Nervous Breakdown Symptoms

Mental breakdown (also known as nervous breakdown) is a non-medical term used to describe a sudden, acute attack of mental illness such as depression or anxiety. When used in common social discourse, the term often has pejorative connotations.

Specific cases are usually described as a "breakdown" only after a person becomes unable to function in day-to-day life due to mental illness. At that point the person's condition is advanced, and seeking professional aid is likely advisable.

Like the term “sanity,” the terms "nervous breakdown" and "mental breakdown" have no medical definition and are not used in a clinical sense. However, the medical or personal problems precipitating a sudden breakdown may well benefit from professional medical or psychological treatment.

A mental breakdown is not the same as a panic attack, though mental breakdowns can trigger panic.

Causes
Causes of breakdown might include:
chronic and unresolved grief
unemployment
academic problems
career burnout
social stress
post-war trauma
chronic insomnia and other sleep disorders
serious or chronic illness of a family member
divorce
death of a family member
pregnancy
a traumatic, violent, or near-death experience
deception by a loved one.

The sudden, acute onset of the following mental illnesses might be classified as breakdowns:
clinical depression
bipolar disorder
psychosis
dissociation
post-traumatic stress disorder
severe stress
anxiety.

Nervous Breakdown Symptoms

Mebendazol

Mebendazole (brand name Ovex®, Vermox®, Antiox® or Pripsen®) is a drug commonly used to combat pinworms, roundworms and hookworms. It is sometimes referred to as "MBZ". Mebendazole (C16H13N3O3) causes slow immobilization and death of the worms by selectively and irreversibly blocking uptake of glucose and other nutrients in susceptible adult intestine where helminths dwell. It is a spindle poison that induces chromosome nondisjunction. Oral dosage is 100 mg 12 hourly for 3 days, although sometimes the dosage is just one 500 mg dose, followed by another dose two weeks later if the infection has not cleared up. The dosage may differ depending on which type of worm someone is infected with.

Janssen Pharmaceutica, is a pharmaceutical company based in Beerse, Belgium, was established in 1953 by Dr. Paul Janssen. It was created not as a subsidiary of a chemical factory but solely with the aim of conducting pharmacological research. The company's stated aim is the continuous development of better drugs to improve the quality of life.

In 1961 Janssen Pharmaceutica joined the Johnson & Johnson group and is now part of the company's worldwide research and development centre, the Johnson & Johnson Pharmaceutical Research and Development (J&J PRD) which conducts research and development activities related to a wide range of human medical disorders, including mental illness, neurological disorders, anaesthesia and analgesia, gastrointestinal disorders, fungal infection, allergies and cancer.

History
The early roots of what would become Janssen Pharmaceutica date back to 1933. In 1933 Dr. Constant Janssen, the father of Paul Janssen, acquires the right to distribute the pharmaceutical products of Richter, a Hungarian pharmaceutical company, for Belgium, the Netherlands and Belgian Congo. On 23 October 1934, he founded the N.V. Produkten Richter in Turnhout. In 1937 Constant Janssen acquired an old factory building in the Statiestraat 78 in Turnhout for his growing company, which he expanded during World War II into a four-storey building. Still a student, Paul Janssen helps on the development of Perdolan. After the war, the name for the company products was changed in Eupharma, although the company name Richter would remain until 1956.

Dr. Paul Janssen founded his own research laboratory in 1953 on the third floor of the building in the Statiestraat, still within the Richter-Eurpharma company of his father. In 1955, he and his team developed their first drug: Neomeritine (ambucetamide), an antispasmodic found to be particularly effective for the relief of menstrual pain. On 5 April 1956, the name of the company was changed in NV Laboratoria Pharmaceutica Dr. C. Janssen (named after Dr. Constant Janssen). On 27 April 1957, the company opened a new research facility in Beerse, but the move to Beerse would not be completed until 1971-1972. On 2 May 1958, the research department in Beerse became a separate legal entity, the N.V. Research Laboratorium Dr. C. Janssen.

On 24 October 1961, the company was acquired by the American group Johnson & Johnson. The negotiations with Johnson & Johnson were led by Frans Van den Bergh, head of the Board of Directors. In 1964, on 10 February, the name was changed to Janssen Pharmaceutica N.V. and the seat of the company in Turnhout was also transferred to Beerse. The company was led by Paul Janssen, Bob Stouthuysen and Frans Van Den Bergh. When, in 1971-1972 the pharmaceutical production also came to Beerse, the move from Turnhout was completed.

Janssen Pharmaceutica expanded worldwide; in 1990, it had already 3000 employees in Belgium, further expanding up to 4600 in 2004. In 2004 there worked about 28000 people for Janssen Pharmaceutica worldwide.

Janssen Pharmaceutica from the beginning emphasized as its core activity research for the development of new drugs. The research department which was established in Beerse in 1957, developed into a large research campus. In 1987, the Janssen Research Foundation (JRF) was founded which performs research into new drugs, also in other laboratories around the globe. Janssen Pharmaceutica became the Flemish company with the largest budget for research and development. Beside the headquarters in Beerse with its research departments, pharmaceutical production and the administrative departments, Janssen Pharmaceutica in Belgium still has offices in Berchem (Janssen-Cilag), a chemical factory in Geel, and Janssen Biotech in Olen.

The Chemical Production plant in Geel, makes the active ingredients for the company’s medicines. In 1975, the first plant of a new chemical factory Plant I was established in Geel, Plant II was opened in 1977, Plant III' in 1984, and Plant IV in 1995. In 1999 the remaining chemical poduction in Beerse would be transferred to Geel. About 80% of its active components are manufactured here. The site in Geel also manufactures about two-thirds of the worldwide chemical production of the pharmaceutical sector of Johnson & Johnson.

In 1999, clinical research and non-clinical development become a global organization within Johnson & Johnson. In 2001, part of the research activities was transferred to the United States with the reorganization of research activities in the Johnson & Johnson Pharmaceutical Research Development (JJPRD) organization. The research activities of the Janssen Research Foundation (JRF) and the R.W. Johnson Pharmaceutical Research Institute (PRI) (United States) were merged into the new global research organization. A new building for pharmaceutical development is completed in Beerse in 2001. In 2002, a new logistics and informatics centre is opened at a new site, Beerse 2. In 2003 two new research buildings are constructed, the Discovery Research Center (DRC), and the Drug Safety Evaluation Center (DSEC). On 27 October 2004, the Dr. Paul Janssen Research Center, for discovery research, was inaugurated.

The success of Janssen Pharmaceutica is commonly attributed to the vision of its founder, who himself was a brilliant scientist, but was also surrounded by talented and motivated employees, both scientifically and commercially. Dr. Paul Janssen created an environment which stimulated the creativity of his research workers.

Janssen Pharmaceutica in China

Xi'an-JanssenIn 1985, Janssen Pharmaceutica was the first Western pharmaceutical company to set up a pharmaceutical factory in the People's Republic of China (Xi'an). Already in 1983, Janssen had signed a cooperation contract to modernise products in an existing, but old, chemical factory in Hanzhong (in the province Shaanxi) and to produce the active compound of some Janssen products, such as mebendazole. Paul Appermont and Joos Horsten were responsible for the project.

In 1976 Paul Janssen had met the Lebanese-American doctor George Shafik Hatem (1912-1988) who was known in China under the name Ma Haide. Paul Janssen met with Ma Haide for three days in 1976, and decided to start a business in China right after the Cultural Revolution (1967-1976) and the opening to the west by Deng Xiaoping in 1978. The first factory was set up by Joos Horsten in Hanzhong, after which the second and larger factory followed in X'ian.

Janssen Pharmaceutica has developed and brought to the market about 70 new active substances (NCE), of which the most well-known are (name may differ):

Imodium (against diarrhoea. Active substance: loperamide)
Motilium (against flatulence - and bowel impairments. Active substance: domperidone)
Reminyl (against Alzheimer disease (dementia). Active substance: galantamine)
Daktarin (against fungal infections. Active substance: miconazole)
Nizoral (against dandruf, Active substance: ketoconazole)
Durogesic (fentanylpatch for pain suppression. Active substance: fentanyl)
Vermox (against worms. Active substance: mebendazole)
Risperdal (antipsychotic, against mental illness such as schizophrenia. Active substance: risperidone)
Five drugs of Janssen Pharmaceutica, in the course of time, were put on the WHO Model List of Essential Medicines:

Haldol (haloperidol)
Ergamisol (levamisole)
Daktarin (miconazole)
Vermox (mebendazole)
Nizoral (ketoconazole) (on the WHO list until 2005)

Mebendazol

IVF Bleeding During Pregnancy

In vitro fertilization (IVF) is a technique in which egg cells are fertilised by sperm outside the woman's womb, in vitro. IVF is a major treatment in infertility when other methods of assisted reproductive technology have failed. The process involves hormonally controlling the ovulatory process, removing ova (eggs) from the woman's ovaries and letting sperm fertilise them in a fluid medium. The fertilised egg (zygote) is then transferred to the patient's uterus with the intent to establish a successful pregnancy.

"In vitro"
Main article: In vitro
The term in vitro, from the Latin root meaning in glass, is used, because early biological experiments involving cultivation of tissues outside the living organism from which they came, were carried out in glass containers such as beakers, test tubes, or petri dishes. Today, the term in vitro is used to refer to any biological procedure that is performed outside the organism it would normally be occurring in, to distinguish it from an in vivo procedure, where the tissue remains inside the living organism within which it is normally found. A colloquial term for babies conceived as the result of IVF, test tube babies, refers to the tube-shaped containers of glass or plastic resin, called test tubes, that are commonly used in chemistry labs and biology labs. However in vitro fertilisation is usually performed in the shallower containers called petri dishes. (Petri-dishes may also be made of plastic resins.) However, the IVF method of Autologous Endometrial Coculture is actually performed on organic material, but is yet called in vitro.

History
On the basis of the findings of Min Chueh Chang's application of in vitro fertilisation to animals, the technique was developed for humans in the United Kingdom by Patrick Steptoe and Robert Edwards. The first "test-tube baby", Louise Brown, was born in Oldham, England, as a result on July 25, 1978 amid intense controversy over the safety and morality of the procedure.

Subhash Mukhopadhyay became the first physician in India, and the second in the world after Steptoe and Edwards, to perform in vitro fertilisation resulting in a test tube baby "Durga" (alias Kanupriya Agarwal) on October 3, 1978. Facing social ostracism, bureaucratic negligence, reprimand and insult instead of recognition from the Marxist West Bengal government and refusal of the Government of India to allow him to attend international conferences, he committed suicide in his Calcutta residence in 1981.

Major pioneering developments in IVF also occurred in Australia under the leadership of Carl Wood, Alan Trounson and Ian Johnston. The world's third IVF baby, Candice Reed was born on June 23, 1980 in Melbourne, Australia.

The first successful IVF treatment in the USA (producing Elizabeth Jordan Carr) took place in 1981 under the direction of Doctors Howard Jones and Georgeanna Seegar Jones in Norfolk, Virginia. Since then IVF has exploded in popularity, with as many as 1% of all births now being conceived in-vitro, with over 115,000 born in the USA to date. At present, the percentage of children born after IVF or intracytoplasmic sperm injection (ICSI) has been up to 4% of all babies born in Denmark.

Jane Mohr, 38, of Manhattan Beach Calif., gave birth to the nation's first set of triplets born 21 months apart due to in vitro fertilisation (IVF) and long-term embryo storage. Jane gave birth November 29, 1988 to two daughters, Mollie McKenna and Hannah Christina Mohr, nearly two years after the birth of her son, Cooper Patrick Mohr.

Indications
Initially IVF was developed to overcome infertility due to problems of the fallopian tube, but it turned out that it was successful in many other infertility situations as well. The introduction of intracytoplasmic sperm injection (ICSI) addresses the problem of male infertility to a large extent.

Thus, for IVF to be successful it may be easier to say that it requires healthy ova, sperm that can fertilize, and an uterus that can maintain a pregnancy. Cost considerations generally place IVF as a treatment when other less expensive options have failed.

This means that IVF can be used for females who have already gone through pregnancy. The donated oocyte can be fertilised in a crucible. If the fertilisation is successful, the fertilised egg will be transferred into the uterus, within which it will develop into an embryo.

Method

Ovarian stimulation
Treatment cycles are typically started on the third day of menstruation and consist of a regimen of fertility medications to stimulate the development of multiple follicles of the ovaries. In most patients injectable gonadotropins (usually FSH analogues) are used under close monitoring. Such monitoring frequently checks the estradiol level and, by means of gynecologic ultrasonography, follicular growth. Typically approximately 10 days of injections will be necessary. Spontanenous ovulation during the cycle is prevented by the use of GnRH agonists or GnRH antagonists, which block the natural surge of luteinizing hormone (LH).

Oocyte retrieval
Main article: Transvaginal oocyte retrieval
When follicular maturation is judged to be adequate, human chorionic gonadotropin (β-hCG) is given. This agent, which acts as an analogue of luteinizing hormone, would cause ovulation about 36 hours after injection, but a retrieval procedure takes place just prior to that, in order to recover the egg cells from the ovary. The eggs are retrieved from the patient using a transvaginal technique involving an ultrasound-guided needle piercing the vaginal wall to reach the ovaries. Through this needle follicles can be aspirated, and the follicular fluid is handed to the IVF laboratory to identify ova. The retrieval procedure takes about 20 minutes and is usually done under conscious sedation or general anesthesia.

Fertilization itself
In the laboratory, the identified eggs are stripped of surrounding cells and prepared for fertilisation. In the meantime, semen is prepared for fertilisation by removing inactive cells and seminal fluid. The sperm and the egg are incubated together (at a ratio of about 75,000:1) in the culture media for about 18 hours. By that time fertilisation should have taken place and the fertilised egg would show two pronuclei. In situations where the sperm count is low, a single sperm is injected directly into the egg using intracytoplasmic sperm injection (ICSI). The fertilised egg is passed to a special growth medium and left for about 48 hours until the egg has reached the 6-8 cell stage.

Selection
Laboratories have developed grading methods to judge oocyte and embryo quality. Typically, embryos that have reached the 6-8 cell stage are transferred three days after retrieval. In many American and Australian programmes, however, embryos are placed into an extended culture system with a transfer done at the blastocyst stage, especially if many good-quality day-3 embryos are available. Blastocyst stage transfers have been shown to result in higher pregnancy rates. In Europe, day-2 transfers are common

Embryo transfer
Embryos are graded by the embryologist based on the number of cells, evenness of growth and degree of fragmentation. The number to be transferred depends on the number available, the age of the woman and other health and diagnostic factors. In countries such as the UK, Australia and New Zealand, a maximum of two embryos are transferred except in unusual circumstances. This is to limit the number of multiple pregnancies. The embryos judged to be the "best" are transferred to the patient's uterus through a thin, plastic catheter, which goes through her vagina and cervix. Several embryos may be passed into the uterus to improve chances of implantation and pregnancy.

Post-transfer
The patient has to wait two weeks before she returns to the clinic for the pregnancy test. During this time she may receive progesterone—a hormone that keeps the uterus lining thickened and suitable for implantation. Many IVF programmes provide additional medications as part of their protocol.

Success rates
While the overall live birth rate via IVF in the U.S. is about 27% per cycle (33% pregnancy rate), the chances of a successful pregnancy via IVF vary widely based on the age of the woman (or, more precisely, on the age of the eggs involved). Where the woman's own eggs are used as opposed to those of a donor, for women under 35, the pregnancy rate is commonly approximately 43% per cycle (36.5% live birth), while for women over 40, the rate falls drastically - to only 4% for women over 42. Other factors that determine success rates include the quality of the eggs and sperm, the duration of the infertility, the health of the uterus, and the medical expertise. It is a common practice for IVF programmes to boost the pregnancy rate by placing multiple embryos during embryo transfer. A flip side of this practice is a higher risk of multiple pregnancy, itself associated with obstetric complications.

IVF programmes generally publish their pregnancy rates. However, comparisons between clinics are difficult as many variables determine outcome. Furthermore, these statistics depend strongly on the type of patients selected.

There are many reasons why pregnancy may not occur following IVF and embryo transfer, including

The timing of ovulation may be misjudged, or ovulation may not be able to be predicted or may not occur
Attempts to obtain eggs that develop during the monitored cycle may be unsuccessful
The eggs obtained may be abnormal or may have been damaged during the retrieval process
A semen specimen may not be able to be provided
Fertilization of eggs to form embryos may not occur
Cleavage or cell division of the fertilised eggs may not take place
The embryo may not develop normally
Implantation may not occur
Equipment failure, infection and/or human error or other unforeseen and uncontrollable factors, which may result in the loss of or damage to the eggs, the semen sample and/or the embryos
According to a 2005 Swedish study published in the Oxford Journal 'Human Reproduction' 166 women were monitored starting one month before their IVF cycles and the results showed no significant correlation between psychological stress and their IVF outcomes. The study concluded with the recommendation to clinics that it might be possible to reduce the stress experienced by IVF patients during the treatment procedure by informing them of those findings. While psychological stress experienced during a cycle might not influence an IVF outcome, it is possible that the experience of IVF can result in stress that leads to depression. The financial consequences alone of IVF can influence anxiety and become overwhelming. However, for many couples, the alternative is infertility, and the experience of infertility itself can also cause extreme stress and depression.


Complications
The major complication of IVF is the risk of multiple births. This is directly related to the practice of transferring multiple embryos at embryo transfer. Multiple births are related to increased risk of pregnancy loss, obstetrical complications, prematurity, and neonatal morbidity with the potential for long term damage. Strict limits on the number of embryos that may be transferred have been enacted in some countries (e.g., England) to reduce the risk of high-order multiples (triplets or more), but are not universally followed or accepted. Spontaneous splitting of embryos in the womb after transfer does occur, but is rare and would lead to identical twins. Recent evidence suggest that singleton offspring after IVF is at higher risk for lower birth weight for unknown reasons.

Another risk of ovarian stimulation is the development of ovarian hyperstimulation syndrome.

If the underlying infertility is related to abnormalities in spermatogenesis, it is plausible, but too early to examine that male offspring is at higher risk for sperm abnormalities.


Birth defects
The issue of birth defects remains a controversial topic in IVF. A majority of studies do not show a significant increase after use of IVF. Some studies suggest higher rates for ICSI , while others do not support this finding. Major birth defect include chromosomal abnormalities, genetic imprinting defects, and multiple organ abnormalities. Hansen et al conducted a systematic review of published studies (including ICSI) and found a 30-40% increase risk of birth defects associated with assisted reproductive technology when compared to children born after spontaneous conception. Possible explanations offered were the underlying cause of the infertility, factors associated with IVF/ICSI, culture conditions, and medications, however, the actual cause is not known.

Cryopreservation

Embryo cryopreservation
If multiple embryos are generated, patients may choose to freeze embryos that are not transferred. Those embryos are placed in liquid nitrogen and can be preserved for a long time. There are currently 500,000 frozen embryos in the United States. The advantage is that patients who fail to conceive may become pregnant using such embryos without having to go through a full IVF cycle. Or, if pregnancy occurred, they could return later for another pregnancy.

Oocyte cryopreservation
Cryopreservation of unfertilised mature oocytes has been successfully accomplished, e.g. in women who are likely to lose their ovarian reserve due to undergoing chemotherapy.

Ovarian tissue cryopreservation
Cryopreservation of ovarian tissue is of interest to women who want to preserve their reproductive function beyond the natural limit, or whose reproductive potential is threatened by cancer therapy. Research on this issue is promising.

Adjunctive interventions
There are several variations or improvements of IVF, such as ICSI, ZIFT, GIFT and PGD. An increasing number of fertility specialists and centers offer acupuncture as a part of their IVF protocol, or maintain a list of acupuncturists specialising in infertility.

ICSI
Intracytoplasmic sperm injection (ICSI) is a more recent development associated with IVF which allows the sperm to be directly injected in to the egg using micromanipulation. This is used for sperm that have difficulty penetrating the egg and when sperm numbers are very low. ICSI results in success rates equal to IVF fertilisation.

ZIFT
In Zygote intrafallopian transfer (ZIFT) eggs are removed from the woman, fertilized and then placed in the woman's fallopian tubes rather than the uterus.

GIFT
In gamete intrafallopian transfer (GIFT) eggs are removed from the woman, and placed in one of the fallopian tubes, along with the man's sperm. This allows fertilization to take place inside the woman's body. Therefore, this variation is actually an in vivo fertilisation, and not an in vitro fertilisation.

PGD
PGD can be performed on embryos prior to the embryo transfer. A similar, but more general test has been developed called Preimplantation Genetic Haplotyping (PGH).

Acupuncture
An increasing number of fertility specialists and centers recognize the benefits of acupuncture and offer acupuncture as a part of their IVF protocol. Limited but supportive evidence from clinical trials and case series suggests that acupuncture may improve the success rate of IVF and the quality of life of patients undergoing IVF and that it is a safe adjunct therapy. However, this conclusion should be interpreted with caution because most studies reviewed had design limitations, and the acupuncture interventions employed often were not consistent with traditional Chinese medical principles.

Mechanism of acupuncture
The literature so far has come up with four mechanisms of how acupuncture could be beneficial for IVF:

Neuroendicrinological modulations
Increased blood flow to uterus and ovaries
Modulation in cytokines
Reducing stress, anxiety and depression

Studies
Summarizing four acupuncture trials published in peer reviewed scientific journal Fertility and sterility, involving a total of just under 800 women, the results clearly showed a pregnancy was twice as likely to occur in the acupuncture group compared to the control group.

Following are examples of individual studies.

According to a report published in Fertility and Sterility, if done correctly, Acupuncture significantly improves IVF success rate. However, many scientific and methodologic issues are unclear and further research has to be done before acupuncture could be used routinely by clinicians.

Researchers in Adelaide has evaluated the effect of acupuncture on women undergoing IVF, and couldn't exclude a smaller treatment effect. However, there was no significant difference compared to a control group of women not getting acupuncture.

A randomized, prospective study showed that acupuncture significantly (p<0.01) increased IVF implantation rates and pregnancy rates. Positive trends were also observed in miscarriage rates although the results were not significant. The study has been criticized for lacking traditional scientific practices when interpreting the data, on the play of chance, and that positive impact of acupuncture on IVF success rates is not definitive. However, assessments of nonpharmacological treatments must take into consideration additional methodological issues. This criticism is possibly arising from lack of understanding of methodological differences in clinical trials evaluating nonpharmacological and pharmacological treatments and in particular methodological issues in trials of acupuncture.

Electro-acupuncture in oocyte retrieval for IVF
Electro-acupuncture has a proven analgesic effect in oocyte retrieval for IVF.

Complementary medicines
Infertility patients commonly use complementary medicines. Health-care practitioners and fertility specialists need to be proactive in acquiring and documenting the use of these practices. There is a need to provide further information to patients on the use of CMs and therapies. Further research examining the reasons for use of CMs and therapies is needed.

Hypnosis
A study of hypnotherapy suggests a higher success rate when integrated with treatment. However, neither this study is without criticism. Experts say the study failed to take into account key differences between the groups compared in the study. These differences would have had a major influence on their chances of conceiving.

Ethics

Issues
Certain ethical issues have been raised from the beginning when IVF was introduced. These concerns include:

Bypassing the natural method of conception.
The creation of life in the laboratory.
Fertilization of more embryos than will be needed.
Discarding of excess embryos.
Unnatural environment for embryos.
Use of untested technology.
Not affordable for many.
Misallocation of medical resources.
Creation of embryos, then freezing them, and keeping them "in limbo".
Exposure of embryos to unnatural substances.
Destruction of embryos in research.
Potential to create embryos for medical purposes.
Potential to select embryos (PGD).
Potential to modify embryos.
Facilitation of the idea that embryos are commodities.
Financial rewards for IVF doctors dissuade them from recommending other methods to couples.
Infertility is treated as a disease and not as a symptom of underlying medical problems.
The long term effect on frozen embryos is unknown.

Separating the traditional mother-father model
The IVF process requires sperm, eggs, and a uterus. To achieve a pregnancy any of these requirements can be provided by a third party (or more parties): third party reproduction. This has created additional ethical and legal concerns. The use of IVF provides also greater range of options for single people and same-sex couples wishing to have children. Although both groups already raise children, IVF facilitates this process. Some people object that this could give psychological problems to the child if they grow up without a mother/father

A number of cases have achieved notoriety:

In 2001, a French woman received worldwide publicity when she posed as the wife of her brother in order to give birth to a donor egg fertilized by his sperm. Some saw this as a form of incest; others thought it would prove psychologically unhealthy for the child when he learned how he was delivered; whereas other people simply couldn't see anything wrong with the situation.
In a few cases laboratory mix-ups (misidentified gametes, transfer of wrong embryos) have occurred leading to legal action against the IVF provider and complex paternity suits. An example is the case of a woman in California who received the embryo of another couple and was notified of this mistake after the birth of her son.

Pregnancy past menopause
While menopause has set a natural barrier to further conception, IVF has allowed women to be pregnant in their fifties and sixties. Women whose uteruses have been appropriately prepared receive embryos that originated from an egg of an egg donor. Therefore, although these women do not have a genetic link with the child, they have an emotional link through pregnancy and childbirth. In many cases the genetic father of the child is the woman's partner. Even after menopause the uterus is fully capable to carry out its function.

IVF Bleeding During Pregnancy

Heart Dieseas

Heart disease is an umbrella term for a number of different diseases which affect the heart and is the leading cause of death in the United States as of 2007.

Types of heart disease

Cardiomyopathy
Cardiomyopathy literally means "heart muscle disease". It is the deterioration of the function of the myocardium (i.e., the actual heart muscle) for any reason. People with cardiomyopathy are often at risk of arrhythmia and/or sudden cardiac death.

Extrinsic cardiomyopathies - cardiomyopathies where the primary pathology is outside the myocardium itself. Most cardiomyopathies are extrinsic, because by far the most common cause of a cardiomyopathy is ischemia. The World Health Organization calls these specific cardiomyopathies:
Alcoholic cardiomyopathy
Coronary artery disease
Congenital heart disease - see below
Nutritional diseases affecting the heart
Ischemic (or ischaemic) cardiomyopathy
Hypertensive cardiomyopathy
Valvular cardiomyopathy - see also Valvular heart disease below
Inflammatory cardiomyopathy - see also Inflammatory heart disease below
Cardiomyopathy secondary to a systemic metabolic disease
Intrinsic cardiomyopathies - weakness in the muscle of the heart that is not due to an identifiable external cause.
Dilated cardiomyopathy (DCM) - most common form, and one of the leading indications for heart transplantation. In DCM the heart (especially the left ventricle) is enlarged and the pumping function is diminished.
Hypertrophic cardiomyopathy (HCM or HOCM) - genetic disorder caused by various mutations in genes encoding sarcomeric proteins. In HCM the heart muscle is thickened, which can obstruct blood flow and prevent the heart from functioning properly.
Arrhythmogenic right ventricular cardiomyopathy (ARVC) - arises from an electrical disturbance of the heart in which heart muscle is replaced by fibrous scar tissue. The right ventricle is generally most affected.
Restrictive cardiomyopathy (RCM) - least common cardiomyopathy. The walls of the ventricles are stiff, but may not be thickened, and resist the normal filling of the heart with blood. ** Noncompaction Cardiomyopathy - the left ventricle wall has failed to properly grow from birth and such has a spongy appearance when viewed during an echocardiogram.

Cardiovascular disease
Cardiovascular disease is any of a number of specific diseases that affect the heart itself and/or the blood vessel system, especially the veins and arteries leading to and from the heart. Research on disease dimorphism suggests that women who suffer with cardiovascular disease usually suffer from forms that affect the blood vessels while men usually suffer from forms that affect the heart muscle itself. Known or associated causes of cardiovascular disease include diabetes mellitus, hypertension, hyperhomocysteinemia and hypercholesterolemia. Types of cardiovascular disease include:

Atherosclerosis

Congenital heart disease
Congenital heart disease, existing primarily at birth, refers to any of a number of heart diseases caused by unavoidable genetic factors.

Aortic valve stenosis

Coronary heart disease
Coronary heart disease is a disease of the heart caused by the accumulation of atheromatous plaques within the walls of the arteries that supply the myocardium. Angina pectoris and myocardial infarction (heart attack) are symptoms of and conditions caused by coronary heart disease.

Ischaemic heart disease - another disease of the heart itself, characterized by reduced blood supply to the organ.

Heart failure
Heart failure, also called congestive heart failure (or CHF), and congestive cardiac failure (CCF), is a condition that can result from any structural or functional cardiac disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body.

Cor pulmonale, a failure of the right side of the heart.

Hypertensive heart disease
Hypertensive heart disease, heart disease caused by high blood pressure, especially localised high blood pressure. Conditions that can be caused by hypertensive heart disease include:

Left ventricular hypertrophy
Coronary heart disease
(Congestive) heart failure
Hypertensive cardiomyopathy
Cardiac arrhythmias

Inflammatory heart disease
Inflammatory heart disease involves inflammation of the heart muscle and/or the tissue surrounding it.

Endocarditis - inflammation of the inner layer of the heart, the endocardium. The most common structures involved are the heart valves.
Inflammatory cardiomyopathy
Myocarditis - inflammation of the myocardium, the muscular part of the heart. It is generally due to infection (viral or bacterial). It may present with chest pain, rapid signs of heart failure, or sudden death.

Valvular heart disease
Valvular heart disease is any disease process involving one or more valves of the heart. The valves in the right side of the heart are the tricuspid valve and the pulmonic valve. The valves in the left side of the heart are the mitral valve and the aortic valve.

Aortic valve stenosis
Mitral valve prolapse
Valvular cardiomyopathy

Heart Dieseas

Erisipelas

Erysipelas (Greek ερυσίπελας - red skin) is an acute streptococcus bacterial infection of the dermis, resulting in inflammation and characteristically extending into underlying fat tissue.

(Erysipelas is also the name given to an infection in animals caused by the bacterium Erysipelothrix rhusiopathiae. Infection by Erysipelothrix rhusiopathiae in humans is known as erysipeloid.)

Risk factors
This disease is most common among the elderly, infants, and children. People with immune deficiency, diabetes, alcoholism, skin ulceration, fungal infections and impaired lymphatic drainage (e.g., after mastectomy, pelvic surgery, bypass grafting) are also at increased risk.

Signs and symptoms
Patients typically develop symptoms including high fevers, shaking, chills, fatigue, headaches, vomiting, and general illness within 48 hours of the initial infection. The erythematous skin lesion enlarges rapidly and has a sharply demarcated raised edge. It appears as a red, swollen, warm, hardened and painful rash, similar in consistency to an orange peel. More severe infections can result in vesicles, bullae, and petechiae, with possible skin necrosis. Lymph nodes may be swollen, and lymphedema may occur. Occasionally, a red streak extending to the lymph node can be seen.

The infection may occur on any part of the skin including the face, arms, fingers, legs and toes, but it tends to favor the extremities. Fat tissue is most susceptible to infection, and facial areas are typically around the eyes, ears, and cheeks. Repeated infection of the extremities can lead to chronic swelling (lymphadenitis).

Etiology
Most cases of erysipelas are due to Streptococcus pyogenes (also known as group A streptococci), although non-group A streptococci can also be the causative agent. Historically, the face was most affected; today the legs are affected most often.

Erysipelas infections can enter the skin through minor trauma, eczema, surgical incisions and ulcers, and often originate from strep bacteria in the subject's own nasal passages.

Diagnosis
This disease is mainly diagnosed by the appearance of the rash and its characteristics. Blood cultures are unreliable for diagnosis of the disease, but may be used to test for sepsis. Erypsipelas must be differentiated from herpes zoster, angioedema, contact dermatitis, and diffuse inflammatory carcinoma of the breast.

Erysipelas can be distinguished from cellulitis by its raised advancing edges and sharp borders. Elevation of the antistreptolysin O titre occurs after around 10 days of illness.

Treatment
Depending on the severity, treatment involves either oral or intravenous antibiotics, using penicillins, clindamycin or erythromycin. While illness symptoms resolve in a day or two, the skin may take weeks to return to normal.

Complications
Spread of infection to other areas of body through the bloodstream (bacteremia), including septic arthritis and infective endocarditis (heart valves).
Septic shock.
Recurrence of infection – Erysipelas can recur in 18-30% of cases even after antibiotic treatment.
Lymphatic damage
Necrotizing fasciitis -- AKA "the flesh-eating bug." A potentially-deadly exacerbation of the infection if it spreads to deeper tissue.

Erisipelas

Diabetes Mangement

Diabetes is a chronic disease with no cure as of 2007. It is associated with an impaired glucose cycle, altering metabolism. Management of this disease may include lifestyle modifications such as achieving and maintaining proper weight, diet, exercise and foot care.

Types of Diabetes
Diabetes mellitus type 1
Diabetes mellitus type 2
Gestational diabetes
Pre-diabetes:
Impaired fasting glycaemia
Impaired glucose tolerance

Disease Management
Diabetes management:
•Diabetic diet
•Anti-diabetic drugs
•Conventional insulinotherapy
•Intensive insulinotherapy
Other Concerns
Cardiovascular disease
Diabetic comas:
•Diabetic hypoglycemia
•Diabetic ketoacidosis
•Nonketotic hyperosmolar

Diabetic myonecrosis
Diabetic nephropathy
Diabetic neuropathy
Diabetic retinopathy

Diabetes and pregnancy

Blood tests
Blood sugar
Fructosamine
Glucose tolerance test
Glycosylated hemoglobin

Overview of management

Issues requiring management
This short section requires expansion.

The primary issue requiring management is the glucose cycle, whereby glucose in the bloodstream is made available to cells in the body, a process dependent upon the twin cycles of glucose entering the bloodstream, and insulin allowing appropriate uptake into the cells of the body. Both aspects can require management.

Complexities relating to management
The main complexities stem from the nature of the feedback loop itself, which is sought to be regulated:

The glucose cycle is a system which is affected by two factors: entry of glucose into the bloodstream and also blood levels of insulin to control its transport out of the bloodstream
As a system, it is sensitive to diet and exercise
It is affected by the need for user anticipation due to the complicating effects of time delays between any activity and the respective impact on the glucose system
Management is highly intrusive and compliance is an issue, since it relies upon user lifestyle change and (often) upon regular sampling and measuring of blood glucose levels, multiple times a day in many cases
It changes as people grow and develop
It can be highly individual
As diabetes is a prime risk factor for cardiovascular disease, controlling other risk factors which may give rise to secondary conditions, as well as the diabetes itself, is one of the facets of diabetes management. Checking cholesterol, LDL, HDL and triglyceride levels may indicate hyperlipoproteinemia, which may warrant treatment with hypolipidemic drugs. Checking the blood pressure and keeping it within strict limits (using diet and antihypertensive treatment) protects against the retinal, renal and cardiovascular complications of diabetes. Regular follow-up by a podiatrist or other foot health specialists is encouraged to prevent the development of diabetic foot. Annual eye exams are suggested to monitor for progression of diabetic retinopathy.

The expense, inconvenience and discomfort of frequent blood glucose measurements has been limited until recently. Recently newer devices which monitor glucose levels on an ongoing basis have been developed, as detailed below.

Early advancements
Late in the nineteenth century, sugar in the urine (glycosuria) was associated with diabetes. Various doctors studied the connection. Frederick Madison Allen studied diabetes in 1909-12, then published a large volume, Studies Concerning Glycosuria and Diabetes, (Boston, 1913). He invented a fasting treatment for diabetes called the Allen treatment for diabetes. His diet was an early attempt at managing diabetes.

Modern approaches to diabetes primarily rely upon dietary and lifestyle management, often combined with regular ongoing blood glucose level monitoring.

Diet management allows control and awareness of the types of nutrients entering the digestive system, and hence allows indirectly, significant control over changes in blood glucose levels. Blood glucose monitoring allows verification of these, and closer control, especially important since some symptoms of diabetes are not easy for the patient to notice without actual measurement.

Other approaches include exercise control, and other lifestyle changes impacting upon the glucose cycle.

Blood sugar level
Blood sugar level is measured by means of a glucose meter, with the result either in mg/dL (milligrams per deciliter in the USA) or mmol/L (millimoles per litre in Canada and Europe) of blood. The average normal person should have a glucose level of around 4.5 to 7.0 mmol/L (80 to 125 mg/dL). In the diabetic patient a before-meal level of <6.1 mmol/L (<110 mg/dL) and a level two hours after the start of a meal of <7.8 mmol/L (<140 mg/dL) is acceptable.

Optimal management of diabetes involves patients measuring and recording their own blood glucose levels. By keeping a diary of their own blood glucose measurements and noting the effect of food and exercise, patients can modify their lifestyle to better control their diabetes. For patients on insulin, patient involvement is important in achieving effective dosing and timing.

Hypo- and hyper-glycaemia
Levels which are significantly above or below this range are problematic and can in some cases be dangerous. A level of <3.8 mmol/L (<70 mg/dL) is usually described as a hypoglycaemic attack (low blood sugar). Most diabetics know when they're going to "go hypo" and usually are able to eat some food or drink something sweet to raise levels. A patient who is hyperglycemic (high glucose) can also become temporarily hypoglycemic, under certain conditions (e.g. not eating regularly, or after strenuous exercise, followed by fatigue).

Levels greater than 13-15 mmol/L (230-270 mg/dL) are considered high, and should be monitored closely to ensure that they reduce rather than continue to remain high. The patient is advised to seek urgent medical attention as soon as possible if blood sugar levels continue to rise after 2-3 tests. High blood sugar levels are known as hyperglycaemia, which is not as easy to detect as hypoglycemia and usually happens over a period of days rather than hours or minutes. If left untreated, this can result in diabetic coma and death.

A blood glucose test strip for an older style (ie, optical color sensing) monitoring systemProlonged and elevated levels of glucose in the blood, which is left unchecked and untreated, will, over time, result in serious diabetic complications and sometimes even death. It is therefore highly important that a diabetic patient checks their blood levels either daily or every few days to see what levels they are achieving over a given period of time. There is also computer software for the PC which is available from blood testing manufacturers which can display results and trends over time. Type 1 patients will have to check on a more regular daily basis due to insulin therapy, which is a fine art to master.

A history of blood sugar level results is especially useful for the diabetic to present to their doctor or physician in the monitoring and control of the disease. Failure to maintain a strict regimen of testing can accelerate symptoms of the condition, and it is therefore imperative that any diabetic patient strictly monitor their glucose levels regularly.

Glycemic control
Glycemic control is a medical term referring to the typical levels of blood sugar (glucose) in a person with diabetes mellitus. Much evidence suggests that many of the long-term complications of diabetes, especially the microvascular complications, result from many years of hyperglycemia (elevated levels of glucose in the blood). Good glycemic control, in the sense of a "target" for treatment, has become an important goal of diabetes care.

Because blood sugar levels fluctuate throughout the day and glucose records are imperfect indicators of these changes, the percentage of hemoglobin which is glycosylated is used as a proxy measure of long-term glycemic control in research trials and clinical care of people with diabetes. This test, the hemoglobin A1c or glycosylated hemoglobin reflects average glucoses over the preceding 2-3 months. In nondiabetic persons with normal glucose metabolism the glycosylated hemoglobin is usually 4-6% by the most common methods (normal ranges may vary by method).

"Perfect glycemic control" would mean that glucose levels were always normal (70-130 mg/dl, or 3.9-7.2 mMol/L) and indistinguishable from a person without diabetes. In reality, because of the imperfections of our treatment measures for replacing a pancreas, even "good glycemic control" describes blood glucose levels that average somewhat higher than normal much of the time.

Accepted "target levels" of glucose and glycosylated hemoglobin that are considered good control have been lowered over the last 25 years, because of improvements in the tools of diabetes care, because of increasing evidence of the value of glycemic control in avoiding complications, and by the expectations of both patients and physicians. What is considered "good control" also varies by age and susceptibility of the patient to hypoglycemia.

In the 1990s the American Diabetes Association conducted a publicity campaign to persuade patients and physicians to strive for average glucose and hemoglobin A1c values below 200 mg/dl (11 mMol/l) and 8%. Currently many patients and physicians attempt to do better than that.

Poor glycemic control refers to persistently elevated blood glucose and glycosylated hemoglobin levels, which may range from 200-500 mg/dl (11-28 mMol/L) and 9-15% or higher over months and years before severe complications occur.

Monitoring

An older style portable blood glucose meter. A blood sample is applied to an inserted strip (see image above) and color changes caused by reaction with blood glucose are measured by the meter.Relying on their own perceptions of symptoms of hyperglycemia or hypoglycemia is usually unsatisfactory as mild to moderate hyperglycemia causes no obvious symptoms in nearly all patients. Other considerations include the fact that, while food takes several hours to be digested and absorbed, insulin administration can have glucose lowering effects for as little as 2 hours or 24 hours or more (depending on the nature of the insulin preparation used and individual patient reaction). In addition, the onset and duration of the effects of oral hypoglycemic agents vary from type to type and from patient to patient.

Personal (home) glucose monitoring
Control and outcomes of both types 1 and 2 diabetes may be improved by patients using home glucose meters to regularly measure their glucose levels. Glucose monitoring is both expensive (largely due to the cost of the consumable test strips) and requires significant commitment on the part of the patient. The effort and expense may be worthwhile for patients when they use the values to sensibly adjust food, exercise, and oral medications or insulin. These adjustments are generally made by the patients themselves following training by a clinician.

Regular blood testing, especially in type 1 diabetics, is essential to keep adequate control of glucose levels and to reduce the chance of long term side effects of the disease. There are many (at least 20+) different types of blood monitoring devices available on the market today; not every meter suits all patients and it is a specific matter of choice for the patient, in consultation with a physician or other experienced professional, to find a meter that they personally find comfortable to use. The principle of the devices is virtually the same: a small blood sample is collected and measured. In one type of meter, the electrochemical, a small blood sample is produced by the patient using a lancet (a sterile pointed needle). The blood droplet is usually collected at the bottom of a test strip, while the other end is inserted in the glucose meter. This test strip contains various chemicals so that when the blood is applied, a small electrical charge is created between two contacts. This charge will vary depending on the glucose levels within the blood. In older glucose meters, the drop of blood is placed on top of a strip. A chemical reaction occurs and the strip changes color. The meter then measures the color of the strip optically.

Self-testing is clearly important in type I diabetes where the use of insulin therapy risks episodes of hypoglycaemia and home-testing allows for adjustment of dosage on each administration. However its benefit in type 2 diabetes is more controversial as there is much more variation in severity of type 2 cases. It has been suggested that some type 2 patients might do as well with home urine-testing alone. The best use of home blood-sugar monitoring is being researched.

Benefits of control and reduced hospital admission have been reported. However, patients on oral medication who do not self-adjust their drug dosage will miss many of the benefits of self-testing, and so it is questionable in this group. This is particularly so for patients taking monotherapy with metformin who are not at risk of hypoglycaemia. Regular 6 monthly laboratory testing of HbAc1 (glycated haemoglobin) provides some assurance of longterm effective control and allows the adjustment of the patient's routine medication dosages in such cases. High frequency of self-testing in type 2 diabetes has not been shown to be associated with improved control. The argument is made, though, that type 2 patients with poor long term control despite home blood glucose monitoring, either have not had this integrated into their overall management, or are long overdue for tighter control by a switch from oral medication to injected insulin.

HbA1c test
A useful test that has usually been done in a laboratory is the measurement of blood HbA1c levels. This is the ratio of glycosylated hemoglobin in relation to the total hemoglobin. Persistent raised plasma glucose levels cause the proportion of these cells to go up. This is a test that measures the average amount of diabetic control over a period originally thought to be about 3 months (the average red blood cell lifetime), but more recently thought to be more strongly weighted to the most recent 2 to 4 weeks. In the non-diabetic, the HbA1C level ranges from 4.0-6.0%; patients with diabetes mellitus who manage to keep their HbA1C level below 6.5% are considered to have good glycemic control. The HbA1c test is not appropriate if there has been changes to diet or treatment within shorter time periods than 6 weeks or there is disturbance of red cell aging (e.g. recent bleeding or hemolytic anemia) or a hemoglobinopathy (e.g. sickle cell disease). In such cases the alternative Fructosamine test is used to indicate average control in the preceding 2 to 3 weeks.

Ongoing monitoring
Main article: Blood glucose monitoring
Recently, devices have been manufactured which provide ongoing monitoring of glucose levels on an automated basis during the day, for example:

The Paradigm REAL-Time by Minimed, is a blood glucose monitoring device that provides blood glucose measurements to be made every five minutes. The patient can thus adjust an insulin infusion pump immediately and mimic the "feed-back" mechanism of a pancreas. Significant reductions in complications of therapy have been demonstrated and reductions in long-term complications from diabetes mellitus are projected.
The US Food and Drug Administration has also approved a non-invasive blood glucose monitoring device, the GlucoWatch G2 Biographer. This allows checking blood glucose levels, while puncturing the skin as little as twice a day. Once calibrated with a blood sample, it pulls body fluids from the skin using small electrical currents, taking six readings an hour for as long as thirteen hours. It has not proven to be reliable enough, or convenient enough to be used in lieu of conventional blood monitoring. Other non-invasive methods like radio waves, ultrasound and energy waves are also being tested.

Approaches to management

Insulin and other drug based approaches
Currently, the goal for diabetics is to avoid or minimize chronic diabetic complications, as well as to avoid acute problems of hyperglycemia or hypoglycemia. Adequate control of diabetes leads to lower risk of complications associated with unmonitored diabetes including kidney failure (requiring dialysis or transplant), blindness, heart disease and limb amputation. The most prevalent form of medication is hypoglycemic treatment through either oral hypoglycemics and/or insulin therapy. There is emerging evidence that full-blown diabetes mellitus type 2 can be evaded in those with only mildly impaired glucose tolerance.

Patients with type 1 diabetes mellitus require direct injection of insulin as their bodies cannot produce enough (or even any) insulin. As of 2005, there is no other clinically available form of insulin administration other than injection for patients with type 1: injection can be done by insulin pump, by jet injector, or any of several forms of hypodermic needle. There are several insulin application mechanisms under experimental development as of 2004. There have also been proposed vaccines for type I using glutamic acid decarboxylase (GAD), but these are currently not being tested by the pharmaceutical companies that have sublicensed the patents to them.

For type 2 diabetics, diabetic management consists of a combination of diet, exercise, and weight loss, in any achievable combination depending on the patient. Obesity is very common in type 2 diabetes and contributes greatly to insulin resistance. Weight reduction and exercise improve tissue sensitivity to insulin and allow its proper use by target tissues. Patients who have poor diabetic control after lifestyle modifications are typically placed on oral hypoglycemics. Some Type 2 diabetics eventually fail to respond to these and must proceed to insulin therapy.

Patient education and compliance with treatment is very important in managing the disease. Improper use of medications and insulin can be very dangerous causing hypo- or hyper-glycemic episodes.

Insulin therapy requires close monitoring and a great deal of patient education, as improper administration is quite dangerous. For example, when food intake is reduced, less insulin is required. A previously satisfactory dosing may be too much if less food is consumed causing a hypoglycemic reaction if not intelligently adjusted. In addition, exercise decreases insulin requirements as exercise increases glucose uptake by body cells whose glucose uptake is controlled by insulin, and vice versa. In addition, there are available several types of insulin with varying times of onset and duration of action.

Insulin therapy creates risk because of the inability to continuously know a person's blood glucose level and adjust insulin infusion appropriately. New advances in technology have overcome much of this problem. Small, portable insulin infusion pumps are available from several manufacturers. They allow a continuous infusion of small amounts of insulin to be delivered through the skin around the clock, plus the ability to give bolus doses when a person eats or has elevated blood glucose levels. This is very similar to how the pancreas works, but these pumps lack a continuous "feed-back" mechanism. Thus, the user is still at risk of giving too much or too little insulin unless blood glucose measurements are made.

The FDA has approved a treatment called Exenatide, based on the saliva of a Gila monster, to control blood sugar in patients with type 2 diabetes.

Diet
For most Type 1 diabetics there will always be a need for some insulin injections throughout their life. However, both Type 1 and Type 2 diabetics can see dramatic normalization of their blood sugars through controlling their diet, and some Type 2 diabetics can fully control the disease by dietary modification. As diabetes can lead to many other complications it is critical to maintain blood sugars as close to normal as possible and diet is the leading factor in this level of control.

The American Diabetes Association in 1994 recommended that 60-70% of caloric intake should be in the form of carbohydrates. This is somewhat controversial, with some researchers claiming that 40% is better, while others claim benefits for a high-fiber, 75% carbohydrate diet.

An article summarizing the view of the American Diabetes Association gives many recommendations and references to the research. One of the conclusions is that it is caloric intake must be limited to that which is necessary for maintaining a healthy weight.

Exercise
Exercise is known to be helpful. A pilot study has also found evidence that Tai Chi and Qigong reduce the severity of type 2 diabetes.

Diabetes Mangement

Blastomyosis

Blastomycosis is a fungal infection caused by the organism Blastomyces dermatitidis. Endemic to portions of North America, blastomycosis causes clinical symptoms similar to histoplasmosis.

History
Blastomycosis was first described by Thomas Casper Gilchrist in 1894 and sometimes goes by the eponym Gilchrist's disease. It is also sometimes referred to as Chicago Disease.

Epidemiology
In the United States, blastomycosis is endemic in the Mississippi river and Ohio river basins and around the Great Lakes. The annual incidence is less than 1 case per 100,000 people in Mississippi, Louisiana, Kentucky, and Arkansas. The cases are greater in northern states such as Wisconsin, where from 1986 to 1995 there were 1.4 cases per 100,000 people.

In Canada, most cases of blastomycosis occur in northwestern Ontario, particularly around the Kenora area. The moist, acidic soil in the surrounding woodland harbours the fungus.

Blastomycosis is distributed internationally; cases are sometimes reported from Africa.

Pathology
Infection occurs by inhalation of the fungus from its natural soil habitat. Once inhaled in the lungs, they multiply and may disseminate through the blood and lymphatics to other organs, including the skin, bone, genitourinary tract, and brain. The incubation period is 30 to 100 days, although infection can be asymptomatic.

Clinical features

Blastomycosis of skinBlastomycosis can present in one of the following ways:

a flulike illness with fever, chills, myalgia, headache, and a nonproductive cough which resolves within days.
an acute illness resembling bacterial pneumonia, with symptoms of high fever, chills, a productive cough, and pleuritic chest pain.
a chronic illness that mimics tuberculosis or lung cancer, with symptoms of low-grade fever, a productive cough, night sweats, and weight loss.
a fast, progressive, and severe disease that manifests as ARDS, with fever, shortness of breath, tachypnea, hypoxemia, and diffuse pulmonary infiltrates.
skin lesions, usually asymptomatic, appear as ulcerated lesions with small pustules at the margins
bone lytic lesions can cause bone or joint pain.
prostatitis may be asymptomatic or may cause pain on urinating.
laryngeal involvement causes hoarseness.

Diagnosis
Once suspected, the diagnosis of blastomycosis can usually be confirmed by demonstration of the characteristic broad based budding organisms in sputum or tissues by KOH prep, cytology, or histology. Tissue biopsy of skin or other organs may be required in order to diagnose extra-pulmonary disease. Commercially available urine antigen testing appears to be quite sensitive in suggesting the diagnosis in cases where the organism is not readily detected. While culture of the organism remains the definitive diagnostic standard, its slow growing nature can lead to delays in treatment of up to several weeks.

However, sometimes blood and sputum cultures may not detect blastomycosis; lung biopsy is another option, and results will be shown promptly.

Treatment
Itraconazole given orally is the treatment of choice for most forms of the disease. Cure rates are high, and the treatment over a period of months is usually well tolerated. Amphotericin B is considerably more toxic, and is usually reserved for critically ill patients and those with central nervous system disease.

Prognosis
Mortality rate in treated cases

0-2% in treated cases among immunocompetent patients
29% in immunocompromised patients
40% in the subgroup of patients with AIDS
68% in patients presenting as acute respiratory distress syndrome (ARDS)

Blastomyosis