Scabies

What is scabies?

Scabies is an itchy, highly contagious skin condition caused by an infestation by the itch mite Sarcoptes scabiei. Mites are small eight-legged parasites (in contrast to insects, which have six legs). They are tiny, just 1/3 millimeter long, and burrow into the skin to produce intense itching, which tends to be worse at night. The mites that infest humans are female and are 0.3 mm-0.4 mm long; the males are about half this size. Scabies mites can be seen with a magnifying glass or microscope. The scabies mites crawl but are unable to fly or jump. They are immobile at temperatures below 20 C, although they may survive for prolonged periods at these temperatures.

Scabies infestation occurs worldwide and is very common. It has been estimated that worldwide, about 300 million cases occur each year. Human scabies has been reported for over 2,500 years. Scabies has been reported to occur in epidemics in nursing homes, hospitals, long-term care facilities, and other institutions. In the U.S., it is seen frequently in the homeless population but occurs episodically in other populations of all socioeconomic groups as well.

How do you get scabies?

Direct skin-to-skin contact is the mode of transmission. Scabies mites are very sensitive to their environment. They can only live off of a host body for 24-36 hours under most conditions. Transmission of the mites involves close person-to-person contact of the skin-to-skin variety. It is hard, if not impossible, to catch scabies by shaking hands, hanging your coat next to someone who has it, or even sharing bedclothes that had mites in them the night before. Sexual physical contact, however, can transmit the disease. In fact, sexual contact is the most common form of transmission among sexually active young people, and scabies has been considered by many to be a sexually transmitted disease (STD). However, other forms of physical contact, such as mothers hugging their children, are sufficient to spread the mites. Over time, close friends and relatives can contract it this way, too. School settings typically do not provide the level of prolonged personal contact necessary for transmission of the mites.

Can you catch scabies from a dog or cat?

Dogs and cats are infected by different types of mites than those which infect humans. Animals are not a source of spread of human scabies. Scabies on dogs is called mange. When canine or feline mites land on human skin, they fail to thrive and produce only a mild itch that goes away on its own. This is unlike human scabies which gets worse and worse unless the condition is treated.

What does scabies look like? What are the signs and symptoms of scabies?

Scabies produces a skin rash composed of small red bumps and blisters and affects specific areas of the body. Scabies may involve the webs between the fingers, the wrists and the backs of the elbows, the knees, around the waist and umbilicus, the axillary folds, the areas around the nipples, the sides and backs of the feet, the genital area, and the buttocks. The bumps (medically termed papules) may contain blood crusts. It is helpful to know that not every bump is a bug. In most cases of scabies affecting otherwise healthy adults, there are no more than 10-15 live mites even if there are hundreds of bumps and pimples.

The scabies rash is often apparent on the head, face, neck, palms, and soles of the feet in infants and very young children but usually not in adults and older children.

Textbook descriptions of scabies always mention "burrows" or "tunnels." These are tiny threadlike projections, ranging from 2 mm-15 mm long, which appear as thin gray, brown, or red lines in affected areas. The burrows can be very difficult to see. Often mistaken for burrows are linear scratch marks that are large and dramatic and appear in people with any itchy skin condition. Scratching actually destroys burrows.

What does scabies feel like?

It is important to note that symptoms may not appear for up to two months after being infested with the scabies mite. Even though symptoms do not occur, the infested person is still able to spread scabies during this time. When symptoms develop, itching is the most common symptom of scabies. The itch of scabies is insidious and relentless. The itch is typically worse at night. For the first weeks, the itch is subtle. It then gradually becomes more intense until, after a month or two, sleep becomes almost impossible.

What makes the itch of scabies distinctive is its relentless quality, at least after several weeks. Other itchy skin conditions -- eczema, hives, and so forth -- tend to produce symptoms that wax and wane. These types of itch may keep people from falling asleep at night for a little while, but they rarely prevent sleep or awaken the sufferer in the middle of the night.

What is the treatment for a scabies infestation?

Curing scabies is rather easy with the administration of prescription scabicide drugs. There are no approved over-the-counter preparations that have been proved to be effective in eliminating scabies. The following steps should be included in the treatment of scabies:

1. Apply a mite-killer like permethrin(Elimite). These creams are applied from the neck down, left on overnight, then washed off. This application is usually repeated in seven days. Permethrin is approved for use in people 2 months of age and older.



2. An alternative treatment is 1 ounce of a 1% lotion or 30 grams of cream oflindane, applied from the neck down and washed off after approximately eight hours. Since lindane can cause seizures when it is absorbed through the skin, it should not be used if skin is significantly irritated or wet, such as with extensive skin disease, rash, or after a bath. As an additional precaution, lindane should not be used in pregnant or nursing women, the elderly, people with skin sores at the site of the application, children younger than 2 years of age, or people who weigh less than 110 pounds. Lindane is not a first-line treatment and is only recommended if patients cannot tolerate other therapies or if other therapies have not been effective.



3. Ivermectin, an oral medication, is an antiparasitic medication that has also been shown to be an effective scabicide, although it is not FDA-approved for this use. The CDC recommends taking this drug at a dosage of 200 micrograms per kilogram body weight as a single dose, followed by a repeat dose two weeks later. Although taking a drug by mouth is more convenient than application of the cream, ivermectin has a greater risk of toxic side effects than permethrin and has not been shown to be superior to permethrin in eradicating scabies. It is typically used only when topical medications have failed or when the patient cannot tolerate them.



4. Crotamiton lotion 10% and cream 10% (Eurax, Crotan) is a another drug that has been approved for the treatment of scabies in adults, but it is not approved for use in children. However, treatment failures have been documented with the use of crotamiton.



5. Sulfur in petrolatum applied as a cream or ointment is one of the earliest known treatments for scabies. It has not been approved by the FDA for this use, and sulfur should only be used when permethrin, lindane, or ivermectin cannot be tolerated. However, sulfur is safe for use in pregnant women and infants.



6. Antihistamines, such as diphenhydramine (Benadryl), can be useful in helping provide relief from itching. Sometimes, a short course of topical or oral steroids is prescribed to help control the itching.



7. Wash linens and bedclothes in hot water. Because mites don't live long away from the body, it is not necessary to dry clean the whole wardrobe, spray furniture and rugs, and so forth.
   
   
8. Treat sexual contacts or relevant family members (who either have either symptoms or have the kind of relationship that makes transmission likely).

Just as the itch of scabies takes a while to reach a crescendo, it takes a few days to subside after treatment. After a week or two, relief is dramatic. If that doesn't happen, the diagnosis of scabies must be questioned.

Are cases of scabies often misdiagnosed?

Scabies is very easy to misdiagnose because early subtle cases may look like small pimples or mosquito bites. Over a few weeks, however, mistakes like this become evident as patients feel worse and worse with symptoms they can't ignore.

What are possible complications of scabies?

The intense itching of scabies leads to prolonged and often intense scratching of the skin. When the skin is broken or injured due to scratching, secondary bacterial infections of the skin can develop from bacteria normally present on the skin, such asStaphylococcus aureus or beta-hemolytic streptococci.

In what special situations can scabies be more easily spread?

Elderly and weakened people in nursing homes and similar institutional settings may harbor scabies without showing significant itching or visible signs. In such cases, there can be widespread epidemics among patients and health-care workers. Such cases are dramatic but, fortunately, uncommon.

What is Norwegian or crusted scabies?

Norwegian scabies, or crusted scabies, is a severe form of scabies first described in Norway. Crusted scabies almost always affects people with a compromised immune system and is observed most frequently in the elderly, those who are mentally or physically disabled, and in patients with AIDS,lymphoma, or other conditions that decrease the effectiveness of the immune response. Due to the poor function of the immune system, an individual may become infested with hundreds of thousands of the mites. The lesions of this distinctive form of scabies are extensive and may spread all over the body. The elbows, knees, palms, scalp, and soles of the feet are most commonly the original sites of involvement, and the scaly areas eventually take on a wart-like appearance. The fingernails can be thickened and discolored. Interestingly, itching may be minimal or absent in this form of scabies.

A particular danger of crusted scabies is that these lesions often predispose to the development of secondary infections, as with staphylococcus bacteria.

Scabies At A Glance

• Scabies is an itchy, highly contagious skin condition caused by an infestation by the itch mite Sarcoptes scabiei.
• Direct skin-to-skin contact is the mode of transmission.
• A severe and relentless itch is the predominant symptom of scabies.
• Sexual contact is the most common form of transmission among sexually active young people, and scabies has been considered by many to be a sexually transmitted disease (STD).
• Scabies produces a skin rash composed of small red bumps and blisters and affects specific areas of the body.
• Treatment includes oral or topical scabicidal drugs.

Medically reviewed by Norman Levine, MD, Board Certified - American Board of Dermatology

ALPRAZOLAM

What is alprazolam?

Alprazolam is in a group of drugs called benzodiazepines (ben-zoe-dye-AZE-eh-peens). It works by slowing down the movement of chemicals in the brain that may become unbalanced. This results in a reduction in nervous tension (anxiety).

Alprazolam is used to treat anxiety disorders, panic disorders, and anxiety caused by depression.

Alprazolam may also be used for purposes other than those listed in this medication guide.

Important information about alprazolam

Do not use this medication if you are allergic to alprazolam or to other benzodiazepines, such as chlordiazepoxide (Librium), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), or oxazepam (Serax). This medication can cause birth defects in an unborn baby. Do not use alprazolam if you are pregnant.

Before taking alprazolam, tell your doctor if you have any breathing problems, glaucoma, kidney or liver disease, or a history of depression, suicidal thoughts, or addiction to drugs or alcohol.

Do not drink alcohol while taking alprazolam. This medication can increase the effects of alcohol.

This medication may be habit-forming and should be used only by the person it was prescribed for. Alprazolam should never be shared with another person, especially someone who has a history of drug abuse or addiction. Keep the medication in a secure place where others cannot get to it.

It is dangerous to try and purchase alprazolam on the Internet or from vendors outside of the United States. Medications distributed from Internet sales may contain dangerous ingredients, or may not be distributed by a licensed pharmacy. Samples of alprazolam purchased on the Internet have been found to contain haloperidol (Haldol), a potent antipsychotic drug with dangerous side effects. For more information, contact the U.S. Food and Drug Administration (FDA) or visit www.fda.gov/buyonlineguide

Before taking alprazolam

Do not use this medication if you have:

• narrow-angle glaucoma;

• if you are also taking itraconazole (Sporanox) or ketoconazole (Nizoral); or

• if you are allergic to alprazolam or to other benzodiazepines, such as chlordiazepoxide (Librium), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), or oxazepam (Serax).

Before taking alprazolam, tell your doctor if you are allergic to any drugs, or if you have:

• asthma, emphysema, bronchitis, chronic obstructive pulmonary disorder (COPD), or other breathing problems;

• glaucoma;

• kidney or liver disease (especially alcoholic liver disease);

• a history of depression or suicidal thoughts or behavior; or

• a history of drug or alcohol addiction.

If you have any of these conditions, you may need a dose adjustment or special tests to safely take alprazolam.

FDA pregnancy category D. Alprazolam can cause birth defects in an unborn baby. Do not use alprazolam without your doctor's consent if you are pregnant. Tell your doctor if you become pregnant during treatment. Use an effective form of birth control while you are using this medication. Alprazolam can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. The sedative effects of this medication may last longer in older adults. Accidental falls are common in elderly patients who take benzodiazepines. Use caution to avoid falling or accidental injury while you are taking alprazolam. Do not give this medication to anyone under 18 years old

Herpes By: Bradley G. Goldberg, M.D

Herpes simplex virus (HSV) is a very common infection. It is divided into two types: HSV type 1 which usually affects the mouth and lips, and HSV type 2 which usually affects the genitals. Although the infection can be controlled with medications, there is currently no cure for this virus. Therefore this infection creates not only physical discomfort, but also emotional and psychological distress as well.

Genital herpes currently affects one out of every ten people, about 30 million Americans. There are 500,000 new cases each year. Even more people have been exposed to the virus but are unaware of their infection because they either have no symptoms, or very mild symptoms. However, these asymptomatic individuals may still be capable of transmitting the virus to others through a process called “asymptomatic viral shedding”. The most likely time to transmit the virus is when active lesions are present, but asymptomatic shedding mandates that condoms be used at all times, though even that can not guarantee protection.

Symptoms may vary between individuals, but typically the first-time or “primary” infection will begin within 3 to 7 days of exposure. Usually many tiny blisters will appear on reddened skin. This is accompanied by tingling or itching, which then becomes very painful. These symptoms may also be accompanied by flu-like symptoms such as fever and generalized muscle aches. The infection tends to recur periodically, but recurrences are usually not as severe as the first outbreak. Things that may trigger a recurrence include sun exposure, fever, and physical or emotional stress.

Although there is no cure for this infection, there is relief in the form of antiviral medications. These include the drugs acyclovir, famciclovir, and valacyclovir. These medicines can shorten the duration of a first outbreak, and can also shorten or even prevent recurrences. Strong pain medicines may also be needed, especially with primary infections.

Special care must be taken during pregnancy if the woman has a history of genital herpes. Although it is rare for the newborn to contract herpes at delivery, it can be a very serious, and even life threatening infection for the baby. Cesarean delivery can help prevent transmission. The standard of care in this country is to deliver the baby by cesarean section if the mother has symptoms or visible blisters when she goes into labor. If no blisters are seen and if the mother has no symptoms, then she may undergo a natural vaginal delivery with very low risk to the baby.

In summary, genital herpes is a very common infection. In addition to the physical discomfort it can cause, it can also create significant emotional stress for the individual who must learn to cope and live with this infection. If a pregnant woman has a genital herpes outbreak at the time of labor, a cesarean section should be performed. If no lesions or symptoms are present, a vaginal delivery may be attempted. Remember that transmission can occur even when no blisters are present, so condoms should always be used.

Bibliography:

1. Herpes simplex virus infection in pregnancy, Z.A. Brown, Contemporary OB/GYN, January 1999.

2. Glass’s Office Gynecology, Fifth Edition, Curtis and Hopkins, Williams & Wilkins, Pennsylvania. 1999.

3. Genital Herpes, ACOG AP054, March 1990.

4. Williams Obstetrics, 20^th Edition, F. Gary Cunningham,M.D. et.al., Appleton & Lange, Stamford, Connecticut, 1997

Internet Counseling Aids Mental Health

Internet Counseling Aids Mental Health
By Rick Nauert PhD Senior News Editor


Internet Counseling Aids Mental HealthA new study has found that psychiatrists can accurately assess a patient’s mental health by viewing web-based or e-mail files.

Specifically, University of California at Davis investigators found psychiatrists could diagnose and counsel individuals after viewing videotaped interviews that are sent via telecommunications lines.

The approach, called asynchronous telepsychiatry, uses store-and-forward technology, in which medical information is retrieved, stored and transmitted for later review using e-mail or Web applications.

It has been used extensively for specialties like dermatology, with photos of skin conditions sent to dermatologists, or X-rays sent to radiologists for assessment.

However, the current study is the first to examine store-and-forward technology for psychiatry, said Peter Yellowlees, professor of psychiatry and behavioral sciences at UC-Davis and the study’s lead author.

“A Feasibility Study of the Use of Asynchronous Telepsychiatry for Psychiatric Consultations” is published in the August issue of the journal Psychiatric Services.

“We’ve demonstrated that this approach is feasible and very efficient,” said Yellowlees, who is an internationally recognized expert in telepsychiatry.

“Using store-and-forward technology allows us to provide opinions to primary-care doctors much more quickly than would usually be the case.”

The researchers conducted the study to determine the effectiveness of asynchronous telepsychiatry for patients in Tulare County, a rural county in California’s San Joaquin Valley. Sixty male and female patients between the ages of 27 and 64 who had mostly mild-to-moderate mental health disorders were included in the study.

Researcher Alberto Odor, associate adjunct professor of anesthesiology and pain medicine, conducted 20- to 30-minute structured, videotaped interviews at a community-based primary care clinic.

The videos were then uploaded to UC-Davis’s specially designed Web-based telepsychiatry consultation record. Yellowlees and Donald Hilty, professor of psychiatry and behavioral sciences, reviewed the videotapes and provided psychiatric evaluations to the patients’ community-based primary care physicians.

Fifty-one percent of patients received diagnoses of mood disorders, 19 percent received diagnoses of substance use disorders, 32 percent received diagnoses of anxiety disorders and 5 percent received other diagnoses — including kleptomania, schizophrenia and parasomnia.

Five patients also were diagnosed with disorders such as borderline personality disorder, obsessive-compulsive disorder or personality disorder. Some of the individuals had multiple diagnoses.

One patient was referred for a face-to-face consultation with a psychiatrist because of the possibility of a diagnosis of early psychosis. The psychiatrists recommended additional laboratory evaluations for more than 80 percent of patients and made recommendations for medication changes in 95 percent of patients.

In instances where medication changes were recommended, physicians also received long-term treatment plans. A variety of psychotherapies, such as individual and cognitive-behavioral therapy, were recommended for many of the patients.

Community-based primary care physicians said they found the practice worked well, the study says.

The consulting psychiatrists provided feedback to referring physicians within two weeks, but asynchronous telepsychiatry could occur within 24 hours if it were to become a regular service, Yellowlees said.

Asynchronous telepsychiatry should not take the place of face-to-face psychiatric evaluations and is not suitable for patients with urgent psychiatric conditions, he said.

But there are a number of circumstances in which it would be helpful in providing more primary care physicians greater access to psychiatric consultations.

“There is a substantial shortage of psychiatrists,” Yellowlees said.

“Asynchronous telepsychiatry would allow us to have better access to information about patients being referred by primary providers and to provide more comprehensive opinions.

“This approach could be used by the military and in many different rural and metropolitan settings. It signals the beginning of the true multimedia electronic medical record with clinical video recordings becoming part of the data set.”

Source: UC Davis School of Medicine
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Baby Feeding

Your baby is the most important thing to you and so you want to feed him a healthy diet that includes the vitamins and nutrients he needs to grow big and strong. But with baby feeding, parents have an overwhelming number of decisions to make. The first is whether to breastfeed.

Nearly all experts agree that breast milk is the best nourishment in the first six months, and we have the tools and information you need to get started with this baby feeding stage. We can help you choose a breast pump and solve breastfeeding problems. And if you bottle-feed out of necessity or by choice, we have tips on everything from preparing bottles for a baby feeding to choosing the right baby formula. And when you're ready to introduce solid foods, we can help you with that too.

Breastfeeding

When it comes to baby feeding, breastfeeding is best for your baby – and your health, too. But it's not always easy. We have helpful information on how to start breastfeeding and go about pumping. Plus, find out about alcohol and nursing, what kind of breastfeeding diet is best, and how to tell if your baby is getting enough breast milk.

Bottle Feeding

Let go of any guilt you feel over not breastfeeding exclusively, or at all. Yes, breastfeeding offers a wonderful bonding experience for mother and child, but baby feeding with a bottle can bring you close as well. Ready to get started? We have tips for you on everything from supplementing breast milk with baby formula to choosing the right bottles for successful baby feeding.

Baby Feeding Problems

Are you struggling with baby feeding problems? Don't worry! Baby feeding problems are normal, whether you're breastfeeding, bottle-feeding, or at the solid foods stage. And we can help you solve common problems. If your baby spits up, we can offer advice on how to help him keep his food down. If breastfeeding is uncomfortable because your nipples are sore, we can help.

Solid Foods

Your baby is growing up – and it's time to start feeding him solid foods! This is one of the most exciting baby feeding stages because you can introduce your baby to a wide variety of flavors and textures. But when should you start on solids? And what should you feed him first? When can you introduce finger foods? Here's everything you need to know about the transition to solids.

About Heart Failure

The term "heart failure" makes it sound like the heart is no longer working at all and there's nothing that can be done. Actually, heart failure means that the heart isn't pumping as well as it should be.

Your body depends on the heart's pumping action to deliver oxygen- and nutrient-rich blood to the body's cells. When the cells are nourished properly, the body can function normally.

With heart failure, the weakened heart can't supply the cells with enough blood. This results in fatigue and shortness of breath. Everyday activities such as walking, climbing stairs or carrying groceries can become very difficult.

Heart failure is a serious condition, and usually there's no cure. But many people with heart failure lead a full, enjoyable life when the condition is managed with medications and healthy lifestyle changes. It's also helpful to have the support of family and friends who understand your condition.

How the normal heart works

The normal heart is a strong, muscular pump a little larger than a fist. It pumps blood continuously through the circulatory system.

The heart has four chambers, two on the right and two on the left:

• Two upper chambers called atria (one is an atrium)
• Two lower chambers called ventricles

Oxygen-rich blood travels from the lungs to the left atrium, then on to the left ventricle, which pumps it to the rest of the body.

The right atria takes in oxygen-depleted blood from the rest of the body and sends it back out to the lungs through the right ventricle.

The heart pumps blood to the lungs and to all the body's tissues by a sequence of highly organized contractions of the four chambers. For the heart to function properly, the four chambers must beat in an organized way.

Watch an animation of heart failure compared to the healthy heart

What is heart failure?

Heart failure is a chronic, progressive condition in which the heart muscle is unable to pump enough blood through the heart to meet the body's needs for blood and oxygen. Basically, the heart can't keep up with its workload.

At first the heart tries to make up for this by:

• Enlarging. When the heart chamber enlarges, it stretches more and can contract more strongly, so it pumps more blood.
• Developing more muscle mass. The increase in muscle mass occurs because the contracting cells of the heart get bigger. This lets the heart pump more strongly, at least initially.
• Pumping faster. This helps to increase the heart's output.

The body also tries to compensate in other ways:

• The blood vessels narrow to keep blood pressure up, trying to make up for the heart's loss of power.
• The body diverts blood away from less important tissues and organs to maintain flow to the most vital organs, the heart and brain.

These temporary measures mask the problem of heart failure, but they don't solve it. Heart failure continues and worsens until these substitute processes no longer work.

Eventually the heart and body just can't keep up, and the person experiences the fatigue, breathing problems or other symptoms that usually prompt a trip to the doctor.

The body's compensation mechanisms help explain why some people may not become aware of their condition until years after their heart begins its decline. (It's also a good reason to have a regular checkup with your doctor.)

Heart failure can involve the heart's left side, right side or both sides. However, it usually affects the left side first.

Warning Signs of Heart Failure And Prevent of it.

First Signs of Heart Failure

By themselves, any one sign of heart failure may not be cause for alarm. But if you have more than one of these symptoms, even if you haven't been diagnosed with any heart problems, report them to a healthcare professional and ask for an evaluation of your heart.

If you have been diagnosed with heart failure, it's important for you to keep track of symptoms and report any sudden changes to your healthcare team.

This table lists the most common signs and symptoms, explains why they occur and describes how to recognize them.

Watch our interactive heart failure signs and symptoms animation.

Sign or Symptom	People with Heart Failure May Experience...	Why It Happens
Shortness of breath (also called dyspnea)	...breathlessness during activity (most commonly), at rest, or while sleeping, which may come on suddenly and wake you up. You often have difficulty breathing while lying flat and may need to prop up the upper body and head on two pillows. You often complain of waking up tired or feeling anxious and restless.	Blood "backs up" in the pulmonary veins (the vessels that return blood from the lungs to the heart) because the heart can't keep up with the supply. This causes fluid to leak into the lungs.
Persistent coughing or wheezing	...coughing that produces white or pink blood-tinged mucus.	Fluid builds up in the lungs (see above).
Buildup of excess fluid in body tissues (edema)	...swelling in the feet, ankles, legs or abdomen or weight gain. You may find that your shoes feel tight.	As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing fluid to build up in the tissues. The kidneys are less able to dispose of sodium and water, also causing fluid retention in the tissues.
Tiredness, fatigue	...a tired feeling all the time and difficulty with everyday activities, such as shopping, climbing stairs, carrying groceries or walking.	The heart can't pump enough blood to meet the needs of body tissues. The body diverts blood away from less vital organs, particularly muscles in the limbs, and sends it to the heart and brain.
Lack of appetite, nausea	...a feeling of being full or sick to your stomach.	The digestive system receives less blood, causing problems with digestion.
Confusion, impaired thinking	...memory loss and feelings of disorientation. A caregiver or relative may notice this first.	Changing levels of certain substances in the blood, such as sodium, can cause confusion.
Increased heart rate	...heart palpitations, which feel like your heart is racing or throbbing.	To "make up for" the loss in pumping capacity, the heart beats faster.

Acute Coronary Syndrome

Acute coronary syndrome and thrombosis

Acute coronary syndrome (ACS) occurs when an atherosclerotic plaque ruptures, leading to thrombus formation within a coronary artery.⁵ Patients who develop symptoms consistent with ACS, such as chest pain and diaphoresis, require timely evaluation to determine the cause.^{9, 83} When ACS is diagnosed, further stratification into categories of ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina guides therapeutic decision-making. Following recovery from an episode of ACS, patients continue to be at heightened risk of heart attack and stroke, for which a range of secondary preventive treatments are available.^{84, 85}

Three types of risk in ACS

There are three types of risk to consider in ACS.^{9, 83, 84}

• Physicians in the emergency care setting must assess the potential for acute, life-threatening disease when diagnosing the cause of chest pain or other symptoms that might indicate ACS
  
• After ACS is recognised, diagnostic acumen is required to stratify the patient as having either unstable angina, non-ST-elevation myocardial infarction (NSTEMI), or ST-elevation myocardial infarction (STEMI)
• Patients who survive an episode of ACS are at heightened risk of recurrent ACS and stroke

ECG showing NSTEMI

Risk assessment in ACS

Risk assessment is a key step in the emergency management of patients with ACS. Stratifying patients by likelihood of morbidity and mortality guides management decisions. A range of risk-scoring systems have been devised to enable clinicians to select the appropriate antithrombotic or fibrinolytic therapy.⁸⁶

Patients with complete occlusion of a coronary artery can often be identified by ST-segment elevation on electrocardiogram (ECG). This group, representing approximately one in three patients presenting with ACS, should receive prompt reperfusion treatment with fibrinolytic therapy or percutaneous coronary intervention (PCI). The remaining two thirds of ACS patients do not have ST-segment elevation on initial ECG and require further risk stratification.⁹

Serial evaluation of biomarkers, including troponin, C-reactive peptide, and B-type natriuretic peptide, provide independent, additive prognostic data to complement history and physical examination findings and ECG results.⁸⁶ These findings determine whether the problem is non-ST-elevation myocardial infarction (NSTEMI) or unstable angina; the urgency of treatment for these conditions varies depending on a patient’s specific clinical situation.

Coronary thrombosis, image 2 of 4

Long-term risks following ACS

The risk of cardiovascular death, recurrent myocardial infarction (MI), or progression to MI in patients initially presenting with unstable angina is greatest during the first two months after the acute event.⁸³ Subsequently, the clinical course of most patients with ACS is similar to that of patients with chronic stable coronary disease.

Because atherosclerotic plaque is often present throughout the arterial tree, patients who survive an episode of ACS live with an ongoing risk of a recurrent acute cardiovascular event, such as MI, sudden cardiac death, or stroke.⁸⁴ For patients who received a drug-eluting stent during revascularisation, there is an additional risk of late in-stent thrombosis.⁸⁷

A wide range of treatments are available to protect the heart and to decrease the propensity for recurrent atherothrombosis in survivors of ACS.⁸⁵

Children and Depression

By Harold Cohen, Ph.D.

Not only adults become depressed. Children and teenagers also may have depression, which is a treatable illness. Depression is defined as an illness when the feelings of depression persist and interfere with a child or adolescent’s ability to function.

About 5 percent of children and adolescents in the general population suffer from depression at any given point in time. Children under stress, who experience loss, or who have attentional, learning, conduct or anxiety disorders are at a higher risk for depression. Depression also tends to run in families.

The behavior of depressed children and teenagers may differ from the behavior of depressed adults. Child and adolescent psychiatrists advise parents to be aware of signs of depression in their youngsters.

If one or more of these signs of depression persist, parents should seek help:

• Frequent sadness, tearfulness, crying
• Hopelessness
• Decreased interest in activities; or inability to enjoy previously favorite activities
• Persistent boredom; low energy
• Social isolation, poor communication
• Low self esteem and guilt
• Extreme sensitivity to rejection or failure
• Increased irritability, anger, or hostility
• Difficulty with relationships
• Frequent complaints of physical illnesses such as headaches and stomachaches
• Frequent absences from school or poor performance in school
• Poor concentration
• A major change in eating and/or sleeping patterns
• Talk of or efforts to run away from home
• Thoughts or expressions of suicide or self destructive behavior

A child who used to play often with friends may now spend most of the time alone and without interests. Things that were once fun now bring little joy to the depressed child. Children and adolescents who are depressed may say they want to be dead or may talk about suicide. Depressed children and adolescents are at increased risk for committing suicide. Depressed adolescents may abuse alcohol or other drugs as a way to feel better.

Children and adolescents who cause trouble at home or at school may also be suffering from depression. Because the youngster may not always seem sad, parents and teachers may not realize that troublesome behavior is a sign of depression. When asked directly, these children can sometimes state they are unhappy or sad.

Early diagnosis and treatment are essential for depressed children. Depression is a real illness that requires professional help. Comprehensive treatment often includes both individual and family therapy. For example, cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) are forms of individual therapy shown to be effective in treating depression. Treatment may also include the use of antidepressant medication. For help, parents should ask their physician to refer them to a qualified mental health professional, who can diagnose and treat depression in children and teenagers.

Antidepressants Not Beneficial in Autism

By Jessica Ward Jones, MD, MPH Associate News Editor

Antidepressants Not Beneficial in AutismThe use of antidepressant medication to improve symptoms in autistic children may not be effective.

According to a new statistical review of previously reported studies, the use of selective serotonin reuptake inhibitor (SSRIs) antidepressants did not improve overall function.

“There is no evidence of effect of SSRIs in children and emerging evidence of harm. There is limited evidence of the effectiveness of SSRIs in adults from small studies in which risk of bias is unclear,” according to Katrina Williams of the School of Women’s and Children’s Health at the University of New South Wales in Australia and her team.

Autism is the most severe syndrome on a range of autism spectrum disorders (ASDs). The numbers of individuals affected appear to be growing, according to the Centers for Disease Control and Prevention (CDC). One out of every 110 eight-year-olds are affected. Four times more common in boys, girls often have more severe symptoms, according to the National Institute of Mental Health. A variety of treatments have been promoted to treat or ‘cure’ autism. Scientific research has shown several forms of therapy to be effective in improving function. However, no cure currently exists, and parents and clinicians struggle to find effective pharmacological options.

According to Williams, “Autism spectrum disorders (ASD) are characterised by abnormalities in social interaction and communication skills, as well as stereotypic behaviours and restricted activities and interests. Selective serotonin reuptake inhibitors (SSRIs) are prescribed for the treatment of co-morbidity associated with ASD such as depression, anxiety and obsessive-compulsive behaviors.”

To assess whether SSRI therapy ”1. improves the core features of autism (social interaction, communication and behavioral problems); 2. improves other non-core aspects of behavior or function such as self-injurious behavior; 3. improves the quality of life of children and their carers; 4. has short- and long-term effects on outcome; 5. causes harm,” the team combined the data gathered by researchers in previously published studies.

Williams and her team searched six large databases that contained previously published medical studies and found seven randomized controlled study research papers that had investigated the treatment of autism spectrum disorders with SSRIs. The medications studied included fluoxetine (Prozac), fluvoxamine (Luvox), fenfluramine and citalopram (Celexa).

Seven randomized controlled trials were included in the study, five with children, and two with adults. Each study had different design characteristics, including specific medications tested, study subjects, or outcomes measured. Statistical analysis to compensate for these differences was done when possible.

The team found that although the designs of the studies made combining the data statistically inappropriate, there was currently no good evidence showing overall improvement in treating children with autism, and “one large, high-quality study in children showed no evidence of positive effect of citalopram.”

In one study, a child who had taken citalopram suffered a prolonged seizure.

However, per the team, “two small studies in adults showed positive outcomes for Clinical Global Impression and Obsessive Compulsive Behavior; one study showed improvements in aggression and another in anxiety.”

“Not all the SSRIs currently in use have undergone controlled trials for autistic spectrum disorders, but parents are often anxious to try treatments regardless of the lack of evidence. It’s important that doctors are open about the lack of evidence, and explain any risks fully, before prescribing these treatments.”

This study is important in giving clinicians and parents additional guidance into which therapies and medications may be of use in treating autistic symptoms. Just as important as finding successful therapies, data on unhelpful therapies are beneficial. While a number of medications are prescribed for autism, many are not FDA-approved. SSRIs are among the most frequently prescribed medications, although none have been specifically approved for use in autism. However, mental health issues, if they occur along with autism, might warrant treatment with medication, including antidepressants.

“We can’t recommend SSRIs as treatments for children, or adults, with autism at this time. However, decisions about the use of SSRIs for co-occurring obsessive-compulsive disorder, aggression, anxiety or depression in individuals with autism should be made on a case by case basis,

Viagra for Women

By all measures Viagra has been a wildly successful drug, and is now used by 20 million men worldwide to boost their sex lives. But a woman might ask: "Why no quick fix for me?"

It's not for lack of trying by pharmaceutical companies. Even before Viagra hit the shelves in 1998, the search was on for a drug that could ramp up women's sex lives. But more than a decade later, still nothing.

The latest disappointment is flibanserin, a contender to be the first approved drug that enhances sexual desire in women. A Food and Drug Administration advisory panel recently reviewed this experimental drug, and advised against its approval. (The FDA usually follows the advice of such panels.) The modest increase in women's sexual satisfaction did not outweigh the side effects, which include fatigue and depression, the panel said.

Some women do have sexual dysfunction. The problem, experts say, is often a lack of desire for sex rather than the ability to perform it, which would be akin to male sexual dysfunction. In fact, some experts object to the creeping medicalization of women's sexual dysfunction, and say there's a potential to overdiagnose women with hypoactive sexual desire disorder (HSDD), a condition characterized by low sexual desire, to the point it causes distress.


Karen M. Hicks, PhD, an adjunct professor at Lehigh University, in Bethlehem, Pa., and a founding member of the Consortium for Sexuality and Aging, says a lack of sex drive has been "framed by the medical community as a disease state that you need to be, or could be, cured from with a pill," says Hicks. For many women, however, sexual problems may be better treated with therapy or other approaches. "Taking a pill is the easy way out," she says.

Although experts agree that some women could get sexual healing from a pill, they're not sure how many women are actually in this group. The fact is that even if there were such a drug on the market, it's unlikely to be a one-size-fits-all cure like Viagra is for men with erectile dysfunction.