A non-cancerous condition that affects many men
past 50 years of age, enlarged prostate makes urinating
more difficult by narrowing the urethra, a tube running
from the bladder through the prostate gland. It can be
effectively treated by surgery and, today, by certain
drugs.

Description

The common term for enlarged prostate is BPH,
which stands for benign (non-cancerous) prostatic
hyperplasia or hypertrophy. Hyperplasia means that the
prostate cells are dividing too rapidly, increasing the
total number of cells, and, therefore, the size of the
organ itself. Hypertrophy simply means “enlargement.”
BPH is part of the aging process. The actual changes in
the prostate may start as early as the 30s but take place
very gradually, so that significant enlargement and
symptoms usually do not appear until after age 50. Past
this age the chances of the prostate enlarging and causing
urinary symptoms become progressively greater.

More than 40% of men in their 70s have an enlarged
prostate. Symptoms generally appear between ages
55–75. About 10% of all men eventually will require
treatment for BPH.

BPH has been viewed as a rare condition in African,
Chinese and other Asian peoples for reasons that are not
clear.

Causes and symptoms

The cause of BPH is a mystery, but age-related
changes in the levels of hormones circulating in the
blood may be a factor. Whatever the cause, an enlarging
prostate gradually narrows the urethra and obstructs the
flow of urine. Even though the muscle in the bladder wall
becomes stronger in an attempt to push urine through the
smaller urethra, in time, the bladder fails to empty completely
at each urination. The urine that collects in the
bladder can become infected and lead to stone formation.
The kidneys themselves may be damaged by infection or
by urine constantly “backing up.”

When the enlarging prostate gland narrows the urethra,
a man will have increasing trouble starting the urine
stream. Because some urine remains behind in the bladder,
he will have to urinate more often, perhaps two or
three times at night (nocturia). The need to urinate can
become very urgent and, in time, urine may dribble out
to stain a man’s clothing. Other symptoms of BPH are a
weak and sometimes a split stream and general aching or
pain in the perineum (the area between the scrotum and
anus). Some men may have considerable enlargement of
the prostate before even mild symptoms develop.
If a man must strain hard to force out the urine,
small veins in the bladder wall and urethra may rupture,
causing blood to appear in the urine. If the urinary stream
becomes totally blocked, the urine collecting in the bladder
may cause severe discomfort, a condition called
acute urinary retention. Urine that stagnates in the bladder
can easily become infected. A burning feeling during
urination and fever are clues that infection may have
developed. Finally, if urine backs up long enough it may
increase pressure in the kidneys, though this rarely causes
permanent kidney damage.

Diagnosis

When a man’s symptoms point to BPH, the first
thing the physician will want to do is a digital rectal
examination, inserting a finger into the anus to feel
whether—and how much—the prostate is enlarged. A
smooth prostate surface suggests BPH, whereas a distinct
lump in the gland might mean prostate cancer.

The next step is a blood test for a substance called
prostate-specific antigen or PSA. Between 30–50% of
men with BPH have an elevated PSA level. This does
not mean cancer by any means, but other measures
are needed to make sure that the prostate enlargement
is in fact benign. An ultrasound exam of the prostate,
which is entirely safe and delivers no radiation, can
show whether it is enlarged and may show that cancer
is present.

If digital or ultrasound examination of the prostate
raises the suspicion of cancer, most urologists will recommend
that a prostatic tissue biopsy be performed. This
is usually done using a lance-like instrument that is
inserted into the rectum. It pierces the rectal wall and,
guided by the physcian’s finger, obtains six to eight
pieces of prostatic tissue that are sent to the laboratory
for microscopic examination. If cancer is present, the
prognosis and treatment are changed accordingly.
A catheter placed through the urethra and into the
bladder can show how much urine remains in the bladder
after the patient urinates—a measure of how severe the
obstruction is. Another and very simple test for obstruction
is to have the man urinate into a uroflowmeter,
which measures the rate of urine flow. A very certain—
though invasive—way of confirming obstruction from an
enlarged prostate is to pass a special viewing instrument
called a cystoscope into the bladder, but this is not often
necessary.

It is routine to check a urine sample for an increased
number of white blood cells, which may mean there is
infection of the bladder or kidneys. The same sample
may be cultured to show what type of bacterium is causing
the infection, and which antibiotics will work best.

The state of the kidneys may be checked in two ways:
imaging by either ultrasound or injecting a dye (the intra-
venous urogram, or pyelogram); or a blood test for creatinine,
which collects in the blood when the kidneys cannot
eliminate it.

Prevention

Whether or not BPH is caused by hormonal changes
in aging men, there is no known way of preventing it.
Once it does develop and symptoms are present that
interfere seriously with the patient’s life, timely medical
or surgical treatment will reliably prevent symptoms
from getting worse. Also, if the condition is treated
before the prostate has become grossly enlarged, the risk
of complications is minimal. One of the potentially most
serious complications of BPH, urinary infection (and
possible infection of the kidneys), can be prevented by
using a catheter to drain excess urine out of the bladder
so that it does not collect, stagnate, and become infected.

Vitamin B6 is used by the body as a catalyst in reactions
that involve amino acids. Vitamin B6 deficiency is
rare, since most foods eaten contain the vitamin.

Description

Vitamin B6 is a water-soluble vitamin. The recommended
dietary allowance (RDA) for vitamin B6 is 2.0
mg/day for the adult man and 1.6 mg/day for the adult
woman. Vitamin B6 in the diet generally occurs as a form
called pyridoxal phosphate. In this form, it cannot be
absorbed by the body. During the process of digestion,
the phosphate group is removed, and pyridoxal is produced.
However, the body readily absorbs pyridoxal, and
converts it back to the active form of the vitamin (pyridoxal
phosphate).

Poultry, fish, liver, and eggs are good sources of vitamin
B6, comprising about 3-4 mg vitamin/kg food; meat
and milk contain lesser amounts of the vitamin. The vitamin
also occurs, at about half this level, in a variety of
plant foods, including beans, broccoli, cabbage, and
peas. Vitamin B6 tends to be destroyed with prolonged
cooking, with storage, or with exposure to light.
As mentioned, vitamin B6 takes various forms. One
of these forms, called pyridoxine, is relatively stable. For
this reason, pyridoxine is the form of vitamin B6 that is
used in vitamin supplements, or when foods are fortified.
Apples and other fruits are poor sources of the vitamin,
containing only 0.2-0.6 mg vitamin/kg food.

Vitamin B6, used mainly in the body for the processing
of amino acids, performs this task along with certain
enzymes. The enzyme that participates in this type of complex
is aminotransferase. Several types of aminotransferase
exist. With vitamin B6 deficiency, while aminotransferase
continues to occur in the various organs of the body,
there is an abnormally low level of the active vitamin
B6/aminotransferase complex present. Thus, this vitamin
deficiency results in the impairment of a variety of activities
in the body. With supplement correction of the vitamin
B6 deficiency, the aminotransferase then readily forms the
active complex, and normal metabolism is restored.
Vitamin B6 converts certain amino acids (glutamic
acid, aspartic acid, glycine) to energy. This allows the
body to process all dietary protein, even when the dietary
protein is in excess of the body’s needs. Vitamin B6 also
allows the body to synthesize certain amino acids. For
example, if the diet is deficient or low in certain amino
acids, such as glycine or serine, vitamin B6 enables the
body to make them from sugar. Vitamin B6 is used also
for the synthesis of certain hormones, such as adrenaline.

Causes and symptoms

Vitamin B6 deficiency occurs rarely. When it does, it
is usually associated with poor absorption of nutrients in
the gastrointestinal tract (as in alcoholism, or with
chronic diarrhea), the taking of certain drugs (as isoniazid,
hydrolazine, penicillamine) that inactivate the vita-
min, with genetic disorders that inhibit metabolism of the
vitamin, or in cases of starvation.

The symptoms of vitamin B6 deficiency in adults are
only vaguely defined. These include nervousness, irritability,
insomnia, muscle weakness, and difficulty in
walking. Vitamin B6 deficiency may produce fissures and
cracking at the corners of the mouth. The deficiency
occurred in infants fed early versions of commercial
canned infant formula, when the vitamin had been inadvertently
omitted from the formula. This error resulted in
infants failing to grow, in irritability, and in seizures.

Diagnosis

Vitamin B6 status is measured by the transaminase
stimulation test. This test requires extraction of red blood
cells, and placement of the cells in two test tubes. Special
chemicals (reagents) are added to both test tubes to allow
for measurement of aminotransferase. This enzyme
requires pyridoxal phosphate. A known quantity of pure
pyridoxal phosphate is added to one of the test tubes. The
activity level of the enzyme is measured, and compared,
in both test tubes. If the added pyridoxal phosphate did
not stimulate activity, the patient is considered not to be
deficient in vitamin B6. Neither is the patient considered
deficient if only slight stimulation occurred. But if a
stimulation of four-fold or more occurred, a vitamin B6
deficiency is present.

Treatment

Vitamin B6 deficiency can be prevented or treated
with consumption of the recommended dietary allowance,
as supplied by food or by vitamin supplements.

Prognosis

The prognosis for correcting vitamin B6 deficiency
is excellent.

Prevention

Vitamin B6 deficiency is not a major concern for
most people. The deficiency can be prevented with consumption
of a mixed diet that includes poultry, fish, eggs,
meat, vegetables, and grains.

Ventricular tachycardia (V-tach) is a rapid heart beat
that originates in one of the lower chambers (the ventricles)
of the heart. To be classified as tachycardia, the
heart rate is usually at least 100 beats per minute.

Description

A rapid heart rate can originate in either the left or
right ventricle. Ventricular tachycardia which lasts more
than 30 seconds is referred to as sustained ventricular
tachycardia. A period of three to five rapid beats is called
a salvo, and six beats or more lasting less than 30 seconds
is called nonsustained ventricular tachycardia. Rapid ventricular
rhythms are more serious than rapid atrial
rhythms because they make the heart extremely inefficient.
They also tend to cause more severe symptoms, and
have a much greater tendency to result in death.

Although generally considered to be among the lifethreatening
abnormal rhythms, harmless forms of sustained
V-tach do exist. These occur in people without any
structural heart disease.

Causes and symptoms

Most ventricular tachycardias are associated with
serious heart disease such as coronary artery blockage,
cardiomyopathy, or valvular heart disease. V-tach is
often triggered by an extra beat originating in either the
right or left ventricle. It also occurs frequently in connection
with a heart attack. V-tach commonly occurs within
24 hours of the start of the attack. It must be treated

quickly to prevent fibrillation. After 48 to 72 hours of the
heart attack, the risk of ventricular tachycardia is small.
However, people who have suffered severe damage to the
larger anterior wall of the heart have a second danger
period, because V-tach often occurs during convalescence
from this type of heart attack.

Sustained ventricular tachycardia prevents the ventricles
from filling adequately so the heart can not pump
normally. This results in loss of blood pressure, and can
lead to a loss of consciousness and to heart failure.
The individual with V-tach almost always experiences
palpitation, though some episodes cause no symptoms
at all.

Diagnosis

Diagnosis is easily made with an electrocardiogram.

Treatment

Any episode of ventricular tachycardia that causes
symptoms needs to be treated. An episode that lasts more
than 30 seconds, even without symptoms, also needs to
be treated. Drug therapy can be given intravenously to
suppress episodes of V-tach. If blood pressure falls below
normal, a person will need electric cardioversion
(“shock”) immediately.

Prognosis

With appropriate drug or surgical treatment, ventricular
tachycardia can be controlled in most people.

Prevention

A person susceptible to sustained ventricular
tachycardia often has a small abnormal area in the ventricles
that is the source of the trigger event. This area
can sometimes be surgically removed. If surgery is not
an option, and drug therapy is not effective, a device
called an automatic cardioverter-defibrillator may be
implanted.

A polyp is any overgrowth of tissue from a surface.
Polyps come in all shapes—round, droplet, and irregular
being the most common.

Description

Nasal polyps tend to occur in people with respiratory
allergies. Hay fever (allergic rhinitis) is an irritation
of the membranes of the nose by airborne particles or
chemicals. These membranes make mucus. When irritated,
they can also grow polyps. The nose is not only a passageway
for air to reach the lungs; it also provides the
connection between the sinuses and the outside world.
Sinuses are lined with mucus membranes, just like the
nose. Polyps can easily obstruct the drainage of mucus
from the sinuses. When any fluid in the body is trapped
so it cannot flow freely, it becomes infected. The result,
sinusitis, is a common complication of allergic rhinitis.

Causes and symptoms

Some people who are allergic to aspirin develop
both asthma and nasal polyps.

Nasal polyps often plug the nose, usually one side at
a time. People with allergic rhinitis are so used to having
a stopped up nose they may not notice the difference
when a polyp develops. Other polyps may be closer to a
sinus opening, so airflow is not obstructed, but mucus
becomes trapped in the sinus. In this case, there is a feeling
of fullness in the head, no sense of smell, and perhaps
a headache. The trapped mucus will eventually get
infected, adding pain, fever, and perhaps bloody discharge
from the nose.

Diagnosis

A physical examination will identify most polyps.
Small polyps located higher up or further back may be
hidden from view, but they will be detected with more
sophisticated medical instruments. The otorhinolaryngologist
is equipped to diagnose nasal polyps. In order to
perform the exam, medicine must be applied to decongest
the membranes. Cotton balls soaked with one of
these agents and left in the nostrils for a few minutes provide
adequate shrinkage.

Treatment

Most polyps can be removed by the head and neck
surgeon as an office procedure called a nasal polypectomy.
Bleeding, the only complication, is usually easy to
control. Nose and sinus infections can be treated with
antibiotics and decongestants, but if airflow is restricted,
the infection will reoccur.

Prognosis

Polyps reappear as long as the allergic irritation continues.

Prevention

If aspirin is the cause, all aspirin containing medications
must be avoided.

Since most nasal polyps are the result of allergic
rhinitis, they can be prevented by treating this condition.
New treatments have greatly improved control of hay
fever. There are now several spray medicines that are
quite effective. Spray cortisone-like drugs are the most
popular. Over-the-counter nasal decongestants have an
irritating effect similar to the allergy they are supposed to
be treating. Continued use can bring more trouble than
relief and result in an addiction to nose sprays. The
resulting disease, rhinitis medicamentosa, is more difficult
to treat than allergic rhinitis.

Allergists and ENT surgeons both treat allergic
rhinitis with a procedure called desensitization. After
identifying suspect allergens using one of several methods,
they will give the patient increasing doses of those
allergens in order to produce blocking antibodies that
will impede the allergic reaction. This is effective in a
number of patients, but the treatment may take a period
of months to years.

Nasal papillomas are warts located inside the nose.

Description

Two types of tumors can grow inside the nose:
polyps and papillomas. By far the most common are
polyps, which have smooth surfaces. On the contrary,
papillomas have irregular surfaces and are, in fact, warts.
Papillomas may be caused by the same viruses that cause
warts elsewhere on the body. They are inside the nose,
more often on the side near the cheek, and, because of
their internal structure, they are much more likely to
bleed than polyps.

There is a special type of nasal papilloma called an
inverting papilloma because of its unique appearance.
About 10 or 15% of these are or can become cancers.

Causes and symptoms

Like polyps, papillomas can plug up the nose and
disable the sense of smell. Unlike polyps, papillomas
often bleed.

Diagnosis

A physical examination with special instruments
will detect these tumors.

Treatment

Because of the possibility of cancer, all nasal papillomas
must be removed surgically and sent to the labora-
tory for analysis. If a cancer is present, further surgery
may be necessary to guarantee that all of the cancer has
been removed. The initial surgery can be done in an
office setting by a specialist in head and neck surgery,
also known as otorhinolaryngology and popularly abbreviated
ENT (ear, nose, and throat). Cancer surgery is
more extensive and often requires hospitalization.

Prognosis

For benign (non-cancerous) lesions, removal is curative,
although they tend to recur, just like warts elsewhere.
The cancerous papillomas may occasionally escape complete
surgical removal and spread to adjacent or distant
sites. The prognosis is then much more complex.

Yellow fever is a severe infectious disease, caused
by a virus called a “flavivirus.” This flavivirus can cause
outbreaks of epidemic proportions throughout Africa and
tropical America. The first written evidence of such an
epidemic occurred in the Yucatan in 1648. Since that
time, much has been learned about the interesting transmission
patterns of this devastating illness.

Description

In order to understand how yellow fever is passed,
several terms need to be defined. The word “host” refers
to an animal that can be infected with a particular disease.
The term “vector” refers to an organism which can carry a
particular disease-causing agent (such as a virus or bacteria)
without actually developing the disease. The vector
can then pass the virus or bacteria on to a new host.

Many of the common illnesses in the United States
(including the common cold, many viral causes of diarrhea,
and influenza or “flu”) are spread via direct passage
of the causative virus between human beings. Yellow
fever, however, cannot be passed directly from one infected
human being to another. Instead, the virus responsible
for yellow fever requires an intermediate vector, a mosquito,
which carries the virus from one host to another.

The hosts of yellow fever include both humans and
monkeys. The cycle of yellow fever transmission occurs
as follows: an infected monkey is bitten by a tree-hole
breeding mosquito. This mosquito acquires the virus, and
can pass the virus on to any number of other monkeys
that it may bite. When a human is bitten by such a mosquito,
the human may acquire the virus. In the case of
South American yellow fever, the infected human may
return to the city, where an urban mosquito (Aedes
aegypti) serves as a viral vector, spreading the infection
rapidly by biting humans.

Symptoms

Once a mosquito has passed the yellow fever virus
to a human, the chance of disease developing is about 5-
20%. Infection may be fought off by the host’s immune
system, or may be so mild that it is never identified.
In human hosts who develop the disease yellow
fever, there are five distinct stages through which the
infection evolves. These have been termed the periods of
incubation, invasion, remission, intoxication, and convalescence.
Yellow fever’s incubation period (the amount of
time between the introduction of the virus into the host
and the development of symptoms) is three to six days.
During this time, there are generally no symptoms identifiable
to the host.

The period of invasion lasts two to five days, and
begins with an abrupt onset of symptoms, including fever
and chills, intense headache and lower backache, muscle
aches, nausea, and extreme exhaustion. The patient’s
tongue shows a characteristic white, furry coating in the
center, surrounded by a swollen, reddened margin. While
most other infections that cause a high fever also cause
an increased heart rate, yellow fever results in an unusual
finding, called Faget’s sign. This is the simultaneous
occurrence of a high fever with a slowed heart rate.
Throughout the period of invasion, there are still live
viruses circulating in the patient’s blood stream. Therefore,
a mosquito can bite the ill patient, acquire the virus,
and continue passing it on to others.

The next phase is called the period of remission. The
fever falls, and symptoms decrease in severity for several
hours to several days. In some patients, this signals the
end of the disease; in other patients, this proves only to
be the calm before the storm.

The period of intoxication represents the most
severe and potentially fatal phase of the illness. During
this time, lasting three to nine days, a type of degeneration
of the internal organs (specifically the kidneys, liver,
and heart) occurs. This fatty degeneration results in what
is considered the classic triad of yellow fever symptoms:
jaundice, black vomit, and the dumping of protein into
the urine. Jaundice causes the whites of the patient’s eyes
and the patient’s skin to take on a distinctive yellow
color. This is due to liver damage, and the accumulation
of a substance called bilirubin, which is normally
processed by a healthy liver. The liver damage also
results in a tendency toward bleeding; the patient’s vomit
appears black due to the presence of blood. Protein,
which is normally kept out of the urine by healthy, intact
kidneys, appears in the urine due to disruption of the kidney’s
healthy functioning.

Patients who survive the period of intoxication enter
into a relatively short period of convalescence. They
recover with no long term effects related to the yellow
fever infection. Further, infection with the yellow fever
virus results in lifelong immunity against repeated infection
with the virus.

Diagnosis

Diagnosis of yellow fever depends on the examination
of blood by various techniques in order to demonstrate
either yellow fever viral antigens (the part of the
virus that stimulates the patient’s immune system to
respond) or specific antibodies (specific cells produced by
the patient’s immune system which are directed against
the yellow fever virus). The diagnosis can be strongly suspected
when Faget’s sign is present. When the classic triad
of symptoms is noted yellow fever is strongly suspected.

Treatment

There are no current anti-viral treatments available to
combat the yellow fever virus. The only treatment of yellow
fever involves attempts to relieve its symptoms.

Fevers and pain should be relieved with acetaminophen,
not aspirin or ibuprofen, both of which could increase the
already-present risk of bleeding. Dehydration (due to
fluid loss both from fever and bleeding) needs to be carefully
avoided. This can be accomplished by increasing
fluids. The risk of bleeding into the stomach can be
decreased through the administration of antacids and
other medications. Hemorrhage may require blood transfusions.
Kidney failure may require dialysis (a process
that allows the work of the kidneys in clearing the blood
of potentially toxic substances to be taken over by a
machine, outside of the body).

Prognosis

Five to ten percent of all diagnosed cases of yellow
fever are fatal. Jaundice occurring during a yellow fever
infection is an extremely grave predictor. Twenty to fifty
percent of these patients die of the infection. Death may
occur due to massive bleeding (hemorrhage), often following
a lapse into a comatose state.

Prevention

A very safe, very effective yellow fever vaccine
exists. About 95% of vaccine recipients acquire longterm
immunity to the yellow fever virus. Careful measures
to decrease mosquito populations in both urban
areas and jungle areas in which humans are working,
along with programs to vaccinate all people living in
such areas, are necessary to avoid massive yellow fever
outbreaks.

Whiplash is a sudden, moderate-to-severe strain
affecting the bones, discs, muscles, nerves, or tendons of
the neck.

Description

The neck is composed of seven small bones. Known
as the cervical spine, these bones:
• support the head
• help maintain an unobstructed enclosure for the spinal
cord
• influence the shape and structure of the spine
• affect posture and balance

About 1,000,000 whiplash injuries occur in the United
States every year. Most are the result of motor vehicle
accidents or collisions involving contact sports. When
unexpected force jerks the head back, then forward the
bones of the neck snap out of position and irritated nerves
can interfere with flow of blood and transmission of nerve
impulses. Pinched nerves can damage or destroy the function
of body parts whose actions they govern.

Risk factors

Osteoarthritis of the spine increases the risk of
whiplash injury. So do poor driving habits, driving in bad
weather, or driving when tired, tense, or under the influence
of alcohol or other drugs.

Causes and symptoms

Tension shortens and tightens muscles. Fatigue
relaxes them. Either condition increases the likelihood
that whiplash will occur and the probability that the
injury will be severe.

Sometimes symptoms of whiplash appear right away.
Sometimes they do not develop until hours, days, or weeks
after the injury occurs. Symptoms of whiplash include:
• pain or stiffness in the neck, jaw, shoulders, or arms
• dizziness
• headache
• loss of feeling in an arm or hand
• nausea and vomiting
Depression and vision problems are rare symptoms
of this condition.

Diagnosis

Whiplash is difficult to diagnose because x rays and
other imaging studies do not always reveal changes in
bone structure. Organs affected by nerve damage or
reduced blood supply may generate symptoms not clearly
related to whiplash.

Diagnosis is based on observation of the patient’s
symptoms, medical history, physical examination, and
neurological studies to determine whether the spine has
been injured.

Treatment

Medication, physical therapy, and supportive measures
are used to treat whiplash. Chiropractors gently
realign the spine to relax pinched nerves or improve
blood flow. A patient whose symptoms are severe may
wear a soft, padded collar (Thomas collar or cervical collar)
until the pain diminishes.

When pressure on the root of the nerve causes loss
of strength or sensation in a hand or arm, a cervical traction
apparatus may be recommended.

Self-care

Inflammation and cramping can be alleviated by
wrapping ice or an ice pack in a thin towel and applying it
to the injured area for 10-20 minutes every hour. After the
first 24 hours, painful muscle spasms can be prevented by
alternating cold packs with heat treatments. Letting a
warm shower run on the neck and shoulders for 10-20
minutes twice a day is recommended. Between showers,
warm towels or a heat lamp should be used to warm and
soothe the neck for 10-15 minutes several times a day.

Improving posture is important, and gentle massage
can be beneficial. Sleeping without a pillow promotes healing,
and a cervical collar or small rolled towel pinned under
the chin can provide support and prevent muscle fatigue.
Alcohol should be avoided. A chiropractor, primary
care physician, or orthopedic specialist should be notified
whenever a painful neck injury occurs. Another situation
requiring attention is if the face or arm weaken or
become painful or numb following a neck injury.

Prognosis

With treatment, whiplash can usually be cured in
one week to three months after injury occurs. If nerve
roots are damaged, numbness and weakness may last
until recovery is complete.

Prevention

Chiropractors can recommend diet and exercise
techniques to reduce stress and tension. Careful, defensive
driving, wearing seatbelts, and using padded automobile
headrests can lessen the likelihood of whiplash.

Ventricular aneurysm is a complication of a heart
attack (myocardial infarction). It is a ballooning of a section
of a blood vessel in the heart that first appears several
days or weeks after an acute myocardial infarction.

Description

A myocardial infarction occurs when a section of
the heart wall is deprived of blood and dies (undergoes
necrosis, or tissue death, and scarring). The heart wall is
mainly muscle. It has two ventricles, the right and left
ventricles, which pump blood to and from the lungs, and
to the body. When part of the heart muscle dies, pumping
power from that part of the wall is lost. After a myocardial
infarction, the part of the heart wall that did not die
must continue pumping blood and compensate for the
dead muscle.

Ventricular aneurysm is one of the complications
that follow a myocardial infarction.

An aneurysm is the outward swelling, or ballooning,
of a blood vessel at a weak spot in the wall of the blood
vessel. In the case of ventricular aneurysm, the aneurysm
occurs in the wall of the heart at the spot where the myocardial
infarction occurred. A scar usually forms in the area of
the dead muscle tissue, and may eventually calcify. Ventricular
aneurysms generally do not rupture. The left ventricle
is involved in most cases of ventricular aneurysm.

Causes and symptoms

The principle symptom of a ventricular aneurysm is
cardiac insufficiency, a condition in which not enough
blood is being pumped to the body. Ventricular aneurysm is
usually found after a large infarction in the muscle wall of a
ventricle. Ventricular aneurysm is seldom seen immediately
after a myocardial infarction. It takes several days or
weeks to several months to develop. Frequently, recurrent
ventricular irregular heartbeats (arrhythmias) and low cardiac
output result from the presence of a ventricular
aneurysm. Blood clots (thrombi) may form on the inside
wall of the aneurysm and produce systemic blood clots that
get stuck in a blood vessel (embolisms), which could lead
to stroke or an ischemic leg (a usually painful condition in
which lack of blood circulation leads to reduced function).

Diagnosis

A number of signs may indicate ventricular
aneurysm, including an abnormal precordial impulse in
the heartbeat, persistent elevation of the S-T segment of
an electrocardiogram, and a characteristic bulge seen on
the heart when x-rayed. The bulge is typically seen when
the heart contracts, driving blood to the aorta, in the systolic
phase of the heartbeat. Echolocation (echocardiography
or ultrasound) can confirm the presence of an
aneurysm. Cardiac catheterization may be performed
to determine the extent of the aneurysm and the status of
the coronary arteries. Stethoscopic examination reveals
abnormal heart sounds, especially those associated with
a backflow of blood from the left ventricle to the left atrium
in systole or contraction beat (mitral regurgitation).

This heart murmur is caused by the heart muscles no
longer being able to properly operate the mitral valve.

Treatment

Most cases of ventricular aneurysm are treated by
close medical follow-up and limiting patient activity. Surgical
removal of the aneurysm is an option when persistent
left ventricular failure or arrhythmia occurs, and the
aneurysm is large. Vasodilators, diuretics, and digoxin
are used to treat heart failure. Anticoagulant drugs are
used to prevent the formation of blood clots. Antiarrhythmic
drugs are used to treat heart arrhythmias.

Prognosis

Ventricular aneurysm occurs more frequently than is
commonly thought. Based on postmortem examination,
ventricular aneurysm occurs in as many as 15% of
myocardial infarction cases. Patients with a large ventricular
aneurysm in the left ventricle have a reduced survival
rate. Many patients have mild symptoms which are
not life-threatening. The survival rate is dependent on the
function of the left ventricle.

Venous insufficiency is described as abnormal blood
flow through veins that can cause local damage, damage
to affected legs, or death.

Description

Syndromes related to venous insufficiency are caused
by valve incompetence. Venous insufficiency is a chronic
(long term) condition. The number of new and existing
cases is dependent on age and gender. Some patients may
have a positive family history. Usually older persons and
females are more commonly affected. Deep situated and
superficial veins can be affected. Cancer obstructing veins
in the pelvis area can cause superficial venous insufficiency.
Deep venous insufficiency is commonly caused by
thrombophlebitis, causing obstruction of valves that regulate
blood flow in veins. Small veins that have been
occluded by a thrombosis may re-canalize (opening up
new channels to re-direct blood flow). These re-canalized
veins are inadequate and cannot correct the impairment of
flow. However, larger veins may still remain occluded.
When a thrombosis occurs the valves that regulate venous
blood flow become thickened and incompetent, rendering
them incapable of regulating back flow of blood. This
valvular incompetence will cause an increase in the presence
within veins (venous hypertension). Venous hypertension
is responsible for most of the symptoms associated
with venous disease. Superficial veins can become dilated
causing varicose veins (veins that bulge and seem tortuous).
Leg ulcers can be severe and are responsible for
100,000 cases of disability in the United States alone.

Causes and symptoms

The symptoms of chronic venous insufficiency can
be subjective and objective. Subjective symptoms
include throbbing, cramping, burning sensations, and leg
fatigue. Patients can also develop chronic leg ulcers that
may not heal. Varicose veins in the legs can bleed (since
veins are delicate structures with thin walls) and cause
death. Patients often develop fluid retention (edema) in
the affected limb. Skin changes can occur and affected
areas can become thin, shiny, discolored (blue-purple),
and atrophic. The skin usually becomes thick and tough.

Diagnosis

There are several techniques used to diagnose
venous disease. Electrical impedance plethysmography
(IPG) provides a functional evaluation for outflow
obstruction ultrasound (a machine that transmits sound
waves) studies can visualize the venous system in certain
areas. Another technique called duplex scanning can
measure velocity within a vein.

Treatment

Periodic elevation of legs and bed rest can help with
leg swelling. Patients are advised to avoid prolonged
periods of standing or sitting. Wearing compression
stockings can also reduce swelling of the leg. Mild skin
infections can be treated with compresses, steroids, and,
if infection is present, with antibiotics. Ulceration’s can
be treated with compresses, possible surgery, special
ointments, and a semi-rigid boot that helps improve
blood flow. Varicose veins can be treated with elastic
stockings. About 15–20% of patients require surgery, but
only after careful evaluation and specialized testing confirms
a beneficial value.

Prognosis

The prognosis is variable and depends on the progression
of disease, extent of damage, and the presence
of other diseases, which may affect the cardiovascular
system.

Prevention

Persons who have a strong family history, evidence
of disease, and/or those who stand on their legs many
hours daily should discuss the option of elastic stocking
with their primary clinician.

Velopharyngeal insufficiency is the improper closing
of the velopharyngeal sphincter (soft palate muscle)
during speech characterized by an acute nasal quality of
the voice.

Description

At the back of the mouth is a circle of structures that
include the tonsils, the tongue, and the palate. During
speech, this apparatus must close off the nose for proper
articulation of the explosive consonants “p,” “b,” “g,” “t,”
and “d.” If it does not close, there is a snort sound produced
through the nose. Improper function of this structure
also produces a nasal tone to the voice.

Causes and symptoms

There are three main causes for this defect:
• Cleft palate is a congenital condition, producing a
defect in the palate that allows air to escape upward
during speech.
• If tonsil and adenoid surgery is done improperly,
velopharyngeal insufficiency may result. The occurrence
rate is approximately one in every 2,000-3,000
tonsillectomies.
• Nerve or muscle disease may paralyze the muscles that
operate the velopharyngeal sphincter.
The primary symptom is the speech impediment.
Some people develop a change in their speaking pattern
or a series of facial grimaces to try to overcome the difficulty.
If the condition is acute, regurgitation through the
nose may occur.

Diagnosis

Examination of the velopharyngeal sphincter through
ultrasound scans, fiber-optic nasopharyngoscopy, and
videofluoroscopy will reveal the extent of velopharyngeal
insufficiency. Speech and velopharyngeal sphincter
movement are compared to make the diagnosis.

Treatment

Velopharyngeal insufficiency is treated with a combination
of surgery and speech therapy. There are several
surgical procedures that can be performed to correct the
physical malfunction. They include:
• Pharyngeal flap procedure that moves the skin flap
from the pharynx to the soft palate.
• Palatal push-back that separates the hard and soft palate
in order to lengthen the soft palate.
• Pharyngoplasty that lengthens the soft palate by turning
the pharyngeal skin flaps.
• Augmentation pharyngoplasty that inserts an implant
into the pharyngeal wall to enlarge it, thus narrowing
the velopharyngeal opening.
• Velopharyngeal sphincter reconstruction.

Prognosis

The combination of surgery to correct the insufficiency
and speech therapy to retrain the voice successfully
alleviate velopharyngeal insufficiency.