Cervical Cancer

Cervical cancer is the second most common malignancy in women worldwide, and it remains a leading cause of cancer-related death for women in developing countries. In the United States, cervical cancer is relatively uncommon. (See Epidemiology.)
The incidence of invasive cervical cancer has declined steadily in the United States over the past few decades; however, it continues to rise in many developing countries. The change in the epidemiological trend in the United States has been attributed to mass screening with Papanicolaou tests. Furthermore, cervical cancer is a preventable disease, primarily with newly approved human papillomavirus (HPV) vaccines and secondarily through treatment of preinvasive disease.
Papanicolaou test screening is recommended in women who meet screening criteria, regardless of symptoms. However, symptoms, abnormal Papanicolaou test results, or women with a gross lesion of the cervix are best evaluated with colposcopy and biopsy. For further recommendations concerning cervical cancer screening, evaluation and management of abnormal Papanicolaou test results, and treatment of cervicalintraepithelial neoplasia (CIN) grade 1, see the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines.  Also see Clinical and Workup.
The treatment of cervical cancer varies with the stage of the disease. For early invasive cancer, surgery is the treatment of choice. In more advanced cases, radiation combined with chemotherapy is the current standard of care. In patients with disseminated disease, chemotherapy or radiation provides symptom palliation. (See Treatment.)

Etiology

Early epidemiological data demonstrated a clear association between cervical cancer and sexual activity. Major risk factors observed were sex at a young age, multiple sexual partners, promiscuous male partners, and history of sexually transmitted diseases. However, the search for a potential sexually transmitted carcinogen was unsuccessful until breakthroughs in molecular biology enabled scientists to detect viral genome in cervical cells.

Strong evidence now implicates human papillomaviruses (HPVs) as prime suspects.  HPV viral DNA has been detected in more than 90% of premalignant and malignant cervical lesions compared with a consistently lower percentage in controls. Both animal data and molecular biologic evidence confirm the malignant transformation potential of papilloma virus–induced lesions. Squamous intraepithelial lesions (SILs) are found predominantly in younger women, while invasive cancers are detected more often in women 10-15 years older, suggesting slow progression of cancer.

HPV infection occurs in a high percentage of sexually active women. Most of these infections clear spontaneously within months to a few years, and only a small proportion progress to cancer. This means that other crucial factors must be involved in the process of carcinogenesis.

Three main factors have been postulated to influence the progression of low-grade SILs to high-grade SILs. These include the type and duration of viral infection, with high-risk HPV type and persistent infection predicting a higher risk for progression; host conditions that compromise immunity, such as multiparity or poor nutritional status; and environmental factors such as smoking, oral contraceptive use, or vitamin deficiencies.

In addition, various gynecologic factors significantly increase the risk for cervical cancer. These include early age of first intercourse and higher number of sexual partners.

Human papillomavirus

HPV is a heterogeneous group of viruses that contain closed circular double-stranded DNA. The viral genome encodes 6 early open reading frame proteins (ie, E1, E2, E3, E4, E6, E7), which function as regulatory proteins, and 2 late open reading frame proteins (ie, L1, L2), which make up the viral capsid.

To date, 77 different genotypes of HPV have been identified and cloned, among which types 6, 11, 16, 18, 26, 31, 33, 35, 39, 42, 43, 44, 45, 51, 52, 53, 54, 55, 56, 58, 59, 66, and 68 have the propensity to infect anogenital tissues.

The HPVs that infect the human cervix fall into 2 broad risk categories. The low-risk types, HPV 6b and 11, are associated with low-grade SILs but are never found in invasive cancer. The high-risk types, mostly HPV 16 and 18, are found in 50-80% of SILs and in up to 90% of invasive cancers. Although less common, types 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82 should also be considered carcinogenic.

The major difference between the 2 types is that after infection, the low-risk HPVs are maintained as extrachromosomal DNA episomes, while the high-risk HPV genome is found integrated into the host cellular DNA. The recombination event often leaves E6 and E7 directly coupled to the viral promoter and enhancer sequences, allowing their continued expression after integration.

Because E7 binds and inactivates the Rb protein while E6 binds p53 and directs its degradation, the functional loss of both TP53 and the RB genes leads to resistance to apoptosis, causing uncensored cell growth after DNA damage. This ultimately results in progression to malignancy.

Human immunodeficiency virus

The role of human immunodeficiency virus (HIV) infection in the pathogenesis of cervical cancer is not fully understood. Studies have shown a higher prevalence of HPV infection in HIV-seropositive women than in seronegative women, and the HPV prevalence was directly proportional to the severity of immunosuppression as measured by CD4 counts.

Impaired lymphocyte function has been postulated to enhance latent or subclinical HPV activity, resulting in a higher rate of persistent infection. Whether HIV has a synergistic effect on HPV infection, either by direct molecular interaction or through an indirect immunologic effect, remains unclear.

Epidemiology

Cervical cancer is the second most common malignancy in women worldwide, and it remains a leading cause of cancer-related death for women in developing countries. In the United States, cervical cancer is relatively uncommon. The incidence of invasive cervical cancer has declined steadily in the United States over the past few decades; however, it continues to rise in many developing countries. The change in the epidemiological trend in the United States has been attributed to mass screening with Papanicolaou tests.
The American Cancer Society estimated that in the United States in 2010, 12,200 new cases of cervical cancer would be diagnosed.  In addition, more than 50,000 cases of carcinoma in situ are diagnosed each year. Internationally, 500,000 new cases are diagnosed each year. Unlike the United States, where the annual incidence is 6.8 cases or less per 100,000 women, rates in parts of South America and Africa range as high as 52.8 cases per 100,000 women.
Forouzanfar et al performed annual age-specific assessments of cervical cancer in 187 countries from 1980-2010. The global cervical cancer incidence increased from 378,000 cases per year in 1980 to 454,000 cases per year in 2010 (annual rate of increase, 0.6%). Cervical cancer death rates have been decreasing, but the disease still accounted for 200,000 deaths in 2010; 46,000 of these women were aged 15-49 years in developing countries.

Race- and age-related demographics

In the United States, cervical cancer is more common in Hispanic, African American, and Native American women than in white women. Additionally, women of these races also have higher mortality from cervical cancers compared with their white counterparts. The Center for Disease Control and Prevention’s Surveillance of Screening-Detected Cancers (Colon and Rectum, Breast, and Cervix)—United States, 2004–2006 reported that incidence rates of late-stage cervical cancer were highest among women aged 50-79 years and Hispanics.  However, cervical cancer may be diagnosed in any woman of reproductive age.

Prognosis

Prognosis of cervical cancer depends on disease stage. In general, the 5-year survival rates are as follows:

• Stage I - Greater than 90%
• Stage II - 60-80%
• Stage III - Approximately 50%
• Stage IV - Less than 30%

The American Cancer Society estimated that 4,210 women would die of cervical cancer in the United States in 2010.  This represents 1.3% of all cancer deaths and 6.5% of deaths from gynecologic cancers.

Patien Education

Cervical cancer is overrepresented among underserved and minority groups in the United States. It is imperative to increase awareness about the benefits of Papanicolaou test screening in these groups.
A Cochrane review found that the best approach to encourage women to undergo cervical screening involved invitations, such as fixed or open appointments, letters, telephone calls, verbal recommendations, prompts, and follow-up letters.  However, these findings relate to screening in developed countries, and their relevance to developing countries is unclear. Further studies are required to determine the effectiveness of promising interventions, such as revealing in an invitation letter the gender of the smear taker, using a health promotion nurse, the use of lay outreach health workers, and intensive attempts at recruitment.
For patient education information, see the Cancer and Tumors Center, Women's Health Center, and Procedures Center, as well as Cervical Cancer, Pap Smear, and Colposcopy.

sources : http://emedicine.medscape.com

Nephrotic Syndrome

Definition 

Nephrotic syndrome is a collection of symptoms which occur because the tiny blood vessels (the glomeruli) in the kidney become leaky. This allows protein (normally never passed out in the urine) to leave the body in large amounts. 

Description 

The glomeruli (a single one is called a glomerulus) are tiny tufts of capillaries (the smallest type of blood vessels). Glomeruli are located in the kidneys, where they allow a certain amount of water and waste products to leave the blood, ultimately to be passed out of the body in the form of urine. Normally, proteins are unable to pass through the glomerular filter. Nephrotic syndrome, however, occurs when this filter becomes defective, allowing large quantities of protein to leave the blood circulation, and pass out or the body in the urine.

Patients with nephrotic syndrome are from all age groups, although in children there is an increased risk of the disorder between the ages of 18 months and four years. In children, boys are more frequently affected; in adults, the ratio of men to women is closer to equal. 

Causes and symptoms 

Nephrotic syndrome can be caused by a number of different diseases. The common mechanism which seems to cause damage involves the immune system. For some reason, the immune system seems to become directed against the person's own kidney. The glomeruli become increasingly leaky as various substances from the immune system are deposited within the kidney.

A number of different kidney disorders are associated with nephrotic syndrome, including:

·         minimal change disease or MCD (responsible for about 80% of nephrotic syndrome in children, and about 20% in adults) MCD is a disorder of the glomeruli

·         focal glomerulosclerosis

·         membranous glomerulopathy

·         membranoproliferative glomerulonephropathy

Other types of diseases can also result in nephrotic syndrome. These include diabetes, sickle-cell anemia, amyloidosis, systemic lupus erythematosus, sarcoidosis, leukemia, lymphoma, cancer of the breast, colon, and stomach, reactions to drugs (including nonsteroidal anti-inflammatory drugs, lithium, and street heroine), allergic reactions (to insect stings, snake venom, and poison ivy), infections (malaria, various bacteria, hepatitis B, herpes zoster, and the virus which causes AIDS), and severe high blood pressure.

The first symptom of nephrotic syndrome is often foamy urine. As the syndrome progresses, swelling (edema) is noticed in the eyelids, hands, feet, knees, scrotum, and abdomen. The patient feels increasingly weak and fatigued. Appetite is greatly decreased. Over time, the loss of protein causes the muscles to become weak and small (called muscle wasting). The patient may note abdominal pain and difficulty breathing. Because the kidneys are involved in blood pressure regulation, abnormally low or abnormally high blood pressure may develop.

Over time, the protein loss occurring in nephrotic syndrome will result in a generally malnourished state. Hair and nails become brittle, and growth is stunted. Bone becomes weak, and the body begins to lose other important nutrients (sugar, potassium, calcium). Infection is a serious and frequent complication, as are disorders of blood clotting. Acute kidney failure may develop. 

Diagnosis 

Diagnosis is based first on the laboratory examination of the urine and the blood. While the urine will reveal significant quantities of protein, the blood will reveal abnormally low amounts of circulating proteins. Blood tests will also reveal a high level of cholesterol. In order to diagnose one of the kidney disorders which cause nephrotic syndrome, a small sample of the kidney (biopsy) will need to be removed for examination. This biopsy can be done with a long, very thin needle which is inserted through the skin under the ribs. 

Treatment 

Treatment depends on the underlying disorder which has caused nephrotic syndrome. Medications which dampen down the immune system are a mainstay of treatment. The first choice is usually a steroid drug (such as prednisone). Some conditions may require even more potent medications, such as cyclophosphamide or cyclosporine. Treating the underlying conditions (lymphoma, cancers, heroine use, infections) which have led to nephrotic syndrome will often improve the symptoms of nephrotic syndrome as well. Some patients will require the use of specific medications to control high blood pressure. Occasionally, the quantity of fluid a patient is allowed to drink is restricted. Some patients benefit from the use of diuretics (which allow the kidney to produce more urine) to decrease swelling. 

Key terms 

Glomeruli — Tiny tufts of capillaries which carry blood within the kidneys. The blood is filtered by the glomeruli. The blood then continues through the circulatory system, but a certain amount of fluid and specific waste products are filtered out of the blood, to be removed from the body in the form of urine.

Immune system — The complex system within the body which serves to fight off harmful invaders, such as bacteria, viruses, fungi.

Kidney failure— The inability of the kidney to excrete toxic substances from the body. 

Prognosis 

Prognosis depends on the underlying disorder. Minimal change disease has the best prognosis of all the kidney disorders, with 90% of all patients responding to treatment. Other types of kidney diseases have less favorable outcomes, with high rates of progression to kidney failure. When nephrotic syndrome is caused by another, treatable disorder (infection, allergic or drug reaction), the prognosis is very good.

Sources : http://medical-dictionary.thefreedictionary.com

Selulitis

DEFINISI

Selulitis adalah suatu penyakit infeksi atau peradangan didaerah jaringan bawah kulit  (Subkutis).
Jika penyakit ini tidak ditangani maka bakteri akan menyebar ke daerah tubuh lainnya, namun yang paling sering bakteri ini menyerang daerah wajah dan tungkai bagian bawah.

PENYEBAB

Selulitis ini disebabkan oleh bakteri S.Aureus atau paling sering terjadi adalah Streptococcus.

Dalam keadaan normal, kulit terdapat berbagai macam jenis bakteri. akan tetapi kulit yang utuh serta kebersihannya merupakan penghalang efektif, yang dapat mencegah proses atau masuk dan berkembangnya bakteri di dalam tubuh kita.

Jika kulit mengalami luka, maka bakteri dapat masuk dan berkembang biak didalam tubuh, yang dapat menyebabkan infeksi dan peradangan.

TANDA DAN GEJALA

Gejala awalnya berupa malaise, menggigil, dan demam yang mendadak sebelum terjadinya lesi, kemerahan di daerah wajah atau tungkai bawah. 

Penyakit Selulitis

Jika telah terjadi infeksi dapat ditemukan lepuhan kecil berisi cairan (vesikel) atau lepuhan besar berisi cairan (bula) akan terasa panas serta bengkak, dan tampak seperti kulit jeruk yang mengelupas (peau d'orange), lesi terasa nyeri jika terkena rabaan, pembengkakan kelenjar getah bening dan mungkin ada riwayat trauma atau penyakit kulit lain yang mendasari.  

DIAGNOSA
Pada pemeriksan fisik akan ditemukan daerah pembengkakan yang terlokalisir (edema), kadang ditemukan pembengkakan kelenjar getah bening.

Pada hasil pemeriksaan darah menunjukkan peningkatan jumlah sel darah putih dan adanya infeksi bakteri.
Bila perlu, bisa dilakukan pembiakan darah.

PENANGANAN

• Umum : Istirahatkan ekstremitas yang terkena infeksi
• Simptomatik : Kompres dengan larutan antiseptik, atau untuk membersihkan nekrotik, irigasi dengan saline steril. Berikan Analgetik bia perlu.
• Kausatif : Untuk pemberian antibiotik sebaiknya konsultasi dengan dokter.

PENCEGAHAN
Untuk menghindari iritasi kulit pada saat bekerja atau berolah raga, gunakanlah pelindung yang tepat.

Jaga kesehatan dan kebersihan diri. 

Dengan tubuh yang sehat akan lebih mudah melawan bakteri sebelum mereka berkembang biak dan menyebabkan infeksi, sedangkan tubuh yang lemah memiliki pertahanan infeksi yang jelek. 

Mungkin itu saja yang dapat saya sajikan tentang penyakit selulitis, semoga bermanfaat..