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Neck Pain - Night Sweats

Neck Pain


  • What is neck pain? What are causes and risk factors for neck pain?
  • What are other symptoms that are associated with neck pain?
  • What are the structures of the neck?
  • How is neck pain diagnosed?
  • What is the treatment for neck pain? What are home remedies for neck pain?
  • Patient Discussions: Neck Pain - Causes
  • Patient Discussions: Neck Pain - Effective Treatments
  • Find a local Orthopedic Surgeon in your town

What is neck pain? What are causes and risk factors for neck pain?

Pain located in the neck is a common medical condition. Neck pain can come from a number of disorders and diseases of any tissues in the neck. Examples of common conditions producing neck pain are degenerative disc disease, neck strain, neck injury such as in whiplash, a herniated disc, or a pinched nerve. Neck pain can come from common infections, such as virus infection of the throat, leading to lymph gland swelling and neck pain. Neck pain can also come from rare infections, such as tuberculosis of the neck and bone infection of the spine in the neck (osteomyelitis and septic discitis), and meningitis (often accompanied by neck stiffness). Neck pain can also come from conditions directly affecting the muscles of the neck, such as fibromyalgia and polymyalgia rheumatica. Neck pain is also referred to as cervical pain.

Risk factors for neck pain include injury from involvement in contact sports, motor vehicle accidents, bull or bronco horse riding, etc. Prevention of neck pain in the context of these activities should include neck strengthening exercises and often neck bracing.

What are other symptoms that are associated with neck pain?

Neck pain is commonly associated with dull aching. Sometimes pain in the neck is worsened with movement of the neck. Other symptoms associated with some forms of neck pain include numbness, tingling, tenderness, sharp shooting pain, fullness, difficulty swallowing, pulsations, swishing sounds in the head, dizziness or lightheadedness, and lymph node (gland) swelling.

Neck pain can also be associated with headache, facial pain, shoulder pain, and arm numbness or tingling (upper extremity paresthesias). These associated symptoms are often a result of nerves becoming pinched in the neck. For example, compressing the nerve of sensation to the back of the head, which comes out of the neck, causes headaches in the back of the head. Depending on the condition, sometimes neck pain is accompanied by upper back and/or lower back pain, as is common in inflammation of the spine from ankylosing spondylitis.

What are the structures of the neck?

There are seven vertebrae that are the bony building blocks of the spine in the neck (the cervical vertebrae) that surround the spinal cord and canal. Between these vertebrae are discs, and nearby pass the nerves of the neck. Within the neck, structures include the skin, neck muscles, arteries, veins, lymph glands, thyroid gland, parathyroid glands, esophagus, larynx, and trachea. Diseases or conditions that affect any of these tissues of the neck can lead to neck pain.

How is neck pain diagnosed?

In diagnosing the cause of neck pain, it is important to review the history of the symptoms. In reviewing the history, the doctor will note the location, intensity, duration, and radiation of the pain. Any past injury to the neck and past treatments are noted. Aggravating and/or relieving positions or motions are also recorded. The neck is examined at rest and in motion. Tenderness is detected during palpation of the neck. An examination of the nervous system is performed to determine whether or not nerve involvement is present.

Further testing of undiagnosed neck pain can include X-ray evaluation, CAT scan, bone scan, MRI scan, myelogram, and electrical tests such as electromyography (EMG) and nerve conduction velocity test (NCV).

What is the treatment for neck pain? What are home remedies for neck pain?

The treatment of neck pain depends on its precise cause. Treatment options include rest, heat or cold applications, traction, soft collar traction, physical therapy (ultrasound, massage, manipulation), local injections of cortisone or anesthetics, topical anesthetic creams, topical pain patches, muscle relaxants, analgesics, and surgical procedures. Home remedies for treatment, such as Jacuzzi treatment, neck pain relief exercises and stretches, and neck pain relief products such as neck pillows for sleep and hot pads can be very beneficial for relief of some forms of neck pain. There are many treatment options, depending on the particular neck problem and past treatment experiences. Alternative treatments that have been used for chronic neck pain include acupuncture.


Necrotizing Fasciitis


  • What is necrotizing fasciitis?
  • Do different types of necrotizing fasciitis exist?
  • What causes necrotizing fasciitis?
  • What are the symptoms of necrotizing fasciitis?
  • How is necrotizing fasciitis diagnosed?
  • How is necrotizing fasciitis treated?
  • How is necrotizing fasciitis prevented? Is it contagious?
  • Who is at risk to get necrotizing fasciitis?
  • What is the prognosis (outcome) for patients with necrotizing fasciitis?
  • What are some additional sources of information on necrotizing fasciitis?
  • Necrotizing Fasciitis At A Glance
  • Patient Discussions: Necrotizing Fasciitis - Cause

What is necrotizing fasciitis?

Necrotizing fasciitis is a term that describes a disease condition of rapidly spreading infection, usually located in fascial planes of connective tissue that results in tissue necrosis (dead and damaged tissue). The disease occurs infrequently, but it can occur in almost any area of the body. Although many cases have been caused by group A beta-hemolytic streptococci (Streptococcus pyogenes), most investigators now agree that many different bacterial genera and species, either alone or together (polymicrobial) can cause this disease. Occasionally, mycotic (fungal) species cause necrotizing fasciitis.

This condition was described by several people in the 1840s to 1870s, and Dr. B. Wilson in 1952 first termed the condition necrotizing fasciitis. It is likely that the disease has been occurring for many centuries before it was first described in the 1800s. Currently, there are many names that have been used loosely to mean the same disease as necrotizing fasciitis: flesh-eating bacterial infection or disease; suppurative fasciitis; dermal, Meleney, hospital, or Fournier's gangrene; and necrotizing cellulitis. Body regions frequently have the term "necrotizing" placed before them to describe the initial localization of necrotizing fasciitis (for example, necrotizing colitis, necrotizing arteriolitis), but they all refer to the same disease process in the tissue. Important in understanding necrotizing fasciitis is the fact that whatever the infecting organism(s), once it reaches and grows in connective tissue, the spread of the infection can be so fast (investigators suggest some organisms can progress about 3 centimeters per hour) that the infection becomes difficult to stop with both antimicrobial drugs and surgery.

Mortality (death) rates have been reported as high as 75% for necrotizing fasciitis associated with Fournier's (testicular) gangrene. Patients with necrotizing fasciitis have an ongoing medical emergency that often leads to death or disability if it is not promptly and effectively treated.

Picture of necrotizing fasciitis (flesh-eating disease)
Picture of necrotizing fasciitis (flesh-eating disease)

 

 

Do different types of necrotizing fasciitis exist?

Variations of necrotizing fasciitis are placed by some investigators into three general groups, roughly based on the genera of organisms causing the infection and some clinical findings that unfortunately vary from patient to patient. Type 1 is either caused by more than two bacterial genera (polymicrobial) or by the infrequently found single bacterial genus such as Vibrio or fungal genera such as Candida. Type 2 is caused by Streptococcus spp, and type 3 (or termed type 3 gas gangrene) is caused by Clostridium spp. One example of clinical findings (gas in tissues) is more often found in type 3, but can be found in types 1 and 2 also. Many investigators elect not to use this typing system and simply identify the organism(s) causing the necrotizing fasciitis.

What causes necrotizing fasciitis?

Most cases of necrotizing fasciitis are caused by bacteria; only rarely do other organisms such as fungi cause this disease. Group A Streptococci and Staphylococci, either alone or with other bacteria, cause many cases of necrotizing fasciitis, although Clostridium spp should be considered as a cause especially if gas is found in the infected tissue. Because of better microbial isolation techniques for anaerobic bacteria, bacterial genera such as Bacteroides, Peptostreptococcus, and Clostridium are often cultured from the infected area. Frequently, culture of tissue involved by necrotizing fasciitis also yields a mixture of other non-anaerobic bacterial genera such as E. coli, Klebsiella, Pseudomonas, and others. Many investigators conclude that non-anaerobic organisms damage tissue areas enough to cause local areas of hypoxia (reduced oxygen) where anaerobic organisms then can thrive and extend the infection further. This results in polymicrobial infection in which one type of bacteria aids the survival and growth of another type of bacteria (synergy). Infrequently, Vibrio vulnificus causes the disease when a person, usually someone with liver function problems (for example, alcoholics or immunosuppressed patients), eats contaminated seafood or a wound gets contaminated with seawater containing Vibrio vulnificus.

In general, the bacteria that cause necrotizing fasciitis utilize similar methods to cause and advance the disease. Most produce toxins that inhibit the immune response, damage or kill tissue, produce tissue hypoxia, specifically dissolve connective tissue, or do all of the above. In polymicrobic infections, one bacterial genus may produce one toxic factor (for example, E. coli causing tissue hypoxia) while different types of coinfecting bacteria may produce other toxins that lyse (disintegrate) damaged tissue cells or connective tissue.

What are the symptoms of necrotizing fasciitis?

The majority of cases begin with an existing infection, most frequently on an extremity or in a wound. The initial infection can be from almost any cause (for example, cuts on the skin, puncture wounds, surgical incisions, or insect bites). Instead of healing, the infected site can show erythema (redness) and swelling. The site may be very sensitive to pain, even past the area of erythema. At the same time, patients often experience fever and chills. Early symptoms resemble those of cellulitis, but progressive skin changes such as skin ulceration, bullae (thin-walled fluid-filled blisters) formation, necrotic eschars (black scabs), gas formation in the tissues, and fluid draining from the site can occur rapidly as the infection progresses. Some patients can become septic (meaning the infection has spread to the bloodstream and throughout the body) before the skin changes are recognized, especially when necrotizing fasciitis begins in deep facial planes. Type 1 often occurs after trauma or surgery and may form little or undetectable amounts of gas. Type 2 usually occurs after more simple skin trauma (cuts, abrasions, and insect bites) and infects more superficial facial planes with almost no gas formation. Type 3 usually occurs after trauma or after wounds become contaminated with dirt that contains Clostridium spp, which produce gas in tissues (gangrene) and necrotic eschars. However, symptoms for types 1-3 are not definitive, and symptoms vary widely which is why some investigators prefer to define the individual patients' disease by the organism(s) isolated from the patient rather than assigning a type label.

One set of patients that is being recognized with a more specific set of symptoms and health history are those infected with Vibrio vulnificus. The organisms occur in the warmer waters in the U.S. (Gulf of Mexico and southern coastal states) and elsewhere in the world with similar water conditions. Either ingesting the organisms or getting Vibrio vulnificus from contaminated seawater into skin abrasions or cuts can cause necrotizing fasciitis. The majority of those affected are either immunosuppressed or have chronic liver problems (for example, alcoholic liver disease, hepatitis, or cirrhosis). Bullae formation and rapid progression of the disease (within hours) on the extremities are hallmarks of Vibrio vulnificus wound infections. Even though this infection is caused by a single type of bacteria, some investigators classify it as a variant of type 1 necrotizing fasciitis.

Necrotizing enterocolitis (also termed NEC; necrosis of gastrointestinal tissue) occurs mainly in premature or sick infants and may be another variant of necrotizing fasciitis. Although investigators suggest that bacterial infection causes this disease, there is no definitive data to prove this and others attribute the disease to a permeable gut tissue. A few individuals think the necrotizing enterocolitis is due to a "leaky gut syndrome," but this concept is not widely accepted by the medical community.

How is necrotizing fasciitis diagnosed?

Often a preliminary diagnosis of necrotizing fasciitis is based on the patient's symptoms, including the medical and exposure history as described above. For example, a diabetic patient with a rectal fistula that develops pain, swelling, and scrotal skin changes may be preliminarily diagnosed with Fournier's gangrene, while another diabetic patient with liver failure and skin changes (bullae) and exposure to seawater may be preliminarily diagnosed with a Vibrio vulnificus infection. Initial treatment is often begun based upon a preliminary diagnosis because waiting for a definitive diagnosis can delay treatment and result in increased morbidity and mortality. Gram staining of exudates (fluid from the infection site) or biopsied tissue may provide the physician clues to determine what organism(s) are causing the infection. For example, the stain can distinguish between Gram-negative and Gram-positive organisms and further distinguish their shapes (coccus or round, rod, or comma-shaped like Vibrio). Definitive diagnosis depends on isolation of the organism(s) from the patient using both aerobic and anaerobic isolation techniques, and rarely, fungal culture methods.

Organisms isolated from necrotizing fasciitis need to have studies done to determine antibiotic resistance, because many organisms causing the disease are multi-drug resistant. A surgeon needs to be consulted early to help obtain tissue samples and to be involved with potential treatment protocols (debridement, amputation). Although X-rays occasionally show gas in tissues, investigators suggest doing Doppler, CT, or MRI studies to help show gas in tissues and to help delineate the extent of the infection. Most physicians run additional tests such as white blood cell (WBC) counts (elevated in necrotizing fasciitis), BUN (blood urea nitrogen), sodium (both decreased in necrotizing fasciitis), and other tests to monitor the patient.

How is necrotizing fasciitis treated?

At the time of preliminary diagnosis, the patient needs to be hospitalized and started on intravenous antibiotics immediately. The initial choice of antibiotics can be made based upon the types of bacteria suspected of causing the infection, but many doctors believe that multiple antibiotics should be used at the same time to protect the patient from methicillin-resistant Staphylococcus aureus (MRSA), as well as infections with anaerobic bacteria, and polymicrobic infections. Antibiotic susceptibility studies, done in the laboratory after the infecting organism(s) has been isolated from the patient, can help the physician choose the best antibiotics to treat the infected individual.

A surgeon needs to be consulted immediately if necrotizing fasciitis is suspected or preliminarily diagnosed. Debridement of necrotic tissue and collection of tissue samples, needed for culture to identify pathogens, are done by a surgeon. The type of surgeon consulted may depend on the area of the body affected; for example, a urologic surgeon would be consulted for Fournier's gangrene. As is the case for immediate antimicrobial therapy, early surgical treatment of most cases of necrotizing fasciitis can reduce morbidity and mortality.

Many patients with necrotizing fasciitis are very sick and require admission to an intensive care unit. Sepsis and organ failure (renal, pulmonary, and cardiovascular systems) need to be treated aggressively to increase the patient's chance for recovery. Treatments such as insertion of a breathing tube, intravenous administration of fluids, and drugs to support the cardiovascular system may be required. Although not available in many hospitals, hyperbaric oxygen therapy (oxygen given under pressure with the patient in a chamber) is sometimes used in treatment as the oxygen can inhibit or stop anaerobic bacterial growth and promote tissue recovery. This therapy does not replace antibiotics or surgical treatment. However, hyperbaric oxygen therapy has been shown by researchers to further reduce morbidity and mortality by about 10%-20% in some patients when used in conjunction with antibiotics and surgery.

How is necrotizing fasciitis prevented? Is it contagious?

Necrotizing fasciitis does not begin unless an infection has already started in tissue; immediate effective treatment of any infection is likely to prevent the disease. Further, anything that can help prevent infections will help prevent necrotizing fasciitis. Practices such as hand washing, checking extremities for cuts or wounds if you have diabetes, avoiding physical contact with people who carry MRSA, and good hygiene practices help prevent initial infections that may lead to necrotizing fasciitis. Immunosuppressed patients should be very careful not to get infections, and people with liver disease should avoid eating seafood that may be contaminated with Vibrio vulnificus. People with liver disease should not have any infections or cuts in the skin exposed to warm seawater to avoid necrotizing fasciitis caused by Vibrio vulnificus.

Physicians, surgeons, and other caregivers play an important role in prevention. Cases of necrotizing fasciitis may occur when surgical sites become infected. Consequently, physicians need to use sterile techniques when doing surgery and to adhere to hospital practices such as glove and gown coverage to help prevent infection spread in hospitalized patients. Careful surgical techniques in sites that can easily become contaminated are required. Some examples of such sites are bowel surgery, episiotomy (surgically enlarging the vaginal outlet), and debridement with closure of traumatic wounds.

Necrotizing fasciitis is not usually contagious. However, it is possible for uninfected people to physically come into contact with some patients with the disease and become infected with an organism that may eventually cause necrotizing fasciitis. For example, a person could come in contact with a lesion containing MRSA organisms causing or contributing to the disease in another person and then become infected with MRSA.

Who is at risk to get necrotizing fasciitis?

Theoretically, anyone with an infection has a small risk of getting necrotizing fasciitis; the risk begins to increase if the infection occurs in immunosuppressed individuals (for example, diabetics, elderly, infants, those with liver disease, or those taking immunosuppressive drugs such as chemotherapy for cancer). Visible infections (skin, hair follicles, fingernails, visible trauma sites) are more likely to be noticed and treated than some deep infections. Patients that have any deep infections (muscle, bone, joint, gastrointestinal) are at somewhat higher risk for the disease because the initial infection and subsequent spread is usually not as noticeable as more visible infections. Although pregnant patients rarely develop the disease, the risk increases in the postpartum period, especially if the mother has diabetes and has procedures such as cesarean delivery (C-section) or episiotomy. Necrotizing enterocolitis occurs mainly in premature or sick infants and may be another variant of necrotizing fasciitis, but there is still controversy about the cause of this disease.

Necrotizing fasciitis has interesting demographics; more males than females are affected (about 3 to 1), and Vibrio vulnificus infections seem limited to coastal areas with warm water where the organisms are found associated with seafood and contaminated water.

What is the prognosis (outcome) for patients with necrotizing fasciitis?

Untreated necrotizing fasciitis has a poor prognosis; death or severe morbidity (for example, limb loss) is the frequent outcome. Data on the number of cases per year are estimated between 500-1,000 per year in the U.S. Data in most other countries is incomplete, and some investigators think the actual U.S. case numbers may be much higher. Even with appropriate treatment, the mortality (death) rate can be as high as 25%. Infection with MRSA and other multi-drug resistant organisms tends to have higher morbidity and mortality rates. Combined mortality and morbidity (for example, limb loss, scar formation, renal failure, and sepsis) for all cases of necrotizing fasciitis has been reported as 70%-80%. Cases of Fournier's gangrene have reported as high as 75% mortality rates, while cases of Vibrio vulnificus-associated necrotizing fasciitis have about a 50% mortality rate. Fortunately, Vibrio vulnificus infection is relatively uncommon, but the incidence seems to be increasing. The U.S. Centers for Disease Control and Prevention (CDC), in 2007, made Vibrio vulnificus infection a reportable disease so the statistics on the incidence (frequency of occurrence) should be more easily obtained in the future.

What are some additional sources of information on necrotizing fasciitis?

http://emedicine.medscape.com/article/1054438-overview

http://www.cdc.gov/nczved/dfbmd/disease_listing/vibriov_gi.html

http://www.medicinenet.com/gangrene/page5.htm

http://www.emedicinehealth.com/mrsa_infection/article_em.htm

http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-acidophilus.html

http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/001148.htm

http://www.cdc.gov/ncidod/dbmd/diseaseinfo/Groupastreptococcal_g.htm

Necrotizing Fasciitis At A Glance
  • Necrotizing fasciitis refers to a rapidly spreading infection, usually located in fascial planes of connective tissue that results in tissue death (necrosis).
  • Different types of bacterial infection can cause necrotizing fasciitis.
  • The majority of cases begin with an existing infection, most frequently on an extremity or in a wound.
  • Necrotizing fasciitis is a serious condition that is often associated with sepsis and widespread organ failure.
  • Treatment involves antibiotics and surgical debridement of the wound areas as well as supportive measures such as insertion of a breathing tube, intravenous administration of fluids, and drugs to support the cardiovascular system.


Nerve Blocks


Pain Management: Nerve Blocks

  • Introduction
  • How are nerve blocks used?
  • Types of nerve blocks
  • Other nerve blocks
  • Side effects and risks of nerve blocks

Introduction

Nerve blocks are used for pain treatment and management. There are several different types of nerve blocks that serve different purposes.

Often a group of nerves, called a plexus or ganglion, that causes pain to a specific organ or body region can be blocked with the injection of medication into a specific area of the body. The injection of this nerve-numbing substance is called a nerve block.

How Are Nerve Blocks Used?

Different kinds of nerve blocks are used for different purposes.

  • Therapeutic nerve blocks are used to treat painful conditions. Such nerve blocks contain local anesthetic that can be used to control acute pain.
  • Diagnostic nerve blocks are used to determine sources of pain. These blocks typically contain an anesthetic with a known duration of relief.
  • Prognostic nerve blocks predict the outcomes of given treatments. For example, a nerve block may be performed to determine if more permanent treatments (such as surgery) to block the activity of a nerve would be successful in treating pain.
  • Preemptive nerve blocks are meant to prevent subsequent pain from a procedure that can cause problems including phantom limb pain.
  • Nerve blocks can be used, in some cases, to avoid surgery.

Types of Nerve Blocks

Various areas of pain require different nerve block types. Below are a few of the available nerve blocks, followed in parentheses by some of the parts of the body for which they are used.

  • Trigeminal nerve blocks (face)
  • Ophthalmic nerve block (eyelids and scalp)
  • Supraorbital nerve block (forehead)
  • Maxillary nerve block (upper jaw)
  • Sphenopalatine nerve block (nose and palate)
  • Cervical epidural, thoracic epidural, and lumbar epidural block (neck and back)
  • Cervical plexus block and cervical paravertebral block (shoulder and upper neck)
  • Brachial plexus block, elbow block, and wrist block (shoulder/arm/hand, elbow, and wrist)
  • Subarachnoid block and celiac plexus block (abdomen and pelvis)

Other Nerve Blocks

Other types of nerve blocks include:

  • Sympathetic nerve block:

    A sympathetic nerve block is one that is performed to determine if there is damage to the sympathetic nerve chain. This is a network of nerves extending the length of the spine. These nerves control some of the involuntary functions of the body, such as opening and narrowing blood vessels.

  • Stellate ganglion block: This is a type of sympathetic nerve block performed to determine if there is damage to the sympathetic nerve chain supplying the head, neck, chest, or arms and if it is the source of pain in those areas. Although used mainly as a diagnostic block, the stellate ganglion block may provide pain relief in excess of the duration of the anesthetic.
  • Facet joint block: Also known as a zygapophysial joint block, the facet joint block is performed to determine whether a facet joint is a source of pain. Facet joints are located on the back of the spine, where one vertebra slightly overlaps another. These joints guide and restrict the spines movement.

Side Effects and Risks of Nerve Blocks

Nerve blocks do have risks and side effects. They include:

  • Elevated blood sugars
  • Rash
  • Itching
  • Weight gain
  • Extra energy
  • Soreness at the site of injection
  • Bleeding
  • Death (in rare cases)

Although many kinds of nerve blocks exist, this treatment cannot always be used. If your pain isn't related to pain in a single or small group of nerves, nerve blocks may not be right for you. Your doctor can advise you as to whether this treatment is appropriate for you.


Nerve Conduction Velocity Test (NCV)


  • What is a nerve conduction velocity test (NCV)?
  • When is a nerve conduction velocity test used?

 

What is a nerve conduction velocity test?

A nerve conduction velocity test (NCV) is an electrical test that is used to determine the adequacy of the conduction of the nerve impulse as it courses down a nerve. This test is used to detect signs of nerve injury.

In this test, the nerve is electrically stimulated, and the electrical impulse 'down stream' from the stimulus is measured. This is usually done with surface patch electrodes (they are similar to those used for an electrocardiogram) that are placed on the skin over the nerve at various locations. One electrode stimulates the nerve with a very mild electrical impulse. The resulting electrical activity is recorded by the other electrodes. The distance between electrodes and the time it takes for electrical impulses to travel between electrodes are used to calculate the speed of impulse transmission (nerve conduction velocity). A decreased speed of transmission indicates nerve disease. A nerve conduction velocity test is often done at the same time as an electromyogram (EMG) in order to exclude or detect muscle conditions.

When is a nerve conduction velocity test used?

Symptoms that might prompt a health care professional to order an nerve conduction velocity test test include numbness, tingling, and/or burning sensations. The nerve conduction velocity test test can be used to detect true nerve disorders (such as peripheral neuropathy and mononeuritis multiplex) or conditions whereby nerves are affected by mechanical compression injury (such as carpal tunnel syndrome and compression neuropathy). A normal body temperature must be maintained for the nerve conduction velocity test test, because low body temperatures slow nerve conduction.


Nerve Disease and Bladder Control


  • What bladder control problems does nerve damage cause?
  • What causes nerve damage?
  • How will the doctor test for nerve damage and bladder control problems?
  • What are the treatments for overactive bladder?
  • How do you do Kegel exercises?
  • What are the treatments for lack of coordination between the bladder and urethra?
  • What are the treatments for urine retention?
  • Hope through research
  • For more information
  • Find a local Urologist in your town

For the urinary system to do its job, muscles and nerves must work together to hold urine in the bladder and then release it at the right time. Nerves carry messages from the bladder to the brain to let it know when the bladder is full. They also carry messages from the brain to the bladder, telling muscles either to tighten or release. A nerve problem might affect your bladder control if the nerves that are supposed to carry messages between the brain and the bladder do not work properly.

What bladder control problems does nerve damage cause?

Nerves that work poorly can lead to three different kinds of bladder control problems.

Nerves carry signals from the brain to the bladder and sphincter.
Nerves carry signals from the brain to the bladder and sphincter.

 

Overactive bladder. Damaged nerves may send signals to the bladder at the wrong time, causing its muscles to squeeze without warning. The symptoms of overactive bladder include

  • urinary frequency -- defined as urination eight or more times a day or two or more times at night
  • urinary urgency -- the sudden, strong need to urinate immediately
  • urge incontinence -- leakage of urine that follows a sudden, strong urge to urinate

Poor control of sphincter muscles. Sphincter muscles surround the urethra and keep it closed to hold urine in the bladder. If the nerves to the sphincter muscles are damaged, the muscles may become loose and allow leakage or stay tight when you are trying to release urine.

Urine retention. For some people, nerve damage means their bladder muscles do not get the message that it is time to release urine or are too weak to completely empty the bladder. If the bladder becomes too full, urine may back up and the increasing pressure may damage the kidneys. Or urine that stays too long may lead to an infection in the kidneys or bladder. Urine retention may also lead to overflow incontinence

What causes nerve damage?

Many events or conditions can damage nerves and nerve pathways. Some of the most common causes are

  • vaginal childbirth
  • infections of the brain or spinal cord
  • diabetes
  • stroke
  • accidents that injure the brain or spinal cord
  • multiple sclerosis
  • heavy metal poisoning

In addition, some children are born with nerve problems that can keep the bladder from releasing urine, leading to urinary infections or kidney damage.

How will the doctor test for nerve damage and bladder control problems?

Any evaluation for a health problem begins with a medical history and a general physical examination. Your doctor can use this information to narrow down the possible causes for your bladder problem.

If nerve damage is suspected, the doctor may need to test both the bladder itself and the nervous system, including the brain. Three different kinds of tests might be used:

Urodynamics. These tests involve measuring pressure in the bladder while it is being filled to see how much it can hold and then checking to see whether the bladder empties completely and efficiently.

Imaging. The doctor may use different types of equipment -- x-rays, magnetic resonance imaging (MRI), and computerized tomography (CT) scans -- to take pictures of the urinary tract and nervous system, including the brain.

EEG and EMG. An electroencephalograph (EEG) is a test in which wires with pads are placed on the forehead to sense any dysfunction in the brain. The doctor may also use an electromyograph (EMG), which uses wires with pads placed on the lower abdomen to test the nerves and muscles of the bladder.

What are the treatments for overactive bladder?

The treatment for a bladder control problem depends on the cause of the nerve damage and the type of voiding dysfunction that results.

In the case of overactive bladder, your doctor may suggest a number of strategies, including bladder training, electrical stimulation, drug therapy, and, in severe cases where all other treatments have failed, surgery.

Bladder training. Your doctor may ask you to keep a bladder diary -- a record of your fluid intake, trips to the bathroom, and episodes of urine leakage. This record may indicate a pattern and suggest ways to avoid accidents by making a point of using the bathroom at certain times of the day -- a practice called timed voiding. As you gain control, you can extend the time between trips to the bathroom. Bladder training also includes Kegel exercises to strengthen the muscles that hold in urine.

Electrical stimulation. Mild electrical pulses can be used to stimulate the nerves that control the bladder and sphincter muscles. Depending on which nerves the doctor plans to treat, these pulses can be given through the vagina or anus, or by using patches on the skin. Another method is a minor surgical procedure to place the electric wire near the tailbone. This procedure involves two steps. First, the wire is placed under the skin and connected to a temporary stimulator, which you carry with you for several days. If your condition improves during this trial period, then the wire is placed next to the tailbone and attached to a permanent stimulator under your skin. The Food and Drug Administration (FDA) has approved this device, marketed as the InterStim system, to treat urge incontinence, urgency-frequency syndrome, and urinary retention in patients for whom other treatments have not worked.

A device can be placed under your skin to deliver mild electrical pulses to the nerves that control bladder function.
A device can be placed under your skin to deliver mild electrical pulses to the nerves that control bladder function.

 

 

Drug therapy. Different drugs can affect the nerves and muscles of the urinary tract in different ways.

  • Drugs that relax bladder muscles and prevent bladder spasms include oxybutynin chloride (Ditropan), tolterodine (Detrol), hyoscyamine (Levsin), and propantheline bromide (Pro-Banthine), which belong to the class of drugs called anticholinergics. Their most common side effect is dry mouth, although large doses may cause blurred vision, constipation, a faster heartbeat, and flushing. A new patch delivery system for oxybutynin (Oxytrol) may decrease side effects. Ditropan XL and Detrol LA are timed-release formulations that deliver a low level of the drug continuously in the body. These drugs have the advantage of once-a-day administration. In 2004, the FDA approved trospium chloride (Sanctura), darifenacin (Enablex), and solifenacin succinate (VESIcare) for the treatment of overactive bladder.
  • Drugs for depression that also relax bladder muscles include imipramine hydrochloride (Tofranil), a tricyclic antidepressant. Side effects may include fatigue, dry mouth, dizziness, blurred vision, nausea, and insomnia.

Additional drugs are being evaluated for the treatment of overactive bladder and may soon receive FDA approval.

Surgery. In extreme cases, when incontinence is severe and other treatments have failed, surgery may be considered. The bladder may be made larger through an operation known as augmentation cystoplasty, in which a part of the diseased bladder is replaced with a section taken from the patient's bowel. This operation may improve the ability to store urine but may make the bladder more difficult to empty, making regular catheterization necessary. Additional risks of surgery include the bladder breaking open and leaking urine into the body, bladder stones, mucus in the bladder, and infection.

How do you do Kegel exercises?

Kegel exercises strengthen the muscles that hold up the bladder and keep it closed.

The first step in doing Kegel exercises is to find the right muscles. Imagine you are trying to stop yourself from passing gas. Squeeze the muscles you would use. If you sense a "pulling" feeling, those are the right muscles for pelvic exercises.

Try not to squeeze other muscles at the same time. Be careful not to tighten your stomach, legs, or buttocks. Squeezing the wrong muscles can put more pressure on your bladder control muscles. Just squeeze the pelvic muscles. Don't hold your breath.

At first, find a quiet spot to practice -- your bathroom or bedroom -- so you can concentrate. Pull in the pelvic muscles and hold for a count of 3. Then relax for a count of 3. Repeat, but don't overdo it. Work up to 3 sets of 10 repeats. Start doing your pelvic muscle exercises lying down. This position is the easiest because the muscles do not need to work against gravity. When your muscles get stronger, do your exercises sitting or standing. Working against gravity is like adding more weight.

Be patient. Don't give up. It takes just 5 minutes a day. You may not feel your bladder control improve for 3 to 6 weeks. Still, most people do notice an improvement after a few weeks.

Some people with nerve damage cannot tell whether they are doing Kegel exercises correctly. If you are not sure, ask your doctor or nurse to examine you while you try to do them. If you are not squeezing the right muscles, you can still learn proper Kegel exercises by doing special training with biofeedback, electrical stimulation, or both.

What are the treatments for lack of coordination between the bladder and urethra?

The job of the sphincter muscles is to hold urine in the bladder by squeezing the urethra shut. If the urethral sphincter fails to stay closed, urine may leak out of the bladder. When nerve signals are coordinated properly, the sphincter muscles relax to allow urine to pass through the urethra as the bladder contracts to push out urine. If the signals are not coordinated, the bladder and the sphincter may contract at the same time, so urine cannot pass easily.

Drug therapy for an uncoordinated bladder and urethra. Scientists have not yet found a drug that works selectively on the urethral sphincter muscles, but drugs used to reduce muscle spasms or tremors are sometimes used to help the sphincter relax. Baclofen (Lioresal) is prescribed for muscle spasms or cramping in patients with multiple sclerosis and spinal injuries. Diazepam (Valium) can be taken as a muscle relaxant or to reduce anxiety. Drugs called alpha-adrenergic blockers can also be used to relax the sphincter. Examples of these drugs are alfuzosin (UroXatral), tamsulosin (Flomax), terazosin (Hytrin), and doxazosin (Cardura). The main side effects are low blood pressure, dizziness, fainting, and nasal congestion. All of these drugs have been used to relax the urethral sphincter in people whose sphincter does not relax well on its own.

 

Botox injection. Botulinum toxin type A (Botox) is best known as a cosmetic treatment for facial wrinkles. Doctors have also found that botulinum toxin is useful in blocking spasms like eye ticks or relaxing muscles in patients with multiple sclerosis. Urologists have found that injecting botulinum toxin into the tissue surrounding the sphincter can help it to relax. Although the FDA has approved botulinum toxin only for facial cosmetic purposes, researchers are studying the safety and effectiveness of botulinum toxin injection into the sphincter for possible FDA approval in the future.

What are the treatments for urine retention?

Urine retention may occur either because the bladder wall muscles cannot contract or because the sphincter muscles cannot relax.

Catheter. A catheter is a thin tube that can be inserted through the urethra into the bladder to allow urine to flow into a collection bag. If you are able to place the catheter yourself, you can learn to carry out the procedure at regular intervals, a practice called clean intermittent catheterization. Some patients cannot place their own catheters because nerve damage affects their hand coordination as well as their voiding function. These patients need to have a caregiver place the catheter for them at regular intervals. If regular catheter placement is not feasible, the patients may need to have an indwelling catheter that can be changed less often. Indwelling catheters have several risks, including infection, bladder stones, and bladder tumors. However, if the bladder cannot be emptied any other way, then the catheter is the only way to stop the buildup of urine in the bladder that can damage the kidneys.

Urethral stent. Stents are small tube-like devices inserted into the urethra and allowed to expand, like a spring, widening the opening for urine to flow out. Stents can help prevent urine backup when the bladder wall and sphincter contract at the same time because of improper nerve signals. However, stents can cause problems if they move or lead to infection.

Surgery. Men may consider a surgery that removes the external sphincter -- a sphincterotomy -- or a piece of it -- a sphincter resection -- to prevent urinary retention. The surgeon will pass a thin instrument through the urethra to deliver electrical or laser energy that burns away sphincter tissue. Possible complications include bleeding that requires a transfusion and, rarely, problems with erections. This procedure causes loss of urine control and requires the patient to collect urine by wearing an external catheter that fits over the penis like a condom. No external collection device is available for women.

Urinary diversion. If other treatments fail and urine regularly backs up and damages the kidneys, the doctor may recommend a urinary diversion, a procedure that may require an outside collection bag attached to a stoma, a surgically created opening where urine passes out of the body. Another form of urinary diversion replaces the bladder with a continent urinary reservoir, an internal pouch made from sections of the bowel or other tissue. This method allows the person to store urine inside the body until a catheter is used to empty it through a stoma.

Hope through research

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) has many research programs aimed at finding treatments for urinary disorders, including bladder control problems caused by nerve damage. NIDDK-supported researchers have narrowed the search for a gene that causes neurological problems in bladder, bowel, and facial muscles. Finding the gene may lead to greater understanding of how nerves and muscles work together and how nerve damage can cause urination problems.

The Eunice Kennedy Shriver National Institute of Child Health and Human Development is supporting Collaborative Urological Research in Spinal Cord Injury, a program devoted to finding novel strategies to treat bladder control problems in people with spinal cord injury.

For More Information

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Neuroblastoma

  • What is neuroblastoma?
  • What are symptoms and signs of neuroblastoma?
  • What tests are used in the detection and diagnosis of neuroblastoma?
  • What is the prognosis for neuroblastoma?
  • What are the stages of neuroblastoma?
  • What is the treatment for neuroblastoma?
  • What are treatment options for neuroblastoma?
  • Find a local Oncologist in your town

What is neuroblastoma?

Neuroblastoma is a disease in which malignant (cancer) cells form in nerve tissue of the adrenal gland, neck, chest, or spinal cord.

Neuroblastoma often begins in the nerve tissue of the adrenal glands. There are two adrenal glands, one on top of each kidney in the back of the upper abdomen. The adrenal glands produce important hormones that help control heart rate, blood pressure, blood sugar, and the way the body reacts to stress. Neuroblastoma may also begin in the chest, in nerve tissue near the spine in the neck, or in the spinal cord.

Neuroblastoma most often begins during early childhood, usually in children younger than 5 years. It sometimes forms before birth but is usually found later, when the tumor begins to grow and cause symptoms. In rare cases, neuroblastoma may be found before birth by fetal ultrasound.

By the time neuroblastoma is diagnosed, the cancer has usually metastasized (spread), most often to the lymph nodes, bones, bone marrow, liver, and skin.

Possible signs of neuroblastoma include bone pain and a lump in the abdomen, neck, or chest.

The most common symptoms of neuroblastoma are caused by the tumor pressing on nearby tissues as it grows or by cancer spreading to the bone. These and other symptoms may be caused by neuroblastoma. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

  • Lump in the abdomen, neck, or chest.
  • Bulging eyes.
  • Dark circles around the eyes ("black eyes").
  • Bone pain.
  • Swollen stomach and trouble breathing in infants.
  • Painless, bluish lumps under the skin in infants.
  • Weakness or paralysis (loss of ability to move a body part).

Less common signs of neuroblastoma include the following:

  • Fever.
  • Shortness of breath.
  • Feeling tired.
  • Easy bruising or bleeding.
  • Petechiae (flat, pinpoint spots under the skin caused by bleeding).
  • High blood pressure.
  • Severe watery diarrhea.
  • Jerky muscle movements.
  • Uncontrolled eye movement.
  • Swelling of the legs, ankles, feet, or scrotum.

Tests that examine many different body tissues and fluids are used to detect (find) and diagnose neuroblastoma.

The following tests and procedures may be used:

  • Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient's health habits and past illnesses and treatments will also be taken.
  • Twenty-four-hour urine test: A test in which urine is collected for 24 hours to measure the amounts of certain substances. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it. A higher than normal amount of the substances homovanillic acid (HMA) and vanillyl mandelic acid (VMA) may be a sign of neuroblastoma.
  • Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it. A higher than normal amount of the hormones dopamine and norepinephrine may be a sign of neuroblastoma.
  • Cytogenetic analysis: A test in which cells in a sample of blood or bone marrow are viewed under a microscope to look for certain changes in the chromosomes.
  • Bone marrow aspiration and biopsy: The removal of a small piece of bone, bone marrow, and blood by inserting a needle into the hipbone or breastbone. A pathologist views both the bone and the bone marrow samples under a microscope to look for signs of cancer. Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer.
  • X-ray: An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
  • Neurological exam: A series of questions and tests to check the brain, spinal cord, and nerve function. The exam checks a person's mental status, coordination, and ability to walk normally, and how well the muscles, senses, and reflexes work. This may also be called a neuro exam or a neurologic exam.
  • Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
  • Immunohistochemistry study: A procedure in which dyes or enzymes are added to a blood or bone marrow sample to test for certain antigens (proteins that stimulate the body's immune response).

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

Age of the child when diagnosed. Stage of the cancer. Where the tumor is in the body. Tumor histology (the shape, function, and structure of the tumor cells). Prognosis and treatment decisions for neuroblastoma are also affected by tumor biology, which includes:

The patterns of the tumor cells. How different the tumor cells are from normal cells. How fast the tumor cells are growing. The number of chromosomes in the tumor cells. How many copies of the N-myc gene there are. The tumor biology is said to be favorable or unfavorable, depending on these factors. A favorable tumor biology means there is a better chance of recovery.

Stages of neuroblastoma

After neuroblastoma has been diagnosed, tests are done to find out if cancer has spread from where it started to other parts of the body.

The process used to find out the extent or spread of cancer is called staging. The information gathered from the staging process helps determine the stage of the disease. For neuroblastoma, stage is one of the factors used to plan treatment. The following tests and procedures may be used to determine the stage:

  • Bone marrow aspiration and biopsy: The removal of a small piece of bone, bone marrow, and blood by inserting a needle into the hipbone or breastbone. A pathologist views both the bone and bone marrow samples under a microscope to look for signs of cancer.
  • Lymph node biopsy: The removal of all or part of a lymph node. A pathologist views the tissue under a microscope to look for cancer cells. One of the following types of biopsies may be done:
    • Excisional biopsy: The removal of an entire lymph node.
    • Incisional biopsy or core biopsy: The removal of part of a lymph node using a wide needle.
    • Needle biopsy or fine-needle aspiration: The removal of a sample of tissue or fluid from a lymph node using a thin needle.
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
  • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • X-rays of the chest, bones, and abdomen: An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
  • Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
  • Radionuclide scan: A procedure to find areas in the body where cells, such as cancer cells, are dividing rapidly. A very small amount of radioactive material is swallowed or injected into a vein and travels through the bloodstream. The radioactive material collects in the bones or other tissues and is detected by a radiation-measuring device.

The following stages are used for neuroblastoma:

Stage 1

In stage 1, the tumor is in only one area and all of the tumor that can be seen is completely removed during surgery.

Stage 2

Stage 2 is divided into stage 2A and 2B.

  • Stage 2A: The tumor is in only one area and all of the tumor that can be seen cannot be completely removed during surgery.
  • Stage 2B: The tumor is in only one area and all of the tumor that can be seen may be completely removed during surgery. Cancer cells are found in the lymph nodes near the tumor.

Stage 3

In stage 3, one of the following is true:

  • the tumor cannot be completely removed during surgery and has spread from one side of the body to the other side and may also have spread to nearby lymph nodes; or
  • the tumor is in only one area, on one side of the body, but has spread to lymph nodes on the other side of the body; or
  • the tumor is in the middle of the body and has spread to tissues or lymph nodes on both sides of the body, and the tumor cannot be removed by surgery.

Stage 4

Stage 4 is divided into stage 4 and stage 4S.

  • In stage 4, the tumor has spread to distant lymph nodes, the skin, or other parts of the body.
  • In stage 4S, the following are true:
    • the child is younger than 1 year; and
    • the cancer has spread to the skin, liver, and/or bone marrow; and
    • the tumor is in only one area and all of the tumor that can be seen may be completely removed during surgery; and/or
    • cancer cells may be found in the lymph nodes near the tumor.

Treatment of neuroblastoma is based on risk groups.

For many types of cancer, stages are used to plan treatment. For neuroblastoma, treatment depends on risk groups. The stage of neuroblastoma is one factor used to determine risk group. Other factors are the age of the child, tumor histology, and tumor biology.

There are 3 risk groups: low risk, intermediate risk, and high risk.

  • Low-risk and intermediate-risk neuroblastoma have a good chance of being cured.
  • High-risk neuroblastoma may be difficult to cure.

Progressive/recurrent neuroblastoma

Progressive neuroblastoma is cancer that has progressed (continued to grow) during treatment. Recurrent neuroblastoma is cancer that has recurred (come back) after it has been treated. The cancer may come back in the same place or in other parts of the body.

Treatment option overview

There are different types of treatment for patients with neuroblastoma.

Different types of treatment are available for patients with neuroblastoma. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

Because cancer in children is rare, taking part in a clinical trial should be considered. Clinical trials are taking place in many parts of the country. Information about ongoing clinical trials is available from the NCI Web site 2. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

Children with neuroblastoma should have their treatment planned by a team of doctors with expertise in treating childhood cancer.

Your child's treatment will be managed by a pediatric oncologist, a doctor who specializes in treating children with cancer. The pediatric oncologist may refer you to other pediatric doctors who have experience and expertise in treating children with neuroblastoma and who specialize in certain areas of medicine. These may include the following specialists:

  • Medical oncologist.
  • Hematologist.
  • Pediatric surgeon.
  • Radiation oncologist.
  • Endocrinologist.
  • Neurologist.
  • Neuropathologist.
  • Neuroradiologist.
  • Pediatric nurse specialist.
  • Social worker.
  • Rehabilitation specialist.
  • Psychologist.

Children who are treated for neuroblastoma may be at higher risk for second cancers.

Some cancer treatments cause side effects that continue or appear years after cancer treatment has ended. These are called late effects. Late effects of cancer treatment include physical problems; changes in mood, feelings, actions, thinking, learning, or memory; and second cancers.

Some late effects may be treated or controlled. It is important that parents of children who are treated for neuroblastoma talk with their doctors about the possible late effects caused by some treatments.

Four types of standard treatment are used:

Surgery

Surgery is usually used to treat neuroblastoma. Depending on where the tumor is and whether it has spread, as much of the tumor as possible will be removed. If the tumor cannot be removed, a biopsy may be done instead.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

The use of two or more anticancer drugs is called combination chemotherapy.

Watchful waiting

Watchful waiting is closely monitoring a patient's condition without giving any treatment until symptoms appear or change.

New types of treatment are being tested in clinical trials. These include the following:

Monoclonal antibody therapy

Monoclonal antibody therapy is a cancer treatment that uses antibodies made in the laboratory, from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to deliver drugs, toxins, or radioactive material directly to cancer cells.

High-dose chemotherapy and radiation therapy with stem cell transplant

High-dose chemotherapy and radiation therapy with stem cell transplant is a way of giving high doses of chemotherapy and radiation therapy and replacing blood -forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of the patient or a donor and are frozen and stored. After chemotherapy and radiation therapy are completed, the stored stem cells are thawed and given back to the patient through an infusion. These reinfused stem cells grow into (and restore) the body's blood cells.

Other drug therapy

13-cis retinoic acid is a vitamin -like drug that slows the cancer's ability to make more cancer cells and changes how these cells look and act.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site 2.

Treatment options for neuroblastoma

Low-risk neuroblastoma

Treatment of low-risk neuroblastoma may include the following:

  • Surgery followed by watchful waiting.
  • Watchful waiting alone for certain infants.
  • Surgery followed by chemotherapy, when less than half of the tumor is removed or when serious symptoms cannot be relieved by surgery.
  • Radiation therapy to treat tumors that are causing serious problems and do not respond quickly to chemotherapy.
  • Low-dose chemotherapy.

Intermediate-risk neuroblastoma

Treatment of intermediate-risk neuroblastoma may include the following:

  • Chemotherapy.
  • Chemotherapy followed by surgery and/or radiation therapy.
  • Radiation therapy to treat tumors that are causing serious problems and do not respond quickly to chemotherapy.

High-risk neuroblastoma

Treatment of high-risk neuroblastoma may include the following:

  • High-dose chemotherapy followed by surgery to remove as much of the tumor as possible.
  • Radiation therapy to the tumor site and, if needed, to other parts of the body with cancer.
  • Stem cell transplant.
  • Chemotherapy followed by 13-cis retinoic acid.
  • A clinical trial of monoclonal antibody therapy after chemotherapy.
  • A clinical trial of radiation therapy with radioactive iodine before stem cell transplant.
  • A clinical trial of stem cell transplant followed by 13-cis retinoic acid.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied.

Progressive/recurrent neuroblastoma

Patients first treated for low-risk neuroblastoma

Treatment for recurrent neuroblastoma that is found in one place in the body may include the following:

  • Surgery followed by watchful waiting or chemotherapy.
  • Chemotherapy.
  • High-dose chemotherapy, stem cell transplant, and 13-cis retinoic acid.

Treatment for recurrent neuroblastoma that has spread to other parts of the body may include the following:

  • Watchful waiting.
  • Surgery followed by chemotherapy.
  • Chemotherapy.
  • High-dose chemotherapy, stem cell transplant, and 13-cis retinoic acid.
  • A clinical trial of a new treatment.

Patients first treated for intermediate-risk neuroblastoma

For recurrent neuroblastoma that is found in one place in the body, treatment is usually surgery, with or without chemotherapy.

For recurrent neuroblastoma that has spread to other parts of the body, treatment is usually high-dose chemotherapy, stem cell transplant, and 13-cis retinoic acid.

Patients first treated for high-risk neuroblastoma

Treatment of recurrent neuroblastoma in patients first treated for high-risk neuroblastoma may include the following:

  • A clinical trial of chemotherapy followed by monoclonal antibody therapy.
  • A clinical trial of radiation therapy with radioactive iodine, alone or before stem cell transplant.
  • A clinical trial of stem cell transplant.

This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied.


Neutropenia


  • What is neutropenia?
  • How is neutropenia defined?
  • What are the clinical consequences of neutropenia?
  • What causes neutropenia?
  • How is neutropenia diagnosed?
  • How is neutropenia treated?
  • Neutropenia At A Glance
  • Patient Discussions: Neutropenia - Treatments
  • Patient Discussions: Neutropenia - Symptoms
  • Patient Discussions: Neutropenia - Describe Your Experience
  • Find a local Hematologist in your town

What is neutropenia?

"Neutropenia" is a condition in which the number of neutrophils in the bloodstream is decreased. Neutrophils are a type of white blood cell also known as polymorphonuclear leukocytes or PMNs. Neutropenia affects the body's ability to fight off infections.

White blood cells are also known as leukocytes. There are five major types of white blood cells:

  1. basophils,

  2. eosinophils,

  3. lymphocytes (T-cells and B-cells),
  4. monocytes, and

  5. neutrophils.

Some white blood cells, called granulocytes, are filled with microscopic granules that are little sacs containing enzymes (compounds that digest microorganisms). Neutrophils, eosinophils, and basophils are all granulocytes and are part of the innate immune system with somewhat nonspecific, broad-based activity. They do not respond exclusively to specific antigens, as do the lymphocytes (B-cells and T-cells).

Neutrophils contain enzymes that help the cell kill and digest microorganisms it has engulfed by a process known as phagocytosis. The mature neutrophil has a segmented nucleus (it is often called a 'seg' or 'poly'), while the immature neutrophil has a band-shape nucleus (it is called a band). Neutrophils are made in the bone marrow and released into the bloodstream. The neutrophil has a life-span of about three days.

How is neutropenia defined?

The white blood cell count (WBC) is the number of white blood cells in a volume of blood. The normal range for the WBC varies slightly among laboratories but is generally between 4,300 and 10,800 cells per microliter or cubic millimeter (cmm). The WBC can also be referred to as the leukocyte count and can be expressed in international units as 4.3 x 109to 10.8 x 109 cells per liter. The percentage of the different types of white blood cells in the WBC is called the WBC differential.

The absolute neutrophil count (ANC) is determined by the product of the white blood cell count (WBC) and the fraction of neutrophils among the white blood cells as determined by the WBC differential analysis. For example, if the WBC is 10,000 per microliter and 70% are neutrophils, the ANC would be 7,000 per microliter.

An ANC of less than 1500 per microliter (1500/microL) is the generally accepted definition of neutropenia. Neutropenia is sometimes further classified as:

  • mild if the ANC ranges from 1000-1500/microL,
  • moderate with an ANC of 500-1000/microL, and
  • severe if the ANC is below 500/microL.

Some medical terms may be used synonymously with neutropenia, even though their precise definitions are different.

  • Leukopenia refers to a reduced number of white blood cells in general, while granulocytopenia refers to a decreased number of all the granulocyte-type blood cells (neutrophils, eosinophils, and basophils).
  • Since neutrophils normally far outnumber the other types of granulocytes, this term is sometimes used to refer to neutropenia.
  • Finally, agranulocytosis literally refers to a complete absence of all granulocytes, but this term is sometimes used to refer to severe neutropenia.

What are the clinical consequences of neutropenia?

Neutropenia results in an increased susceptibility to bacterial infections. The degree of risk depends upon the cause and severity of the neutropenia, the underlying medical condition of the patient, and the presence or absence of bone marrow reserves for the production of neutrophils.

The most common type of infections seen in neutropenic patients are caused by bacteria normally found on the skin (such as Staphylococcus aureus) or from the gastrointestinal and urinary tract. Fungal infections are also more frequent in patients with neutropenia. The infections may be limited to certain areas of the body (commonly the oral cavity, genital area, and skin) or may spread via the bloodstream to the lungs and other organs in severe, prolonged neutropenia.

What causes neutropenia?

Neutropenia can be present (though it is relatively uncommon) in normal healthy individuals, notably in some persons of African or Arabic descent and and Yemenite Jews. Neutropenia may arise as a result of decreased production of neutrophils, destruction of neutrophils after they are produced, or pooling of neutrophils (accumulation of the neutrophils out of the circulation).

Neutropenia may arise as a result of numerous medical conditions:

  • Infections (more commonly viral infections, but also bacterial or parasitic infections). Examples include: HIV, tuberculosis, malaria, Epstein Barr virus (EBV);
  • Medications that may damage the bone marrow or neutrophils, including cancer chemotherapy;
  • Vitamin deficiencies (megaloblastic anemia due to vitamin B12 and/or folate deficiency);
  • Diseases of the bone marrow such as leukemias, myelodysplastic syndrome, aplastic anemia, myelofibrosis;
  • Radiation therapy;
  • Congenital (inborn) disorders of bone marrow function or of neutrophil production, for example, Kostmann syndrome;
  • Autoimmune destruction of neutrophils (either as a primary condition or associated with another disease such as Felty's syndrome) or from drugs stimulating the immune system to attack the cells
  • Hypersplenism, which refers to the increased sequestration and/or destruction of blood cells by the spleen

How is neutropenia diagnosed?

Neutropenia is diagnosed by a blood cell count performed on a sample of blood removed from a vein. To determine the specific cause of neutropenia in a given situation, other tests may be required. Sometimes a bone marrow biopsy may be required to diagnose the specific cause of neutropenia.

How is neutropenia treated?

Treatment of neutropenia is based upon the underlying cause, severity, and the presence of associated infections or symptoms as well as the overall health status of the patient. Obviously, treatment must also be directed toward any underlying disease process. Treatments that directly address neutropenia may include (note that all of these treatments may not be appropriate in a given setting):

  • antibiotic and/or antifungal medications to help fight infections;
  • administration of white blood cells growth factors (such as recombinant granulocyte colony-stimulating factor (G-CSF, filgrastim) in some cases of severe neutropenia;
  • granulocyte transfusions; or
  • corticosteroid therapy or intravenous immune globulin for some cases of immune-mediated neutropenia.

Preventive measures may also be implemented in neutropenic patients to limit risk of infections. These measures might include strict attention to hand washing, use of private rooms, or in some cases, use of gloves, gowns, and/or face masks by caregivers.

Neutropenia At A Glance
  • Neutropenia is a condition in which the number of neutrophils (a type of white blood cell) in the bloodstream is decreased, affecting the body's ability to fight off infections.
  • Neutropenia is defined as an absolute neutrophil count (ANC) of less than 1500 per microliter (1500/microL)
  • Neutropenia may be caused by or associated with numerous medical conditions
  • Most infections that occur as a result of neutropenia are due to bacteria that are normally present on the skin or in the gastrointestinal or urinary tract.
  • Treatment depends upon the cause and severity of he condition as well as the underlying disease state responsible for the neutropenia.


Newborn Infant Hearing Screening


  • What is a newborn infant hearing screening program?
  • Why is it important to screen for hearing loss in all newborn infants?
  • How common is hearing loss in infants?
  • What are some of the causes of hearing loss in the newborn?
  • How is hearing in infants tested?
  • What is an ABR test?
  • What is an OAE evaluation?
  • OAEs and ABRs, is one test better than the other?
  • What does it mean when an infant does not pass the hearing screen?
  • What is the difference between a hearing screen and a diagnostic hearing test?
  • If an infant does not pass a hearing screen in the hospital, what happens next?
  • If an infant has a hearing loss, what is the next step?
  • Find a local Pediatrician in your town

What is a newborn infant hearing screening program?

Newborn infant hearing screening programs are designed to identify hearing loss in infants shortly after birth. All states have implemented these screening protocols within hospitals and birthing clinics. About 95% of hearing screening tests are done prior to discharge from the hospital or birthing clinics.

Typically, nurses or medical assistants are trained extensively on how to operate automated equipment for testing infants. Prior to discharge, each newborn has his/her hearing tested. If, for some reason, the newborn does not pass the screen, a rescreen is usually done. If the infant still does not pass the second hearing test, he/she is referred to a specialist for further testing.

Specialists who are experts at testing hearing are called audiologists. Audiologists have had training that emphasizes diagnostic hearing testing techniques as well as hearing rehabilitation of children and adults. Their postgraduate academic training requires a minimum of a master's degree.

Why is it important to screen for hearing loss in all newborn infants?

Significant hearing loss is the most common disorder at birth. Approximately 1%-2% of newborns are affected.

Several national committees, including the National Institutes of Health, the American Academy of Otolaryngology/Head and Neck Surgery, and the American Academy of Pediatrics, have recommended that hearing loss in infants be identified, and when possible treated, prior to 6 months of age. This recommendation is based on studies that have shown that children identified with hearing loss prior to 6 months of age have a better chance of developing skills equivalent to their peers by the time they enter kindergarten. Children not identified until later (for example, it is very common to first identify hearing impaired children at age 2 to 3 years) may ultimately suffer from irreversible and permanent impairments in speech, language, and cognitive abilities when compared to their peers.

Prior to the implementation of hearing screen programs, it was customary to only test those newborns who had known significant risk factors for hearing loss. This group included infants whose mothers suffered from illness during pregnancy, those who had a family history of hearing loss, or those who were exposed to drugs known to affect hearing. In addition, infants with the following conditions were included for hearing screening:

  • low birth weight and/or prematurity, or oxygen deprivation or breathing difficulties at birth;
  • high bilirubin levels (yellow color);
  • syndromes associated with hearing loss;
  • abnormal head or face structures;
  • infections such as cytomegalovirus, syphilis, herpes, or toxoplasmosis; or
  • low Apgar scores (which assess several health factors at one and again at five minutes after birth).

However, despite the testing of all infants who fell into this "high-risk registry," over half of all newborns with hearing loss were missed!

In order to identify this large group of hearing-impaired infants not identified with current testing protocols, it is now recommended that all newborns have a hearing test prior to discharge from the hospital. The goal of this program is to identify all hearing-impaired infants at an early age, thereby increasing these children's chance at healthy and more productive lives.

How common is hearing loss in infants?

Most permanent hearing loss is due to damage/malfunction of the nerve that transmits sound from the inner ear to the brain (auditory nerve). For those infants in whom a cause is determined, approximately half have a genetic condition and the remaining half have an acquired condition to explain their hearing loss.

What are some of the causes of hearing loss in the newborn?

Hearing loss in a newborn can be caused by a number of conditions. Some of the known risk factors include high bilirubin levels (jaundice), drugs that are toxic to the ears (for example, medicines that are given to the newborn to battle a serious infection may damage hearing as a side effect), prolonged mechanical ventilation, low Apgar scores, meningitis, prematurity, and/or low birth weight. Malformed structures in the middle or outer ear can also lead to hearing loss. Viral illness during the pregnancy, such as rubella (German measles) or cytomegalovirus (CMV), can be passed to the newborn and result in hearing loss. Hearing loss can sometimes be inherited in abnormal genes passed from the parents to the newborn or be the result of a gene mutation that occurred during fetal development. Genetic counseling is often recommended for parents to determine if heredity is the cause of the hearing loss. In approximately half of all cases of hearing loss, the cause is never determined.

How is hearing in infants tested?

Hearing in infants can be tested using two different methods: the auditory brainstem response (ABR) evaluations or the otoacoustic emission (OAE) measures. Both tests are accurate, noninvasive, automated, and do not require any observable response from the infant. Which test is used depends on the screening program's choice of instrumentation and training. For a screening tool, both methods are extremely effective. There are, however, some distinct differences in how the hearing is measured using an ABR versus an OAE.

What is an ABR test?

In order to process sounds, electrical impulses are transmitted through nerves from our ears to the brainstem at the base of the brain. An auditory brainstem response (ABR) is a physiological measure of the brainstem's response to sound. It tests the integrity of the hearing system from the ear to the brainstem. The test is performed by placing four to five electrodes on the infant's head, after which a variety of sounds is presented to the infant through small earphones. As the hearing nerve fires, the sound stimulus travels up to the brain. This electrical activity generated by the nerve can be recorded by the electrodes and is represented as waveforms on a computer screen. The audiologist can then present different loudness levels of each sound and determine the softest levels at which the infant can hear. For infant-screening purposes, only one sound is used to test the hearing, commonly referred to as a "click." The click is a grouping of several sounds to test a wider area of the hearing organ at one time. The click is typically presented at a loud level and a soft one. If a healthy response is recorded, then the infant has "passed" the hearing screen. Testing usually takes five to 15 minutes to complete.

What is an OAE evaluation?

An otoacoustic emission test (OAE) measures an acoustic response that is produced by the inner ear (cochlea), which in essence bounces back out of the ear in response to a sound stimulus. The test is performed by placing a small probe that contains a microphone and speaker into the infant's ear. As the infant rests quietly, sounds are generated in the probe. Once the cochlea processes the sound, an electrical stimulus is sent to the brainstem. In addition, there is a second and separate sound that does not travel up the nerve but comes back out into the infant's ear canal. This "byproduct" is the otoacoustic emission. The emission is then recorded with the microphone probe and represented pictorially on a computer screen. The audiologist can determine which sounds yielded a response/emission and the strength of those responses. If there is an emission present for those sounds that are critical to speech comprehension, then the infant has "passed" the hearing screen. Testing generally takes about five to eight minutes.

OAEs and ABRs, is one test better than the other?

Both tests have advantages and disadvantages when used for screening, and depending on the program and experience of the audiologist, either one can be utilized successfully. The OAE is easy and cost-effective. However, the false-positive rate (for example, an infant fails a hearing test but actually has normal hearing) may be higher for an OAE than for an ABR. The false-positive rate for ABR testing is approximately 4% when testing is done during the first three days of life. The false positive rate for OAE testing is 5%-21% for testing done during the first three days of life. This large variation between ABR and OAE testing is commonly felt to reflect the OAE testing device's increased sensitivity to residual amniotic fluid and vernix that is commonly found in the neonate's ear canal.

The two tests, however, rely on different mechanisms of hearing for the screening. For in-depth testing and a complete hearing evaluation of infants, these tests work best together as a complement to each other.

What does it mean when an infant does not pass the hearing screen?

A newborn who fails an initial hearing screen may not necessarily have a permanent hearing loss or a hearing loss at all. There are many possible reasons why an infant may fail a hearing screening test. One common reason is that fluid from the birth may still be present in the ear canal. This fluid blocks the sound stimulus, preventing it from reaching the inner ear, and therefore causes the newborn to fail. Similarly, fluid in the middle-ear space behind the eardrum (a common site for infection in children) can also block the sound stimulus and lead to a false failed test. After these problems resolve, the infant usually passes the rescreen. Therefore, it is important to have at least one week between the initial hearing screen and the rescreen to allow the newborn a chance to "dry out."

Another possible reason for a false failure is excessive noise or movement from the infant during the test. The responses that are recorded with an ABR or OAE are very, very small. Any movement or crying from the infant can prevent the equipment from detecting the response. Therefore, it is important that the newborn is quiet or sleeping for the hearing screen. Feeding the infant just prior to the screening is often very helpful. Although neither test is painful, they are novel experiences for the newborn and can be momentarily upsetting.

If it becomes evident that an infant has a hearing loss, then a full diagnostic exam is necessary to determine the type and amount of hearing loss.

What is the difference between a hearing screen and a diagnostic hearing test?

The basic difference between a diagnostic test and a hearing screen is the amount of information gathered during the session. For example, if an infant fails the hearing screen, it is unknown if there truly is a hearing loss, how much hearing loss is present, or whether or not the hearing loss is permanent or correctable. A diagnostic test can usually answer these questions. The diagnostic test session is understandably longer and requires more interaction with the infant. Typically, a more extensive ABR is conducted, using a variety of test stimuli. OAEs are also performed to cross-check the results of the ABR. To complete a thorough test, the infant needs to sleep in the office for upward of 45 minutes. The more information that can be collected, the more complete the results will be.

If an infant does not pass a hearing screen in the hospital, what happens next?

Most hospital screening programs will refer infants who failed the initial screening test to a secondary center that specializes in more complete testing for diagnosis. Sometimes, simple problems, such as too much residual amniotic fluid and vernix in the ear canal, will resolve prior to the rescreen and the infant will pass the second test. The rescreen is an important step in determining whether the infant is able to hear, so it should not be taken lightly.

If an infant does not pass the rescreen, then a full diagnostic test will be necessary. This test may be completed at the rescreen site or at another facility, depending on several factors.

If an infant has a hearing loss, what is the next step?

The ability of an infant to compensate for the hearing loss will depend on both the type and the degree of hearing loss.

The type of hearing loss refers to where in the ear the hearing loss is located and what is causing it. There are two basic types of hearing loss, conductive and sensorineural. A conductive loss is caused by problems in the outer or middle ear. This is the type of loss that results when a child has a middle-ear infection, trapped fluid from birth, impacted wax in the outer ear or malformation of the ear and associated structures. It is usually correctable with medical treatment or surgery. Occasionally, a conductive loss cannot be corrected with surgery. However, these children typically do extremely well with hearing aids. A sensorineural loss is indicative of a problem in the inner ear or somewhere along the nerve to the ear (auditory nerve). This type of loss is typically permanent and cannot be corrected with surgery. A hearing aid or a cochlear implant may be utilized in this situation.

The degree of hearing loss refers to the severity of the hearing loss, which can range from mild to profound. Although the term "mild" sounds relatively benign, a mild hearing loss in a child who is trying to develop speech and language can have a huge impact on his/her success.

If the hearing loss, whether it is conductive, sensorineural, or a combination of both, is determined to be uncorrectable by a physician, then the next step is to fit the infant with hearing aids. This is accomplished by a pediatric audiologist who can adjust the hearing aids according to the baby's hearing loss and monitor the infant's progress through regular visits. The infant should also be enrolled in an early childhood intervention program that is often provided through the school system.

In addition to the early medical or surgical treatment of the hearing loss, parental involvement is essential. Parents need to monitor the child's progress and facilitate and encourage the use of the hearing aids and other therapeutic exercises that are designed to help the child become a careful listener and talker. Research has found that the one common denominator among successful hearing-impaired children is the parent's willingness to help the child throughout his/her lifetime.

Summary & Recommendations (from the American Academy of Pediatrics Preventative Series Task Force -- July 2008)

Importance: Children with hearing loss have increased difficulties with verbal and nonverbal communication skills, increased behavioral problems, decreased psychosocial well-being, and lower educational attainment compared with children with normal hearing.

Detection: Because half of the children with hearing loss have no identifiable risk factors, universal screening (instead of targeted screening) has been proposed to detect children with permanent congenital hearing loss. There is good evidence that newborn hearing screening testing is highly accurate and leads to earlier identification and treatment of infants with hearing loss.

Benefits of detection and early treatment: Good quality evidence shows that early detection improves lingual outcomes.


Non-Hodgkin's Lymphoma

  • Non-Hodgkin's lymphoma facts
  • What is non-Hodgkin's lymphoma?
  • What causes non-Hodgkin's lymphoma?
  • What are risk factors for non-Hodgkin's lymphoma?
  • What are symptoms and signs of non-Hodgkin's lymphoma?
  • How is non-Hodgkin's lymphoma diagnosed?
  • What are the types of non-Hodgkin's lymphoma, and how is non-Hodgkin's lymphoma staging determined?
  • What is the treatment for non-Hodgkin's lymphoma?
  • What is the prognosis and survival rates of non-Hodgkin's lymphoma?
  • Where can people find more information about non-Hodgkin's lymphoma?
  • Patient Discussions: Non-Hodgkins Lymphomas - Treatments
  • Patient Discussions: Non-Hodgkin's Lymphomas - Describe Your Experience
  • Find a local Oncologist in your town

Non-Hodgkin's lymphoma facts

  • NHL is a cancer that originates in the lymphatic system.
  • About 66,000 patients are diagnosed yearly, and approximately 18,000 patients die of NHL yearly in the U.S.
  • There are several subtypes of NHL, each requiring different treatments.
  • Symptoms include swollen lymph nodes, weight loss, fever, and night sweats.
  • NHL is staged on a 1-4 scale with A (no associated symptoms like fever, weight loss, or night sweats) and B subtypes.
  • Staging the cancer is important to determine treatment and predict the outcome of treatment.
  • Depending on the stage and type of NHL, treatment can include chemotherapy, biological therapy, stem cell transplant, and/or radiation therapy.

What is non-Hodgkin's lymphoma?

Non-Hodgkin's lymphoma is a type of cancer that originates in the lymphatic system. It is estimated to be the sixth most common cancer in the United States. The lymphatic system is part of the body's immune system and helps fight infections and other diseases. In addition, the lymphatic system filters out bacteria, viruses, and other unwanted substances.

The lymphatic system consists of the following:

Lymph vessels: These vessels branch out throughout the body similar to blood vessels.

  • Lymph: The lymph vessels carry a clear fluid called lymph. Lymph contains white blood cells, especially lymphocytes such as B cells and T cells.
  • Lymph nodes: Lymph vessels are interconnected to small masses of lymph tissue called lymph nodes. Lymph nodes are found throughout the body. Collections of lymph nodes are found in the neck, underarms, chest, abdomen, and groin. Lymph nodes store white blood cells. When you are ill and the lymph nodes are active, they will swell and be easily palpable (your doctor can feel them when she examines you).
  • Additional parts of the lymphatic system: The tonsils, thymus, and spleen are additional components of the lymphatic system. Lymphatic tissue is also found in other parts of the body, including the stomach, skin, and small intestine.

Because lymphatic tissue is found in many parts of the body, non-Hodgkin's lymphoma can start almost anywhere.

What causes non-Hodgkin's lymphoma?

We don't know what causes non-Hodgkin's lymphoma (NHL). NHL occurs when your body produces too many abnormal lymphocytes. In the normal life cycle of lymphocytes (a type of white blood cell), old lymphocytes die and your body creates new ones to replenish the supply. In NHL, lymphocytes grow indefinitely, so the number of circulating lymphocytes increases, filling up the lymph nodes and causing them to swell.

In NHL, either B cells or T cells are involved in this process. These are the two subtypes of lymphocytes.

B cells produce antibodies that fight infections. This is the most common type of cell involved in NHL.

T cells kill the foreign substances directly. NHL less frequently originates from T cells.

The following are some of the common subtypes of NHL:

Burkitt's lymphoma: This lymphoma has two major subtypes, an African type closely associated with an infection with the Epstein-Barr virus and the non-African, or sporadic, form that is not linked to the virus.

Diffuse large cell lymphoma: This represents the most common lymphoma (approximately 30% of NHL) and can be rapidly fatal if not treated.

Follicular lymphoma: These lymphomas exhibit a specific growth pattern when viewed under the microscope (follicular or nodular pattern); they are usually advanced at the time of diagnosis.

MALT lymphoma: This is a B cell lymphoma that usually affects individuals in their 60s. The most common area for this lymphoma to develop is the stomach.

Mantle cell lymphoma: One of the rarest of the NHL, mantle cell lymphoma accounts for about 6% of cases. This NHL is difficult to treat and is a subtype of B cell lymphoma.

Adult T cell lymphoma/leukemia: This is a rare but aggressive NHL of the immune system's T cells. Human T cell leukemia/lymphotropic virus type (HTLV-1) is believed to be the cause.

What are risk factors for non-Hodgkin's lymphoma?

In many cases, people who develop NHL have no risk factors, and doctors seldom know why one person develops non-Hodgkin's lymphoma and another does not.

Certain risk factors increase the chance that a person will develop this disease although most people who have these risk factors will never develop the disease.

Risk factors

Medications that suppress your immune system: Using immunosuppressive agents (such as after an organ transplant) is a risk factor as it reduces your bodies ability to fight infection.

Weakened immune system: The risk of developing lymphoma may be increased by having a weakened immune system.

Certain infections: Certain viral and bacterial infections increase the risk of NHL. Examples are HIV, hepatitis C virus, and Epstein-Barr virus. A type of bacteria sometimes linked to NHL is the ulcer-causing H. pylori.

Note: Lymphoma is not contagious. You cannot catch lymphoma from another person.

Age: Although non-Hodgkin's lymphoma can occur in young people, the chance of developing this disease increases with age. Most people with non-Hodgkin's lymphoma are older than 60 years of age.

Other possible links: People who work with herbicides or certain other chemicals may be at increased risk of this disease. Researchers are also looking at a possible link between using hair dyes before 1980 and non-Hodgkin's lymphoma. None of these possible links have definitely been proven.

Note: Having one or more risk factors does not mean that a person will develop non-Hodgkin's lymphoma. Most people who have risk factors never develop cancer.

What are symptoms and signs of non-Hodgkin's lymphoma?

Signs and symptoms of NHL include the following:

  • Swollen, painless lymph nodes in the neck, armpits, or groin
  • Unexplained weight loss
  • Fever
  • Night sweats
  • Coughing, trouble breathing, or chest pain
  • Weakness and tiredness that don't go away (fatigue)
  • Abdominal pain or swelling, or a feeling of fullness in the abdomen
  • Itching of the skin

How is non-Hodgkin's lymphoma diagnosed?

Physical exam: Your doctor will complete a physical examination with a special emphasis on palpating your lymph nodes in your neck, underarms, and groin and establishing if they are swollen. He or she will also try to find out if your spleen or liver are swollen. In most cases, swollen lymph nodes are signs of infection (rather then lymphoma), and your doctor will try to establish if you have any other signs of infection and what the source of the infection could be.

Medical history: You will be asked questions in regards to your past medical history and about risk factors for NHL.

Blood tests: A complete blood count (CBC) will usually be performed to check the number of white blood cells. Additional tests might include a lactate dehydrogenase level (can be elevated in lymphoma). Additional tests might be performed to rule out an infection causing the swollen lymph nodes.

Imaging procedures: A chest X-ray or CT scan of the chest or neck might help detect the presence of tumors or more enlarged lymph nodes. Positron emission tomography (PET) scanning is a newer modality to help detect NHL.

Biopsy: Your doctor might recommend a biopsy of lymph nodes to diagnose the cause of the swelling. The samples will then be given to a pathologist who will review the sample under the microscope and establish a diagnosis.

There are three ways to diagnose a lymph node: removal of the entire lymph node (excisional biopsy); partial removal of a lymph node (incisional biopsy); fine-needle aspiration (using a thin needle to remove some lymph node tissue) is often not diagnostic as not enough tissue is removed for the pathologist to make a diagnosis.

Bone marrow biopsy: A bone marrow biopsy can establish the spread of the disease. This involves the insertion of a needle into bone to obtain bone marrow. In adults, the most common site for this biopsy is the pelvic bone.

What are the types of non-Hodgkin's lymphoma, and how is non-Hodgkin's lymphoma staging determined?

NHL is classified into many different types. Several classification systems exist for NHL, including the Revised European American Lymphoma Classification which is the foundation for the WHO lymphoma classification. The classifications uses cell types and defining other characteristics. Basically there are three large groups: the B cell, T cell, and natural killer cell tumors.

Newer techniques such as immunophenotyping (a way to study the proteins on a cell and identify the precise types of B or T cells that are involved) are used to diagnose and classify lymphomas. This technique is especially useful in the case of B cell lymphomas.

Testing of DNA from the lymphoma is used to detect gene defects that help determine the prognosis and response to treatment.

To plan the best treatment for NHL, your health-care provider needs to stage (know the extent of) the disease. This is an attempt to find out what part of your body is involved.

Different tests are involved in the staging process, and they can include the following:

  • Bone marrow biopsy (see above)
  • CT scan
  • MRI
  • Ultrasound
  • PET scan: Radioactive material is injected, and a CT scan is performed to determine the metabolism of this material. Lymphoma cells show faster metabolism than normal cells, and areas with lymphoma look brighter on the pictures.

Doctors will also stage the lymphoma based on spread of the disease and organ involvement as well as symptoms:

  • Stage I: The cells are found in only one lymph node area (such as in the neck or axilla). Or, if the abnormal cells are not in the lymph nodes, they are in only one part of a tissue or organ (such as the lung, but not the liver or bone marrow).
  • Stage II: The lymphoma cells are found in at least two lymph node areas on the same side of the body or only above or below the diaphragm. Or the cells are in one organ and the lymph nodes affected are near that organ
  • Stage III: The lymphoma is in lymph nodes above and below the diaphragm. There might be spread into an organ near this lymph node group.
  • Stage IV: In addition to lymph cell spread, lymphoma cells are found in several parts of one or more organs or tissues.
  • A: No symptoms (You have not had weight loss, fever or night sweats)
  • B: Presence of any of the following symptoms: weight loss (10 % or more in the last six months), fever (greater then 101.5 F) night sweats, or severe itching.

What is the treatment for non-Hodgkin's lymphoma?

Your doctor will usually refer you to an oncologist for evaluation and treatment. Some large academic medical centers have oncologists who specialize in lymphomas.

The treatment plan depends mainly on the following:

  • The type of non-Hodgkin's lymphoma
  • Its stage (where the lymphoma is found)
  • How quickly the cancer is growing
  • The patient's age
  • Whether the patient has other health problems
  • If there are symptoms present such as fever and night sweats (see above)

If you have a slow-growing non-Hodgkin's lymphoma without symptoms, you may not require treatment for the cancer right away. You will be watched closely by your health-care team. These cancers might not require treatment for years, although close follow-up is necessary. If the indolent lymphoma produces symptoms, therapy will usually consist of chemotherapy and biological therapy. Stage I and II often require radiation therapy.

For an aggressive type of lymphoma, a combination of chemotherapy and biological therapy is usually indicated, and sometimes radiation therapy will be added.

If treatment is required, there are several options that are utilized alone or in combination:

Chemotherapy: This is a drug treatment either as an injection or oral form that kills cancer cells. This treatment can involve one medication or multiple medications and be given alone or in conjunction with other therapies. This therapy is given in cycles, alternating treatment periods and nontreatment periods. The repetition of these cycles and the number of cycles will be determined by your oncologist based on the staging of your cancer and the medications used. Chemotherapy also harms normal cells that divide rapidly. This can lead to hair loss, GI symptoms, and difficulty with your immune system.

Radiation therapy: High doses of radiation are used to kill cancer cells and shrink tumors. This modality can be used alone or in conjunction with other therapies. Side effects usually depend on the type and dosage of the therapy as well as the area undergoing radiation therapy. Universally, patients tend to get tired during radiation therapy, especially toward the later stages of treatment.

Stem cell transplant: This procedure allows you to receive large doses of chemotherapy or radiation therapy to kill the lymphoma cells that might not be killed with standard levels of therapy. This therapy is used if your lymphoma returns after treatment. For this therapy, you need to be admitted to the hospital. After the therapy, healthy stem cells (that were either taken from you before the therapy or from a donor) are injected to form a new immune system.

Biological drugs: These are medications that enhance your immune system's ability to fight cancers. In NHL, monoclonal antibodies are used for treatment. The therapy is administered via an IV, and the monoclonal antibodies bind to the cancer cells and augment the immune system's ability to destroy cancer cells. Rituximab (Rituxan) is such a drug used in the treatment of B cell lymphoma. Side effects for this treatment are usually flu-like symptoms. Rarely, a person can have a severe reaction, including a drop in blood pressure or difficulty breathing.

Radio immunotherapy medications: These are made of monoclonal antibodies that transport radioactive materials directly to cancer cells. Because the radioactive material is traveling and binding directly to the cancer cell, more radiation is delivered to the cancer cell and less to the normal tissue. Ibritumomab (Zevalin) and tositumomab (Bexxar) are two drugs approved for this use in lymphomas. Side effects usually include getting very tired or experiencing flu-like symptoms.

Additional aspects of cancer treatments

In addition to medical therapies, patients will also require supportive care. You should have the opportunity to learn about your disease and the treatment options and discuss this with your care team. Most cancer centers will have support groups where you can share your concerns with other patients and learn from their experiences.

Some patients find moderate physical activity helpful. You should discuss with your doctor what kind of activities are appropriate.

Eating the appropriate amounts of foods, as well as the right foods, is an important part of your treatment. Speaking with a nutritionist can be very helpful.

In addition, vitamin deficiencies (especially vitamin D) have recently been linked to worse survival in some subgroups of cancer patients. Patients should discuss their nutritional requirements with their health-care team.

Appropriate caloric intake is important especially if nausea is present as a result of your treatments. Some people find that exercise can help their nausea during therapy. Acupuncture has also shown to decrease the side effects of cancer treatments.

What is the prognosis and survival rate for non-Hodgkin's lymphoma?

The prognosis of NHL can be good but is linked to the type of lymphoma, the extent of spread (staging), and response to therapy. Prognosis should be discussed with the patient's health-care provider.

Approximately 66,000 patients were diagnosed with non-Hodgkin's lymphoma in 2011, and about 18,000 patients died in 2011.

Five-year survival is a measure used to predict and gauge the severity of the cancer. Please discuss your own risk factors, staging, and classifications with your own health-care team as none of these numbers should be applied to an individual patient without considering all the circumstances of the patient's illness.

The National Cancer Institute reports the following average five-year survival:

Stage at diagnosis Stage distribution (%) 5-year relative survival (%)
Localized (confined to primary site) 29 81.1
Regional (spread to regional lymph nodes) 15 70.5
Distant (cancer has metastasized) 48 58.5
Unknown (unstaged) 8 64.1

Where can people find more information about non-Hodgkin's lymphoma?

http://www.lls.org/


Nicotine

  • What is nicotine?
  • What are the common street names for nicotine?
  • How is nicotine used?
  • How many teens use nicotine?
  • What are the common effects of nicotine?
  • Tobacco kills
  • Can nicotine make me nervous or depressed?

What is nicotine?

Nicotine is the drug in tobacco leaves. Whether someone smokes, chews, or sniffs tobacco, he or she is delivering nicotine to the brain. Each cigarette contains about 10 milligrams of nicotine. Nicotine is what keeps people smoking despite its harmful effects. Because the smoker inhales only some of the smoke from a cigarette and not all of each puff is absorbed in the lungs, a smoker gets about 1 to 2 milligrams of the drug from each cigarette. A drop of pure nicotine would kill a person-in fact, nicotine can be used as a pesticide on crops.

What are the common street names for nicotine?

You might hear cigarettes referred to as smokes, cigs, or butts. Smokeless tobacco is often called chew, dip, spit tobacco, or snuff.

How is nicotine used?

Tobacco can be smoked in cigarettes, cigars, or pipes. It can be chewed or, if powdered, sniffed.

An alternative to cigarettes is "bidis." Originally from India, bidis are hand-rolled. In the U.S., bidis are popular with teens because they come in colorful packages with flavor choices. Some teens think that bidis are less harmful than regular cigarettes. But bidis have even more nicotine, which may make people smoke more, causing them to be more harmful to the lungs than cigarettes.

How many teens use nicotine?

More than 3 and one-half million teens between the ages of 12 and 17 use tobacco-that's about 15 percent of teens that age. Of those, just over 3 million, or 13 percent, smoke cigarettes. In the U.S., 66.5 million people, or about 29 percent of the population, use tobacco.

What are the common effects of nicotine?

With each puff of a cigarette, a smoker pulls nicotine into his or her lungs where it is absorbed into the blood. In eight seconds, nicotine is in the brain, changing the way the brain works. This process happens so fast because nicotine is shaped like the natural brain chemical acetylcholine. Acetylcholine is one of many chemicals called neurotransmitters that carry messages between brain cells. Neurons have special spaces called receptors, into which specific neurotransmitters can fit, like a key fitting into a lock. Nicotine locks into acetylcholine receptors in different parts of the brain, rapidly causing changes in the body and brain. Nicotine raises the heart rate and respiration (breathing) rate, and causes more glucose, or blood sugar, to be released into the blood. This might be why smokers feel more alert after smoking a cigarette.

Nicotine also attaches to neurons (brain cells) that release a neurotransmitter called dopamine. Nicotine stimulates neurons to release unusually large amounts of dopamine. Dopamine stimulates the brain's pleasure and reward circuit, a group of brain structures called the limbic system involved in appetite, learning, memory, and feelings of pleasure. Normally, pleasurable feelings come from food, comfort, and the company of people you love. But smoking cigarettes causes a flood of dopamine in the smoker's brain. It's this flood of dopamine that gives the smoker intense feelings of pleasure.

Normally, neurons reabsorb neurotransmitters after they've done their job of signaling other brain cells. But cigarette smoke causes dopamine to stay in the spaces between neurons called synapses. Researchers don't yet know exactly what component of tobacco smoke blocks the reabsorption of dopamine into neurons.

In 40 minutes, half the effects of nicotine are gone. So smokers get the urge to light up for another dose of the drug. After repeated doses of nicotine, the brain changes. To adjust to too much dopamine, the brain cuts production of the neurotransmitter and reduces the number of some receptors. Now, the smoker needs nicotine just to create normal levels of dopamine in his or her brain. Without nicotine, the smoker feels irritable and depressed. The smoker has trained the limbic system to crave tobacco. Think about how you long for a cold drink on a hot day. Or how you want a sandwich when you are hungry. Craving for tobacco is much stronger.

These changes in the brain and body make nicotine highly addictive. Other addictive drugs of abuse, including heroin and cocaine, cause the same changes in the brain.

 

While inhaling a cigarette, smokers are pulling more than nicotine into their lungs. Tobacco smoke contains more than 4,000 chemicals. Besides nicotine, the most dangerous chemicals in cigarette smoke are tar and carbon monoxide. Tar causes lung cancer, emphysema, and bronchial diseases. Carbon monoxide causes heart problems; smokers are at high risk for heart disease.

Smokers also have a dulled sense of smell and taste, reduced stamina for exercise and sports, and they smell of smoke. After smoking for a long time, smokers find that their skin ages faster and their teeth turn brown or discolored.

Tobacco Kills

Each year, nearly half a million Americans die from tobacco use. One of every six deaths in the United States is a result of smoking tobacco, making tobacco more lethal than all other addictive drugs combined.

Can nicotine make me nervous or depressed?

Scientists are learning how tobacco and nicotine affect teen smokers. Studies going on for 25 years show a link between heavy teen smoking and fear of going outside (agoraphobia). Teens who smoke were 6 times more likely to get agoraphobia. And, teen smokers were 15 times more likely to have panic attacks than teens who did not smoke. Scientists think the reason is that nicotine hurts blood vessels to the brain, and also blocks air from the lungs. Whatever the reason, teen smokers are more likely to have panic attacks, anxiety disorders, and depression.


Night Sweats


  • Introduction
  • What are the causes of night sweats?
  • Menopause
  • Idiopathic hyperhidrosis
  • Infections
  • Cancer
  • Medications
  • Hypoglycemia
  • Hormone Disorders
  • Neurologic conditions
  • Patient Discussions: Night Sweats - Treatments
  • Patient Discussions: Night Sweats - Describe Your Experience
  • Find a local Internist in your town

 

Introduction

Doctors in primary care fields of medicine often hear their patients complain of night sweats as they are common. Night sweats refer to any excess sweating occurring during the night. However, if your bedroom is unusually hot or you are using too many bedclothes, you may begin to sweat during sleep - and this is normal. In order to distinguish night sweats that arise from medical causes from those that occur because one's surroundings are too warm, doctors generally refer to true night sweats as severe hot flashes occurring at night that can drench sleepwear and sheets, which are not related to an overheated environment.

In one study of 2267 patients visiting a primary care physician, 41% reported experiencing night sweats during the previous month, so the perception of excessive sweating at night is fairly common. It is important to note that flushing (a warmth and redness of the face or trunk) may also be hard to distinguish from true night sweats.

What are the causes of night sweats?

There are many different causes of night sweats. To determine what is causing night sweats in a particular patient, a doctor must obtain a detailed medical history and order tests to decide if an underlying medical condition is responsible for the night sweats.

The following are some of the known conditions that can cause night sweats.

Menopause

The hot flashes that accompany the menopausal transition can occur at night and cause sweating. This is a very common cause of night sweats in perimenopausal women. It is important to remember that hot flashes and other symptoms of the perimenopause can precede the actual menopause (the cessation of menstrual periods) by several years

Medication

Taking certain medications can lead to night sweats. In cases without other physical symptoms or signs of tumor or infection, medications are often determined to be the cause of night sweats.

Antidepressant medications are a common type of medication that can lead to night sweats. All types of antidepressants including tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and the newer agents, venlafaxine (Effexor) and bupropion (Wellbutrin) can cause night sweats as a side effect, with a range in incidence from 8% to 22% of persons taking antidepressant drugs. Other psychiatric drugs have also been associated with night sweats.

 

Medicine taken to lower fever (antipyretics) such as aspirin and acetaminophen can sometimes lead to sweating.

Other types of drugs can cause flushing (redness of the skin, typically over the cheeks and neck), which, as mentioned above, may be confused with night sweats. Some of the many drugs that can cause flushing include:

  • niacin [(Niacor, Niaspan, Slo-Niacin) (taken in the higher doses used for lipid disorders)],
  • tamoxifen (Nolvadex),
  • hydralazine,
  • nitroglycerine, and
  • sildenafil (Viagra).
 

Many other drugs not mentioned above, including cortisone,  prednisone, and prednisolone, may also be associated with flushing or night sweats.

Hypoglycemia

Sometimes low blood glucose (hypoglycemia) can cause sweating. People who are taking insulin or oral anti-diabetic medications may experience hypoglycemia at night that is accompanied by sweating.

Hormone disorders

Sweating or flushing can be seen with several hormone disorders, including pheochromocytoma, carcinoid syndrome, and hyperthyroidism.

Neurologic conditions

Uncommonly, neurologic conditions may cause increased sweating and possibly lead to night sweats including:

  • autonomic dysreflexia,
  • post-traumatic syringomyelia,
  • stroke, and
  • autonomic neuropathy.

In summary, night sweats are usually a harmless annoyance; however, they are sometimes a sign of an underlying medical condition. Persons with unexplained night sweats should seek medical care.


Nightmares

  • What are nightmares?
  • How common are nightmares?
  • How are nightmares viewed in different cultures?
  • How are nightmares related to posttraumatic stress disorder (PTSD)?
  • Are there any effective treatments for nightmares?
  • What are psychological treatments for nightmares?
  • What are psychopharmacological treatments for nightmares?
  • What happens if nightmares are left untreated?
  • Find a local Psychiatrist in your town

What are nightmares?

Nightmares refer to complex dreams that cause high levels of anxiety or terror. In general, the content of nightmares revolves around imminent harm being caused to the individual (e.g., being chased, threatened, injured, etc.). When nightmares occur as a part of posttraumatic stress disorder (PTSD), they tend to involve the original threatening or horrifying set of circumstances that was involved during the traumatic event. For example, someone who was in the Twin Towers on Sept. 11, 2001, might experience frightening dreams about terrorists, airplane crashes, collapsing buildings, fires, people jumping from buildings, etc. A rape survivor might experience disturbing dreams about the rape itself or some aspect of the experience that was particularly frightening (e.g., being held at knifepoint).

Nightmares can occur multiple times in a given night, or one might experience them very rarely. Individuals may experience the same dream repeatedly, or they may experience different dreams with a similar theme. When individuals awaken from nightmares, they can typically remember them in detail. Upon awakening from a nightmare, individuals typically report feelings of alertness, fear, and anxiety. Nightmares occur almost exclusively during rapid eye movement (REM) sleep. Although REM sleep occurs on and off throughout the night, REM sleep periods become longer and dreaming tends to become more intense in the second half of the night. As a result, nightmares are more likely to occur during this time.

How common are nightmares?

The prevalence of nightmares varies by age group and by gender. Nightmares are reportedly first experienced between the ages of 3 and 6 years. From 10% to 50% of children between the ages of 3 and 5 have nightmares that are severe enough to cause their parents concern. This does not mean that children with nightmares necessarily have a psychological disorder. In fact, children who develop nightmares in the absence of traumatic events typically grow out of them as they get older. Approximately 50% of adults report having at least an occasional nightmare. Estimates suggest that between 6.9% and 8.1% of the adult population suffer from chronic nightmares.

Women report having nightmares more often than men do. Women report two to four nightmares for every one nightmare reported by men. It is unclear at this point whether men and women actually experience different rates of nightmares, or whether women are simply more likely to report them.

Nightmares and cultural differences

The interpretation of and significance given to nightmares varies tremendously by culture. While some cultures view nightmares as indicators of mental health problems, others view them as related to supernatural or spiritual phenomena. Clinicians should keep this in mind during their assessments of the impact that nightmares have on clients.

How are nightmares related to PTSD?

Nightmares are 1 of 17 possible symptoms of PTSD. One does not have to experience nightmares in order to have PTSD. However, nightmares are one of the most common of the "re-experiencing" symptoms of PTSD, seen in approximately 60% of individuals with PTSD. A recent study of nightmares in female sexual assault survivors found that a higher frequency of nightmares was related to increased severity of PTSD symptoms. Little is known about the typical frequency or duration of nightmares in individuals with PTSD.

Are there any effective treatments for nightmares?

Yes. There are both psychological treatments (involving changing thoughts and behaviors) and psychopharmacological treatments (involving medicine) that have been found to be effective in reducing nightmares.

Psychological treatment for nightmares

In recent years, Barry Krakow and his colleagues at the University of New Mexico have conducted numerous studies regarding a promising psychological treatment for nightmares. This research group found positive results in applying this treatment to individuals suffering from nightmares in the context of PTSD. Krakow and colleagues found that crime victims and sexual assault survivors with PTSD who received this treatment showed fewer nightmares and better sleep quality after three group-treatment sessions. Another group of researchers applied the treatment to Vietnam combat veterans and found similarly promising results in a small pilot study.

The treatment studied at the University of New Mexico is called "Imagery Rehearsal Therapy" and is classified as a cognitive-behavioral treatment. It does not involve the use of medications. In brief, the treatment involves helping the clients change the endings of their nightmares, while they are awake, so that the ending is no longer upsetting. The client is then instructed to rehearse the new, nonthreatening images associated with the changed dream. Imagery Rehearsal Therapy also typically involves other components designed to help clients with problems associated with nightmares, such as insomnia. For example, clients are taught basic strategies that may help them to improve the quality of their sleep, such as refraining from caffeine during the afternoon, having a consistent evening wind-down ritual, or refraining from watching TV in bed.

Psychologists who use cognitive-behavioral techniques may be familiar with Imagery Rehearsal Therapy, or may have access to research literature describing it.

Psychopharmacological treatment for nightmares

Researchers also have conducted studies of medications for the treatment of nightmares. However, it should be noted that the research findings in support of these treatments are more tentative than findings from studies of Imagery Rehearsal Therapy. Part of the reason for this is simply that fewer studies have been conducted with medications at this point in time. Also, the studies that have been conducted with medications have generally been small and have not included a comparison control group (that did not receive medication). This makes it difficult to know for sure whether the medication is responsible for reducing nightmares, or whether the patient's belief or confidence that the medication will work was responsible for the positive changes (a.k.a., a placebo effect).

Some medications that have been studied for treatment of PTSD-related nightmares and may be effective in reducing nightmares include topiramate (Topamax), prazosin (Minipress), nefazodone (Serzone), trazodone (Desyrel), and gabapentin (Neurontin, Gabarone). Because medications typically have side effects, many patients choose to try a behavioral treatment first. If that does not help improve their symptoms, they may choose to try medication.

 

What happens if nightmares are left untreated?

Nightmares can be a chronic mental health problem for some individuals, but it is not yet clear why they plague some people and not others. One thing that is clear is that nightmares are common in the early phases after a traumatic experience. However, research suggests that most people who have PTSD symptoms (including nightmares) just after a trauma will recover without treatment. This typically occurs by about the third month after a trauma. However, if PTSD symptoms (including nightmares) have not decreased substantially by about the third month, these symptoms can become chronic. If you have been suffering from nightmares for more than three months, you are encouraged to contact a mental health professional and discuss with him or her the behavioral treatments described above.

Idiopathic hyperhidrosis

Idiopathic hyperhidrosis is a condition in which the body chronically produces too much sweat without any identifiable medical cause.

Infections

Classically, tuberculosis is the infection most commonly associated with night sweats. However, bacterial infections, such as the following conditions can also be associated with night sweats:

  • endocarditis (inflammation of the heart valves),
  • osteomyelitis (inflammation within the bones due to infection),
  • abscesses (for example, boils, appendix, tonsils, perianal, peritonsillar, diverticulitis), and
  • AIDS virus (HIV) infection.

Cancer

Night sweats are an early symptom of some cancers. The most common type of cancer associated with night sweats is lymphoma. However, people who have an undiagnosed cancer frequently have other symptoms as well, such as unexplained weight loss and fever.


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