can  be found even in adolescents who use smokeless tobacco.  The Treatment  The usual route for treating oral cancers is surgery to remove the  tumor in the mouth and enough surrounding tissue to make sure all the  cancer is gone. If there are indications that the cancer may have  spread, the surgeon will also remove lymph nodes in the neck to check  for the presence of cancer cells. In still more advanced cases, the  operation may involve removal of muscles and other tissues. Large  tumors may necessitate removal of part of the palate, tongue or jaw,  which can permanently impair the patient's ability to chew, swallow or  talk.  The second line of treatment involves radiation therapy, which may be  given before surgery to shrink the tumor as well as after surgery to  try to destroy any residual cancer cells. The side effects, which may  include soreness of the mouth and permanent dryness, can make eating a  challenge. An acceptable diet is likely to include soft, bland foods  moistened with a sauce or gravy, soups, puddings, nutritious shakes  and nutrient-rich liquid supplements.  After treatment, patients may need reconstructive surgery to recreate  lost structures in the mouth and training to use dental or facial  prostheses. Speech therapy and dietary counseling are also often  helpful. 

The cancer inst booklet on oral cancer can be had free by calling the Cancer Info Service at 1-800-4-CANCER or 800)422-6237. 

Fighting Oral Cancer, by Looking for It By JANE E. BRODY Aug 15, 2000


\11 Cancer, Skin

Cancer is the leading cause of death. Only 14% of Americans diag with lung cance live five years. 

You're never too young -- or too old -- to think about skin cancer. This year more than a million people in the U.S. will be diagnosed with skin cancer. Most people who are diagnosed with skin cancer are age 50 or older, but because this disease often is a result of too much exposure to the sun, everyone -- even the youngest toddlers -- should take precautions to protect against skin cancer. 

Fortunately there are ways to prevent many skin cancers and to detect it early when it does arise. 

Your skin is the largest organ in your body. It protects the structures underneath, regulates your body temperature, prevents the loss of fluids, serves as a sense organ for touch, heat, cold, and pain, and performs many other functions. The skin is formed of three layers. The deepest, the subcutaneous layer, is composed of fat and connective tissue and connects the skin to the underlying muscle. Above that is the dermis, the layer that contains sweat glands, oil glands, and other structures of the skin. The third layer, on the surface, is called the epidermis; it is there that most skin cancers arise. 

There are three primary types of skin cancer: basal cell carcinoma, squamous cell carcinoma, and melanoma. Basal cell carcinoma and squamous cell carcinoma, the most common forms, are often grouped as non-melanoma skin cancer; they account for about one million new cases of skin cancer each year. About 41,600 people in the U.S. will develop melanoma this year. 

All three types of skin cancer have been linked to sun exposure, especially when the exposure resulted in sunburn and blistering. Other, less common causes of skin cancer include repeated exposure to x-rays and exposure to coal tar, arsenic, and other industrial compounds. 

Basal cell carcinoma is the most common form of skin cancer, accounting for about 80 percent of all new cases. It arises from epithelial cells, which form the bulk of the epidermis (the outermost layer of your skin). It is most often found on the face, neck, hands, or other parts of the body that have been exposed to the sun. This type of cancer can have many different appearances: a red patch or irritated area; a small, pink pearly bump; a white or yellow scar-like area; a smooth growth with a dent in the center; or an open sore that bleeds or oozes. Basal cell carcinomas rarely spread throughout the body and deaths from them are very rare. Unfortunately, basal cell carcinomas often occur on the face, where their locally destructive effects can result in serious cosmetic deformity if not diagnosed and treated early. 

Squamous cell carcinomas also arise from epithelial cells, usually on places that have been exposed to the sun. It is most commonly found on the ears, the face, and the mouth. They tend to occur in people who are slightly older than those who get basal cell tumors. This type of skin cancer often arises from a precancerous lesion known as an actinic keratosis, a type of lesion that appears as a rough, flat pink spot. If the lesion becomes cancerous, it is usually raised above the normal skin surface and is firmer to the touch. Squamous cell tumors tend to be more aggressive than basal cell cancers, and unlike them, can spread to other parts of the body. 

Basal cell and squamous cell carcinomas are highly curable. They may be treated with surgery or radiation therapy. The surgical treatments include simple surgical removal, curettage and electrodessication (scraping away the tumor tissue and then destroying a thin surrounding layer with heat), or Mohs' surgery (a specialized type of microscopically controlled surgery). Despite the high cure rate for these cancers, however, about 1,900 people in the U.S. will die of these conditions this year. 

Prevention The best way to prevent skin cancer is to protect yourself and your family from the sun -- and not only when you go to the beach. Skin cancer prevention should be practiced every day by wearing protective clothing, avoiding the mid-day sun, and using sunscreen. 

When skin cancer does arise, the best possible chance for a complete cure occurs when it is found as early as possible. Perform a periodic skin self-examination to look for the tell-tale signs of skin cancer, and schedule regular visits to a dermatologist or other physician to ensure that skin cancers will be diagnosed and treated before they can become life-threatening. 

Screening Regular head-to-toe skin examinations are the key to diagnosing skin cancer at its earliest stage, when it is most easily cured. MSK offers skin cancer screening examinations through the Cancer Prevention and Wellness Program at the Laurance S. Rockefeller Outpatient Pavilion. (The Wellness Program also offers a comprehensive package of screening exams for other cancers, nutritional counseling, and other cancer preventive measures.) During a skin examination the clinician notes the location and appearance of any moles or other discolorations of your skin and will determine whether any look like they might be cancerous or precancerous. After you have been examined for skin cancer, you will also be taught how to examine your skin yourself, paying particular attention to any moles that are changing in appearance. 

For people who are at higher than average risk of skin cancer because of personal or family history or a large number of moles, MSK offers a more intensive surveillance program. Such a program usually includes regular skin examinations as well as maintenance of a photographic record of the skin. By comparing the skin to a set of baseline photos, clinicians can more easily spot very subtle changes that might mean a mole is becoming precancerous or cancerous. Such close surveillance ensures that changes in the skin are found as early as possible and can also eliminate the need to remove a large number of moles that are not currently harmful. In the near future, MSK physicians expect to use computers to compare current and baseline photos, which will enable them to spot even more subtle changes. 

Self-Examination Although some 34,100 Americans get melanoma each year, the number who die from it could be greatly reduced if all Americans would examine their skin regularly. Here? how to do it: 

Check yourself after a shower in a well-lighted room using a full-length mirror and a hand-held mirror.  Start by checking the moles and birthmarks that you?e had since birth. Look for any changes, especially a new mole or skin discoloration, a sore that does not heal, or any change in the size, shape, texture, or color of an existing mole.  Look at the front and back of your body in the mirror. Then raise your arms and look at your left and right sides.  Bend your elbows and look carefully at your fingernails, palms, forearms, and upper arms.  Examine the back, front, and sides of your legs. Look between the buttocks and around the genital area.  Sit and closely examine your feet, including the toenails, soles, and the space between the toes.  Look at your face, neck, ears, and scalp. Use a comb or hair dryer to move your hair so that you can see better. Better yet, get someone else to check your scalp for you.

If you find anything suspicious, visit a dermatologist right away. 
  Diagnosis Most suspected skin cancers are first noticed by the patient or by a family member and brought to the attention of a doctor. To make a diagnosis of skin cancer, the doctor will take a complete medical history and also question the patient about his or her history of sun exposure, history of normal and abnormal moles, and family history of skin conditions. He or she will perform a skin examination and may also check for enlarged lymph nodes, which can indicate that a cancer has spread. 

If the doctor believes there is any cause for concern about a particular mole or patch of skin, he or she will perform a biopsy, in which all or part of the growth is surgically removed. This is usually done in the doctor's office using just a local anesthetic. The skin that was removed is then examined under a microscope by a pathologist to determine if any cancer is present. If so, the doctor will determine the stage of disease, or how far it has progressed, in order to determine the best possible treatment. 

 Treatment

Most early basal cell and squamous cell skin cancers can be removed in a simple outpatient surgical procedure. The surgeon will often use special techniques to ensure that as little normal tissue is removed as possible, particularly in areas where scars would be noticeable. One surgical technique that helps to ensure that as little healthy tissue as possible is removed is called "Mohs' micrographic surgery." In this procedure, the surgeon removes just one thin layer of skin at a time, and each layer is immediately examined for cancerous cells under a microscope. Eventually, a layer will be free of cancer cells, and the surgeon will know that all of the cancer has been removed, along with as little healthy tissue as possible. 

Some skin precancers and cancers might also be treated with chemotherapy (often in a cream that is placed on the skin), electrodesiccation (destroying the tissue with heat), or cryosurgery (destroying the tissue by freezing it with liquid nitrogen). The type of treatment chosen depends on how large the precancer or cancer is and its location on the body. 

Patients are advised to return for annual follow-up visits to check on their skin, since those who have had a previous cancer are more likely to develop new lesions. Other than follow-up skin examinations, once a lesion has been removed, no further treatment is usually necessary. 

 Quick Tips: Safer Skin

Avoid the sun between 10 a.m. and 3 p.m., when the sun's rays are the strongest. Schedule outdoor activities for other times of the day, even on cloudy days. Clouds provide little protection from the sun's rays. Check news reports for the daily Ultraviolet Index, which tells you how strong the sun's rays will be.  Wear protective clothing such as long pants and a long-sleeved shirt whenever possible. Put a T-shirt on children when they are swimming.  Wear a wide-brimmed hat and protective sunglasses.  Sit in the shade when you are outdoors. Keep infants out of the sun altogether.  Don't use a sunlamp or visit a tanning parlor.  Know your skin and report anything unusual to your doctor. Also look for the ABCD warning signs of melanoma: Asymmetry, irregular Borders, Color that is not uniform or is black, and Diameter greater than 6 millimeters (about the size of a pencil eraser). If you have a mole with any of these features, or a spot on your skin that is changing in color, shape, or size, see your doctor. Learn how to do a complete skin self-examination, which can significantly reduce your risk of dying of melanoma.  Use sunscreen with an SPF of 15 or higher on yourself and your children (except for babies under six months of age). Also look for a product that is labeled "broad spectrum," which means that it protects against both of the major types of sun rays. Apply it liberally on all exposed skin a half-hour before going in the sun, and reapply after swimming or perspiring. Regardless of activity, reapply sunscreen every two hours, even on cloudy days. Also use a lip balm with an SPF of 15. And remember to use sunscreen often, not just when you are visiting the beach or the pool. You are exposed to the sun when you walk from the car to the store, too. 


Skin Cancer - How does ultraviolet radiation cause skin cancer? A. The prevailing theory involves damage to the DNA of skin cells, said Dr. Darrell Rigel, a prof of dermatology at NYU. It is the shorter UVB rays, which penetrate only the top layers of the skin, that are suspect, while the longer and more deeply penetrating UVA rays cause wrinkles and aging. 

"In tissue cultures, UV damages the DNA of cells, but humans have an enzyme that repairs it," he said. "In a genetic defect, some people lack the repair enzyme. How does this convert to skin cancer? The hypothesis is that in the body such DNA damage occurs all the time and is constantly repaired, but some cells do not get repaired, or get repaired improperly, and this is how skin cancer begins."

Researchers found a specific kind of DNA damage in a gene called p53 that occurs in this way. In the error, two DNA units of the type designated as thymine are side by side, instead of two units of the cytosine type. The error is called a thymine dimer. It is presumed that the brakes on cell multiplication come off because of it, leading to uncontrolled proliferation of cells into a tumor. 

Ultraviolet radiation is implicated in the vast majority of non- melanoma skin cancers, like basal cell carcinoma and squamous cells carcinoma, according to the American Cancer Society. It is also linked to melanoma, though less clearly.


\12 Cancer, Stomach

Stomach cancer, also known as gastric cancer, is cancer that starts in any part of the stomach. The stomach is just one of many organs located in the abdomen, the area of the body between the chest and the pelvis. Among other organs found in the abdomen are the liver, pancreas, gallbladder, and colon. It is important to differentiate among these organs, because cancers and other diseases that occur in them have different symptoms and are treated differently. The American Cancer Society estimates that 21,900 people will be diagnosed with stomach cancer in 1999, and 13,500 people will die from it.

What causes stomach cancer? The exact cause of stomach cancer is not known, although there are many risk factors believed to contribute to cells in the stomach becoming cancerous.

What are the risk factors for stomach cancer? The following are suggested as risk factors for stomach cancer:  Helicobacter pylori infection  diet that includes: 

large amounts of smoked foods  salted fish and meat  foods high in starch and low in fiber  pickled vegetables  foods and beverages that contain nitrates and nitrites 

tobacco abuse  alcohol abuse  previous stomach surgery>  pernicious anemia (caused by vitamin B12 deficiency)  Menetrier's disease  being male -- occurs twice as frequently in men  age 55 or older -- most patients are in their 60s or 70s  having blood type A  family history of:  nonpolyposis colon cancer  familial adenomatous polyposis  stomach cancer  history of stomach polyps  exposure to environmental factors such as dusts and fumes in the workplace 

What is a risk factor? A risk factor is anything that may increase a person's chance of developing a disease. It may be an activity, such as smoking, diet, family history, or many other things. Different diseases, including cancers, have different risk factors. Although these factors can increase a person's risk, they do not necessarily cause the disease. Some people with one or more risk factors never develop the disease, while others develop disease and have no known risk factors.

But, knowing your risk factors to any disease can help to guide you into the appropriate actions, including changing behaviors and being clinically monitored for the disease. Recent studies have also concluded that a diet very high in red meat, particularly if the meat is barbecued or well done, contributes to stomach cancer.

What are the symptoms of stomach cancer? The following are the most common symptoms for stomach cancer, however, each individual may experience symptoms differently. Symptoms may include:  indigestion or heartburn (burning sensation)  discomfort or pain in the abdomen  nausea and vomiting  diarrhea or constipation  bloating after meals  loss of appetite  weakness and fatigue  bleeding -- vomiting blood or blood in the stool 

The symptoms of stomach cancer may resemble other conditions or medical problems. Consult your physician for a diagnosis.

How is stomach cancer diagnosed? In addition to a complete medical history and physical examination, the physician may request the following diagnostic procedures:  fecal occult blood test - a test that checks for hidden blood in the stool.  upper GI (gastrointestinal) series - a series of x-rays of the esophagus, upper gastrointestinal tract, and stomach. The x-rays are taken after the patient swallows barium.  endoscopy - an examination, using a lighted tube called a gastroscope, that allows the physician to look directly into the stomach. During endoscopy, the physician may also perform:  biopsy - removal of a tissue sample for examination in a laboratory by a pathologist.  endoscopic ultrasound - imaging technique that uses sound waves to create a computer image of the inside of the stomach, the wall of the stomach and adjacent organs 

Treatment for stomach cancer: Specific treatment will be determined by your physician(s) based on:  your age, overall health, and medical history  extent of the disease  your tolerance for specific medications, procedures, or therapies  expectations for the course of the disease  your opinion or preference 

Treatment for stomach cancer may include:  surgery - to remove cancerous tissue, as well as nearby noncancerous tissue. The most common operation is called gastrectomy. If part of the stomach is removed, it's called a subtotal or partial gastrectomy. If the entire stomach is removed, it is called a total gastrectomy.  radiation therapy - uses external beams directed at the cancerous tissue, or internal seeds implanted into the cancerous tissues, to destroy the cancer cells.  chemotherapy - uses anticancer drugs to destroy cancerous and noncancerous cells. 


Each year, about 24,000 people in the US learn that they have cancer of the stomach. This National Cancer Institute (NCI) booklet will give you important information about the symptoms, diagnosis, and treatment of stomach cancer. This booklet also has information to help you deal with this disease if it affects you or someone you know. 

Cancer is a group of more than 100 different diseases. They affect the body's basic unit, the cell. Cancer occurs when cells become abnormal and divide without control or order. Like all other organs of the body, the stomach is made up of many types of cells. Normally, cells divide to produce more cells only when the body needs them. This orderly process helps keep us healthy.  If cells keep dividing when new cells are not needed, a mass of tissue forms. This mass of extra tissue, called a growth or tumor, can be benign or malignant. Benign tumors are not cancer.

They can usually be removed and, in most cases, they do not come back. Most important, cells from benign tumors do not spread to other parts of the body. Benign tumors are rarely a threat to life. Malignant tumors are cancer. Cancer cells can invade and damage tissues and organs near the tumor. Also, cancer cells can break away from a malignant tumor and enter the bloodstream or lymphatic system. This is how cancer spreads from the original (primary) tumor to form new tumors in other parts of the body. The spread of cancer is called metastasis. Stomach cancer (also called gastric cancer) can develop in any part of the stomach and may spread throughout the stomach and to other organs. It may grow along the stomach wall into the esophagus or small intestine. It also may extend through the stomach wall and spread to nearby lymph nodes and to organs such as the liver, pancreas, and colon. Stomach cancer also may spread to distant organs, such as the lungs, the lymph nodes above the collar bone, and the ovaries. When cancer spreads to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if stomach cancer spreads to the liver, the cancer cells in the liver are stomach cancer cells. The disease is metastatic stomach cancer (it is not liver cancer). However, when stomach cancer spreads to an ovary, the tumor in the ovary is called a Krukenberg tumor. (This tumor, named for a doctor, is not a different disease; it is metastatic stomach cancer. The cancer cells in a Krukenberg tumor are stomach cancer cells, the same as the cancer cells in the primary tumor.) 

Symptoms: Stomach cancer can be hard to find early. Often there are no symptoms in the early stages and, in many cases, the cancer has spread before it is found. When symptoms do occur, they are often so vague that the person ignores them. Stomach cancer can cause the following: Indigestion or a burning sensation (heartburn); Discomfort or pain in the abdomen; Nausea and vomiting; Diarrhea or constipation; Bloating of the stomach after meals; Loss of appetite; Weakness and fatigue; and Bleeding (vomiting blood or having blood in the stool). Any of these symptoms may be caused by cancer or by other, less serious health problems, such as a stomach virus or an ulcer. Only a doctor can tell the cause. People who have any ff these symptoms should see their doctor. They may be referred to a gastroenterologist, a doctor who specializes in diagnosing and treating digestive problems. These doctors are sometimes called gastrointestinal (or GI) specialists. 

Diagnosis: To find the cause of symptoms, the doctor asks about the patient's medical history, does a physical exam, and may order laboratory studies. The patient may also have one or all of the following exams: Fecal occult blood test--a check for hidden (occult) blood in the stool. This test is done by placing a small amount of stool on a plastic slide or on special paper. It may be tested in the doctor's office or sent to a laboratory. This test is done because stomach cancer sometimes causes bleeding that cannot be seen. However, noncancerous conditions also may cause bleeding, so having blood in the stool does not necessarily mean that a person has cancer. Upper GI series--x-rays of the esophagus and stomach (the upper gastrointestinal, or GI, tract. The x-rays are taken after the patient drinks a barium solution, a thick, chalky liquid. (This test is sometimes called a barium swallow.) The barium outlines the stomach on the x-rays, helping the doctor find tumors or other abnormal areas. During the test, the doctor may pump air into the stomach to make small tumors easier to see.  Endoscopy --an exam of the esophagus and stomach using a thin, lighted tube called a gastroscope, which is passed through the mouth and esophagus to the stomach. The patient's throat is sprayed with a local anesthetic to reduce discomfort and gagging. Patients also may receive medicine to relax them. Through the gastroscope, the doctor can look directly at the inside of the stomach. If an abnormal area is found, the doctor can remove some tissue through the gastroscope. Another doctor, a pathologist, examines the tissue under a microscope to check for cancer cells. This procedure--removing tissue and examining it under a microscope--is called a biopsy. A biopsy is the only sure way to know whether cancer cells are present. A patient who needs a biopsy may want to ask the doctor some of these questions: How long will the procedure take? Will I be awake? Will it hurt? How soon will I know the results? If I do have cancer, who will talk with me about treatment? When? 

Staging: If the pathologist finds cancer cells in the tissue sample, the patient's doctor needs to know the stage, or extent, of the disease. Staging exams and tests help the doctor find out whether the cancer has spread and, if so, what parts of the body are affected. Because stomach cancer can spread to the liver, the pancreas, and other organs near the stomach as well as to the lungs, the doctor may order a CT (or CAT) scan, an ultrasound exam, or other tests to check these areas. Staging may not be complete until after surgery. The surgeon removes nearby lymph nodes and may take samples of tissue from other areas in the abdomen. All of these samples are examined by a pathologist to check for cancer cells. Decisions about treatment after surgery depend on these findings. 

Treatment: The doctor develops a treatment plan to fit each patient's needs. Treatment for stomach cancer depends on the size, location, and extent of the tumor; the stage of the disease; the patient's general health; and other factors. Many people who have cancer want to learn all they can about the disease and their treatment choices so they can take an active part in decisions about their medical care. The doctor is the best person to answer questions about their diagnosis and treatment plan. When a person is diagnosed with cancer, shock and stress are natural reactions. These feelings may make it difficult for people to think of everything they want to ask the doctor. Often, it helps to make a list of questions. Also, to help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some people also want to have a family member or friend with them when they talk to the doctor--to take part in the discussion, to take notes, or just to listen. Patients should not feel the need to ask all their questions or remember all the answers at one time. They will have other chances to ask the doctor to explain things and to get more information. When talking about treatment choices, the patient may want to ask about taking part in a research study. Such studies, called clinical trials, are designed to improve cancer treatment. More information about clinical trials is in the Clinical Trials section. These are some questions a patient may want to ask the doctor before treatment begins: What is the stage of the disease? What are my treatment options? Which do you suggest for me? Why?  Would a clinical trial be appropriate for me? What are the expected benefits of the treatment? What are the risks and possible side effects of the treatment? What can be done about side effects? What can I do to take care of myself during therapy? How long will my treatment last? Patients and their loved ones are naturally concerned about the effectiveness of the treatment. Sometimes they use statistics to try to figure out whether the patient will be cured, or how long he or she will live. It is important to remember, however, that statistics are averages based on large numbers of patients. They cannot be used to predict what will happen to a particular person because no two cancer patients are alike; treatments and responses vary greatly. Patients may want to talk with the doctor about the chance of recovery (prognosis). When doctors talk about surviving cancer, they may use the term remission rather than cure. Even though many patients recover completely, doctors use this term because the disease can return. (The return of cancer is called a recurrence.) 

Getting a Second Opinion: Treatment decisions are complex. Sometimes it is helpful for patients to have a second opinion about the diagnosis and the treatment plan. (Some insurance companies require a second opinion; others may pay for a second opinion if the patient requests it.) There are several ways to find another doctor to consult: The patient's doctor may be able to suggest a specialist. Specialists who treat this disease include gastroenterologists, surgeons, medical oncologists and radiation oncologists. The Cancer Information Service, at 1-800-4-CANCER, can tell callers about treatment facilities, including cancer centers and other programs supported by the National Cancer Institute. Patients can get the names of doctors from their local medical society, a nearby hospital, or a medical school.

Methods of Treatment Cancer of the stomach is difficult to cure unless it is found in an early stage (before it has begun to spread). Unfortunately, because early stomach cancer causes few symptoms, the disease is usually advanced when the diagnosis is made. However, advanced stomach cancer can be treated and the symptoms can be relieved. Treatment for stomach cancer may include surgery, chemotherapy, and/or radiation therapy. New treatment approaches such as biological therapy and improved ways of using current methods are being studied in clinical trials. A patient may have one form of treatment or a combination of treatments.

Surgery is the most common treatment for stomach cancer. The operation is called gastrectomy. The surgeon removes part (subtotal or partial gastrectomy) or all (total gastrectomy) of the stomach, as well as some of the tissue around the stomach. After a subtotal gastrectomy, the doctor connects the remaining part of the stomach to the esophagus or the small intestine. After a total gastrectomy, the doctor connects the esophagus directly to the small intestine. Because cancer can spread through the lymphatic system, lymph nodes near the tumor are often removed during surgery so that the pathologist can check them for cancer cells. If cancer cells are in the lymph nodes, the disease may have spread to other parts of the body. These are some questions a patient may want to ask the doctor before surgery: What kind of operation will I have? What are the risks of this operation? How will I feel afterwards? If I have pain, how will you help me? Will I need a special diet? Who will teach me about my diet? 

 Chemotherapy is the use of drugs to kill cancer cells. This type of treatment is called systemic therapy because the drugs enter the bloodstream and travel through the body. Clinical trials are in progress to find the best ways to use chemotherapy to treat stomach cancer. Scientists are exploring the benefits of giving chemotherapy before surgery to shrink the tumor, or as adjuvant therapy after surgery to destroy remaining cancer cells. Combination treatment with chemotherapy and radiation therapy is also under study. Doctors are testing a treatment in which anticancer drugs are put directly into the abdomen (intraperitoneal chemotherapy). Chemotherapy also is being studied as a treatment for cancer that has spread, and as a way to relieve symptoms of the disease. Most anticancer drugs are given by injection; some are taken by mouth. The doctor may use one drug or a combination of drugs. Chemotherapy is given in cycles: a treatment period followed by a recovery period, then another treatment, and so on. Usually a person receives chemotherapy as an outpatient (at the hospital, at the doctor's office, or at home). However, depending on which drugs are given and the patient's general health, a short hospital stay may be needed.  These are some questions patients may want to ask about chemotherapy: What is the goal of this treatment? What drugs will I be taking? Will the drugs cause side effects? What can I do about them? How long will I need to take this treatment? How will we know if the treatment is working? 

 Radiation therapy (also called radiotherapy) is the use of high-energy rays to damage cancer cells and stop them from growing. Like surgery, it is local therapy; the radiation can affect cancer cells only in the treated area. Radiation therapy is sometimes given after surgery to destroy cancer cells that may remain in the area. Researchers are conducting clinical trials to find out whether it is helpful to give radiation therapy during surgery (intraoperative radiation therapy). Radiation therapy may also be used to relieve pain or blockage.  The patient goes to the hospital or clinic each day for radiation therapy. Usually treatments are given 5 days a week for 5 to 6 weeks. These are some questions a patient may want ask the doctor before receiving radiation therapy: What is the goal of this treatment?  How will the radiation be given? When will the treatment begin? When will it end? Will I have side effects? What can I do about them? How will we know if the radiation therapy is working? 

 Biological therapy (also called immunotherapy) is a form of treatment that helps the body's immune system attack and destroy cancer cells; it may also help the body recover from some of the side effects of treatment. In clinical trials, doctors are studying biological therapy in combination with other treatments to try to prevent a recurrence of stomach cancer. In another use of biological therapy, patients who have low blood cell counts during or after chemotherapy may receive colony-stimulating factors to help restore the blood cell levels. Patients may need to stay in the hospital while receiving some types of biological therapy.

Clinical Trials Many patients with stomach cancer are treated in clinical trials (treatment studies). Doctors conduct clinical trials to find out whether a new approach is both safe and effective and to answer scientific questions. Patients who take part in these studies are often the first to receive treatments that have shown promise in laboratory research. In clinical trials, some patients may receive the new treatment while others receive the standard approach. In this way, doctors can compare different therapies. Patients who take part in a trial make an important contribution to medical science and may have the first chance to benefit from improved treatment methods. Researchers also use clinical trials to look for ways to reduce the side effects of treatment and to improve the quality of patients' lives. Many clinical trials for people with stomach cancer are under way. Patients who are interested in taking part in a trial should talk with their doctor. The booklet Taking Part in Clinical Trials: What Cancer Patients Need To Know explains the possible benefits and risks of treatment studies. One way to learn about clinical trials is through PDQ, a computer database developed by the National Cancer Institute. PDQ contains information about cancer treatment and about clinical trials. The Cancer Information Service can provide PDQ information to doctors, patients, and the public. 

 Side Effects of TreatmentIt is hard to limit the effects of therapy so that only cancer cells are removed or destroyed. Because healthy cells and tissues also may be damaged, treatment can cause unpleasant side effects.  The side effects of cancer treatment are different for each person, and they may even be different from one treatment to the next. Doctors try to plan treatment in ways that keep side effects to a minimum; they can help with any problems that occur. For this reason, it is very important to let the doctor know about any problems during or after treatment. The National Cancer Institute booklets Radiation Therapy and You and Chemotherapy and You have helpful information about cancer treatment and coping with side effects. 

 Surgery Gastrectomy is major surgery. For a period of time after the surgery, the person's activities are limited to allow healing to take place. For the first few days after surgery, the patient is fed intravenously (through a vein). Within several days, most patients are ready for liquids, followed by soft, then solid, foods. Those who have had their entire stomach removed cannot absorb vitamin B12, which is necessary for healthy blood and nerves, so they need regular injections of this vitamin. Patients may have temporary or permanent difficulty digesting certain foods, and they may need to change their diet. Some gastrectomy patients will need to follow a special diet for a few weeks or months, while others will need to do so permanently. The doctor or a dietitian (a nutrition specialist) will explain any necessary dietary changes. Some gastrectomy patients have cramps, nausea, diarrhea, and dizziness shortly after eating because food and liquid enter the small intestine too quickly. This group of symptoms is called the dumping syndrome. Foods containing high amounts of sugar often make the symptoms worse. The dumping syndrome can be treated by changing the patient's diet. Doctors often advise patients to eat several small meals throughout the day, to avoid foods that contain sugar, and to eat foods high in protein. To reduce the amount of fluid that enters the small intestine, patients are usually encouraged not to drink at mealtimes. Medicine also can help control the dumping syndrome. The symptoms usually disappear in 3 to 12 months, but they may be permanent. Following gastrectomy, bile in the small intestine may back up into the remaining part of the stomach or into the esophagus, causing the symptoms of an upset stomach. The patient's doctor may prescribe medicine or suggest over-the-counter products to control such symptoms. 

Chemotherapy The side effects of chemotherapy depend mainly on the drugs the patient receives. As with any other type of treatment, side effects also vary from person to person. In general, anticancer drugs affect cells that divide rapidly. These include blood cells, which fight infection, help the blood to clot, or carry oxygen to all parts of the body. When blood cells are affected by anticancer drugs, patients are more likely to get infections, may bruise or bleed easily, and may have less energy. Cells in hair roots and cells that line the digestive tract also divide rapidly. As a result of chemotherapy, patients may have side effects such as loss of appetite, nausea, vomiting, hair loss, or mouth sores. For some patients, the doctor may prescribe medicine to help with side effects, especially with nausea and vomiting. These effects usually go away gradually during the recovery period between treatments or after the treatments stop.

Radiation Therapy Patients who receive radiation to the abdomen may have nausea, vomiting, and diarrhea. The doctor can prescribe medicine or suggest dietary changes to relieve these problems. The skin in the treated area may become red, dry, tender, and itchy. Patients should avoid wearing clothes that rub; loose-fitting cotton clothes are usually best. It is important for patients to take good care of their skin during treatment, but they should not use lotions or creams without the doctor's advice. Patients are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can. 

Biological Therapy The side effects of biological therapy vary with the type of treatment. Some cause flu-like symptoms, such as chills, fever, weakness, nausea, vomiting, and diarrhea. Patients sometimes get a rash, and they may bruise or bleed easily. These problems may be severe, and patients may need to stay in the hospital during treatment.

Nutrition for Cancer PatientsIt is sometimes difficult for patients who have been treated for stomach cancer to eat well. Cancer often causes loss of appetite, and people may not feel like eating when they are uncomfortable or tired. It is hard for patients to eat when they have nausea, vomiting, mouth sores, or the dumping syndrome. Patients who have had stomach surgery are likely to feel full after eating only a small amount of food. For some patients, the taste of food changes. Still, good nutrition is important. Eating well means getting enough calories and protein to help prevent weight loss, regain strength, and rebuild normal tissues.
 Doctors, nurses, and dietitians can offer advice for healthy eating during and after cancer treatment. Patients and their families also may want to read the National Cancer Institute booklet Eating Hints for Cancer Patients, which contains many useful suggestions.

 Support for Cancer PatientsLiving with a serious disease is not easy. Cancer patients and those who care about them face many problems and challenges. Coping with these problems is often easier when people have helpful information and support services. Several useful booklets, including Taking Time, are available from the Cancer Information Service. Cancer patients may worry about holding their job, caring for their family, or keeping up with their daily activities. Concerns about tests, treatments, hospital stays, and medical bills are common. Doctors, nurses, and other members of the health care team can answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy also can be helpful for patients who want to talk about their feelings or discuss their concerns about the future or about personal relationships. Friends and relatives can be very supportive. Also, it helps many patients to discuss their concerns with others who have cancer. Cancer patients often get together in support groups, where they can share what they have learned about coping with cancer and the effects of treatment. It is important to keep in mind, however, that each patient is different. Treatments and ways of dealing with cancer that work for one person may not be right for another--even if they both have the same kind of cancer. It is always a good idea to discuss the advice of friends and family members with the doctor.
 Often, a social worker at the hospital or clinic can suggest groups that can help with rehabilitation, emotional support, financial aid, transportation, or home care. For example, the American Cancer Society has many services for cancer patients and their families. Local offices of the American Cancer Society are listed in the white pages of the telephone directory. The Cancer Information Service also has information on local resources.

National Cancer Institute Information Resources You may want more information for yourself, your family, and your health care provider. The following National Cancer Institute (NCI) services are available to help you.

Telephone Cancer Information Service (CIS) Provides accurate, up-to-date information on cancer to patients and their families, health professionals, and the general public. Information specialists translate the latest scientific information into understandable language and respond in English, Spanish, or on TTY equipment.  Toll-free: 1-800-4-CANCER (1-800-422-6237) TTY (for deaf and hard of hearing callers): 1-800-332-8615 

Internet These Web sites may be useful: 
 http://www.cancer.gov NCI's primary Web site; contains information about the Institute and its programs.

http://cancertrials.nci.nih. gov cancerTrials™; NCI's comprehensive clinical trials information center for patients, health professionals, and the public. Includes information on understanding trials, deciding whether to participate in trials, finding specific trials, plus research news and other resources. 

http://cancernet.nci.nih. gov CancerNet™; contains material for health professionals, patients, and the public, including information from PDQ® about cancer treatment, screening, prevention, supportive care, and clinical trials; and CANCERLIT®, a bibliographic database. 
 
 E-mail CancerMail Includes NCI information about cancer treatment, screening, prevention, and supportive care. To obtain a contents list, send e-mail to cancermail@icicc.nci.nih.gov with the word "help" in the body of the message. Fax  CancerFax® Includes NCI information about cancer treatment, screening, prevention, and supportive care. To obtain a contents list, dial 301-402-5874 from a fax machine hand set and follow the recorded instructions. 


\13 Colon and Rectal (Colorectal) Cancer

Colorectal cancer is malignant cells found in the colon or rectum. The colon and the rectum are part of the large intestine, which is part of the digestive system. Because colon cancer and rectal cancers have many features in common, they are sometimes referred to together as colorectal cancer. Cancerous tumors found in the colon or rectum also may spread to other parts of the body.

Colorectal cancer is the second leading cause of cancer deaths in the US. However, the number of new cases of colorectal cancer and the number of deaths due to colorectal cancer have decreased, which is attributed to increased sigmoidoscopic screening and polyp removal.

What are the symptoms of colorectal cancer? The following are the most common symptoms for colorectal cancer, however, each individual may experience symptoms differently. People who have any of the following symptoms should check with their physicians, especially if they are over 40 years old or have a personal or family history of the disease:

a change in bowel habits such as diarrhea, constipation, or narrowing of the stool that lasts for more than a few days  rectal bleeding or blood in the stool  cramping or gnawing stomach pain  decreased appetite  vomiting  weakness and fatigue  jaundice (yellowish coloring) of the skin or sclera of the eye 

The symptoms of colorectal cancer may resemble other conditions, such as infections, hemorrhoids, and inflammatory bowel disease. It is important to talk to the physician since finding colorectal cancer early makes successful treatment more likely. It is also possible to have colon cancer and not have any symptoms.

What are the risk factors for colorectal cancer? Risk factors may include: age Most people who have colorectal cancer are over age 50, however, it can occur at any age.  diet Colorectal cancer is associated with a diet high in fat and calories, and low in fiber.  polyps Benign growths on the wall of the colon or rectum are common in people over age 50, and are believed to lead to colorectal cancer.  personal history People who have had colorectal cancer, as well as ovarian, uterine, or breast cancers, have a slightly increased risk for colorectal cancer.  family history People with first-degree relatives who have had colorectal cancer have an increased risk for colorectal cancer.  ulcerative colitis People who have ulcerative colitis, inflamed lining of the colon, have an increased risk for colorectal cancer. 

What causes colorectal cancer? The exact cause of most colorectal cancer is unknown, but the known risk factors listed above are the most likely causes. Less than 10 percent of colorectal cancers are caused by inherited gene mutations. People with a family history of colorectal cancer, may wish to consider genetic testing. The American Cancer Society suggests that anyone undergoing such tests have access to a physician or geneticist qualified to explain the significance of these test results.

Prevention of colorectal cancer: Although the exact cause of colorectal cancer is not known, it is possible to prevent many colon cancers through:

diet and exercise It is important to manage the risk factors you can control, such as diet and exercise. Eating more fruits, vegetables, and whole grain foods and avoiding high-fat, low-fiber foods, plus appropriate exercise, even small amounts on a regular basis, can be helpful. 

drug therapy Some studies have shown that low doses of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, and estrogen replacement therapy for post-menopausal women may reduce the risk of colorectal cancer. Discuss this with your physician. 

screenings Perhaps most important to the prevention of colorectal cancer is having screening tests at appropriate ages. Because some colorectal cancers cannot be prevented, finding them early is the best way to improve the chance of a successful treatment, and reduce the number of deaths caused by colorectal cancer.

The following screening guidelines can lower the number of cases of the disease and can also lower the death rate from colorectal cancer by detecting the disease at an earlier, more treatable stage. 

Methods of screening for colorectal cancer: Screening methods for colorectal cancer, for people who do not have any symptoms or strong risk factors, include:

digital rectal examination (DRE) - a physician or health care provider inserts a gloved finger into the rectum to feel for anything unusual or abnormal. fecal occult blood test - a sample of stool is examined for blood. A test kit will explain how to take a sample at home. It is then returned to the physician's office to be checked. 

sigmoidoscopy - a slender, flexible, hollow, lighted tube is placed into the rectum allowing the physician to look at the inside of it and part of the colon for cancer or for polyps. 

colonoscopy - a long, flexible, lighted tube (much longer than a sigmoidoscope) about the thickness of a finger is inserted through the rectum up into the colon, allowing the physician to see the colon lining. 

barium enema with air contrast (also called a double contrast barium enema) - barium sulfate, a chalky substance used to partially fill and open up the colon, is given in the anus and x-rays are made. 

Diagnostic procedures for colorectal cancer: In addition to a complete medical history and physical examination, diagnostic procedures for colorectal cancer may include: digital rectal examination (DRE)  fecal occult blood test  sigmoidoscopy  colonoscopy  barium enema  biopsy 

CEA assay to measure a protein called carcinoembryonic antigen, which is sometimes higher in patients who have colorectal cancer. 

Treatment for colorectal cancer: Specific treatment will be determined by your physician(s) based on: your age, overall health, and medical history extent of the disease your tolerance for specific medications, procedures, or therapies expectations for the course of the disease your opinion or preference. 

Treatment choices for the person with colon cancer depend on the stage of the tumor -- if it has spread and how far. When the disease has been found and staged, your physician will suggest a treatment plan. Treatments may include: colon surgery - The main treatment for colon cancer and the usual operation is called a segmental resection, in which the cancer and a length of normal tissue on either side of the cancer are removed, as well as the nearby lymph nodes. 

Radiation therapy - is the use of high energy radiation to kill cancer cells either after surgery, to kill small areas of cancer that may not be seen during surgery, or instead of surgery. Radiation may also be used to ease (palliate) symptoms such as pain, bleeding, or blockage. There are two ways to deliver radiation therapy:  External beam radiation uses radiation from outside the body, which is focused on the cancer. Internal radiation therapy uses small pellets of radioactive material placed directly into the cancer. 

Chemotherapy - Drugs (medications) are given into a vein or by mouth to kill cancer cells throughout the body. Studies have shown that chemotherapy after surgery can increase the survival rate for patients with some stages of colon cancer. Chemotherapy can also help relieve symptoms of advanced cancer. 

Anatomy of the colon: The colon is the first six feet of the large intestine. It has four sections: The first section is called the ascending colon. It extends upward on the right side of the abdomen. The second section is called the transverse colon since it goes across the body to the left side. There it joins the third section, the descending colon, which continues downward on the left side. The fourth section is known as the sigmoid colon because of its S-shape. The sigmoid colon joins the rectum, which in turn joins the anus, or the opening where waste matter passes out of the body. 

What is a risk factor? Anything that may increase a person's chance of developing a disease. It may be an activity, such as smoking, diet, family history, or many other things. Different diseases, inc cancers, have different risk factors. 

Although these factors can increase a person’s risk, they do not necessarily cause the disease. Some people with one or more risk factors never develop the disease, while others develop disease and have no known risk factors. But, knowing your risk factors to any disease can help to guide you into the appropriate actions, inc changing behaviors and being clinically monitored for the disease.

Screening Guidelines for Colorectal Cancer - Screening guidelines from the American Cancer Society for early detection are: Beginning at age 50, both men and women should follow this testing schedule: 

Digital rectal exam should be performed at the time of each screening sigmoidoscopy, colonoscopy, or barium enema examination. Yearly fecal occult blood test, plus.. flexible sigmoidoscopy every 5 yrs, or colonoscopy every 10 yrs, or double contrast barium enema every 5-10 yrs 

People with any of the following colorectal cancer risk factors should begin screening procedures at an earlier age: strong family history of colorectal cancer or polyps (cancer or polyps in a first degree relative younger than 60 or in two first degree relatives of any age) family with hereditary colorectal cancer syndromes (familial adenomatous polyposis and hereditary non-polyposis colon cancer) personal history of colorectal cancer or adeno- matous polyps personal history of chronic inflammatory bowel disease


A disease in which cancerous growths (tumors) are found in the tissues of the colon and rectum. The colon and rectum are part of the digestive system. Together they form a long, muscular tube called the large intestine. The colon is the lower 5 - 6 feet of the intestines and the rectum is the last 6 - 8 inches of the colon. 

Colorectal cancer is rare in young people. Fewer than 6% of cases occur before the age of 50 years old. Incidence increases markedly after age 50. The average age at time of diagnosis is at 60 years.

The colon and rectum are made of many kinds of cells. Normally cells divide in an orderly way to produce more cells only when the body needs them. If cells keep dividing when new cells are not needed, a mass of extra tissue, called a tumor, forms. The tumor can be either benign (non-cancerous) or malignant (cancerous). Malignant cells grow and spread beyond their original site. Most colorectal cancer develops from certain type of polyps (a benign tumor of mucous membranes) which arise in the epithelial tissue, or lining, of the colon. Colorectal cancer spreads directly from the lining of the colon and into adjacent tissues. The tumor may spread (metastasize) to other parts of body such as the lymph nodes, liver, lungs, brain, kidneys and bladder.

Colon cancer is the third most common cancer and the second leading cause of cancer death in the United States. In 1996, an estimated 133,500 new cases of colorectal cancer were diagnosed and there were 54,900 deaths. Incidence increases with age, and is higher in men than in women. 

The causes of colorectal cancer are thought to include: polyp formation, genetic defects, family history of familial adenomatous polyposis (FAP). FAP is a rare disease in which numerous adenomatous polyps (often a thousand or more) are found in the colon and rectum. high-fat, low fiber/calcium diets. 

Some people are more "at risk" of developing colorectal cancer. The risk factors include: age; over 50 years old. family history of colorectal cancer. a personal history of cancer of the female reproductive tract, especially of the breast or uterus. evidence of polyps in the colon and rectum. male sex. having FAP •having inflammatory bowel disease such as ulcerative colitis (inflammation of the colon lining) and Crohn's disease (an ulcerative condition of the small and large bowel). eating diets high in fat and low in fiber and calcium. 

Since cancer is highly curable in the early stages, several screening techniques for early detection of colorectal cancer are recommended: Name of exam Description Recommended Age of Screening and Schedule Digital rectal exam (DRE) doctor inserts a lubricated gloved finger in the rectum to feel for abnormalities annually for men and women over 40

Fecal Occult Blood (FOB) Test* blood taken from a stool sample is tested annually for men and women over 50

Sigmoidoscopy doctor examines the rectum and lower colon with a lighted flexible tube every 3 - 5 years for men and women over 50

* To minimize the chance of misleading results on the stool test, postpone the test if a woman is menstruating or if a person has bleeding hemorrhoids, bleeding gums, or blood in the urine. Also it is important to avoid the following items during the test period and for two days beforehand: red meat, raw fruits and vegetables (particularly cauliflower, horseradish, and other radishes), melons, turnips, aspirin or other non-steroidal anti-inflammatory drugs.

SIGNS AND SYMPTOMS Colorectal cancer may exist without symptoms until it is advanced. If symptoms do occur, they may include:

diarrhea or constipation. a change in bowel habits •blood in or on the stool (either bright red or very dark in color) narrow stools •general stomach discomfort (bloating, fullness, and/or cramps) •frequent gas pains •a feeling that the bowel does not empty completely •loss of weight with no known reason, anemia 

DETECTION AND DIAGNOSIS The diagnosis of colorectal cancer includes asking about the patient’s personal and family medical history, doing a physical examination and ordering various laboratory and diagnostic tests. The physical exam includes a digital rectal examination (DRE) which involves the doctor inserting a lubricated, gloved finger into the rectum and feeling for abnormalities. The laboratory tests will include a fecal occult blood (FOB) test as well as blood and urine samples. The FOB test involves taking a small sample of the person’s stool testing it for hidden (occult) blood. The diagnostic tests might include a sigmoidoscopy, and if needed a colonoscopy and lower GI series (barium enema).

Sigmoidoscopy involves inserting a lighted flexible tube (called a sigmoidoscope) into the rectum and lower part of the colon. The doctor then looks through the sigmoidoscope to check for polyps, tumors or other abnormalities. •Colonoscopy involves inserting a lighted flexible tube (longer than a sigmoidoscope) called a colonoscope through the entire colon. The doctor then looks through the colonoscope to check for polyps, tumors or other abnormalities. •Barium enema involves giving the patient an enema (an injection of fluid into the rectum) containing a white, chalky solution consisting of barium. The barium outlines the colon and rectum, and using x-rays, the doctor can look for tumors or other abnormalities. 

If a polyp or other abnormal growth is found during a sigmoidoscopy or colonoscopy the growth is removed and checked for cancer cells. This is called a biopsy. If the growth is cancerous, the doctor needs to determine the stage, or extent, of the disease.

STAGING Staging exams and tests help the doctor find out whether the cancer has spread and, if so, what parts of the body are affected. The staging exams include x-rays, ultrasounds or CT (or CAT) scans of the colon, rectum, liver and lungs. The staging test may include an additional blood test called the carcinoembryonic antigen (CEA) test. This test measures the blood level of CEA, a substance that is sometimes found in higher than normal amounts in people with colorectal cancer.

The stages of colorectal cancer are: Stage 0 (or carcinoma in situ) Tumor is in innermost lining of colon wall only

Stage I (Dukes A) Tumor in innermost lining, and second and third layers of the colon wall

Stage II (Dukes B) Tumor has spread through colon wall to nearby tissue, but has not gone into the lymph nodes

Stage III (Dukes C) Tumor has spread to the lymph nodes but not to other parts of the body

Stage IV (Dukes D) Tumor has spread to other parts of the body

Recurrent Cancer has come back after it has been treated

TREATMENT Treatment for colorectal cancer depends on the size and location of the tumor, the stage of the disease, the patient’s general health and other factors. There are three primary ways to treat colorectal cancer: surgery, radiation therapy, and/or chemotherapy.

Surgery Surgery is the most common treatment for all stages (Stage 0 - Recurrent) of colorectal cancer. The location and size of the tumor determines the type of surgical procedure to be done. The types of procedures include a local excision or polypectomy, colon resection, or colectomy with colostomy. If the cancer is found in a very early stage, the doctor may be able to remove the cancer without cutting through the abdomen. The doctor may be able to put a tube in the rectum and cut the tumor out. This is called a local excision. Polypectomy is the removal of a polyp using either a sigmoidoscope or colonoscope to locate the growth and another surgical instrument to remove the polyp.

Colon resection is the removal of part of the rectum or colon (whichever is cancerous) and a small amount of surrounding healthy tissue. The healthy parts of the colon or rectum are then sewn back together. This part of the surgery is called anastomosis. Additionally, during this procedure the doctor will take out lymph nodes near the intestine and examine them for cancerous growth. Colectomy with colostomy is done if, after the portions of the colon or rectum and tissue are removed, the healthy tissues cannot be sewn back together. In this procedure part of the colon is brought through an incision in the abdominal wall and formed into an artificial opening (stoma). This allows feces to be eliminated into a lightweight bag attached to the skin. A colostomy may be temporary or permanent. A temporary colostomy is sometimes needed to allow the lower colon or the rectum to heal after surgery. Later, in a second surgery, the doctor reconnects the healthy sections of the colon or rectum. A permanent colostomy may be necessary when the tumor is in the rectum, and in very few cases, in the lower colon.

Radiation Therapy In radiation therapy (also called x-ray therapy, radiotherapy, cobalt treatment, or irradiation), high-energy rays are used to stop the cancer cells from growing and multiplying. Radiation therapy is sometimes used before surgery to shrink the tumor. More often, it is used after surgery to destroy any cancer cells that may remain, or to relieve pain. Radiation may come from a machine outside the body (called external radiation therapy) or from putting radioactive materials through thin plastic tubes into the intestinal area (called internal radiation therapy). Radiation therapy may be used in combination with surgery and/or chemotherapy to treat Stage 2 through recurrent cancer 

Chemotherapy Chemotherapy is the use of drugs to kill cancer cells. Given orally or by injection, these drugs enter the bloodstream, travel through the body and kill cancer cells outside the colon. Chemotherapy may be given after surgery to kill any cancer cells that are left, or as a preventive measure after surgery to assure the cancer does not spread. This preventive measure is called adjuvant therapy. Anticancer drugs may also be used when there are signs that the cancer has spread. 

Depending on which drugs are used, the patient may need to stay in the hospital for a few days so the effects of the drugs can be watched. From then on, the patient may be given chemotherapy as an outpatient, or at home. Chemotherapy is most often given in cycles-a treatment period, followed by a rest period, then another treatment, and so on. Chemotherapy may be used in combination with surgery and radiation therapy for Stages II - IV. Chemotherapy or radiation therapy with surgery may be used to treat Recurrent colorectal cancer. 

PREVENTION The following preventive measures appear to reduce the risk of developing colorectal cancer:

Regular screening for colorectal cancer using DRE, FOB and sigmoidoscopy (See DESCRIPTION section for more details) •Eat a diet that is low in fat and high in fiber (25 g per day) •Consume at least 1,000 mg of calcium each day •Eat foods that contain antioxidants such as citrus fruits and dark-green and yellow vegetables •Take estrogen. Studies suggest that postmenopausal women who take estrogen are less likely to develop colorectal cancer than similar women who don’t take estrogen •Stop smoking •Limit alcohol consumption. Older adults should consume no more than the equivalent of one glass of wine daily. •Remove polyps and adenomas upon discovery 


Cancer, Colorectal Health news Feb 27 2001 Bowel cancer #1 in SIN: Chinese men most at risk By Margaret Perry COLORECTAL or bowel cancer is the most common form of cancer in Singapore - and Chinese men living here are most at risk of getting it. When cancer rates for men and women are exam indepen- dently, it is #2 on the list, after lung & breast cancer respectively. But it rises to top spot when the figures for both sexes are combined. Between 93-97, there were 4899 cases, compared to 4601 cases of lung cancer and 3574 of breast cancer, said the SIN Cancer Registry.

These are the most recent figures available as the registry releases them only once every five years. While levels of lung cancer in men are falling, female breast cancer, and bowel cancer in both sexes, continue to rise. Currently, one in 25 people here will get bowel cancer, but Chinese Singaporean men have the highest risk; one in 17 of them is likely to fall victim. Indian Singaporean men are the least affected. Just one in 100 will have it.

The reason for Chinese men's susceptibility is not known. Colorectal surgeon Denis Nyam said a high-fat, low-fibre diet, lack of exercise and a family history are all causes. Although more bowel-cancer cases are being detected, the death rate from the illness has remained at about 60%. 'Until now, we've been telling people to see a doctor when they have such symptoms as bleeding, but this can be too late,' he said. According to Dr Nyam, the majority of cases can be prevented.

'Most colon cancers start as polyps - small growths - in the bowel. 'It usually takes about 3-10 yrs for a polyp to grow into a tumour. By undergoing a colonoscopy and removing any polyps spotted, most cases of colon cancer can be prevented,' he said. Madam Y.F. Wong, 67, is one of the many bowel-cancer victims who might have benefited from screening. She was diagnosed last June and was operated on to remove the tumour.

A month later, one of her brothers, a 45-yr-old civil servant, was diagnosed with the disease. As a precaution, her other three brothers had colonoscopies, and polyps were found in the bowels of the youngest one. They were removed, and he now has to go for a ck-up every two yrs. 

GLOSSARY OF MEDICAL TERMS anemia: lower than normal amounts of hemoglobin (the chemical that carries oxygen) in the red blood cells

biopsy: The removal of a sample of tissue or cells for examination under a microscope for purposes of diagnosis

colon: The large intestine that ends in the anus. It is responsible for extracting water from undigested food, storing it and then eliminating it from the body during a bowel movement

constipation: a change in normal bowel habits such as a decrease in the frequency of stool (body’s waste product), passage of hard, dry stools, or difficulty in passage of the stool. 

CT scan: a series of detailed x-rays of areas inside the body created by a computer linked to an x-ray machine

diarrhea: an increase in the number, amount or liquid content of bowel movements, as compared to the usual pattern for a particular person.

estrogen: one of the female sex hormones produced primarily by the ovaries before menopause, and by fat and other tissues after menopause

fiber: The parts of food that are not digested

lymph nodes: small, bean-shaped structures that are found thoughout the body. They produce and store cells that fight infection 

orally: by mouth

polyp: a growth of tissue that is on a stalk or pedicle

ultrasound examination: a test where sound wave are beamed into the body and are used to show a picture of the internal organs on a computer screen

uterus: the womb. A muscular organ of the female reproductive system that holds a growing baby during pregnancy

John Hopkins Health Info and Clinical Ref Systems. (96). Colon and rectal cancer.intelihealth.com

National Cancer Inst, NIH 1997. Colon cancer. cancernet.nci.nih.gov/clinpdq/pif/colon_cancer_patinet. html.

Nat Cancer Inst, NIH 98. Rectal cancer.  cancernet.nci.nih.gov/clinpdq/pif/rectal_cancer_patinet. html.


QUESTIONS TO ASK YOUR DOCTOR What tests are needed to diagnose the condition?  What tests need to be done to determine the extent of (stage) the disease? 

What stage of the cancer is it?  Will surgery be required? What procedure? How much colon and/or rectum will be removed? What are the risks?  What can be expected after the surgery?  Will radiation therapy be given? At what point in the treatment?  What can be expected from the treatments?  Will chemotherapy be required? What are the side effects? How will it be given?  What is the prognosis?

The reason for Chinese men's susceptibility is not known. Colorectal surgeon Denis Nyam said a high-fat, low-fibre diet, lack of exercise and a family history are all causes. Although more bowel-cancer cases are being detected, the death rate from the illness has remained at about 60%. 'Until now, we've been telling people to see a doctor when they have such symptoms as bleeding, but this can be too late,' he said. According to Dr Nyam, the majority of cases can be prevented. 'Most colon cancers start as polyps - small growths - in the bowel. 'It usually takes about 3-10 yrs for a polyp to grow into a tumour. By undergoing a colonoscopy and removing any polyps spotted, most cases of colon cancer can be prevented,'


\14 Prostatic Cancer and Diet

Prostatic Cancer and Diet by Dr Iain Corness

Cancer of the prostate gland is very common in the Western world, with 30% of all males over 50 showing microscopic elements of prostatic cancer. This does not mean that 30% of men are going to progress to full blown cancer - but the “start” is there. Sobering thought.

Another interesting fact, from the files of the statisti- cians, is that Western males have a much higher incidence than those from South East Asia. Even more interesting is that if you then look at the male offspring of S.E. Asian immigrants to America, they have four times the incidence of prostatic cancer, compared to those SE Asian males that remained in their country. This would appear to show that environment is more important than genetic inheri- tance, and one important part of environment is diet.

Looking further into the diet side of things, there has been shown to be a strong association between high dietary fat and prostatic cancer. The next step in the research was to examine laboratory mice with prostate cancer, feeding them diets with known levels of fat. The results were that with diets less than 21% fat there was regression of the tumours. The mice were thrilled!

Another dietary ingredient is called Phytoestrogen, pres- ent in grains, fruit, legumes, soy beans and vegetables. Soy is much more prevalent in the Japanese diet than in the Western. Some research has been done to compare the incidence of prostatic cancer between Jap men and Finnish men, each taking their own “national” diets. Result? Prostatic cancer is much more common in Finnish men.

Vitamins have also been explored as far as their relationship to prostate cancer is concerned. Men taking Vitamin E were found to have a 34% lower incidence of the cancer. However, Vitamins A, C and D had no effect.

Selenium (recommended dose 70 microgrammes per day - 300 mgms are toxic) also seems to be beneficial, while Zinc is not. Another strange one is Lycopene, found in tomato paste and tomato sauce, which appears to have an association with decreased risk of prostatic cancer.

Also examined have been some of the alternative therapies such as Saw palmetto, stinging nettle root and shark cartilage. There was no reliable scientific evidence to show that any of them had any role in prostate cancer prevention or treatment - despite what the Health Food” shops would say.

So what should you males do? (You women are not at risk here, you have your own particular problem areas.) Undoubtedly there is merit in looking at a more “Asian” diet than the Western one. Decreasing fat intake will certainly help. Vit-E easily added with a capsule a day. Selenium and tomato sauce? Don’t think I’d get too excited about them at this stage. The problem with tomato sauce is that one tends to have it with high fat foods like hamburgers and chips, though taken with pizza should be fine.

However, the most important thing for all males over 50 is to have an annual check-up, including a prostate check. The queue forms on the right!

 National Center for Chronic Disease Prevention and Health Promotion Cancer Prevention and Control Prostate Cancer: Can We Reduce Deaths and Preserve Quality of The Burden of Prostate Cancer Prostate cancer is the most commonly diagnosed form of cancer, other than skin cancer, among men in the United States and is second only to lung cancer as a cause of cancer-related death among men. The American Cancer Society (ACS) estimates that 180,400 new cases of prostate cancer will be diagnosed and that approx 31,900 men will die of the disease in 2000. 

At all ages, African American men are diagnosed with prostate cancer at later stages and die of the disease at higher rates than white men. The incidence of prostate cancer among African American men is the highest known rate in the world.  This cancer is most common among men aged 65 years or older. About 80% of all men with clinically diagnosed cases of prostate cancer are in this age group. Because prostate cancer usually occurs at an age when other medical conditions, such as heart disease and stroke, may contribute significantly to the cause of death, the actual number of men who die with prostate cancer rather than of it is unknown.

Early Detection Preventable risk factors for prostate cancer are unknown, and effective measures to prevent this disease have not been determined. Screening for and treating disease at an early stage have been proposed to reduce the risk of dying of prostate cancer. However, scientific evidence is insufficient to determine if screening for prostate cancer reduces deaths or if treatment of disease at an early stage is more effective than no treatment in prolonging a man's life. Currently, health practitioners cannot accurately determine which prostate cancers will progress to become clinically significant and which will not.

Thus, widespread screening and testing for early detection of prostate cancer are not scientifically justified at this time. Professional med orgs are divided on the issue of screening for prostate cancer. The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening but stresses the need for informed decision making, acknowledging that patients who request screening should be given objective info about early detection and the potential benefits and risks of treatment. CDC supports the USPSTF recommendations.

The ACS recommends that health care providers offer the prostate-specific antigen measurement annually, beginning at age 50, to men who have at least a 10-year life expectancy and who choose to have early detection testing. To help patients make informed decisions about testing, providers should explain the potential benefits and risks of early detection and treatment.

The ACS also recommends that screening start at a younger age for men in higher-risk groups, such as men with two or more affected first-degree relatives (e.g., father and a brother, two brothers) or African American men. Two commonly used methods for detecting prostate cancer are currently available to clinicians: 

Digital rectal exam (DRE) has been used for years as a screening test for prostate cancer. However, its ability to detect prostate cancer is limited. Small tumors often form in portions of the prostate that cannot be reached by a DRE. Clinicians may also have difficulty distingui- shing between benign abnormalities and prostate cancer, and the interpretation and results of the exam may vary with the experience of the examiner. 

The prostate-specific antigen (PSA) measurement is a blood test that many clinicians use, but medical consensus on its use and interpretation has not been reached. PSA is an enzyme measured in the blood that may rise naturally as men age. It also rises in the presence of prostate abnormalities. However, the PSA test cannot distinguish prostate cancer from benign growth of the prostate and other conditions of the prostate, such as prostatitis. PSA testing also fails to detect some prostate cancers—about 20% of patients with biopsy-proven prostate cancer have PSA levels within normal range. 

Treatment Options Physicians have become increasingly aware of the psychosocial aspects of prostate cancer and its treatment. Health professionals are realizing that the question is not merely how a life can be saved, but also how quality of life can be preserved. Many community education and support programs are available to help men and their families make informed decisions that will suit their needs, desires, and lifestyles.

Appropriate treatment options for men with prostate cancer are based on the stage of the cancer at the time of diagnosis. Patient outcomes and the quality of life after treatment are influenced by the patient’s age, the presence of other med conditions, and the aggressiveness of the tumor. 

When Prostate Cancer Has Not Spread Several treatment alternatives are available to patients with early-stage cancer that has not spread beyond the prostate. These include the following: Radical prostatectomy, or complete surgical removal of the prostate, is frequently used for patients younger than 70 years who are otherwise in good health. Complications of radical prostatectomy may be short- or long-term; 5%-19% of men become incontinent, and 24%-62% become sexually impotent. The risk for these complications increases with age and with the amount of damage to nerve and blood supplies during the surgical procedure. Currently, definitive evidence that this surgical procedure reduces deaths or prolongs life is not available.

Radiation therapy, or treatment of the tumor site with low levels of radiation, is used for cancer that is confined to the prostate or surrounding tissue. Some side effects, which can include acute inflammation of the bladder, rectum, and intestines, are generally reversible. Following radiation therapy, 25%-44% of men experience some degree of sexual impotence, and 0.5%-7% of men become incontinent. 

Watchful waiting, or no immediate treatment, is also an option for men with prostate cancer because of the often slow progress of this disease. When this option is chosen, the tumor is evaluated periodically for changes that suggest rapid growth. Recent studies have found that watchful waiting may be an acceptable management alternative, particularly for older men with small low-grade tumors that are unlikely to spread.

When Prostate Cancer Has Spread Patients with cancer that has spread beyond the prostate gland may receive radiation and hormonal therapies to inhibit further progression of the cancer, but most of these tumors eventually become resistant to hormonal therapy. Some patients with advanced disease may choose to participate in clinical trials of experimental therapies.  

cancerinfo@cdc.gov http://www.cdc.gov/cancer 

 Prostatic Cancer and Diet by Dr Iain Corness PM 2/01. Cancer of the prostate gland is very common in the Western world, with 30% of all males over 50 showing microscopic elements of prostatic cancer. This does not mean that 30% of men are going to progress to full blown cancer - but the “start” is there. Sobering thought. Another interesting fact, from the files of the statisticians, is that Western males have a much higher incidence than those from South East Asia.

Even more interesting is that if you then look at the male offspring of S.E. Asian immigrants to America, they have four times the incidence of prostatic cancer, compared to those S.E. Asian males that remained in their own country. This would appear to show that environment is more important than genetic inheritance, and one important part of environment is diet.

Looking further into the diet side of things, there has been shown to be a strong association between high dietary fat and prostatic cancer. The next step in the research was to examine laboratory mice with prostate cancer, feeding them diets with known levels of fat. The results were that with diets less than 21% fat there was regression of the tumours. The mice were thrilled!

Another dietary ingredient is called Phytoestrogen, present in grains, fruit, legumes, soy beans and vegetables. Soy is much more prevalent in the Japanese diet than in the Western. Some research has been done to compare the incidence of prostatic cancer between Japanese men and Finnish men, each taking their own NATIONAL diets. Result? Prostatic cancer is much more common in Finnish men.
     Vitamins have also been explored as to their relationship to prostate cancer is concerned. Men taking Vit-E were found to have a 34% lower incidence of the cancer. However, Vit-A, C and D had no effect. Selenium (recommended dose 70 mgms/day - 300 mgms are toxic) also seems to be beneficial, while Zinc is not. Another strange one is Lycopene, found in tomato paste and tomato sauce, which appears to have an assoc with decreased risk of prostatic cancer.

Also examined have been some alternative therapies such as Saw palmetto, stinging nettle root and shark cartilage. There was no reliable scientific evidence to show that any of them had any role in prostate cancer prevention or treatment - despite what the Health Food shops say.

So what should you males do? (women are not at risk here, you have your own problems.) Undoubtedly there is merit in looking at a more Asian diet than the Western one. Decreasing fat intake will certainly help. Vit-E easily added with a capsule a day. Selenium and tomato sauce? Don't think I'd get too excited about them at this stage. The problem with tomato sauce is that one tends to have it with high fat foods like hamburgers and chips, though taken with pizza should be fine. The most important thing for all males over 50 is to have an annual check-up, inc a prostate check.

\15 Smoking Goes From Bad to Worse, New Research Finds

Health: It's a deadlier carcinogen and causes more cancers than scientists had believed. Jun 20, 2002 By THOMAS H. MAUGH II  Los Angeles Times
Tobacco smoke is a much deadlier carcinogen and triggers a broader variety of cancers than researchers had previously believed, according to the most comprehensive study of smoking ever undertaken.

The new study also provides the first definitive evidence that secondhand smoke causes lung cancer, increasing the risk to those people exposed by about 20%. The new study firmly links smoking to stomach, liver, cervical and kidney cancer, as well as to myeloid leukemia. Such links were suspected, but not proved.

"We are still learning just how damaging cigarette smoking is," Dr. Jonathan Samet of the Johns Hopkins School of Public Health told a London news conference Wednesday. "Only now are we beginning to see the full picture of what happens when a generation begins to smoke at an early age ... the full picture is more disturbing than what we saw when we only had the smaller pieces."

Samet chaired an international panel of 29 experts convened by the United Nations' International Agency for Research on Cancer to conduct the first comprehensive evaluation of smoking research since 1986. The team examined more than 3,000 studies involving millions of smokers. Their report will be published later this year, but parts of it are scheduled to be posted on the agency's Web site—http://www.iarc.fr—today.

"When we put all that information together, the picture becomes much clearer," said Dr. Patricia A. Buffler of UC Berkeley, a member of the research group. "This confirms many things that people were concerned about."

An estimated 1.2 billion people worldwide smoke, and their prognosis is grim, according to the study. At least half of them will be killed prematurely by smoking-related diseases, including cancer, heart disease and emphysema. Half of those deaths will occur in middle age, with an average loss of 20 to 25 years of life expectancy.

In addition to finding new links, researchers concluded that the risks for some tumors previously linked to smoking was higher than suspected.

For tumors of the bladder and kidney, for example, researchers had previously thought smokers had three to four times the normal risk. The new data indicate the actual risk is five to six times normal, IARC director Dr. Paul Kleihuis said.

Some of the cancers are associated with other factors as well. Cervical cancer is associated with the human papilloma virus, stomach cancer with the bacterium Helicobacter pylori, and liver cancer with hepatitis viruses. But in each of those cases, Buffler said, smoking doubles the risk.

The study, which Buffler said was the most comprehensive ever undertaken, found no evidence, however, that smoking increases the risk of prostate, breast or endometrial cancers. That is probably because these tumors are triggered primarily by hormones rather than by exposure to chemicals in the environment, said Sir Richard Doll of Oxford University, a member of the panel.

The team also looked at more than 50 studies focused on exposure to secondhand smoke and concluded that such exposure is linked to lung cancer, but no others. "It is a very strong association," Buffler said. There are more than 4,000 chemicals in cigarette smoke and new studies have shown that they can be measured in the body fluids and urine of nonsmokers.

"It is now well established that they are being breathed in by nonsmokers, absorbed, and are having an impact on genetic material," Buffler said.

Some national agencies, including the U.S. Environmental Protection Agency and the National Cancer Institute, had concluded that secondhand smoke causes cancer, but this is the first time an international group like the U.N. has reached the same conclusion.

The study also pointed to some disturbing trends, such as the marked increase in the number of women smoking and the growing incidence of smoking in developing countries