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Quick Health

Reference
Copyright ® 2007 Ben M. Mpanzu

www.ebizdigital.co.uk

Foreword

This is a free sample. Find everything you need to know
about medical conditions, symptoms, health tests,
treatments, operations and services in the United Kingdom.
You may distribute this e-book freely to anyone you desire.
For actual full version copies of this ebook, available in
Mobireader, PDF format, Microsoft reader format. please
visit www.ebizdigital.co.uk for full details.

B. MPZ

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CONTENT PAGE

Blood disorders
Cancer
Contraception and family planning
Digestive disorders
Family support
Genetic disorders
Gynaecology
Infections
Medicines, treatments and drugs
Mental health
Minor ailments and illnesses
Muscles, joints and bones
Babies' health
Men’s health
Children's health
Senior health
Glossary

Blood disorders

• Anaemia
• Blood poisoning
• Blood pressure (high)
• Blood pressure (low)
• Diabetes
• Diabetes insipidus
• Haemophilia
• Hughes syndrome
• Hyperglycaemia
• Hypoglycaemia
• Jaundice
• Jaundice - newborn
• Leukaemia

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• Multiple myeloma
• Poisoning
• Rhesus disease
• Septic shock
• Sickle cell anaemia
• Thalassaemia
• Toxic shock syndrome

Anaemia

Introduction
Blood
Blood contains a fluid called plasma that includes three different
types of cells:

• white blood cells are part of the body's immune system, and
defend it against infection,
• red blood cells carry oxygen around the body in a substance
called haemoglobin, and
• platelets help the blood to clot.

Red blood cells are produced in the bone marrow. Vast quantities
(millions) of new cells are produced each day to replace old cells
that break down. Nutrients from food, such as iron and certain
vitamins, help ensure that your bone marrow remains healthy, and
is able to produce a constant supply of red blood cells and
haemoglobin.
Anaemia
Red blood cells carry oxygen around the body. Anaemia is a
condition where the blood is unable to carry enough oxygen due to
a low number of red blood cells, or because each red blood cell is
unable to carry as much oxygen as normal. Common symptoms of
anaemia include feeling tired, faint, or breathless.
There are several different types of anaemia, and each one has a
different cause. One of the most common causes is iron deficiency.
Other causes can include pregnancy, heavy periods, poor iron
absorption caused by certain intestinal (gut) diseases, bleeding from
the intestines, and a lack of certain vitamins, such as folic acid and
vitamin B12.

Symptoms
Common symptoms of anaemia include:

• tiredness,
• lethargy,

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• feeling faint, and
• breathlessness.

Less common symptoms of anaemia include:

• headaches,
• palpitations (irregular heart beat),
• an altered sense of taste, and
• ringing in the ears (tinnitus).

Depending on the underlying cause of your anaemia, you may also
develop a number of other symptoms (as outlined below).
Iron deficiency anaemia
Iron deficiency anaemia is the most common type of anaemia,
affecting up to 30% of the worlds population. In developed
countries, up to 14% of menstruating women have iron deficiency
anaemia. The symptoms of iron deficiency anaemia include:

• sore tongue (glossitis),
• painful cracks at the corners of the mouth (cheilosis),
• difficulty in swallowing (dysphagia),
• brittle, flaking nails,
• spoon-shaped nails,
• pale skin (pallor), and
• loss of weight.

Occasionally, if you have iron deficiency anaemia, you may have
unusual dietary cravings (known as pica). In young children, iron
deficiency anaemia can sometimes cause behavioural and
developmental problems, and weaken their immune system.
Pernicious anaemia
Pernicious anaemia occurs when vitamin B12 cannot be absorbed
properly from the diet. It causes soreness of the tongue, weight loss,
skin pallor (often with a lemon tint), and intermittent diarrhoea. If
left untreated, pernicious anaemia can affect the nervous system,
causing tingling of the fingers and toes, muscle weakness, pains in
the legs and difficulty walking, depression, and confusion.
Megaloblastic anaemia
In megaloblastic anaemia, the red blood cells are large and
abnormal (megablastic). This type of anaemia develops if there is a
deficiency of vitamin B12, or folic acid. As well as the general
symptoms listed above, megaloblastic anaemia can also cause
soreness of the tongue, indigestion, and diarrhoea.
Haemolytic anaemia
The symptoms of haemolytic anaemia include pale skin (often with a
yellowish tinge), and an enlarged spleen, due to the break down of
red blood cells (haemolysis).
Aplastic anaemia

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Aplastic anaemia is a very rare condition, affecting just 2-5 people
per million. It occurs when the bone marrow fails to produce
sufficient numbers of red blood cells. It causes fever, sore throat,
bruising, bleeding and blood spots, pale skin, and signs of heart
failure (chest pain).

Causes
Each type of anaemia has a different cause.
Iron deficiency anaemia
Iron deficiency anaemia is caused by a shortage of iron. It affects
women more often than men because, between puberty and the
menopause, women lose blood through their periods during each
menstrual cycle. A balanced, healthy diet, including foods from all
the major food groups, will usually contain enough iron to make up
for normal menstrual losses. However, if your periods are
particularly heavy (menorrhagia), or if you have a poor diet, or lose
a large amount of weight, it can lead to a shortage of iron.
Certain conditions, such as ulcerative colitis (inflammation of the
colon), bowel cancer, or piles, can cause bleeding (and a loss of
iron) from the stomach or intestines. Bleeding high up in the
intestines turns the stools (faeces) black, and bleeding piles produce
red blood. Diseases, such as cancer and rheumatoid arthritis, can
also cause iron deficiency anaemia. With these conditions, your diet
may contain enough iron, but the developing red blood cells in your
bone marrow are unable to use it properly.
Pernicious anaemia
Pernicious anaemia is caused by a shortage of vitamin B12. Usually,
when you eat food containing vitamin B12, the vitamin combines
with a protein in your stomach called intrinsic factor. This compound
(vitamin B12 and intrinsic factor) is then absorbed into your body
further down in your gut (intestine).
Pernicious anaemia develops as a result of an autoimmune disease.
Normally, your immune system makes antibodies that attack
bacteria, viruses, and germs. However, if you have an autoimmune
disease, your immune system makes antibodies that attack certain
healthy tissues in your body. In pernicious anaemia, antibodies are
created against the cells in your stomach that make intrinsic factor,
preventing it from attaching itself to vitamin B12, so that it cannot
be absorbed into your body.
It is not known why the immune system makes antibodies against
intrinsic factor. Pernicious anaemia is more common in people aged
over 50, and tends to affect women more than men. It often runs in
families, and is more common in those with other autoimmune
diseases, such as thyroid disease, and vitiligo (a deficiency of the
skin pigment, melanin).
Megaloblastic anaemia
Megaloblastic anaemia develops if there is a lack of vitamin B12, or
folic acid. It is usually caused by a diet that is low in fresh fruit and
vegetables. Excessive alcohol consumption, and some medicines,

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can reduce your bodys ability to absorb folic acid fully. During
pregnancy, there is an increased need for folic acid, and a deficiency
sometimes occurs. If you have cancer, or coeliac disease (gluten
sensitivity), you may also have reduced levels of folic acid.
Haemolytic anaemia
Haemolytic anaemia occurs when red blood cells are destroyed by
another condition that interferes with normal red blood cell
production. Some genetic conditions that produce irregular-shaped
red blood cells, such as spherocytosis, sickle cell anaemia, and
thalassaemia, can cause haemolytic anaemia.
Aplastic anaemia
In aplastic anaemia, the bone marrow does not make any new red
blood cells (or any other type of blood cells), and so the immune
system does not work properly. The average life span of a red blood
cell is 120 days, so new cells have to be made continually. If
continuous production does not happen, the anaemia will steadily
get worse, creating a very serious situation.
About a third of all cases of aplastic anaemia follow viral infections,
particularly measles, mumps and hepatitis, or are caused by
adverse reactions to medicines, such as some antibiotics and anti-
inflammatory medications. Inhaling benzene fumes can also cause
aplastic anaemia.

Anaemia and pregnancy
Iron deficiency anaemia and megaloblastic anaemia can occur
during pregnancy.
A pregnant woman needs up to twice as much iron as normal
(usually 30 mgs a day). Iron is needed so that the baby has a
sufficient blood supply and receives the necessary oxygen and
nutrients. Up to half of all pregnant women require an iron
supplement from the 20th week of pregnancy.
A lack of folic acid (vitamin B9) can make a pregnant woman
anaemic. Folic acid is needed for the development of the baby's
spinal cord and general growth. For most women, taking extra folic
acid (400 micrograms) is recommended before conception (if
possible) and during the first 12 weeks of pregnancy, to avoid spinal
damage to the baby.
Good dietary sources of folic acid include green, leafy vegetables,
cereals, and bread. You can check the nutritional information on
food labels to see how much folic acid a product contains.

Diagnosis
If you have any of the typical symptoms of anaemia, such as
tiredness, faintness, or difficulty breathing, you should visit your GP.
Your GP will ask you some questions about your symptoms, medical
history and diet, and may also give you a physical examination.
Blood test
To diagnose iron deficiency anaemia, a simple blood test will be
used to measure the amount of haemoglobin and the number of red

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blood cells in your blood. The amount of haemoglobin is measured
in grams (g) per decilitre (dl). In men, a normal level is 13.5-18g per
dl and, in women, it is 11.5-16 g per dl.
If you are anaemic, you will have fewer red blood cells than normal
in a given volume of blood. The cells may also be smaller than
usual, and contain less than the normal amount of haemoglobin. For
adult men, a normal blood count is 4.7-6.1 million/uL, and for adult
women it is 4.2-5.4 million/uL (uL = a millionth of a litre).
A normal blood test will confirm whether you are anaemic, but it will
not identify the underlying cause. In some situations, this may be
obvious for example, if you are a woman who is pregnant, or if you
have particularly heavy periods. However, it may be necessary to
carry out a wider range of investigations in order to detect reduced
levels of iron, vitamin B12, or folic acid. In rare cases, a sample of
blood-forming bone marrow may also be taken for examination.
Colonoscopy
If you have bleeding in your gut (intestines), a colonoscopy may be
used to investigate the cause. This involves examining the lining of
your colon (large bowel) using a long, flexible, telescope called a
colonoscope. It is carefully inserted into your rectum (back passage)
and passed into your colon. During the procedure, a biopsy (small
tissue sample) may be taken from the lining of your gut, for further
examination. A colonoscopy is a safe procedure, although it can be
slightly uncomfortable. You may be given a painkiller, or a sedative
to help you to relax.
Barium enema
A barium enema is another test that may be used if you have
bleeding in your bowel. A fluid containing barium dye is inserted into
your bowel, and an X-ray is then taken. The barium shows up as
white on the X-ray, highlighting the bowel and any problems with it.

Treatment
Once anaemia has been diagnosed, and the underlying cause
determined, the condition can be treated.
Iron deficiency anaemia
Iron deficiency anaemia is usually treated by replacing the iron that
is missing from your body. Iron tablets, or liquid medicines, are often
used to restore normal levels of iron. Your GP will be able to advise
you which are most suitable for you, and how long you should take
them for, which will depend on the severity of your anaemia.
A few weeks after starting to take iron medication, you will have a
blood test to see whether your iron level has returned to normal.
Once it has, you should continue taking iron supplements for a
further three months to build up the iron reserves in your body. You
may also be advised to include more iron in your diet.

Sometimes, iron medications can cause side effects. These can
include nausea (feeling sick), stomach pain, an upset stomach,
constipation, or diarrhoea. If you have side effects, tell your GP, but

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continue taking the iron supplements. Your GP will be able to
suggest ways to reduce the problem, such as taking the iron tablets
with meals (which can reduce iron absorption), or taking a lower
dose. In both cases, you will need to take a longer course of
medication in order to correct the anaemia.

Vitamin B12 deficiency

If your anaemia is caused by a vitamin B12 deficiency, vitamin B12
injections may be used to restore your levels to normal. To start
with, you will usually be given a course of six injections, one every
2-4 days. Once your body's vitamin B12 level has been restored, you
will only need a further injection once every three months in order
to top up your supply. You should not experience any side effects
with this treatment.

Folic acid deficiency

If your anaemia is caused by a folic acid deficiency, it can be treated
by simply taking a daily folic acid tablet. You will usually need to
take the tablets for about four months until your level of folic acid
has been restored.

Your GP will also be able to advise you on how to increase the
amount of folic acid in your diet. Once your diet has been corrected,
you may be able to stop taking the tablets. However, if your
anaemia is not caused by a poor diet, you may need to continue to
take folic acid supplements indefinitely.

Pernicious anaemia
Pernicious anaemia is often treated using a form of vitamin B12
known as hydroxocobalamin. It is given twice in the first week and
then weekly until the blood has returned to normal. In very severe
cases, a blood transfusion may be needed. Following, treatment
with hydroxocobalamin, a normal a dose of vitamin B12 needs to be
taken every three months for life.
Haemolytic anaemia
As haemolysis (the break down of red blood cells) can cause a folic
acid deficiency, you may be advised to increase your intake of folic
acid if you have haemolytic anaemia. Steroids and
immunosuppressive medications are also sometimes used to
manage the condition and, in some cases, blood transfusions, or
removal of your spleen (splenectomy) may be necessary.
Aplastic anaemia
Aplastic anaemia may be more difficult to treat. As your bone
marrow does not produce any blood cells, including disease fighting
cells, you are at considerable risk of contracting infections. Bleeding
may also be a problem because of the absence of platelets within

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the bone marrow, which are needed for blood clotting. Without
treatment the condition can be fatal.
A bone marrow transplant is often used to treat people with severe
aplastic anaemia. This involves finding a donor whose bone marrow
is compatible with the recipients. It is also likely that you will need
to have a number of red blood cell transfusions, and a platelet
transfusion. People without a suitable donor are usually given
immunosuppressive therapy (treatment to prevent damage being
caused by the immune system). They will also require regular blood
transfusions.
During (and before) pregnancy
If possible, it is recommended that women take folic acid
supplements for three months before they become pregnant. In
cases of unplanned pregnancy, it is recommended that women start
taking folic acid as soon as they know that they are pregnant, for at
least the first 12 weeks of pregnancy. The recommended dose is 400
micrograms a day. Folic acid can be found in green leafy vegetables,
root vegetables, mushrooms, fruit, nuts and pulses.
Iron tablets are recommended for pregnant women who may not be
getting enough iron from their diet. The normal recommended daily
dose for a pregnant woman is 30mg. Around the 20th week is when
the most iron will be needed, as this is usually when extra blood
production is at its highest.

Iron can be found in leafy green vegetables such as broccoli,
spinach, and kale, strawberries, and high fibre or wholemeal foods,
such as cereals and bread. Vitamin C helps the body absorb iron,
and can be found in orange or cranberry juice, or it can be taken as
a supplement. Tea and coffee affect the bodys absorption of iron
and should be reduced or eliminated from the diet.

Blood poisoning

Introduction
Blood poisoning, or septicaemia, is a bacterial infection that occurs
when bacteria get into the bloodstream and multiply rapidly. Blood
poisoning normally happens when bacteria enter the bloodstream in
large numbers, and spread too quickly for the immune system to
destroy them. Once in the bloodstream, some types of bacteria
release poisons known as toxins that attack the bodys tissues. Blood
poisoning is a potentially life-threatening infection that must be
treated rapidly in order to prevent the infection from spreading to
the heart and lungs.
Septicaemia begins as an infection in the walls of the blood vessels,
before developing into a tissue infection such as cellulitis. Blood
poisoning commonly occurs as a complication of a serious infection,

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such as a kidney infection. Blood poisoning is dangerous because
once bacteria get into the bloodstream, it is difficult to prevent them
flowing to the bodys vital organs. Meningitis is caused when the
membranes covering the brain and spinal cord become infected and
inflamed, which can be a consequence of blood poisoning. Elderly
people with existing health conditions are particularly susceptible to
blood poisoning, as are children. The risk of blood poisoning is
increased if your immune system has been weakened by a chronic
illness, or if you have undergone surgery recently.

Symptoms
Symptoms may develop suddenly and can include the following:

• fever,
• chills and shivering,
• rapid breathing and headache,
• nausea, vomiting and diarrhoea,
• low blood pressure and possible loss of consciousness,
• skin may feel pale, cold, and clammy,
• delirium and/or depression.

Causes
In most cases, blood poisoning occurs when bacteria escape from an
infection and enter the bloodstream. Blood poisoning can also result
from wounds, burns and infected surgical incisions, all of which
release enough bacteria into the bloodstream to cause
septicaemia. Internal conditions ranging from urinary tract infections
and pneumonia, to boils, abscessed teeth and gum problems, may
cause blood poisoning if enough bacteria escape into the
bloodstream. The bacteria from the infected sites are then carried in
the blood to the bodys tissues. The immune system attempts to
combat this by releasing endotoxins into the bloodstream to defend
the blood vessels against leaking. You may feel feverish and chilled,
as the body attempts to bring the poisoning under control and
prevent fluid loss into tissues. If this not prevented, infections such
as meningitis or typhoid that affect the whole body may develop.

Diagnosis
If you think you may have blood poisoning and are displaying any of
the symptoms, it is important to seek urgent medical attention. Your
doctor will assess your symptoms and carry out a blood test to
identify the bacteria causing the infection. If septic shock is
suspected, you will be hospitalised while the blood is tested for
bacteria, blood gas levels, and other indicators. An
electrocardiogram (ECG) may also be taken to check for an irregular
heartbeat.

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Treatment
Once the bacteria have been identified, blood poisoning is normally
treated with oral or intravenous antibiotics. Additionally, the
infected area may need to be drained in order to disinfect it. If
septic shock develops, emergency treatment and antibiotics
including penicillin will be administered. As blood poisoning can be
fatal, it is usually necessary to remain in hospital until a complete
recovery is made, in order for any potential complications to be
monitored.

Prevention
The following measures will reduce the risk of blood poisoning:

• Be aware of the symptoms of blood poisoning. The infection
can spread very quickly and it is important to know the signs
to look out for.
• Vaccines against meningitis and tuberculosis are offered
within existing immunisation programmes. Although they do
not offer protection against all strains of infection, they still
provide an excellent defence.
• Keep wounds clean. If you cut, scratch or break your skin in
any way, make sure the wound is cleaned, treated with
antiseptic, and covered with a plaster or dressing if necessary.
• If you develop a mouth infection, see your dentist straight
away for treatment. For a faster recovery from an abscessed
tooth, apply a warm-water compress and rinse with warm salt
water. Eating soft foods and flossing regularly can also help to
prevent infection spreading.
• A boil should be treated by applying a warm-water compress
to the affected area for 20 minutes, three times a day, until it
bursts. You should continue to apply the compress until the
boil has completely drained of puss. Do not be tempted to
squeeze boils as this can spread the infection.

Blood pressure (high)

Introduction
Persistent high blood pressure (hypertension), if untreated puts you
at greater risk of having a heart attack (myocardial infarction) or
stroke.
To measure blood pressure, two readings are taken:

• The systolic pressure. This is the first and higher
measurement. It is a measure of the blood pressure as the
heart contracts and pumps blood out.

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• The diastolic pressure. This is the second and lower number. It
is a measure of the blood pressure when the heart is relaxed
and filling up with blood.

Blood pressure is measured in terms of millimetres of mercury
(mmHg). Hypertension (high blood pressure) is defined as a systolic
pressure of 140 mmHg or more, or a diastolic pressure of 90 mmHg
or more.
Blood pressure varies constantly during the day. The level of
physical exertion, anxiety, stress, emotional changes and other
factors may also cause changes in blood pressure. So blood
pressure should be checked under resting conditions and single
measurements are not particularly meaningful. A diagnosis of
hypertension is not normally made unless a high blood pressure is
measured on three separate occasions (usually over 3 months).
Lifestyle changes, such as a healthy diet and increased exercise are
important for everyone with raised blood pressure. Medicines to
treat hypertension are particularly recommended for a sustained
systolic pressure of 160 mmHg or more and/or diastolic pressure
100 mmHg or more.
High blood pressure is common. Moderately high diastolic pressures
(90-109 mmHg) are found in about 1 in 4 middle-aged people. They
are less common in younger people and more common in those who
are older. Very high diastolic pressures (110-129 mmHg) are found
in about 1 in 25 people. It is believed that there are large numbers
of people who have high blood pressure but are not aware of it.

Symptoms
Most people with hypertension will not get any symptoms. The only
way to find out if you have high blood pressure is to have it
measured.
In rare cases, the blood pressure can rise dramatically and without
warning. The systolic blood pressure can reach 220mmHg and the
diastolic pressure 120mmHg. Urgent treatment is required. This
happens to less than 1 in 100 people who have hypertension.
The symptoms of this type of severe high blood pressure include:

• a bad headache,
• feeling confused,
• feeling sick,
• having trouble seeing,
• feeling very sleepy.

Causes
High blood pressure is very common, affecting as many as 1 in 4
people.
In approximately 90% of cases, the cause is unknown. This type of
high blood pressure is known as essential hypertension.

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Certain lifestyle and genetic factors may contribute to the risks of
developing essential hypertension.
Risk factors include:

• getting older,
• being male - hypertension is slightly more common in men,
• having a family member with high blood pressure,
• being overweight,
• drinking excessive amounts of alcohol,
• stress may cause a temporary rise in blood pressure,
• smoking,
• lack of exercise.
• ethnic group- as many as half of all people of black African or
Caribbean origin over 40 years of age are likely to have high
blood pressure. Likewise British people of South Asian (Indian,
Pakistani or Bangladeshi) origin are also more likely to have
high blood pressure and are more prone to stroke and heart
attacks.

In a few people, the cause of hypertension can be identified. The
cause may be Cushing's syndrome, kidney disease, taking certain
medicines e.g. oral contraceptives or, rarely, a tumour of the
adrenaline-producing cells in the adrenal gland (small gland above
the kidney).

Diagnosis
To measure blood pressure, two readings are taken:

• The systolic pressure. This is the first and higher
measurement. It is a measure of the blood pressure as the
heart contracts and pumps blood out.
• The diastolic pressure. This is the second and lower number. It
is a measure of the blood pressure when the heart is relaxed
and filling up with blood.

Blood pressure is measured in terms of millimetres of mercury
(mmHg). High blood pressure (hypertension) is defined as a systolic
pressure of 140 mmHg or more, or a diastolic pressure of 90 mmHg
or more.
Blood pressure is measured using a sphygmomanometer. An
inflatable cuff is wrapped around your upper arm. The cuff is inflated
and stops the blood flow in the main blood vessel in your arm. The
doctor or nurse then watches a gauge in the sphygmomanometer
and listens through a stethoscope as the air in the cuff is released.
When the first sound of the heartbeat is heard, the systolic pressure
is recorded. When the sound disappears, the diastolic pressure is
recorded. Sometimes a computerised blood pressure machine is
used that takes the readings automatically.

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Blood pressure varies constantly during the day. The level of
physical exertion, anxiety, stress and emotional changes may also
cause changes in blood pressure. So blood pressure should be
checked under resting conditions and single measurements are not
particularly meaningful.
Some people become nervous when visiting the doctor, which may
make their blood pressure rise temporarily. As a result, a diagnosis
of high blood pressure is not normally made unless the blood
pressure is raised when tested on three separate occasions (usually
over 3 months).
If high blood pressure is diagnosed, the doctor will decide what kind
of treatment is needed by assessing:

• age, sex and ethnic background,
• blood pressure measurements,
• relevant medical history, such as diabetes,
• existing risk factors for heart disease or stroke, such as
smoking or high cholesterol levels,
• previous history of heart attack or stroke,
• whether the hypertension has already caused damage to the
heart or kidneys.

Treatment
The aim of treatment is to keep the diastolic blood pressure less
than 85mmHg and the systolic blood pressure less than 140 mmHg.
These targets are set slightly lower, diastolic less than 80 mmHg
and systolic less than 135 mmHG, for people at greater risk of heart
attack (myocardial infarction) and stroke e.g. if you have angina, a
previous heart attack, chronic renal failure or diabetes.
In some people, it may not be possible to reduce the blood pressure
below these targets, despite treatment.
Lifestyle changes
In many cases, mild high blood pressure can be treated with lifestyle
changes. See the 'Prevention' section.
Losing weight, regular exercise, a low-fat and low salt diet, quitting
smoking and reducing the amount of alcohol consumed will often be
enough to get blood pressure down to normal levels.
Antihypertensive medicines
If lifestyle changes are not successful, then antihypertensive
medicines will be necessary. Antihypertensive medicines are
particularly recommended if the systolic pressure is 160 mmHg or
more and/or the diastolic pressure is 100 mmHg or more.
There are different antihypertensive medicines and your doctor will
assess which type is best for you start on.
A single antihypertensive medicine may not be adequate and others
will be added one by one until good blood pressure control is
achieved. Unless it is necessary to lower the blood pressure
urgently, an interval of at least 4 weeks is usual before adding in
more treatment.

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Antihypertensive medicines can have side effects. However, it is
important to continue with treatment. Discuss any side effects with
your doctor, as there are options of different antihypertensive
medicines which suit you better.
Treatment should be regularly reviewed. If you make lifestyle
changes and your blood pressure has returned to a normal level,
your GP may advise you to cut down or come off antihypertensive
medicines for a trial period.
Antihypertensive medicines include:
Thiazide diuretics ('water tablets') e.g. bendroflumethiazide,
chlortalidone, indapamide, metolazone are usually the first choice
antihypertensive medicine for people over 55 years. They work by
flushing excess water and salt from your body via the urine. With
long-term use, they also open up the blood vessels.
Beta-blockers e.g. acebutolol, atenolol, bisoprolol, metoprolol,
propranolol, work by making the heart beat more slowly and with
less force, so lowering the pressure in your arteries. Some beta-
blockers also block renin, a chemical in the kidney that controls the
loss of sodium and water.
Angiotensin-converting-enzyme inhibitors (ACE inhibitors)
e.g. captopril, enalapril, lisinopril, perindopril, ramipril.
Blood pressure is controlled in part by angiotensin, a natural
chemical produced by the kidney. Angiotensin causes the blood
vessels to narrow and so raise the blood pressure. ACE inhibitors
lower your blood pressure by stopping the formation of angiotensin.
About a third of all people taking ACE Inhibitors get a persistent dry
cough. If this occurs, an alternative type of antihypertensive
medicine should be tried.
Angiotensin II receptor antagonists e.g. candesartan, losartan,
valsartan work similarly to ACE Inhibitors. Instead of blocking the
formation of angiotensin II, they prevent the chemical from working
at its site of action.
They are an alternative for people who experience a cough with ACE
inhibitors.
Calcium channel blockers e.g. amlodipine, diltiazem, nifedipine,
nicardipine, verapamil keep your blood vessels relaxed and open,
making it easier for blood to flow through them. This lowers the
blood pressure. Some calcium channel blockers also make the heart
beat more slowly.
Alpha blockers e.g. doxazosin, prazosin, terazosin keep the blood
vessels relaxed and open, making it easier for blood to flow through
them. This lowers your blood pressure.
Some people feel faint after taking the first few doses of an alpha-
blocker. For this reason, it is best to take the first few doses at night
just before going to bed. Also, the doctor will usually start you on a
low dose and gradually increase the dose as you get used to it.
Medicines to reduce the risk of heart attack and stroke
Statins e.g. atorvastatin, fluvastatin, pravastatin, rosuvastatin,
simvastatin lower the blood cholesterol level by preventing

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cholesterol from being made in the liver. For people with high blood
pressure, the aim is to reduce the total blood cholesterol level to
below 4 mmol/l or by 25% of the original blood level whichever
gives the greatest reduction.
Generally, the higher the blood cholesterol level, the greater the risk
of atherosclerosis (fatty deposits in the arteries). Atherosclerosis
causes narrowing of the arteries (blood vessels) which when
combined with high blood pressure can put you at a greater risk of
heart attack and stroke.
Low dose aspirin
Taking low dose aspirin, usually 75mg, when you have high blood
pressure helps to reduce the risk of having a heart attack or stroke.
Low dose aspirin reduces the 'stickiness' of platelets (tiny particles
in the blood that help the blood to clot). When a large number of
platelets stick to an atheroma (fatty deposit) inside an artery, they
can form a thrombosis (clot). If a clot forms in an artery to the heart
muscle, it can cause a heart attack or in an artery to the brain, a
stroke.

Complications
It is important not to ignore high blood pressure. The complications
of uncontrolled high blood pressure causes more deaths and severe
disability than any other group of diseases.
Sustained high blood pressures are very damaging to your blood
vessels, causing atherosclerosis (build up of fatty deposits in the
lining of the arteries) and arteriosclerosis (thickening of the muscle
wall of the blood vessels). This results in narrowing of the arteries
and a reduced blood supply to your vital organs, particularly the
brain, heart, kidneys and eyes.
The risks of uncontrolled high blood pressure are:

• stroke,
• heart attack,
• heart failure (heart doesnt pump effectively),
• angina,
• damage to the kidneys,
• damage to the eyes.

High blood pressure rarely has any symptoms so every adult should
have regular blood pressure checks. Fortunately, proper and
effective treatment can avoid these serious complications.

Prevention
You can help treat and reduce your risk of developing high blood
pressure by making lifestyle changes:

• eat a healthy, well-balanced diet, with less salt,
• lose weight if necessary,
• exercise regularly,

16
• stop smoking,
• reduce your alcohol and caffeine consumption to
recommended levels.

Regular checks of your blood pressure are important, especially if
you have a family history of hypertension. Treatment can then be
started before complications have a chance to develop.

Blood pressure (low)

Introduction
Your blood pressure
Your heart pumps blood around your body through a circulatory
system that is made up of tubes called arteries and capillaries. The
blood flows back to your heart through a network of veins.
When your heart contracts (squeezes in) it pushes blood into your
arteries, causing an increase in pressure. At this stage, the pressure
in your arteries is at its highest, and is known as the systolic
pressure. When your heart relaxes and refills with blood, the
pressure in your arteries decreases. This is known as the diastolic
pressure. Both your systolic and diastolic pressures are measured in
terms of millimetres of mercury (mmHg).
Throughout the day, your blood pressure can vary by between 30-40
mmHg (both systolic and diastolic) depending on what you are
doing. When you are asleep, or relaxed, your blood pressure will be
at its lowest. When you exercise, or you are stressed or anxious,
your blood pressure will increase. Therefore, each time you have
your blood pressure measured, it is important that the test is carried
out under similar conditions so that the results are consistent.
The highs and lows
For a young, healthy adult, normal blood pressure is about 110/70,
but generally, the lower your blood pressure is, the better. If you
have a reading of 140/90 or more, you have high blood pressure,
also known as hypertension. If your blood pressure is high, your GP
may give you advice about how to lower it by making some simple
lifestyle changes, such as altering your diet, giving up smoking, and
taking regular exercise. Alternatively, you may be prescribed drugs
that will help to reduce your blood pressure.
Low blood pressure is also known as hypotension. People with a
reading of around 90/60, or less, are commonly regarded as having
low blood pressure. If you have low blood pressure, to a certain
degree you have some protection against factors that increase
blood pressure, such as eating too much salt, not eating enough
fruit and vegetables, or being overweight. However, some people
who have low blood pressure may experience symptoms, and there
may be an underlying cause.

17
Symptoms
On its own, low blood pressure does not always cause symptoms. If
you have low blood pressure, and do not have any symptoms, you
do not require treatment. However, sometimes if your blood
pressure is too low, there may not be enough blood flowing to your
brain, and other vital organs. As a result, you may experience
symptoms such as dizziness and fainting. If you do, your GP will try
to find out whether there is an underlying cause for your symptoms.
As well as dizziness and fainting, other symptoms of hypotension
may include:

• light-headedness,
• blurred vision,
• palpitations,
• confusion,
• nausea,
• general weakness, and a
• temporary loss of consciousness.

Postural, or orthostatic hypotension
You may feel dizzy, or faint, after changing posture - for example,
when you sit up from a lying position, or stand up from a sitting
position. However, the fall in blood pressure usually only lasts for a
few minutes as it adjusts to your new posture. This is known as
postural, or orthostatic hypotension, and can affect you more as you
get older. Similar symptoms may also occur after exercise.
Postprandial hypotension
Dizziness, light-headedness, faintness, and falls, are symptoms that
can sometimes occur after eating, as a result of low blood pressure.
This condition, known as postprandial hypotension, tends to occur
more often in older people, particularly in those who have high
blood pressure, or a condition such as Parkinsons disease, or
diabetes.
After a meal, the intestines need a large amount of blood for
digestion, and so the heart rate increases, and the blood vessels in
other parts of the body constrict (narrow) to help maintain blood
pressure. However, the heart rate of some elderly people may not
increase enough, and their blood vessels may not constrict enough
to maintain blood pressure. As a result, their blood pressure falls.
Lying down after eating, and eating frequent, small, low-
carbohydrate meals may help to reduce the effects of postprandial
hypotension.

Causes
There are a number of things that can cause low blood pressure.
They include:

• the use of certain medications, such as anti-depressants,
and medicines to treat high blood pressure,

18
• diabetes mellitus which can cause damage to the nerves
that supply your blood vessels, resulting in a fall in blood
pressure when you stand up (postural or orthostatic
hypotension),
• serious injuries, such as burns, or those that cause severe
blood loss, and lead to shock, and a reduction in blood
volume,
• serious illnesses, or conditions, such as a heart attack, or
adrenal gland failure,
• rare nerve conditions that affect the nerves in your legs can
cause a severe drop in blood pressure when you stand up
(postural or orthostatic hypotension),
• increasing age - as you get older, your arteries become
stiffer which can cause your blood pressure to drop,
particularly when you stand up, and
• pregnancy during the early to mid stages of pregnancy, low
pressure is fairly common.

Blood pressure lowering medicines
Nowadays, most blood pressure lowering medicines do not cause a
drop in blood pressure when you stand up. Alpha-blockers, such as
doxazosin, are the only type of medicine that may cause a decrease
in your standing blood pressure. You should have your standing
blood pressure checked, if you are taking doxazosin, and you feel
dizzy, or faint, when you stand up.
In the past, it was thought that low blood pressure could cause
tiredness, depression, and anxiety. However, recent studies have
found no strong evidence to suggest that low blood pressure causes
these symptoms.
Adrenal gland failure
The adrenal glands are two small glands that are located just above
your kidneys. They produce a number of hormones, including
aldosterone, which controls the amount of salt in your body. If your
adrenal glands become damaged, the production of aldosterone
may be reduced, resulting in a loss of salt from your body. This can
lead to low blood pressure, and may make you feel dizzy, or faint, if
you stand up too quickly. Adrenal gland failure is rare but, if it is
diagnosed, it can be treated by increasing the amount of
aldosterone.
Serious illnesses
Sometimes, severe illnesses that cause infection, blood loss, or
heart damage, may result in low blood pressure, particularly when
sitting up or standing. If you have an acute illness, your blood
pressure will be measured regularly because it is a good indicator of
the severity of your illness.

Diagnosis
Blood pressure is measured using two numbers the first is known as
systolic (the pressure in your arteries when your heart contracts and

19
pushes the blood around your body), and the second is known as
diastolic (the pressure in your arteries when the heart refills with
blood between heart beats). Both your systolic and diastolic
pressures are measured in millimetres of mercury (mmHg).

Your GP, or practice nurse, will use an inflatable cuff to measure
your blood pressure. The cuff is placed around your upper arm and
inflated. S/he will watch a pressure gauge and listen to the blood
flow in the main artery of your arm, using a stethoscope. Upon
hearing the heart beat, the systolic pressure will be recorded, and
when the sound disappears, the diastolic pressure will be recorded.
Alternatively, a computerised blood pressure machine may be used
to take readings automatically.

After you have had your blood pressure taken, your GP, or nurse, will
give you your systolic reading first, followed by your diastolic
reading. If your systolic blood pressure is 120 mmHg, and your
diastolic blood pressure is 80 mmHg, you will be told that your blood
pressure is 120 over 80, which is commonly written as 120/80.
Your blood pressure may be measured both while you are lying
down, and while you are standing. If you have high or low blood
pressure, and you are taking medication, you should have your
blood pressure checked on a regular basis.

Treatment
If you have low blood pressure, but do not have any symptoms, you
do not require treatment. Only a small number of people who have
low blood pressure are prescribed medication to treat the condition.
For example, some elderly people may experience symptoms when
changing posture, and are sometimes given medication to constrict
(narrow) their arteries.
Medications that cause low blood pressure
If you are taking medication and your GP suspects that it may be
causing low blood pressure, s/he will probably advise a change of
medication, or alter the dose. If you are taking a blood pressure
lowering medicine, such as the alpha blocker, doxazosin, and you
feel dizzy or faint when you stand up, you should have your blood
pressure measured to see if it drops. If it does, you might need to
have your medicine changed. You should discuss this with your GP
or practice nurse.
Underlying illnesses or conditions
If your GP suspects that a disorder, such as a heart condition,
adrenal gland failure, or a nerve condition, is causing your low blood
pressure, you may be referred to hospital for further tests and
treatment. If adrenal gland failure is the cause of your low blood
pressure, replacing the missing hormone, aldosterone, will rectify
the problem. If a nerve condition is causing low blood pressure, it
can be more difficult to treat. You might be given medicines in order
to stimulate your nervous system.

20
Salt and fluids
While people who have high blood pressure are usually advised to
restrict their salt intake, if you have low blood pressure, you may be
advised to include more salt in your diet. If you have postural
(orthostatic) hypotension, you may be advised to increase your salt
intake, either by adding more salt to your food, or by using salt
tablets. You GP will be able to advise you about how much additional
salt you require. Also, if you are dehydrated, ensuring that you drink
enough fluid (at least eight glasses a day) will help.
Other treatments
If you have low blood pressure, your GP may recommend wearing
support stockings to help stimulate your circulation, or using several
pillows, to raise your head, while sleeping.

Prevention
If you have low blood pressure, and it is part of your genetic make
up, you are lucky because it means that, to a certain degree you
have some natural protection against the factors that cause high
blood pressure (hypertension).

Older people, particularly those with diabetes, may have a tendency
for their blood pressure to fall when standing, and blood pressure
lowering drugs may make this worse. However, getting up slowly
will help you to avoid sudden falls in your blood pressure. When
getting out of bed, you should sit up slowly first, before standing up
slowly.

Diabetes

Introduction
Diabetes mellitus is a chronic condition caused by too much glucose
(sugar) in your blood. Your blood sugar level can be too high if your
body does not make enough of the hormone insulin. Insulin is
produced by the pancreas (a gland behind the stomach) and moves
glucose out of the blood and into cells, where it is broken down to
produce energy.
If diabetes is not treated it can cause long-term health problems
because the high glucose levels in the blood damage the blood
vessels.
There are two types of diabetes.
Type 1 or insulin-dependent diabetes
In type 1 diabetes, the body produces little or no insulin. Someone
with this type of diabetes needs treatment for the rest of their life.
They must check the levels of glucose in their blood regularly and
watch out for complications. Type 1 diabetes is also known as
juvenile diabetes, or early onset diabetes because it usually
develops before the age of 40, often in the teenage years.
Type 2 or non-insulin dependent diabetes

21
In type 2 diabetes, the body does not make enough insulin, or
cannot use insulin properly. This is called insulin resistance. This
type of diabetes is usually linked with obesity. It is sometimes
referred to as maturity onset diabetes because it occurs mostly in
people over the age of 40.
Diabetes in pregnancy (gestational diabetes)
Some pregnant women have such high levels of glucose in their
blood that their body cannot produce enough insulin to absorb it all.
This is known as gestational diabetes. It is quite rare affecting less
than 1 in 20 pregnant women. Gestational diabetes usually
disappears after the baby is born. However, women who develop
gestational diabetes are more likely to develop type 2 diabetes later
in life.
Diabetes affects 2 million people in the UK and there may be as
many as a million more people who have the condition but do not
know about it. The risk of developing type 2 diabetes is increased if
it runs in your family. Nine out of ten people with diabetes have type
2 diabetes and over 80% of these people are overweight. However,
symptoms can develop slowly over time, or not at all. Routine
screenings are the most effective way to diagnose the condition.

Symptoms
Without treatment, the main symptoms of diabetes are:

• feeling very thirsty,
• producing excessive amounts of urine (going to the toilet a
lot), and
• tiredness, weight loss and muscle wasting (loss of muscle
bulk).

Other symptoms can include:

• itchiness around the vagina or penis,
• getting thrush regularly, due to the excess sugar in your urine
encouraging infections, and
• blurred vision, caused by the lens of your eye becoming very
dry.

Symptoms of type 1 diabetes can develop quickly, usually over
days or weeks.
If your blood glucose levels become too high, you can suffer a
hyperglycaemic attack (excess of sugar and dehydration leading to
weakness and possible convulsion). This can happen if you have not
taken your insulin. The symptoms of a hyperglycaemic attack
include dehydration, drowsiness and a frequent need to urinate. If
left untreated, hyperglycaemia can lead to diabetic ketoacidosis,
which can eventually cause unconsciousness and even death.
Diabetic ketoacidosis occurs when your body begins to break down

22
fats for energy instead of glucose, leading to a build up of ketone
acids in your blood (see Selected links for more details).
If your glucose levels become too low you can suffer a
hypoglycaemic attack (hypo). This can happen if you have taken too
much insulin. Symptoms of a hypo include feeling shaky and
irritable and can be brought under control by eating or drinking
something sugary, such as a fizzy drink, sugar cubes or raisins,
which should stop the attack. After having something sugary, you
should then eat a longer-acting carbohydrate food such as a few
biscuits or a sandwich.
Symptoms of type 2 diabetes usually develop over weeks or
months. Some people with type 2 diabetes have few symptoms or
even no symptoms at all. However, they still need to have treatment
so that other health problems, such as kidney disease, do not
develop later on.

Causes
Diabetes is usually caused by the pancreas (a gland behind the
stomach) not producing enough (or any) of the hormone insulin.
Diabetes can also be caused by your body being unable to use
insulin properly. This is called insulin resistance. In rare cases,
diabetes can be caused by a disease of the pancreas called
pancreatitis.
Type 1 diabetes
If you have type 1 diabetes, your body is unable to produce insulin,
or is not able to produce enough. Type 1 is often referred to as an
auto-immune disease. This is because your immune system attacks
the cells in your pancreas, destroying them or damaging them
enough to reduce insulin production. In some cases, a virus infection
can trigger type 1 diabetes. You are more at risk of developing type
1 diabetes runs in your family.
Type 2 diabetes
If you have type 2 diabetes, your body does not produce enough
insulin, or the cells in your body do not react properly to the insulin.
Type 2 diabetes is closely linked to obesity. If you are overweight,
then losing weight, eating a healthy balanced diet, and taking
regular exercise, will greatly reduce your risk of developing
diabetes.
You are also more at risk of developing type 2 diabetes if:

• you have high blood pressure or high cholesterol,
• type 2 diabetes runs in your family,
• you are of Asian, Afro-Caribbean or Middle-Eastern
background, or
• you are a woman who has given birth to a large baby (over 9
lbs/4 kg).

The risk of developing type 2 diabetes also increases as you get
older.

23
Diagnosis
In order to diagnose diabetes, your GP will ask for a urine sample.
This will be tested to see if it contains glucose. A blood test will then
confirm the diagnosis, and whether or not your diabetes has an
underlying cause, such as high cholesterol.
If your glucose levels are not high enough for your GP to diagnose
diabetes, you may need to have an oral glucose tolerance test. This
is also sometimes referred to as a glucose tolerance test (GTT). Your
doctor will give you a glucose drink and take blood tests every half
an hour, for two hours to see how your body is dealing with the
glucose.

Treatment
Diabetes cannot be cured, but you can control the symptoms in
order to help prevent health problems developing later on in life. It
is important to diagnose diabetes as early as possible so that you
can start treatment. If you experience symptoms, you should see
your GP as soon as possible.
Type 1 diabetes
If you have type 1 diabetes, you will need to have regular insulin
injections for the rest of your life in order to keep your glucose levels
normal. Insulin injections can be administered using a syringe or an
injection pen, also referred to as an insulin pen (auto-injector). Most
people need either 2-4 injections a day and your GP or diabetes
nurse will teach you and/or a friend or relative how to inject the
insulin properly.
An alternative to injecting insulin is insulin pump therapy. An insulin
pump is a small device about the same size as a pack of cards that
holds the insulin. The pump is attached to you by a long piece of
thin tubing with a needle at the end, that is inserted under your
skin. Most people insert the needle into their stomach, but the hips,
thighs, buttocks or arms can also be used. The pump allows insulin
to flow into your bloodstream at a rate that you can control. This
means that you no longer need to give yourself injections (see
selected links section for further information).
A new device for delivering insulin without using a needle is now
available on the NHS. Known as the insulin jet system, it can be
used on the stomach, buttocks and thighs. It works by forcing a very
small stream of insulin through a nozzle placed against the skin. The
insulin travels at such high speed it goes through the skin. Your GP
will be able to advise you if this needle free method of insulin
delivery is suitable for you.
You will need to regularly check your glucose levels. This can be
done at home using a simple finger prick blood test. Your GP will talk
to you about your ideal glucose blood level as it varies from person
to person, and it also varies throughout the day. The normal blood
glucose level is between 4 -7 mmol/l before meals, and less than 10
mmol/l two hours after meals. Mmol/l means millimoles per litre and
is a way of defining the concentration of glucose in the blood.

24
To help reduce the level of glucose in your blood, you should also
make sure you have a healthy balanced diet and take regular
exercise.
Type 2 diabetes
You can usually control type 2 diabetes by making changes to your
diet (see prevention section), losing weight (if you are overweight),
and taking regular exercise. Some people with type 2 diabetes may
also need to take tablets or have insulin injections.
There are several different types of medicines that are used to treat
type 2 diabetes. It may be necessary to take a combination of two,
or more, of these medicines to control your blood glucose level:

• Metformin this is often the first medicine that is advised for
type 2 diabetes. It mainly works by reducing the amount of
glucose that your liver releases into the bloodstream.
• Sulphonylureas for example, glibelclamide, gliclazide,
glimerpirizide, glipizide, gliquidone, increase the amount of
insulin produced by your pancreas. They also make your
bodys cells more sensitive to insulin so that more glucose is
taken up from the blood.
• Acarbose this slows down the absorption of carbohydrate
from the stomach and digestive tract, preventing a high peak
in the blood glucose level after eating a meal.
• Nateglinide and repaglinide stimulate the release of insulin
by the pancreas. They are not commonly used but are an
option if other medicines do not control your blood glucose
levels.
• Thiazolidinediones (glitazones) (e.g. pioglitazone,
rosiglitazone) - These make the body's cells more sensitive to
insulin so that more glucose is taken up from the blood. They
are a third line treatment for people who do not respond to
other treatments or in whom other treatments are not
suitable.

If you have type 2 diabetes, you need to keep a regular check on
your blood glucose levels. This is usually done with a finger prick
blood test or sometimes a urine test.
Other treatments
If you have type 1 or type 2 diabetes, you are at risk of developing
heart disease, stroke and kidney disease. To reduce the chance of
this, you may be advised to take:

• anti-hypertensive medicines to control high blood pressure,
• a statin, such as simvastatin or atorvastatin, to reduce high
cholesterol levels,
• low dose aspirin to prevent stroke, and
• an Angiotensin Converting Enzyme Inhibitor (ACE Inhibitor)
such as enalapril, lisnopril, or ramipril, if you have the early
signs of diabetic kidney disease. This is identified by the

25
presence of small amounts of albumin (a protein) in your urine
and is often reversible if treated early enough. For more
information on the ACE inhibitor see the selected links section.

You are also advised to have an influenza (flu) vaccine each year
and a one-off pneumococcal polysaccharide vaccine (PPV), as these
infections can be particularly unpleasant and more serious if you
have diabetes.
Regular check-ups
You will need to see your GP, or diabetes nurse, for regular check-
ups to see how well you are managing the symptoms of your
diabetes. You will have regular blood tests, urine tests, and blood
pressure tests. At least once a year your GP should carry out a
HbA1c test (glycated haemoglobin). This consists of a blood test
that indicates your blood glucose levels for the previous 2-3 months.
Your GP will also need to check your eyes, feet and nerves regularly
as these can be affected by diabetes (see complications section).
Your GP may also refer you to a dietician who will be able to give
you advice on maintaining a healthy lifestyle.

Medicine guides
The list of medicines below is a combination of the generic drug
names (scientific name for the active ingredient of the medicine)
and the various brands (company names for the medicine) available
in the UK.
The name provides a link to a separate website that provides
detailed information about these medicines and in some cases
animations (moving pictures). The information is provided as part of
an on-going project between NHS Direct and Datapharm
Communications Ltd. and others, including patients.
If you are taking one of the medicines listed for a different condition,
or your medicine for this condition is not listed and you would like
more information, speak to your GP, pharmacist, prescriber, or
contact NHS Direct on 0845 46 47.

Complications
If diabetes is not treated it can lead to many different health
problems. This is because large amounts of glucose can damage
your blood vessels, nerves and organs.
Even a slightly raised glucose level that does not cause any
symptoms in the short-term can affect your blood vessels, nerves
and organs in the long-term. This may lead to complications often
years after your diabetes was first diagnosed. These include:

• Heart disease and stroke if you have diabetes, you are five
times more at risk of heart disease and stroke compared with
those without diabetes. Prolonged, poorly controlled blood
glucose levels increases the likelihood of atherosclerosis
(furring up and narrowing of the blood vessels). This may

26
result in poor blood supply to the heart, causing angina. It also
increases the chance that a blood vessel in the heart or brain
will become completely blocked, causing a heart attack or
stroke.

• Retinopathy (damage to the retina at the back of the eye)
blood vessels in the retina of your eye can become blocked,
leaky or grow haphazardly. This damage gets in the way of the
light passing through to your retina and, if left untreated, can
damage your vision.

• Kidney disease the small blood vessels of the kidney
become blocked and leaky, making the kidneys work less
efficiently.

• Foot problems damage to the nerves of the foot can mean
that small nicks and cuts are not noticed, leading to the
development of a foot ulcer. About 1 in 10 people with
diabetes get foot ulcers, which can cause serious infection.
You should keep your nails short and your feet clean. Wear
shoes that fit properly and see a podiatrist or chiropodist (a
specialist in foot care) regularly so that any problems are
found early.

• Impotence in men damage to the nerves can lead to
erection problems in men. However, this may be treated using
medication.

In general, the risk of developing complications is greatly reduced if
your blood glucose level is well controlled and if other risk factors,
particularly high blood pressure and high cholesterol are controlled.
Pregnant women with diabetes are at increased risk of miscarriage
and stillbirth. If their blood sugar level is not carefully controlled in
the early stages of pregnancy, there is also an increased risk of the
baby developing a serious birth defect. Pregnant women with
diabetes will usually have their antenatal check-ups in hospital or in
a diabetic clinic where doctors can keep a close watch on their blood
sugar levels, and control their insulin dosage more easily.

Prevention
You may be at risk of developing type 2 diabetes if it runs in your
family, or if you are overweight and do not get enough regular
exercise. Therefore, to help prevent diabetes, you should eat a
healthy balanced diet and take regular exercise.
A healthy diet is one that is low in saturated fat, salt and sugary
snacks and drinks. Try to eat regular meals throughout the day to
keep your blood sugar level constant, and eat at least five portions
of fruit and vegetables every day. Stopping smoking and reducing
your alcohol intake will also help. The Department of Health
recommends that adult males should drink no more than 3-4 units

27
of alcohol a day, and that adult females should drink no more than
2-3 units of alcohol a day. However, it is important to remember that
alcohol affects different people in different ways. Women tend to
have different metabolisms and tend to be lighter than men, which
may lead them to have a lower tolerance to alcohol. If you have
diabetes, you can still eat foods such as chocolate and sweets as
long as you keep your overall diet healthy.
Ideally, you should take a minimum of 30 minutes of exercise at
least three times a week. However, regular exercise does not have
to be a chore you can make sure you keep active by walking instead
of taking the bus and using the stairs instead of the lift.
If you have type 1 diabetes, you should wear an identity bracelet to
let others know that you have the condition. This will ensure that if
you blackout, or collapse, emergency medical professionals will be
quickly made aware that you have the condition. See the symptoms
section for details regarding hyperglycaemic and hypoglycaemic
attacks.

Diabetes insipidus

Introduction
Diabetes insipidus is a rare condition in which the kidneys allow too
much water to leave the body. It is characterised by needing to
urinate often and passing a large quantity of urine, and feeling
extremely thirsty. It is a completely different disease from diabetes
mellitus.
The job of the kidneys is to filter the blood. The kidneys sort the
substances that the blood carries, such as minerals, toxins and
water, and sends them to different places around the body. Minerals
are sent around the body to help the it grow and heal. Toxins are
made to leave the body through sweat and urine. Some water is
kept in the body and stored in the cells and blood. Any water that is
left over leaves the body with the toxins, through sweat and urine.
A hormone called antidiuretic hormone (ADH) is used to control the
amount of water in the body. ADH is released from a part of the
brain called the pituitary gland when there is not enough water in
the body. It tells the kidneys to keep more water and not to send it
out of the body. In diabetes inspidus, either there is not enough ADH
in the body, or the kidneys do not respond to it. This means that too
much water is leaving the body, and makes you feel dehydrated.
ADH is also called vasopressin.

Symptoms
The two most common symptoms of diabetes insipidus are:

• Feeling thirsty all the time (polydipsia),
• Making a lot of urine (polyuria) more than 3 litres in 24 hours,

28
• Needing to urinate often at night-time (nocturia).

When too much water is lost, the concentration of other substances
in the body can get dangerously high. For example, there may be
too much sodium in the body. Sodium is part of sodium chloride also
known as salt which is needed to make the body work. If there is too
much of it, however, it can cause confusion and possibly coma.
Children with untreated nephrogenic diabetes insipidus (caused by
problems in the kidneys) tend to feed poorly and do not grow or
gain weight at the normal rate. They can become very dehydrated
when they are ill, when they get too hot, or when they do not have
water for a short period of time. They may be short for their age and
have a painful, swollen bladder.

Causes
Diabetes insipidis is caused either by a shortage of ADH in the body,
or by the kidneys not responding properly to ADH.
Lack of ADH may be caused by:

• A tumour (cancerous or non-cancerous) in or around the
pituitary gland;
• Damage to the pituitary gland caused by illnesses such as
meningitis, or trauma (injury) such as head injuries or brain
surgery;
• Some cases do not seem to have a cause. These tend to be
the cases in which other members of the same family have
the condition, which suggests there may be a genetic cause.

Sometimes ADH is produced, but the kidneys do not respond to it,
and continue to get rid of too much water. The parts of the kidney
that does the filtering are called nephrons. There are several
reasons why the nephrons might not work properly:

• Genetic (inherited) faults in the nephrons. This is the most
common cause of ADH being ignored by the kidney, and it is
called nephrogenic diabetes insipidus.
• Other problems with the chemistry of the body (the
metabolism), including conditions when the body produces too
much calcium, or too little potassium. These conditions
prevent the nephrons from being sensitive to ADH.
• Certain drugs, such as lithium and tetracycline. These also
reduce the sensitivity of the nephrons.

Diagnosis
Symptoms such as producing large amounts of urine can be linked
to many conditions, such as diabetes mellitus, so tests are needed
to diagnose diabetes insipidus.
Urinalysis involves testing a sample of urine. Usually doctors will
take a sample of urine and a blood sample from patients who have

29
not had anything to drink for a few hours. People with diabetes
insipidus will continue to pass large amounts of dilute urine,
whereas most people would pass a small amount of concentrated
(dark) urine.
The blood and urine will be tested for substances such as blood
sugar (glucose), calcium, and potassium. If there is lots of sugar in
the urine, the cause is more likely to be diabetes mellitus.
Other tests can be used to work out the type of diabetes insipidus.
To test whether it is caused by a lack of ADH, the patient may be
given a dose of ADH. If the amount of urine produced returns to a
normal level, this shows that ADH is the cause. There will be no
effect if the condition is caused by a problem in the kidneys.
Magnetic resonance imaging (MRI scans) can be used to look at the
head, to see if there are any tumours or any damage to the pituitary
gland.
It is also possible to test unborn babies for diabetes insipidus. This
allows doctors to treat the baby as early as possible, and make sure
they do not become dehydrated or have any of the complications of
diabetes insipidus (see Complications section).

Treatment
In order to treat diabetes insipidus, it is important to find the cause.
When diabetes insipidus is caused by lack of ADH, it can be treated
with a substance called desmopressin. This is a manmade version of
ADH, and is more powerful than the ADH that is naturally produced
in the body. It can be given as tablets or as a nasal spray, because it
can be absorbed through the mucous in the nose.
In mild cases of this type of diabetes insipidus, it may be possible to
treat the condition simply by taking more fluids.
Nephrogenic diabetes insipidus cannot be treated with
desmopressin. A diuretic drug such as thiazide, and a very low salt
diet, can help to reduce the amount of urine being made by up to
half.
If nephrogenic diabetes insipidus is being caused by medications,
stopping these medicines may help, but you should not stop
medication without discussing this with your GP.
Hereditary nephrogenic diabetes insipidis is treated by giving more
fluids, and drugs including diuretics and anti-inflammatories.

Complications
If a person with diabetes insipidus does not store enough water,
their body can become dehydrated. Dehydration can cause:

• dry skin,
• dry mucous membranes (such as around the mouth and
eyes),
• sunken appearance of eyes,
• fever,
• rapid heart rate, and

30
• weight loss.

Diabetes insipidus can also cause an electrolyte imbalance.
Electrolytes are minerals in your blood that have an electric charge,
such as sodium, calcium, potassium, chlorine, magnesium, and
bicarbonate. If they are not balanced, the amount of water in the
body is affected. This can disrupt other body functions such as the
way muscles work, leading to headache, fatigue, irritability and
muscle pains.
Babies with untreated diabetes insipidus cannot say when they are
thirsty, which means they can have a severe shortage of water. This
can lead to fever, vomiting and convulsions (fits). If treatment is not
started early, it may lead to brain damage.

Haemophilia

Introduction
Haemophilia is a disorder of the blood-clotting system. Normally,
when you cut yourself your blood plugs the wound by changing from
a liquid to a solid and forming a blood clot. If you have haemophilia,
your blood will not clot normally and you may bleed for longer than
normal, or you may bleed internally, particularly into joints such as
your knees, elbows and ankles.
Blood contains special proteins, called 'clotting factors', which are
involved in the clotting process. There are 20 different clotting
factors. If you have haemophilia, your body does not produce
enough, or produces none, of one of these clotting factors.
There are different types of haemophilia. If you have haemophilia A,
you have a deficiency of clotting factor VIII (known as factor VIII).
Haemophilia A is also known as classical haemophilia and is the
cause of about 80% of cases. If you have haemophilia B, you have a
deficiency of clotting factor IX (known as factor IX). Haemophilia B is
also known as Christmas disease and is the cause of about 20% of
cases. Deficiencies of factors VIII and IX are the most common;
deficiencies of other factors do exist but are very rare.
Haemophilia can be mild, moderate or severe, depending on how
much factor VIII or IX is missing from your blood:

• Mild haemophilia - your blood contains 5-25% per cent of the
normal amount of factor VIII or IX.
• Moderate haemophilia - your blood contains 1-5% of the
normal amount of factor VIII or IX.
• Severe haemophilia - your blood contains less than 1% of the
normal amount of factor VIII or IX.

Haemophilia is rare and almost always affects men. Haemophilia A
occurs in about 1 in 10,000. Haemophilia B occurs in about 1 in
40,000. About 6,000 people have haemophilia in the UK.

31
Symptoms
The signs and symptoms of haemophilia vary, depending on the
severity of the clotting factor deficiency. They include:

• bleeding from cuts or injuries that continues for much longer
than normal,
• unexplained bleeding, bruising or nosebleeds,
• unusually large or deep bruising forming as a result of injury,
• joint pain or swelling, or a feeling of warmth in the joint, and
• blood in the urine or faeces.

Internal bleeding into the joints, muscles or other tissue can occur
spontaneously (without an external cause), or as a result of an
injury.
The joints most commonly affected by internal bleeding are the
knees, followed by the elbows, ankles, shoulders and wrists. If left
untreated, bleeding into a joint causes a feeling of warmth or
tightness in the joint, pain, swelling and spasm of the muscles
surrounding. Once a joint has suffered a 'bleed', it is more likely to
bleed in the future. Repeated bleeding in a joint can lead to arthritis
or permanent joint damage, causing stiffness and mobility
problems.
Bleeding can occur in or around the brain or spinal cord. This is rare
and usually occurs only in those with severe haemophilia, but
occasionally it can occur in those with the mild or moderate forms of
the condition. This type of bleeding is normally caused by injury to
the head or spine, but it can occur spontaneously. Bleeding into the
brain can cause headache, nausea, vomiting and seizures (fits).
How easily or badly a person with haemophilia bleeds depends on
the severity of their haemophilia. In those with mild haemophilia,
bleeding often occurs only after moderately severe injury or after
surgery. Children with mild haemophilia may not have any
noticeable symptoms for years. However, those with severe
haemophilia may experience spontaneous bleeding as often as 30
or more times a year.

Causes
Haemophilia is caused by a deficiency of one of the clotting factors
involved in the blood clotting process, most commonly factor VIII or
IX. The production of these factors is controlled by a gene; if the
gene has a defect it can lead to not enough of the factor being
produced. Haemophilia can be inherited because the defective gene
can be passed on from parent to child. About 70% of cases of
haemophilia are inherited.
Everyone has two sex chromosomes - they inherit one from each
parent. Females inherit an X chromosome from their mother and an
X chromosome from their father. Males inherit an X chromosome
from their mother and a Y chromosome from their father.

32
The gene that controls the production of factor VIII and IX is located
on the X chromosome. As a man only has one X chromosome, if that
chromosome carries the defective gene they will have haemophilia.
Men can't pass - on the gene that causes haemophilia to their sons.
Haemophilia is passed from mother to son via the X chromosome.
Most women who inherit an X chromosome with the defective gene
will have a normal version of the gene on their second X
chromosome - only if both their inherited X chromosomes have the
defective gene will they have haemophilia. Women who have the
defective gene on only one of their X chromosomes normally
develop no symptoms of haemophilia and are known as carriers of
the condition. Women who are carriers have a 50% chance that their
sons will have haemophilia.
In about 30% of cases there is no family history of haemophilia.
These cases are the result of the gene responsible for producing
factor VIII or IX mutating spontaneously, either in a man's sperm or
a woman's egg. A mutated gene is often defective, so if a sperm or
egg with the mutated gene is fertilised, the child may have
haemophilia.

Diagnosis
To diagnose haemophilia, a doctor will take a family history, ask
about any history of abnormal bleeding and take a blood sample
that can be tested to identify any problems with the blood clotting
process.
Blood tests can identify whether the blood has low levels of any of
the clotting factors or whether one of the factors is missing entirely.
They can also measure the 'clotting time' of the blood. Normal
clotting time is between four and seven minutes, but in a person
with haemophilia it will be longer. The results of these tests will
show if the person has haemophilia, what type of haemophilia they
have, and whether it is mild, moderate or severe.
A blood test can also identify women who are carriers of the gene
that causes haemophilia. This means that a woman who wants to
become pregnant and who has a family history of haemophilia can
be tested to find out whether she is a carrier. Women who are
carriers and who are already pregnant can be given an ultrasound
scan to find out the sex of the baby. If it is a boy, they can then
decide whether to have an amniocentesis or Chorionic Villus
sampling (CVS) test that will show whether their child has
haemophilia.

Treatment
There is no cure for haemophilia. Treatment for the condition is
based on 'replacement therapy' - replacing the clotting factor that is
too low or missing.
For those with mild haemophilia, cuts and grazes usually cause few
problems as gentle pressure on the wound is normally enough to
stop any bleeding. If necessary, mild haemophilia A can be treated

33
with an injection of the hormone desmopressin, which stimulates
the body's production of clotting factor VIII. Replacement therapy is
not normally needed for mild haemophilia.
Moderate to severe haemophilia can be treated with an injection of
replacement clotting factor. Unfortunately, replacement clotting
factor remains active for only a short period - it loses half its activity
after only 12 hours - so if the bleeding is serious, repeated injections
are necessary. Injections can be given in hospital, but many people
with haemophilia are taught to inject themselves at home.
Replacement clotting factor can be given as needed, or regular
injections can be given two or three times a week to keep the levels
of clotting factor in the blood high enough so that bleeding does not
occur. This can reduce the amount of time those with severe
haemophilia need to spend in hospital and minimise the likelihood of
long term joint damage.
For many years replacement clotting factors were made from
donated human blood. However, as a precaution against the
theoretical risk from Creutzfeldt-Jakob disease (CJD), synthetic
alternatives called 'recombinant factors' are now used. Recombinant
factors are regarded as free from the risk of blood infections as well
as the theoretical risk from CJD. Since 1998 all children under 16
have been treated with recombinant and recombinant clotting
factors are now available to all haemophiliacs in the UK.

Complications
The most common complication of haemophilia is arthritis or
permanent joint damage due to repeated bleeding within the joint.
This can cause long-term pain and loss of mobility.
Some people with haemophilia can develop antibodies to the
replacement clotting factors used to treat the condition. The
antibodies can destroy the clotting factor before it has a chance to
work. This can be a serious problem as it means that the main
treatment for haemophilia is no longer effective. When antibodies
develop, doctors may use larger doses of clotting factor or try
different types of factor. Antibodies to clotting factor develop in
about 20% of those with severe haemophilia A, and about 1% of
those with haemophilia B.
Before the dangers of the AIDS epidemic were fully recognised,
blood containing the HIV virus was used to produce replacement
clotting factors and many haemophiliacs acquired the disease
between 1979 and 1985. Hepatitis has also been a problem in the
past, with many haemophiliacs contracting the disease from blood
carrying the virus.
Blood donors are now carefully screened and all donated blood
products tested for these viruses. Blood products used to create
clotting factors are treated with a detergent and heated to destroy
viruses. Vaccination against hepatitis A and B is also offered to all
haemophiliacs. In recent years synthetic alternatives to clotting
factors made from human blood have become available. Known as

34
recombinant clotting factors, they are regarded as free from the risk
of any blood infections as well as the theoretical risk from
Creutzfeldt-Jakob disease (CJD).

Hughes syndrome

Introduction
Hughes syndrome is a condition where clots (thromboses) form in
the blood vessels. It is sometimes called 'sticky blood', and is also
known as antiphospholipid syndrome (APS). The condition is named
after Dr Graham Hughes who discovered it in 1983.
Hughes syndrome is a relatively common cause of recurrent stroke,
heart attack, thrombosis and miscarriage. It affects both men and
women, but is mainly seen in women.
There are two types of Hughes syndrome:

• Primary - this is where Hughes syndrome develops by itself
and is not caused by another condition, and
• Secondary - this is when another condition causes you to
develop Hughes syndrome. These conditions are typically
autoimmune disorders, such as lupus (a condition where the
body develops antibodies that attack healthy tissue).

Symptoms
The symptoms of Hughes syndrome will depend on where clots in
your blood occur, and where they move to. A clot in your blood may
cause the conditions outlined below.

• Deep vein thrombosis - a blood clot in your leg. This results in
a painful swelling in your leg, normally starting in your calf.
• Pulmonary embolism - a blood clot that moves into your lung.
This may cause you to have a shortness of breath, chest pain,
or it may result in you coughing up a small amount of blood.
• Repeated miscarriages or still births - this can happen when
blood clots block the supply of blood to the foetus. If you have
had three, or more, consecutive miscarriages, you should be
tested for Hughes syndrome.
• Heart attacks or stokes - this can happen when blood clots
block the supply of blood to your heart or brain. As you get
older, your blood vessels can get narrower (atherosclerosis),
leading to a higher chance of a blood clot. However, if you
have Hughes syndrome, this can happen at a much earlier
age. Therefore, if you are under 45 years of age, and you have
had a stroke or a heart attack, you should be tested for
Hughes syndrome.

Other less common symptoms Hughes syndrome include:

35
• headaches or migraines,
• rashes - a 'net-like' rash may appear on your wrist or your
knee which is sometimes known as 'livedo reticularis',
• bleeding from nose or gums,
• sudden uncontrollable movement of your body, and
• memory loss.

Causes
The exact trigger of Hughes syndrome is unknown, but research has
shown that antiphospholipid antibodies play a role in causing blood
clots.
Antibodies are produced by your body's immune system to attack
harmful bacteria, or viruses. Hughes syndrome causes your body to
produce antibodies that mistakenly attack a type of fat found in your
blood called phospholipids. This can lead to clotting of your blood.

Diagnosis
Hughes syndrome is usually diagnosed using a combination of
different methods.
Your GP will take a look at your medical history and will ask you if
you have had a history of clotting problems, heart attacks or strokes
(particularly at a young age), migraines, or memory loss.
Women will be asked about previous pregnancies, and whether
there were any complications, or a history of miscarriages.
You may have a physical examination to check for a rash, and your
blood pressure, cholesterol and glucose levels may be tested to rule
out other causes of blood clots, such as hypertension and diabetes.
If the diagnosis uncovers evidence that suggests that you might
have Hughes syndrome, your blood will be tested for
antiphospholipid antibodies. The same test is usually run 6-8 weeks
later to confirm the diagnosis.
If the tests show the presence of antiphospholipid antibodies, you
will be diagnosed with Hughes syndrome and your treatment will
begin.

Treatment
Once Hughes syndrome has been diagnosed, the treatment is
relatively straightforward, and if you are being treated for the
condition, you are much less likely to experience any further blood
clots.
Aspirin
The main aim of treatment for Hughes syndrome is to thin the
blood. The vast majority of people find that one-quarter of an aspirin
(which has blood thinning properties) per day is all that is required
to thin the blood.
Warfarin and herparin
In cases where aspirin is not suitable, or a blood clot is present,
blood thinning medication called warfarin is used. This can be taken
in pill form. There is a small chance that warfarin can cause birth

36
defects, so it is not recommended during pregnancy. In such cases,
heparin is recommended. This is a similar medication to warfarin
and is considered safe to take during pregnancy. However, unlike
warfarin, herparin has to be injected.
For Hughes syndrome, long term treatment is usually required. If
you develop the condition, you may need treatment for the rest of
your life because suddenly stopping could increase the risk of blood
clots re-occurring.

Prevention
As little is known about what causes Hughes syndrome, there is not
much you can do to prevent the condition developing.
However, if you have been diagnosed with Hughes syndrome, there
are steps you can take to reduce the risks of blood clots occurring.
For example, you should:

• stop smoking,
• make sure you are a healthy weight, and
• take regular exercise.

Hyperglycaemia

Introduction
Hyperglycaemia occurs when there is a higher than normal level of
glucose in your blood. It is generally found in people with diabetes.
There are two types of diabetes:
Type 1 or insulin-dependent diabetes
In type 1 diabetes, the body produces little, or no, insulin. Insulin is
a hormone that is released by the pancreas and helps the body to
control blood sugar levels. If you have type 1 diabetes, you will
require life-long treatment, and will need to constantly check the
level of sugar (glucose) in your blood. The condition needs to be
carefully monitored in order to prevent any complications from
developing.
Type 2 or non-insulin dependent diabetes
In type 2 diabetes, the body does not make enough insulin, or
cannot use insulin properly. This is called insulin resistance. This
type of diabetes is usually linked with obesity. It is sometimes
referred to as 'maturity onset diabetes' because it occurs mostly in
people over the age of 40.
Hyperglycaemia often only affects people with type 1 diabetes.
Fortunately, if you have hyperglycaemia, it is normally easy to
recognise the signs that your glucose is high, and you can take the
appropriate steps to get it back to normal. This will usually involve
adjusting the levels of insulin (which is normally taken by people
with type 1 diabetes) to control your condition.

If you have type 2 diabetes, you can manage your diabetes by
carefully controlling your diet, or by using a combination of diet and

37
tablets. However, there are some people with type 2 diabetes who
also need to take insulin.

Symptoms
Symptoms of hyperglycaemia are the same as those of untreated
diabetes. They do not appear suddenly, but develop gradually, over
a period of time. Symptoms include:

• thirst,
• frequent urination,
• tiredness, and
• increased susceptibility to infections, such as thrush.

If the symptoms of hyperglycaemia are prolonged, they may cause
weight loss and blurred vision.
Weight loss is the result of your body trying to remove the excess
glucose from your blood through your urine, causing your to lose
calories.
High blood sugar can also changes the shape of the lenses in your
eyes causing your vision to blur.
In the long term, hyperglycaemia can increase the likelihood of
complications of diabetes, such as damage to your kidneys, eyes,
and the nerves of the feet. The condition can also cause heart
disease, circulation problems in your legs, and erectile problems (in
men).

Causes
An increase in blood glucose levels causes hyperglycaemia. The
increase can be the result of:

• emotional stress,
• a change of medication,
• a wrong (or missed dose) of insulin,
• less exercise than usual,
• a change in eating habits, or
• an illness, such as a cold or throat infection.

Recent studies have shown that people taking the medications,
olanzapine and risperidone - which are sometimes used to treat
schizophrenia and bi-polar disorder - have an increased risk of
developing hyperglycaemia and diabetes. If you are taking either of
these medications, your GP should arrange for you to have regular
blood sugar tests.

Diagnosis
The diagnosis of hyperglycaemia is based on the symptoms of the
condition (which are the same as for untreated diabetes). They
include; thirst, frequent urination tiredness, and an increased
susceptibility to infections, such as thrush.

38
If your GP suspects that you have hyperglycaemia, your blood
glucose levels, and the level of chemicals in your blood, such as
potassium and sodium chloride (salt) may be tested.

Treatment
If you have type 1 diabetes, you can be treated with insulin
injections, as well as diet and exercise control. Your blood sugar
levels will also all need to be closely monitored on a regular basis. A
small portable instrument called a blood glucose meter can be used
to check your blood sugar.
Type 1 diabetes
Usually, if you have type 1 diabetes, you will recognise the signs
that your glucose level is high, such as extreme thirst, frequent
urination and tiredness. Adjusting the levels of insulin in your blood,
and drinking fluids, will help to bring your glucose levels down. You
should contact your GP if your symptoms include nausea, vomiting,
or drowsiness.
Type 2 diabetes
Hyperglycaemia is rare in people with type 2 diabetes but you can
develop a condition called HONK (hyperosmolar non ketotic coma).
The loss of blood sugar causes your body to become extremely
dehydrated and this causes you to fall into a coma (a state of
unconsciousness).
If this happens, the person will need urgent hospital treatment for
the dehydration, and to correct the levels of certain chemicals in
their blood, such as glucose, potassium and sodium chloride (salt).
Hyperglycaemia can sometimes occur later in life (from middle-age
onwards) in those who have not been diagnosed as being diabetic.

Prevention
If you have type 1 diabetes, in order to prevent hyperglycaemia
from occurring, you will need to control your blood glucose levels by
maintaining the right combination of diet and insulin injections (or
tablets). You GP will be able to provide you with information and
advice about how you can do this.
It is important not to miss or alter your dose of insulin and to
maintain your fluid and food intake. It is also important that you test
your blood glucose levels regularly. Your GP will advise you when,
and how often, you should test your glucose levels. If you have
uncontrolled type 2 diabetes, or if it is difficult to control, you will be
carefully monitored by the healthcare professionals who are looking
after you.

Hypoglycaemia

39
Introduction
Hypoglycaemia is a condition where a person has an abnormally low
level of sugar (glucose) in the blood. This is dangerous because the
brain is totally dependent on a constant supply of glucose as its sole
provider of energy. Hypoglycaemia occurs mainly in people with
diabetes who have either taken too much diabetes medication,
missed a meal, or have been drinking alcohol on an empty stomach.
Untreated hypoglycaemia may lead to unconsciousness, during
which the brain may be damaged from a lack of oxygen.
Fortunately, most people will have some warning that their blood
glucose levels are too low, giving them time to eat or drink some
carbohydrate-rich food.

Symptoms
The symptoms of hypoglycaemia can include:

• headache,
• mental confusion (which may include aggressive behaviour),
• slurred speech,
• abnormal behaviour,
• loss of memory,
• numbness,
• double vision, and
• temporary paralysis and seizures (fits).

If you are hypoglycaemic, you may also experience trembling,
faintness and palpitations, and excessive sweating. Sometimes,
behaviour can be irrational, and disorderly, and may be mistaken for
drunkenness.

Causes
For people with type 1 diabetes, maintaining the correct blood
glucose is a balance between the amount of insulin injected and the
amount of food eaten. Most people with type 2 diabetes manage
their diabetes by carefully controlling their diet, but there are some
people with type 2 diabetes who also take insulin and are at risk of
becoming hypo (hypoglycaemic).
The most common cause of hypoglycaemia is having too much
insulin in the body. This is usually the case if you have taken too
much diabetes medication which causes a drop in blood pressure.
You may have taken your dose of insulin as usual, but your
carbohydrate intake may have been less than normal, or been used
up quicker than normal. This may be because you missed a meal or
did too much exercise.
A drop in blood sugar can also happen with oral hypoglycaemia
drugs. These medicines are used to lower your blood glucose and
are often used in type-2 diabetes.
In rare cases, hypoglycaemia may also occur in people with
conditions that affect the liver, kidneys, or disorders in the

40
endocrine system, such as the pancreas or thyroid gland or tumours
in the pancreas cells. Another cause could also be the presence of
an advanced tumour elsewhere in the body.
Hypoglycaemia is known to occur after binge or heavy drinking of
alcohol. It may occur in people on certain medication such as
quinine (malaria), salicylates (rheumatic disease) and propranolol
(high blood pressure).

Diagnosis
A hypoglycaemic attack (a hypo) can be confused with having too
much sugar in the blood which is called hyperglycaemia. If you are
not sure, always give the person some food containing sugar, such
as a chocolate bar, or a glass of fruit juice. As long as they are fully
conscious, it will do them no harm.
There are early warning signs you can watch out for. These include
feeling:

• shaky unstable on your feet,
• sweaty,
• feeling hungry,
• having tingling lips,
• your face going pale,
• heart palpitations irregular heart beats, or increased heart
rate, and
• feeling confused and irritable.

Your blood sugar level can be checked by your GP who will take a
blood sample for testing.

Treatment
A hypo is unlikely in people with type 2 diabetes because they keep
their diabetes under control with their diet.
The immediate treatment for a hypo is to have some food or drink
containing sugar straightaway to end the attack. Examples of ideal
types of food or drink include a glass of fruit juice that contains
sugar, sugar lumps, chocolate, biscuits, a handful of sweets, glucose
tablets or dextrose gel (such as GlucoGel).

After having something sugary, you should have a longer-acting
carbohydrate food such as a few biscuits, or a sandwich.
If you have type 1 diabetes should carry glucose gel or some sugary
food with them at all times. They are more likely to have a hypo
than people with type 2.
Injections of the hormone glucagon can be used in an emergency,
particularly if the person is unconscious, during which NO food or
drink should be given to them. This is best done by a friend or
family member who knows what they are doing, or a trained health
care professional.

41
If you go hypo for other reasons, you should be examined by a
doctor, and you may need to have tests done to find and treat the
cause.

Complications
A hypo itself is not normally dangerous to the body, but being
unconscious is because of the risk of choking. Therefore, it is
important to stop the hypo with some sugar straight away.
Alcohol can affect your bodys ability to release glucose. If you have
type 1 diabetes, you are advised to drink no more than 2-3 units of
alcohol per day, and to eat a snack after drinking alcohol.

Prevention
The safest way of avoiding a hypoglycaemic attack is to keep a
regular check on your blood sugar, and know how to recognise the
early symptoms.
Make sure you eat regularly and do not miss meals. Do not drink a
lot of alcohol either because this can lower your glucose levels.
Parents of children with type 1 diabetes very quickly recognise the
symptoms, but children should carry a carton or fruit juice that
contains sugar, or a chocolate bar with them at all times in case
they feel the symptoms coming on.
People with diabetes are advised to carry a form of identification
stating their condition so that they can be helped quickly and
efficiently.

Jaundice

Introduction
Jaundice is a yellowy tinge to the skin and the whites of the eyes. It
is caused by a build-up of the chemical bilirubin in the blood.
Bilirubin is made when red-blood cells are broken down. The body is
usually able to get rid of it easily unless there is something wrong
with your liver or biliary system (this releases bile to help with
digestion).
Neonatal jaundice often affects newborn babies during the first few
weeks of life. This is because their livers take a while to get working
properly. Jaundice in adults and older children is not related to
neonatal jaundice; it is usually the sign of a health problem.
There are three types of jaundice in adults and older children:
haemolytic jaundice, hepatocellular jaundice and obstructive
jaundice. Hepatocellular jaundice is the most common. It is usually
caused by a problem with the liver.

42
Symptoms
Jaundice makes your skin and the whites of your eyes turn a yellowy
colour. This may look a bit like a suntan. In people with dark skin,
jaundice can be noticed in the whites of the eyes.
Depending on what is causing your jaundice, you may have other
symptoms such as tiredness, abdominal pain, weight loss, vomiting
and fever.
If you have obstructive jaundice, you may be very itchy. Your urine
will probably be darker than usual and your stools might be paler.

Causes
The liver is a very important organ. One of its functions is to remove
a yellowy chemical, called bilirubin from the body.
Bilirubin is found in bile and is made from the breakdown of red
blood cells, which carry oxygen around the body. The body usually
removes bilirubin from the bloodstream by passing it though the
liver and to the kidneys for disposal. If there is too much bilirubin in
the blood or the liver cannot get rid of it for some reason, this can
lead to jaundice.
There are three types of jaundice:
Haemolytic jaundice - too much bilirubin is produced. This is
usually caused by excessive breakdown of red blood cells. This can
be due to a number of conditions such as anaemia or a problem
with the metabolism (the way the body makes energy).
Hepatocellular jaundice - bilirubin cannot leave the liver cells and
get into the bile to be removed by from the body by the kidneys.
This type of jaundice is usually caused by liver failure, liver disease
(cirrhosis), hepatitis (inflammation of the liver) or taking certain
drugs. It may also be caused by a tumour in the liver, or a tumour
elsewhere that has spread to the liver. People who have been
drinking excess amounts of alcohol over a length of time can do
serious damage to their liver.
Obstructive jaundice - there is an obstruction (blockage) in the
bile duct and the bilirubin cannot leave the liver. This type of
jaundice is usually caused by a gallstone, or a tumour or cyst in the
bile duct or pancreas.
People with inherited conditions such as Gilbert's syndrome, Rotor's
syndrome, Dubin-Johnson syndrome, or Crigler-Najjar syndrome are
more likely to get jaundice.

Diagnosis
If your GP thinks you may have jaundice they will send you for some
tests to confirm it, and see what's causing it.
A blood test will be done to see if your liver is working properly, if
you have enough red blood cells, and if you have any infections.
If an obstruction is suspected, you may have a scan to look at the
liver. You may also have a liver biopsy, which means a small sample
of tissue from your liver is taken away to be examined. You will be
given a local anaesthetic and the doctor will use a special needle to

43
get the sample. You may have to stay in hospital overnight after
your liver biopsy.
You might need to have a scan such as an ultrasound, MRI
(magnetic resonance imaging) or CT (computerised tomography) to
look at your liver or bile ducts.

Treatment
Treatment of jaundice in adults and older children depends on what
is causing it. Your doctor will carry out a number of tests (see
diagnosis) to find out what is causing your jaundice. You will then be
able to have the appropriate treatment.

• If it is caused by anaemia you might have to start taking iron
tablets.
• If it is caused by hepatitis you might need to start taking
tablets, but not all types of hepatitis can be treated.
• If it is caused by taking particular drugs, your doctor might
prescribe an alternative.
• If it is caused by an obstruction such as a gallstone or a
tumour, you may need to have surgery.
• If the liver is severely damaged, the damage cannot be
reversed. If you stop drinking alcohol this will increase your
chances of survival. You may be considered for a liver
transplant if the damage is very severe.

Prevention
As the liver is such a vital organ it is important that you look after it.
Stop smoking and don't drink excess amounts of alcohol. Drink lots
of water (about 8 glasses a day) and cut down on tea, coffee and
cola drinks, which all contain caffeine.
Eat lots of fruit and vegetables and have a low-fat diet. Get regular
exercise and lots of sleep.

Jaundice - newborn

Introduction
Jaundice is very common in newborn babies - over half of all
newborns have some degree of jaundice. It's usually nothing to
worry about, and needs no treatment as it disappears after a couple
of weeks.
Jaundice is caused by the liver not being fully developed and not yet
fully functioning properly.
A jaundiced baby's skin will look slightly yellow. In some babies the
yellowing can be noticed in the whites of the eyes.
Jaundice is more common in boys than girls (1) and in premature
babies.

44
Symptoms
Jaundice usually appears 2-3 days after birth. In premature babies,
who are more prone to jaundice, it can take 5-7 days to appear and
usually lasts slightly longer. Jaundice is also more common in babies
who are breastfed.
A jaundiced baby's skin will look slightly yellow, it often looks like a
suntan. In babies with dark skin, the yellowing can be noticed in the
whites of the eyes and the soles of the feet and palms of the hands.
Jaundice usually starts on the head and face and spreads to the
chest and stomach. In some babies it reaches the legs and arms.
Your baby may have other symptoms, including itchy skin, poor
sucking/feeding, sleepiness, dark urine or pale stools. See your GP
as soon as possible if you think your baby is ill.

Causes
The liver is a very important organ. One of its functions is to remove
a yellow chemical, called bilirubin. Bilirubin is found in bile and
made from the breakdown of red blood cells, which carry oxygen
around the body.
The body usually removes bilirubin from the bloodstream and it
passes though the liver and to the kidneys for disposal.
Newborn babies have a greater number of red blood cells than
normal at birth and these are broken down more quickly. This makes
more bilirubin, which the liver needs to get rid of. In newborn babies
the liver is not fully developed and cannot work efficiently yet, so
bilirubin builds up and causes jaundice.
In some cases the mother's milk may contain a harmless substance
that makes the baby jaundiced. There is no need to stop
breastfeeding (see complications).
Other, rarer, causes of jaundice include:

• liver disease,
• infection,
• an underactive thyroid gland,
• rhesus incompatibility (when the mother and baby have
different blood types),
• inherited deficiencies in enzymes,
• blockages of the bowel or bile duct, and
• hepatitis.

Diagnosis
When your baby is born, the doctors will check for jaundice, but it
doesn't usually appear for a few days. If it is noticed, your baby may
be kept in hospital for a few days for observation.
When your baby comes home from hospital keep an eye on him/her.
Check his/her skin and whites of the eyes in a well-lit room. Your
midwife or health visitor will also check for jaundice.
To test for jaundice, gently press your fingers on the tip of your
child's nose or forehead. If the pressed skin goes white your child

45
does not have jaundice, if it goes yellow you should see your GP as
soon as possible.
If the doctor thinks your baby may have jaundice they may do a
blood test (serum bilirubin or SBR). This is to check for levels of
bilirubin in the blood. If your baby's symptoms of jaundice last for
longer than two weeks, another blood test may be carried out. This
is called a split bilirubin test and determines whether your baby's
jaundice is caused by an underlying liver disease.
Other indications of jaundice are the colour of your baby's urine and
stools. The urine of a newborn baby should be colourless. The stools
of a newborn baby should not be pale. If they are breastfed the
stools should be greeny-yellow, and if they are bottlefed the stools
should be a greeny-mustard colour.

Treatment
As long as your baby is well, there is no need for treatment as
jaundice usually disappears after a few weeks. See your GP
immediately if the jaundice does not disappear after this time. Also
see your GP if his/her stools are pale or urine is dark, or if the
jaundice spreads to the arms and legs.
In some cases, a jaundiced baby has to have a treatment called
phototherapy. The baby is placed under a UV (ultraviolet) lamp,
called a bili-light for about 1-2 days. The baby is usually naked and
has its eyes covered up. This light treatment helps the body get rid
of the bilirubin and makes it easier for your baby's liver to get rid of
it. The side effects from phototherapy may include a rash and
diarrhoea.
If the jaundice is severe and bilirubin levels are very high, a blood
transfusion may be needed. This is called exchange transfusion. This
procedure will only be considered if phototherapy has not worked.
If jaundice is caused by something else, such as an infection, this
will have to be treated as appropriate. This may mean surgery or
drug treatment.

Complications
Without prompt treatment, a build up of bilirubin in the brain can
lead to a condition called kernicterus. This can lead to brain damage
or even death, so it is important that high levels of bilirubin are
treated immediately.
If the levels of bulirubin rise dramatically about 6-7 days after birth
it may be caused by breast-milk jaundice. This occurs in 2 out of 100
breastfed babies (2) but usually clears up in about two weeks. The
mother may be asked to stop breastfeeding for a few days to see if
the levels drop.

Leukaemia

46
Introduction
Leukaemia is the name for a number of cancers of the white blood
cells. White blood cells are the cells that fight infection in the body.
Blood cells are produced in the bone marrow, the spongy tissue that
forms the centre of the bone. In leukaemia, white blood cells
multiply in an uncontrolled and abnormal way. They gradually take
the place of the other parts that normally make up the blood. There
is little room in the bone marrow for the other types of blood cells
and for new blood cells to be produced. This can cause a shortage of
red blood cells (anaemia), severe bleeding (because normal blood
clotting doesn't happen) or serious infection (as a result of
weakened immune system).
There are different types of leukaemia, depending on what type of
white blood cell is involved, and how it is affected. The two main
groups are:

• Chronic leukaemias, in which those affected may live with
symptoms for years. In chronic lymphocytic leukaemia
(CLL) there is an increase in the number of a type of white
blood cells called lymphocytes. In chronic myeloid
leukaemia (CML) there is overproduction of another type of
white blood cell called myeloids or granulocytes. These cells
are abnormal, so are not able to carry out the normal
functions of white blood cells, such as fighting infection. They
also live too long, so over a period of time they replace the
fully-functioning cells (white, red and platelets) in the bone
marrow. This is a slow process and tends to get worse over
time.
• Acute leukaemias, which are more aggressive and develop
quickly. Acute lymphoblastic leukaemia (ALL) is
overproduction of immature (underdeveloped) lymphocytes,
called lymphoblasts. Acute myeloid leukaemia (AML) is
overproduction of immature myeloid white blood cells. In
acute leukaemias, the cells reproduce very rapidly, and so do
not become mature enough to carry out their jobs in the
immune system. This is a quicker process than in chronic
leukaemias.

Leukaemia forms only around 2% of cancers diagnosed in the UK
each year. In 2000, there were 6,800 new cases (Cancer Research
UK). Leukaemia is the most common cancer in children, causing
around one third of childhood cancers, but there are far more cases
in adults.
The most common childhood leukaemia is acute lymphoblastic
leukaemia (ALL) but the most common leukaemia overall is chronic
lymphocytic leukaemia (CLL).

47
Symptoms
Acute leukaemias start suddenly and can cause the person to feel
very ill in just a few days or weeks. Symptoms may include:

• Pale skin (due to anaemia);
• repeated infections, such as sore throats;
• abnormal bleeding from the gums and into the skin;
• heavy periods in women;
• loss of appetite and weight;
• flu-like symptoms such as tiredness and achiness;
• pain in the joints (sometimes mistaken for growing pains, in
children);
• nosebleeds; and
• bruising more easily than usual without any apparent cause.

In addition to bruising more easily, small red spots called petechiae
may appear on the legs or in the mouth.
Chronic leukaemias begin slowly with a gradual feeling of tiredness.
The spleen (an organ in the upper left abdomen that is part of the
immune system) grows until it becomes massive, causing a
dragging weight and pain in the upper left side of the abdomen.
Other symptoms may include:

• gradual loss of weight;
• aching in the bones;
• nosebleeds;
• unwanted and prolonged erections (priapism) in men;
• fever, heavy sweating and night sweats;
• swollen lymph glands especially in the neck, groin and
armpits;
• bruising easily;
• lack of energy; and
• breathlessness.

Sometimes the early stage of chronic leukaemia has no symptoms
and the condition is discovered during a routine blood test.

Causes
For most leukaemias, no specific single cause is known. It seems
likely that in most cases a number of different factors combine to
cause the disease. These factors include genetics, radiation,
environmental chemicals and cancer-causing viruses. There may be
other unknown causes.
The cause of some leukaemias is now well understood. For example,
leukaemia cells in some people with chronic myeloid leukaemia
contain an abnormal chromosome called the Philadelphia
chromosome (it was first described in Philadelphia). This causes a
protein to be made that interferes with the way white blood cells are

48
made in the bone marrow. This is not inherited and you cannot pass
it on to your children.
Exposure to certain things may increase the risk of leukaemia,
including

• large doses of radiation,
• drugs used to treat certain cancers,
• some industrial chemicals (e.g. benzene, found in oil refineries
and the rubber industry), and
• certain viruses.

It should be noted, however, that even large doses of radiation do
not necessarily cause leukaemia. Over a period of 12 years after the
atomic bombs were exploded in Japan, the proportion of survivors
who developed leukaemia was 1 in 60 (1.7 per cent). Leukaemias
caused in this way are myeloid leukaemias and acute lymphoblastic
leukaemias, never chronic lymphocytic leukaemias. Research is
ongoing as to whether living close to a nuclear power plant can
cause leukaemia.
Although cancer cannot be inherited from parent to child, genetic
factors do have an effect. If one of a pair of identical twins develops
leukaemia, in one out of four cases the other will also do so, within
weeks or months. People with certain genetic disorders, including
Downs syndrome and Fanconis anaemia, are known to have a higher
risk of developing leukaemia.
Smoking and exposure to electromagnetic fields are both sometimes
talked about as possible causes of leukaemia, but there is not
enough evidence to support this.

Diagnosis
When a person with symptoms of leukaemia goes to their GP, they
will usually be physically examined. A blood test is then carried out,
which will usually show severe anaemia (too few red blood cells) and
deformed white blood cells. By examining the appearance of the
white blood cells under the microscope, the exact type of leukaemia
can be identified, so that the most suitable treatment can be given.
Sometimes it is necessary to carry out a bone marrow test to
confirm the diagnosis or to work out the type of leukaemia. After a
local anaesthetic, a needle is passed through the skin and into the
bone, and a small sample of the material inside your bone (the
marrow) is drawn out. The sample is usually taken from the back of
the hip bone, or sometimes the breast bone. This procedure lasts
around 15 to 20 minutes.
A small lump of marrow may sometimes be needed. This is called a
trephine biopsy, and is carried out in a similar way to the bone
marrow test, although it takes a little longer and may cause mild
bruising or aching. It gives additional information such as the
structure of the bone marrow and how the cells inside are spread
out.

49
In chronic lymphocytic leukaemia, it is occasionally necessary to
remove an enlarged lymph gland to look at the cells under a
microscope.
Other scans and x-rays may be performed, to help doctors to decide
the best treatment and to check that your other organs are healthy.
In lymphocytic leukaemias, computerised tomography (CT scan)
may be used to see how many of your lymph glands are affected.
CT scans can also be used to see whether your spleen is enlarged.

Treatment
Chemotherapy
The first treatment for all types of leukaemia is usually
chemotherapy. This is a powerful drug treatment that kills the
leukaemia cells.
Chemotherapy drugs can be given in the form of tablets or injected
directly into a vein (intravenous). Sometimes they are injected
directly into the fluid around the brain and spinal cord, to destroy
any cells that are in the nervous system. How you receive the drugs
depends on whether your leukaemia is chronic or acute, and what
stage of treatment you are at.
The first stage of chemotherapy is called induction. It consists of
several sessions each lasting a few days, with rest periods of several
weeks in between. Induction is a period of intensive therapy and
usually manages to kill most of the cancerous cells.
Induction is usually followed by one or two further cycles of
treatment. This is the intensification or consolidation stage, and
aims to increase the chances of a cure by continuing to destroy
leukaemia cells. In both induction and consolidation, chemotherapy
drugs are usually injected directly into a vein.
Finally, there is a stage of maintenance therapy. This is less
intensive and the drugs are given as tablets. It can continue for
another two years and is designed to kill any remaining leukaemia
cells.
Steroid drugs are sometimes given at the same time as
chemotherapy, to help destroy the leukaemia cells.
Bone marrow transplant
Bone marrow transplant is also used to treat leukaemia. It can be
used in conjunction with chemotherapy to greatly improve the
patients chances of recovery. It provides the patient with a new set
of parent blood-forming cells (stem cells) that can produce healthy
new red and white blood cells.
Before a transplant takes place, the patients abnormal bone marrow
is destroyed through total body radiation, in combination with the
drug cyclophosphamide.
Bone marrow transplant requires a matched donor (whose cells are
compatible with the patients) to donate some of their stem cells.
Matched donors may be found among close relatives such as
brothers or sisters, or can be from an unrelated donor. In certain
forms of leukaemia it is even possible to take marrow from a person

50
in remission, store it, expose the person to heavy radiation and then
replace the original sample to start up the marrow function again.
The transplant involves sucking marrow out of the pelvis or
breastbone of the donor and injecting it into one of the recipients
veins. The bloodstream carries the marrow cells to the recipients
bone marrow, where they settle and begin to produce new cell lines
(clones).
Other treatments

• Removal of the spleen is often recommended in chronic
leukaemias. The spleen is part of the immune system. In
certain leukaemias, such as chronic lymphocytic leukaemia,
the spleen can swell up causing abdominal pain and swelling.
It may cause a type of anaemia which weakens the red blood
cells.
• People who have certain types of acute myeloid leukaemia will
be treated with a special form of vitamin A called ATRA (all
transretinoic acid). Given alongside chemotherapy, it can
reduce the symptoms of leukaemia very quickly.
• In chronic myeloid leukaemia, you may be treated with a drug
called interferon alpha. This drug is injected under the skin
and may be used in combination with chemotherapy.

Some chronic leukaemias may not require treatment. It depends
how old the person is, how advanced the symptoms are, and
whether they have developed other problems such as swollen
glands or anaemia. But it is still important to go to regular check-ups
with your GP or outpatient clinic, so that your blood can be
monitored.

Recovery
Treatment aims to destroy all the white blood cells affected by
leukaemia. When a blood or bone marrow sample is examined under
a microscope, and no leukaemia cells can be found, the person is
said to be in remission. This is not a guaranteed cure, because
leukaemia can return, but it is a sign that the treatment has worked.
If leukaemia comes back, this is called a relapse. Further treatment
can be given but it may have to be slightly different from the first
time, because the leukaemia cells may have grown immune to
certain drugs that were used. If you did not have a bone marrow
transplant in your first round of treatment, this may be considered
as an option.
Certain treatments for leukaemia can have an effect on your fertility
(your ability to have children). Some drugs have more effect on
fertility than others; radiation prior to bone marrow transplant is
very likely to cause infertility, but patients treated with certain
chemotherapy drugs will still be able to have children. If you may
want to have children in the future, you should discuss options with

51
your hospital consultant prior to treatment, because it is sometimes
possible to remove sperm or eggs from your body and store them
for future use.

Multiple myeloma

Introduction
Plasma cells a type of white blood cell live within bone marrow (the
soft, spongy tissue in the centre of the bones). White blood cells are
the main part of our immune system, helping defend the body from
infection. The role of plasma cells is to produce and release special
proteins called antibodies, which help destroy disease-causing
germs, such as bacteria and viruses (known as antigens).
The cells in the human body are able to divide and multiply so when
an old cell is worn out or damaged, a new cell is formed to replace
it. Multiple myeloma occurs when a plasma cell (a type of white
blood cell that lives in bone marrow) becomes abnormal and
cancerous. The cancerous plasma cell then divides and multiplies
out of control, creating an excessive amount of abnormal antibodies
(which cannot perform their normal function and protect the body
from antigens).
Multiple myeloma can double the amount of the plasma cells in your
bone marrow, even clumping together to form tumours, which can
spread throughout the bone marrow. This can lead to bone pain and
eventual wearing away (erosion) of the bones. It can also damage
your immune system, making your vulnerable to infection and
viruses, such as kidney infection, shingles and pneumonia.
Multiple myeloma is an uncommon cancer; it develops in about
3,000 people in the UK each year. It is most common in people aged
65 and over, rarely occurs in younger people and does not occur in
children. Men are more affected than women.
The cause of multiple myeloma is not known and it cannot be cured,
but there are treatments to stop the progress of the condition and
help relieve symptoms.

Symptoms
There may be no symptoms early on in myeloma, and some people
dont even realise they have it until they get the results of a routine
blood test.
It is likely, however, that youll start to experience some symptoms
and problems as the disease progresses, caused by the uncontrolled
growth of abnormal plasma cells. This affects the normal production
of red blood cells, white blood cells and platelets, and creates a
large amount of abnormal antibodies. This can cause bone related
problems such as:

52
• Bone pain. Often the first of the symptoms are continual aches
and pains, usually in the lower back, pelvis and ribs (although
any bone can be affected).
• Bone erosion. The excessive amount of plasma cells and
antibodies in the bone marrow can cause the bones to weaken
and wear away.
• Fractures. Because the bones are so weak they may fracture
or break very easily, often for no apparent reason.
• Hypercalcaemia. Once the bones begin to break down, they
release a high level of calcium into the blood. This can cause
dehydration, constipation, nausea and vomiting, kidney
damage, tiredness, and also the need to pass urine a lot more
than usual.

As well as bone problems, other possible symptoms of multiple
myeloma include:

• Anaemia. This is when you have fewer red blood cells in your
blood than expected - symptoms may include tiredness,
breathlessness and headaches.
• Loss of appetite and weight loss.
• Excessive bleeding after cuts or scrapes, due to the lack of
platelets being produced (the cells which cause blood to clot
and stop bleeding).
• Repeated infection, such as flu, sinusitis, bladder or kidney
infections, shingles and pneumonia. This is due to a weakened
immune system caused by reduced white blood cells and
abnormal antibodies.

Causes
The exact cause of myeloma isn't known, but the condition begins
with one abnormal plasma cell in your bone marrow, which then
multiples uncontrollably.
The condition occurs more in people over 50, with the most common
age being 65. It is also more common in men than women. Factors
that may increase your risk of developing myeloma include:

• obesity,
• exposure to radiation, and
• working in the petrol, rubber or leather industries.

Myeloma can sometimes develop from a harmless condition called
monoclonal gammopathy of undetermined significance (MGUS). This
condition, like multiple myeloma, causes the plasma cells to create
excessive amounts of antibodies but in MGUS, this amount isn't high
enough to affect a persons health. And although MGUS can lead to
myeloma, it can take up to 20 years for this to happen.

53
Diagnosis
There are a number of tests doctors commonly use to diagnose
myeloma and find out how far the disease has progressed. These
tests may be repeated from time to time to monitor the progress of
the disease, and response to treatment.
Blood and urine tests
Samples will be tested to check for abnormal amounts of antibodies,
protein and calcium, as well as any signs of anaemia.
Erythrocyte sedimentation rate (ESR) is a common blood test for
myeloma. A blood sample is mixed with a chemical to prevent it
clotting and left to stand upright in a test-tube. This test measures
how fast the red blood cells (erythrocytes) separate from the plasma
(the clear, yellowish fluid part of the blood) and fall to the bottom of
the test-tube. They fall faster if myeloma is present, as the
abnormal amount of antibody proteins cause red cells to clump
together and therefore drop faster.
X-rays and other scans
An X-ray of your bones will show any weakened, thinned or eroded
areas.
If the doctors need a closer view of your bones they may use a
Computerised Tomography (CT) scan - instead of a single X-ray of
the bone, several beams are sent from different angles at the same
time.
A Magnetic Resonance Imaging (MRI) scan produces detailed, two-
dimensional images and is especially useful for scanning the inside
of bones.
Bone marrow test
Local anaesthetic is used to numb the area, and a small sample (a
biopsy) of bone marrow is removed from the pelvic bone using a
needle and syringe. This sample is put under a microscope to check
for a large number of abnormal plasma cells.

Treatment
Myeloma cannot be cured but there are treatments available to
control the progress of the condition, ease the symptoms and
significantly improve quality of life. Standards treatments include
chemotherapy and radiotherapy. After treatment, a stem cell
transplant may be necessary.
Chemotherapy
Chemotherapy is the most common treatment for myeloma.
Different drug combinations are given depending on the severity of
the disease and whether you have any kidney damage as a
complication of myeloma. The drugs are given either by mouth, or
more commonly by injection into a vein, to try and kill the abnormal
cells and stop them spreading. In most cases, each cycle of
chemotherapy is followed by a rest period of one to four weeks.
There is usually a maximum of six cycles.
Depending on the type of chemotherapy you have, you may be able
to go home on the same day as you are given chemotherapy, or you

54
may need to stay hospital for a few days. Again, depending on
which drug combination you are given, there may be some side
affects, such as sickness, diarrhoea, and hair loss.
Radiotherapy
Radiotherapy aims to damage the abnormal cells and stop their
growth with radiation from X-rays. This treatment is very important
as it can target specific areas in the body so, for example, if a
tumour (a clump of abnormal cells) in the bone marrow is causing
bone pain or eroding the bone, then radiation can target the
tumour, and shrink and destroy it. Your treatment plan is created to
suit your general health, and the severity of the myeloma.
Radiotherapy affects people in different ways some people have
side effects such as tiredness, lack of appetite, and depression,
whilst some people have none.
Stem cell transplant
Stem cells are the immature cells in the bone marrow that go on to
become mature, fully functional blood cells (including plasma cells).
Chemotherapy and radiotherapy attempts to destroy the abnormal
plasma cells. However, they can also kill the normal stem cells, so
after these treatments you may need a stem cell transplant (often
called a bone marrow transplant).
Healthy stem cells will be injected into your blood stream, usually
through a vein in the neck or groin. You will either be given stem
cells from a donor, or some of your healthy stem cells will be taken
from your body before you have chemotherapy or radiotherapy and
put back into your body when your treatment is complete.
For some time after the transplant you may need to have regular
blood transfusions (when donor blood is given through a vein) to
maintain the right level of blood cells in your body and prevent
anaemia.
Other treatment
Because myeloma can cause a number of symptoms and problems,
you may also need specific treatment to help relieve those. Whether
you require these treatments, how often and for long depends on
your individual situation. They include:

• painkillers,
• antibiotics to clear up infections, such as flu and shingles,
• bisphosphonates (medicine to help strengthen bones and
relieve bone pain that can be taken daily by mouth between
meals, or every three weeks into a vein),
• erythropoietin injections (erythropoietin is a hormone that
helps increase the number of red blood cells made in your
bone marrow), and
• kidney dialysis (treatment to remove waste products and
toxins from the blood) if you have kidney damage or failure.

There are also some self-care techniques you can use to keep the
condition under control.

55
• Drink plenty of fluids. This will help you to dilute the abnormal
proteins in your urine, which may help prevent any kidney
damage and help reduce high calcium levels.
• Eat a balanced diet, with plenty of fresh fruit and vegetables,
starchy carbohydrates (bread, potatoes, pasta and wholegrain
cereals) and protein rich foods such as chicken, fish and eggs.
The amount of protein in your system isnt affected by how
much protein you eat, so you wont have to limit your protein
intake unless your doctor says to do so.
• Exercise helps to keep the bones strong so keep as active as
you can. If pain is stopping you from exercising, ask your
doctor to help you come up with a fitness plan to suit you.

Palliative care
If a case of myeloma is too advanced for treatment and the
symptoms are proving difficult to control, palliative care can be
given to improve the quality of life for patients. The goal of palliative
care is to relieve, rather than cure the illness, and help the patients
live more comfortably. This usually takes place in a hospice, but can
take place at home. Specially trained physicians and caregivers will
give pain relief, control ongoing symptoms and offer counselling.

Complications
Multiple myeloma can cause a number of complications.

• A weakened immune system can result in repeated infection
from viruses, even serious illnesses like pneumonia.
• Kidney damage or kidney failure symptoms include tiredness,
water retention (when the body stores water), nausea,
increased need to pass urine, and shortness of breath. Kidney
dialysis can be given to treat this.
• Hyperviscosity (when the blood becomes too thick) can lead
to bruising, nosebleeds, headaches, blurred vision and
confusion. This can be treated with plasma exchange
(plasmapheresis), which involves removing the plasma and
separating it from the actual blood cells. The blood cells are
then put back into your body, but with a liquid similar to
plasma instead, which then thins the blood. This treatment
can be given more than once if needed

Poisoning

Introduction
Poisons are substances that cause damage to the cells of the body
when they come into contact with them. There are lots of different
poisonous substances including medications, household products,
such as bleach, industrial chemicals, and certain plants and berries.

56
Also, substances that we may not usually think of as poisons, such
as alcohol and tobacco, can be very harmful.
Methods of poisoning
Poisoning can occur in several different ways. The most common
method of poisoning is by ingestion (where the poison is swallowed),
but poisons can also be inhaled (breathed in), splashed onto the
skin or eyes, or be injected, or through a bite (as with snake bites).
Accidental poisoning
Most cases of poisoning (85%) are accidental and occur in the
home. Children are most at risk from poisoning, although cases
involving fatal child poisonings are very rare. Elderly people also
have a greater risk of being poisoned accidentally.
Intentional poisoning
Occasionally, poisoning may be deliberate. For example, a person
may attempt to poison themselves by taking an overdose of
prescription medication, such as antidepressants, or over-the-
counter (OTC) medications, such as paracetamol. Intentional
poisoning may also be carried out by someone who uses a
poisonous substance to deliberately harm someone else.

Causes
Many common household substances can be harmful if they are not
stored properly, or used in the correct way. Children under the age
of 5 have the highest risk of accidental poisoning, with medicines
being the most common cause of poisoning in children between 2-4
years of age.
Lots of substances are poisonous if they are eaten, inhaled
(breathed in), or come into contact with the skin, or eyes.
Some common items that can cause poisoning are listed below.

• Prescription drugs and medicines, such as calamine
lotion, petroleum jelly, evening primrose oil, folic acid, oral
contraceptive and hormone replacement (HRT) preparations,
simple linctus, steroid creams, and zinc oxide creams and
lotions.

• Household products, such as bleach, carpet cleaner,
furniture polish, fabric conditioner, fabric washing powders, or
liquids, dishwasher liquid, washing up liquid and liquid soap.

• DIY products, such as emulsion paint, putty, PVA (polyvinyl
alcohol) glue, and wallpaper paste.

• Cosmetics, such as baby oil, baby wipes, shampoo, hair
conditioner, hair dye, moisturising cream, or lotion, and solid
cosmetics, such as lipstick and eye shadow.

• Garden chemicals, such as weed killer, ant, rat or mouse
poison, insect repellents, petrol, methylated spirits, paint, and
paint stripper.

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• Garden objects, such as earth, soil, and compost. Animal
faeces (pooh), although not poisonous, may cause infections.
However, worms, snails, and slugs are not poisonous if eaten.

• Insects and snakes, such as bees, wasps and hornets, inject
venom (poison) into the skin when they sting us, which can
cause pain, swelling and itchiness in the area of the bite or
sting. Bites from snakes that contain venom (the adder is the
only poisonous snake found in the UK), can cause symptoms
such as diarrhoea and sickness. How severely you are affected
by a poisonous bite or sting depends on the amount of venom
injected, and whether you are allergic to the venom. For
further information, see the separate health encyclopaedia
topics on insect bites, insect stings, and snake bites.

• Plants most plants that grow in the UK are harmless and, if
eaten, may only cause a mild stomach upset. However, some
types of plant can cause a more serious response, so it is
important that you know what plants are growing in your
garden. If one has been eaten, try to identify it so that you can
inform medical staff about it. Fungi, mushrooms, and
toadstools can be difficult to identify, but few are very
dangerous. Avoid eating fungi that has not been reliably
identified as being edible. However, if someone has eaten it,
you should take a sample to A&E with you so that it can be
identified.

• Food can cause poisoning if it contains harmful bacteria. This
can happen if it goes mouldy, if cross contamination occurs,
for example, between cooked and raw meat, or if it has not
been cleaned or prepared properly. For further information
about food poisoning, please see the separate health
encyclopaedia topic.

• Carbon monoxide is a poisonous, odourless gas that is
produced by incomplete burning of fuels, such as gas, wood or
petrol. These types of fuels are used in many household
appliances, such as heaters, fires and cookers. If appliances
are not regularly serviced, and well maintained, carbon
monoxide can leak from them without you realising, which can
have serious consequences and, in some cases, can cause
death. For further information about carbon monoxide
poisoning, see the separate health encyclopaedia topic.

Symptoms
If you suspect that someone has ingested (swallowed) a
poisonous substance, immediately call 999 to seek medical
assistance.
The symptoms of poisoning depend on the substance and the
amount taken. Some poisonous substances, such as carbon

58
monoxide, interfere with the blood's ability to carry oxygen, while
others, such as bleach, burn and irritate the digestive system.
Symptoms of poisoning can include:

• nausea,
• vomiting and/or diarrhoea,
• abdominal pain,
• drowsiness, dizziness or weakness,
• fever,
• chills (shivering),
• loss of appetite,
• headache or irritability,
• difficulty swallowing,
• producing more saliva than normal,
• skin rash,
• burns around the nose or mouth,
• double or blurred vision,
• seizures (fits), and
• coma.

As well as the general symptoms of poisoning outlined above,
specific symptoms are associated with different types of medication
overdose. These are outlined below.
Paracetamol
Symptoms of an overdose of paracetamol include:

• nausea,
• vomiting,
• a general feeling of being unwell,
• upper abdominal pain,
• jaundice,
• confusion,
• drowsiness, and
• coma (may develop at a later stage).

Aspirin
Symptoms of an overdose of aspirin include:

• nausea,
• vomiting,
• rapid breathing,
• tinnitus,
• fever,
• disorientation,
• lethargy,
• coma,
• seizures,
• sweating, and
• abdominal pain.

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Tricyclic antidepressants
The physical condition of someone who has overdosed on tricyclic
antidepressants can change rapidly. Symptoms of an overdose may
include:

• excitability (tricyclic antidepressants affect the central
nervous system),
• confusion,
• blurred vision,
• dry mouth,
• fever,
• pupil dilation,
• seizures,
• coma,
• cardiac arrhythmia (irregular heart beat),
• hypotension (low blood pressure), and
• tachycardia (heart rhythm disorder).

Selective serotonin uptake inhibitors (SSRIs)
Symptoms of an overdose with SSRIs include:

• nausea,
• agitation,
• tremor, and
• nystagmus (uncontrolled movement of the eyes).

In rare cases, poisonings with SSRIs can lead to serotonin syndrome
(an adverse, spontaneous, potentially life-threatening reaction).
Severe symptoms include hypertension (high blood pressure) and
tachycardia (heart rhythm disorder) which can lead to shock. A
person with serotonin syndrome may also be delirious (confused)
and experience severe muscular tension.
Beta blockers
Symptoms of an overdose with beta blockers can vary depending on
the type of beta blocker, but they can be extreme an include
dizziness, hypotension (low blood pressure), and bradycardia (a
pulse rate of below 60 beats per minute).
Calcium channel blockers
Symptoms of an overdose with calcium channel blockers include:

• drowsiness,
• confusion,
• chest pain,
• hypotension (low blood pressure),
• bradycardia (a pulse rate of below 60 beats per minute),
• peripheral cyanosis (blue skin discolouration),
• coma,
• seizures, and
• respiratory distress.

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Benzodiazepines
Benzodiazepines are mild tranquilisers and the symptoms of an
overdose can include:

• drowsiness,
• lethargy,
• dysarthria ataxia (coordination and speech difficulties),
• hypotension (low blood pressure),
• hypothermia (where body temperature drops below
35°C/95°F,
• coma, and
• respiratory depression (in severe cases).

Opioids
Opioids are pain killers and the symptoms of an overdose can
include:

• drowsiness,
• nausea,
• vomiting,
• miosis (pupil constriction),
• respiratory depression,
• cyanosis (blue skin),
• coma,
• seizures, and
• noncardiac pulmonary oedema (fluid on the lungs).

Cocaine
Symptoms of a cocaine overdose include:

• anxiety,
• euphoria,
• nausea,
• headache,
• chest pain,
• fever,
• hypertension (high blood pressure),
• rapid breathing,
• tachycardia (heart rhythm disorder),
• vomiting,
• agitation,
• twitching,
• confusion,
• hallucinations,
• abdominal cramps,
• seizures,
• hypotension (low blood pressure),
• dysrhythmias (abnormal heart rhythms), and

61
• cardiopulmonary arrest (combined heart attack and
respiratory failure).

Parents and carers should be aware of sudden, unexplained illness
in young children, particularly if they are drowsy or unconscious, as
poisoning could be the cause.

What to do
Being poisoned can be a life-threatening situation. If someone has
swallowed a poisonous substance, do not try to treat them yourself,
seek medical help immediately.
Dial 999 for an ambulance, or take the person to your local
Accident and Emergency department.
If you think someone has ingested (swallowed) poison, and they
appear to be unconscious, try to rouse them, and encourage them
to spit out any pills. However, do not put your hand into their mouth.
While waiting for medical help to arrive, you should lie the person on
their side, with a cushion behind their back and their upper leg,
pulled slightly forward so they do not fall on their face or roll
backwards. Wipe any vomit away from their mouth and keep their
head pointing downward to allow any vomit to escape without them
breathing it in or swallowing it. Do not give them anything to eat or
drink.
Provide medical staff with as much information as you can
In order to effectively treat a person who has been poisoned,
medical staff will need to establish a detailed history. Therefore,
when the paramedics arrive, or when you arrive at A&E, you should
provide as much information as you can including:

• what substances you think the person may have swallowed,
• when the substance was taken (how long ago),
• how it was taken (for example, swallowed), and
• how much was taken (if known).

You should provide details of any symptoms that the person has
had, for example, whether they have vomited. If they have been
sick, you should collect a sample of their vomit as it may help
medical staff to identify the poison. Medical staff may also want to
know the persons age and estimated weight, whether they have any
existing medical conditions, and whether they are taking any
medication (if you know).
If possible, you should give medical staff the container that the
substance came in to give them a clear idea of what they are
dealing with. If it is not known what substance caused the poisoning,
blood tests may be needed to identify it.
Poisonous fumes
If you think that someone has inhaled poisonous fumes, assess the
situation first, and do not put yourself in danger. Call for help and, if
it is safe to do so, remove the person from the contaminated area.

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Before entering the contaminated area, take two or three deep
breaths, and hold your breath until you come out. As soon as you
are out of the affected area, dial 999 for medical assistance.
Check that the persons airway is open (by lifting the chin with one
hand, while gently pushing down on the forehead with the other to
tilt the head back) and check they are still breathing (by placing
your cheek close to their mouth). If they are not breathing, begin
cardio pulmonary resuscitation (CPR) if you know how. If the person
is breathing and conscious, cover him or her with a blanket and
check whether he or she is breathing every 10 minutes until the
ambulance arrives.
For further information on CPR see the how it is performed section of
the accidents and first aid health encyclopaedia topic.

Diagnosis
Most people who have swallowed a poisonous substance, or have
overdosed on medication, will be admitted to hospital for
examination and further assessment. Investigations may include
blood tests and an electrocardiogram.

• Blood tests to check serum drug levels, electrolytes, and
glucose level. Blood tests may also be used to perform a
toxicology screen, liver function test, and a coagulation
screen.

• Electrocardiogram (ECG) an electrical recording of the heart
to check that it is functioning properly.

Treatment
As outlined in the What to do section, do not try to treat
someone who has swallowed a poisonous substance
yourself. You should seek medical assistance immediately by
dialling 999.
When someone has swallowed a poisonous substance, there are a
number of actions that you may need to take while you are waiting
for medical help to arrive. However, they should only be carried if
you are instructed to do so by a healthcare professional. They are:

• Forcing the person who has been poisoned to be sick
(vomit). Its very important that you only do this if advised to
by a healthcare professional. For example, forcing a person
who has swallowed a caustic (burning) substance, such as
washing machine detergent, to vomit, can be very dangerous.

• Giving milk to a child who has been poisoned is
sometimes recommended by doctors but, again, you should
only do this under medical advice.

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Healthcare professionals sometimes use inactivated charcoal to
treat someone who has been poisoned, as it stops the poison from
being absorbed by the stomach. Do not use charcoal tablets that
you can buy from pharmacies to try to treat poisoning. They are for
indigestion and flatulence only, and the dose is too small to work as
an antidote to poisoning.
If someone has been poisoned by carbon monoxide, they will usually
be given pure oxygen (100%) to breathe. This is known as oxygen
therapy and helps replace the carbon monoxide in the blood.
Snake and insect bites
The adder is the only poisonous snake in the UK, and can be
identified by the black, zigzag pattern along its back. If you are
bitten by a poisonous snake, keep the area that has been bitten still
so that the venom does not travel around your body. Go to your
local Accident and Emergency department, where you may receive
anti-venom tratment.
If you are stung by an insect, carefully remove the sting as soon as
possible using tweezers, or your fingers. Be careful not to spread the
venom further under the skin. See your GP if the redness and itching
does not clear up after 48 hours, and call 999 for an ambulance
if you have an allergic reaction.
For further information, see the separate health encyclopaedia
topics on snake bites, insect bites, and insect stings.

Prevention
Avoiding poisoning in the home
As most cases of accidental poisoning involve children, it is
important to make sure that all poisonous substances are safely
stored out of the reach of children. Below is some advice about to
help prevent your child from being accidentally poisoned.

• Make sure that all medicines (including herbal medicines and
vitamin tablets), cleaning products, and chemicals are locked
away, out of sight, and out of the reach of children.

• Do not store medicines, cleaning products, or chemicals near
food.

• Keep all chemicals in their original containers, and never put
medicines or chemicals, such as weed killer, in soft drinks
bottles.

• When necessary, encourage children to take medicine, but do
not refer to tablets as sweets.

• Do not leave old medicines lying around take them to your
local pharmacist to dispose of safely.

• Keep cigarettes and tobacco out of the reach of children and
avoid smoking in front of children.

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• Small batteries, such as those that are often used for
television remote controls, can be easily swallowed, so keep
them out of the reach of children.

• Whenever possible, always buy medicines that have child
resistant containers.

• Rinse out medicine, or cosmetic containers, and dispose of
them in a place where children cannot reach them.

• Do not take, or give, medicines in the dark to avoid taking an
incorrect dosage.

• As soon as they are old enough, make sure that your children
know the difference between products that are poisonous and
those that are non-poisonous.

If you have young children, it is important to be vigilant when you
have guests to stay, or when you go to visit other people. If your
friends and relatives do not have children, they may not be so aware
of keeping certain items out of the reach of children, and their home
is unlikely to be child proof. Keep an eye on your children at all
times, and politely ask guests to keep items like alcohol and
cigarettes out of reach.
The Royal Society for the Prevention of Accidents (ROSPA) will be
able to provide you with further advice about how to avoid accidents
in the home. See selected links section.
Household appliances
Always ensure that all fuel-burning appliances, such as electric fires,
and heaters, are well maintained and serviced regularly to prevent
carbon monoxide poisoning. Keep rooms containing appliances well
ventilated and consider fitting carbon monoxide detectors, or
alarms, in your home. Do not block air vents, flues or chimneys and
do not have indoor fires in rooms that do not have adequate
ventilation.
In the garden
Make sure you know what plants you have growing in your garden,
or around your home, and whether the leaves, berries, flowers or
fruit of certain plants are poisonous. If you have young children, you
may want to consider removing any potentially harmful plants from
your garden. Most importantly, make sure your child knows not to
put things from the garden into their mouth. It is a good idea to
know what the plants in your garden are called (including their Latin
name) so that, if needed, you can give healthcare professionals the
correct information.
You should also avoid keeping houseplants that have poisonous
leaves, flowers, or berries, indoors. Even if you put them out of
reach, the poisonous parts may still fall on to the floor. Also, keep
items such as barbeque fuel, weed killers, fertilisers, and

65
methylated spirits in the garden shed, or garage, and make sure
that it is locked at all times.
Burning rubbish
If you have to burn any rubbish, always do so in an open area, and
be careful not to allow the smoke to blow towards your family or
neighbours. It is not safe to burn certain plants, treated wood,
plastics and old chemical containers because they produce
poisonous gases.
You should also never pour hazardous chemicals down the sink,
drain or toilet.
Try to recycle wherever possible, and get in touch with your local
council to find out what facilities they offer for recycling hazardous
household and garden waste, such as pesticides, battery acid, and
weed killers.

Rhesus disease

Introduction
Rhesus disease happens when antibodies in a mother's blood attack
her baby's blood cells. This can happen when a woman who has
rhesus-negative blood has a baby that has rhesus-positive blood.
The antibodies occur if the woman's blood has previously come into
contact with rhesus-positive blood. This contact usually only occurs
if she has previously given birth to a rhesus-positive baby. Because
of this, the chances of a first baby being affected are small.
Symptoms of rhesus disease in newborn babies include jaundice and
anaemia (lack of red blood cells). Affected babies usually require
admission to a neonatal unit (a hospital unit that specialises in
caring for newborn babies), and treatment includes phototherapy
(treatment with light) and possibly blood transfusions.
Rhesus disease is uncommon nowadays as it is easily prevented. It
is possible to give an injection to rhesus-negative women who may
have come into contact with rhesus-positive blood during pregnancy.
The injection prevents the mother developing the antibodies that
cause the problems.
If rhesus disease occurs and is not treated, the effects of the
jaundice in the newborn baby can lead to learning difficulties,
deafness and blindness. Severe cases can lead to stillbirth (when a
baby dies in the womb before it is born).
Rhesus disease is also known as haemolytic disease of the newborn.

Symptoms
The two main signs of rhesus disease in a newborn baby are
haemolytic anaemia and jaundice. If a baby has rhesus disease, the
symptoms of anaemia and jaundice are not always present at birth.
They can develop up to eight weeks afterwards.
Haemolytic anaemia
Haemolytic anaemia happens when red blood cells (the cells in your
blood that transport oxygen) are destroyed. Symptoms are:

66
• breathlessness,
• palpitations (rapid or irregular heartbeats), and
• jaundice.

Jaundice
Jaundice happens as a result of haemolytic anaemia. It is caused by
a build-up of a chemical called bilirubin in the blood, which is made
naturally in the body when red blood cells are broken down. Bilirubin
is broken down by the liver.
In newborn babies, the liver may not be able to deal with bilirubin as
effectively as later in life - this is the reason why many newborn
babies get mild jaundice. However, in rhesus disease, more red
blood cells than normal are destroyed and so the amount of bilirubin
released is increased. The baby's liver usually cannot deal with the
increased amount of bilirubin, and the bilirubin levels in the babys
blood remain high.
Jaundice will make a baby's skin and the whites of their eyes turn a
yellowy colour. In babies with dark skin, it will be noticed mainly in
the whites of their eyes.

Causes
There are differences in human blood known as blood groups. There
are four main blood groups: A, B, AB and O. Each of these blood
groups can then be either rhesus-positive, or rhesus-negative.
Around 85% of the UK population is rhesus-positive.
Blood groups are identified by the presence of molecules called
antigens on the red blood cells. Antibodies are your body's natural
defence against any foreign antigens that enter your blood. If your
blood comes into contact with blood that carries different antigens,
your body will produce antibodies to those antigens. These
antibodies will destroy the foreign blood cells.
People with rhesus-positive blood have D antigens in their blood,
while people who are rhesus-negative do not. If a person who is
rhesus-negative comes into contact with rhesus-positive blood, the
rhesus-negative blood will produce antibodies that attack the D
antigens in the rhesus-positive blood. If the antibodies reach a
sufficient level, they start to destroy the red blood cells in the
rhesus-positive blood. These antibodies can cross the placenta from
the mothers circulation into the babys. When red blood cells are
destroyed it causes anaemia, which then causes jaundice as too
much bilirubin is made in the blood.
To be rhesus-positive, an individual may have inherited either a
single copy of the D antigen (called heterozygote Dd) or two copies
(called homozygote DD).
If a woman who is rhesus-negative has a rhesus-positive partner,
there is a chance that their baby will be rhesus-positive. If the male
partner of a rhesus-negative woman has two copies of the D antigen
(homozygote DD), the baby will definitely inherit one copy of the D
antigen, and so be rhesus-positive. If he has one copy of the D

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antigen (heterozygote Dd), there is a 50% chance that the baby will
be rhesus-positive and 50% chance that they will be rhesus-
negative. A rhesus-negative baby will not get rhesus disease.
Using special laboratory techniques, it is now possible to test a
rhesus-negative mothers blood in early pregnancy to see if the baby
she is carrying is rhesus-positive or negative. If the baby is rhesus-
negative, there is no risk of rhesus disease. However, if the baby is
rhesus-positive, there is a chance that rhesus disease can occur.
If blood from a rhesus-positive baby comes into contact with the
blood of a rhesus-negative mother, the mother will develop
antibodies that fight the baby's rhesus-positive red blood cells. This
is called sensitisation. As the mother and baby have separate
circulatory systems, it is uncommon for their blood to mix, although
it is now known that small numbers of fetal blood cells cross into the
mothers blood in normal pregnancy, which can occasionally lead to
sensitisation.
The most likely time for mothers and babys blood to come into
contact is during delivery. When this happens in a first delivery the
mother's body won't have time to produce enough antibodies to
affect the baby's red blood cells before the baby is delivered.
However, if sensitisation has happened earlier, or in a previous
pregnancy, then subsequent rhesus-positive babies are at risk.
Examples of where sensitisation can occur during pregnancy
include:

• following bleeding in pregnancy - for example during a
threatened miscarriage,
• following an invasive procedure during pregnancy, such as
amniocentesis or chorionic villus sampling (CVS), or
• following abdominal injury - for example a road traffic
accident.

Sensitisation can also occur following a previous miscarriage or
ectopic pregnancy, or if a rhesus-negative woman has received a
transfusion of rhesus-positive blood.
After sensitisation, the antibodies will continue to be present in the
mother's blood. If more rhesus-positive cells enter the mothers
circulation, for example during a future pregnancy, she will make
more antibodies, which may be sufficient to cross the placenta and
destroy her babys red blood cells in the womb. This will then cause
rhesus disease.

Diagnosis
As part of your pregnancy, you should be offered several routine
screening tests. Your doctor or midwife will discuss each test with
you before it is done. You can refuse to have a test if you don't want
it.
A sample of blood will be taken early on in your pregnancy and
tested for conditions such as anaemia, rubella, HIV and hepatitis B.

68
Your blood will also be tested to see which ABO blood group you are,
and whether your blood is rhesus-positive or negative. If you are
rhesus-negative, a test will also be carried out to make sure that
your blood isn't producing antibodies (known as anti-D antibodies).
Your blood will also be checked again at 28 and 36 weeks of
pregnancy. If you are rhesus-negative, and your blood is producing
anti-D antibodies, it is possible that your baby could develop rhesus
disease.
Diagnosis in a newborn baby
If you are rhesus-negative, blood will be taken from your babys
umbilical cord after birth to check your babys blood group and to
see if there is any evidence that anti-D antibodies have crossed the
placenta (called a Coombs test). If you are known to have anti-D
antibodies, the babys blood will also be tested for anaemia and
jaundice.
Diagnosis in an unborn baby
If you develop anti-D antibodies during pregnancy, or if you have
antibodies present from a previous pregnancy, there is a risk that
your baby will be affected and become anaemic before it is born. For
this reason, you and your baby will be monitored more frequently
than in an uncomplicated pregnancy.
Your baby will be monitored by measuring the blood flow in their
brain. If your baby is anaemic, their blood will be thinner and so flow
more quickly. Your babys blood flow can be measured using a type
of ultrasound scan called a Doppler ultrasound.
If a Doppler ultrasound shows that your babys blood is flowing at a
higher speed than normal, a procedure called fetal blood sampling
(FBS) can be used to check whether your baby is anaemic. In FBS a
needle is inserted through your abdomen and used to take a small
sample of blood for testing, either from your babys umbilical cord, or
from the umbilica vein as it passes through their liver. The
procedure is performed under local anaesthetic, usually as an
outpatient procedure.
If your baby is found to be anaemic, they can be given a transfusion
of blood through the same needle. This is known as an intrauterine
transfusion (IUT). After a transfusion, you may need to stay
overnight in hospital.
FBS and IUT are only available in some hospitals, so if you need to
have one of these procedures it may be necessary for you doctor to
send you to a different hospital from the one where you are booked
to have your baby.

Treatment
Mild rhesus disease requires no treatment, but after birth your baby
will need to be monitored on a regular basis, as symptoms can get
worse within the first 6-8 weeks.
If your baby has a moderate case of rhesus disease, they can be
treated with phototherapy (treatment with light), which speeds up
the removal of bilirubin from the body.

69
More severe rhesus disease requires a blood transfusion. This is
when blood is taken from someone else and given to your baby
through a vein. The blood will be matched to their blood group and
will replace the red blood cells that have been destroyed. Your baby
may need more than one blood transfusion, depending on how
severe their jaundice and anaemia is.
If your baby develops rhesus disease while still in the womb, they
can be given an intrauterine fetal blood transfusion (IUT). Even if the
disease is not sufficient to cause anaemia before birth, it is likely
that your baby will be born a little earlier than your due date.
Your baby may require more than one IUT, depending on how
severely they are affected by rhesus disease. Transfusions can be
repeated every 2-4 weeks until your baby is mature enough to be
delivered (usually 34 weeks).

Complications
Rhesus disease makes the body produce excessive amounts of
bilirubin. If left untreated, too much bilirubin in the body can cause
complications such as deafness, blindness, brain damage and
learning difficulties.
Although intrauterine transfusion (IUT) has a low rate of
complication, sometimes the baby can become distressed during
the procedure and need to be delivered. Sometimes preterm labour
(labour that begins before the 37th week of pregnancy) can occur
after an IUT.
Very severe rhesus disease before birth can lead to stillbirth.

Prevention
If you are rhesus-negative, and routine tests during your pregnancy
show sensitisation hasn't happened, you will be offered an injection
of anti-D immunoglobulin at 28 and 36 weeks. This helps prevent
sensitisation by destroying any rhesus-positive cells in your blood
stream before you can develop antibodies. You will also be offered
anti-D if you experience any bleeding, have an invasive procedure
(such as amniocentesis), or experience any abdominal injury.
After birth, a sample of your baby's blood will be taken from the
umbilical cord. If your baby is rhesus-positive, you will be offered an
injection of anti-D within 72 hours of giving birth. This injection
destroys the rhesus-positive blood cells that may have crossed over
into your blood stream before your blood has a chance to produce
antibodies. This will significantly lower the risk of your next baby
having rhesus disease.
However, if tests during your pregnancy show that you are already
sensitised and producing antibodies to rhesus-positive blood, you
will not be offered injections of anti-D. If you have already been
sensitised, anti-D will not work. You will be monitored with regular
blood tests and scans. You will also be offered the chance to have
the babys blood group checked if your partner is heterozygous (Dd).

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Some women may develop a slight short-term allergic reaction to
anti-D immunoglobulin, which may include a rash or flu-like
symptoms.

Septic shock

Introduction
Septic shock is a life- threatening condition that can happen when a
large amount of bacteria get into your bloodstream. It happens if
the number of bacteria in the blood multiplies uncontrollably and
causes a fall in blood pressure caused by blood poisoning
(septicaemia).
Bacteria are harmful because they can produce powerful poisons
(toxins). If a large amount of toxins are produced, they can have a
dangerous effect on blood circulation.
Up to half of all people who get septic shock die without treatment.

Symptoms
Septic shock causes a dramatic drop in blood pressure, affecting the
supply of oxygen to major organs such as the brain, heart, liver and
kidneys. Signs of septic shock include:

• A rapid and very weak pulse
• Reduced urine flow
• Confusion
• Pallor (pale-looking skin)
• Cold clammy skin (only in later stages)
• Collapse

Very low blood pressure prevents blood being supplied to all parts of
the body, and leads to organ failure.
Another dangerous effect of bacterial toxins is widespread clotting
of the blood within the small blood vessels. This is called
disseminated intravascular coagulation, and can be fatal if not
treated quickly.

Causes
Germs can get into the blood through wounds in your skin, as well
as from infections in body organs, including the ears, lungs and
urinary system. Normally your body is able to kill off any bacteria
that get into the blood, but if your immune system isn't working
well, it may be overwhelmed.
Some of the toxins produced by bacteria can severely damage cells
in your body. The toxins attack the walls of the small blood vessels,
causing them to become leaky so that fluid is lost from the blood
into the surrounding tissues.

71
The loss of fluid from the blood may be so great that the normal
circulation (the rate the heart pumps at) can't be maintained and
blood pressure drops. This is called acute circulatory failure, or
shock. In the case of blood poisoning, because it is caused by
bacterial toxins, it is called septic shock.
Those most at risk of septic shock are newborn babies, elderly
people, and pregnant women. This is because their immune systems
may be weaker than normal, making it harder to fight off infection.
People who have had recent major surgery or invasive (inside the
body) medical procedures are also more at risk, because of the
potential for germs to get inside their body. It may occur, following
bowel surgery, after a penetrating wound to the abdomen.
The condition is more common in those people whose immune
systems aren't working properly (immunocompromised). This may
be due to a medical condition affecting the immune system, such as
AIDS, or following treatment with medicines to suppress the immune
system, such as for cancer treatment. The risk of septic shock is
also higher in those with cirrhosis of the liver or major burns.

Treatment
Septic shock requires urgent treatment with antibiotics. It is a
medical emergency and is normally treated in an intensive care unit.
Large doses of antibiotics, along with Infusions of fluids, are given to
fight off the infection, and maintain the blood pressure. The shock
may get worse initially as the bacteria release toxins as they are
killed.
Drugs known as vasopressors such as dopamine, dobutamine, and
adrenaline may also be given. They help to maintain blood pressure
and increase blood flow into organs of the body.
Oxygen is given if there are breathing problems.

Sickle cell anaemia

Introduction
Sickle cell anaemia is the most common genetic (inherited) disease
in England, affecting around 12,500 people.
Sickle cell anaemia affects the ability to carry oxygen around your
body using your red blood cells. Normally, red blood cells carry
oxygen from your lungs to the rest of your body. The cells are round
and flexible, allowing them to easily move around your body.
However, in people with sickle cell anaemia, the shape and texture
of the blood cells can change. They become hard and sticky and are
shaped like sickles, or crescents. The cells die prematurely, leading
to a shortage of red blood cells. This causes the symptoms of
anaemia, such as tiredness and breathlessness.
If you have sickle cell anaemia, your blood cells can get stuck when
moving through small blood vessels, stopping the supply of oxygen

72
to parts of your body. This is known as a 'sickling crisis'. This can
cause pain, tissue damage, and can lead to other serious
complications, such as a stroke, or blindness.
The only cure for sickle cell anaemia is a bone marrow transplant.
However, the procedure has many potentially serious side-effects
and is not recommended for all cases.
The symptoms of sickle cell anaemia can be treated, and people
with the condition can learn how to help prevent sickling crises from
happening.

Symptoms
The symptoms of sickle cell anaemia normally start to appear after
four months of age.

Symptoms can vary from person to person, as can their severity.
The common symptoms of sickle cell anaemia are outlined below.

• Anaemia - the sickle cells are more fragile than normal cells
and they die more easily than normal blood cells. This leads to
a lack of the oxygen-carrying red blood cells in your body. As
your body is not getting all the oxygen you need, you will feel
tired, weak, and out of breath.
• Hand-foot syndrome - swollen hands and feet are often the
first sign of sickle cell anaemia in babies. The sickle cells block
the small blood vessels in your hands and feet causing them
to swell.
• Jaundice - this is a yellowing of the skin and eyes caused by
damage to the liver. The liver filters out harmful substances
from your blood. Sickle cell anaemia causes a build up of dead
sickle cells that the liver is not designed to deal with. These
can damage the liver.
• Frequent infections - the sickle cells can also damage the
spleen - an organ that helps your body to fight infections. This
will make you more at risk of getting an infection. Children
with sickle cell anaemia are typically given antibiotics to
prevent serious infections, such as pneumonia.

Sickling crises
A sickling crisis happens when the sickle cells block small blood
vessels in your body. This means that oxygen cannot get to the
affected area, leading to tissue damage and pain.
The 'sickling' of your cells may be triggered by a lack of oxygen, a
cold or infection, or a lack of water in your body (dehydration).
However, they can often occur for no obvious reason.
The severity and frequency of sickling crises varies from person to
person. Some people experience one or two per year, and will be
able to control the symptoms using over-the-counter (OTC)
painkillers, whereas others may require hospital treatment.
When sickling crises occur, the main symptoms are:

73
• gradually worsening pain in your bones and joints,
• severe pain in your abdomen with rigidity (inflexibility) of the
muscular wall,
• fever,
• difficulty breathing, and a stabbing chest pain on breathing,
• weakness on one side of your body and, if the brain is
affected, seizures are possible,
• pain in your upper abdomen, from your liver and spleen,
• blood in your urine from kidney damage, and
• in men, persistent and painful erections (priaprism).

Causes
All blood cells contain a protein called haemoglobin. Haemoglobin is
vital because it binds to the oxygen in our lungs, and transports it to
the rest of your body.
Haemoglobin is created by a pair of genes - you inherit one gene
from your mother and one from your father.
Thousands of years ago a mutation appeared in one of the genes.
The mutated gene evolved in parts of the world where malaria was
common, such as Africa, the Middle East and India. Due to patterns
of migration, sickle cell anaemia is common among black Caribbean,
black African, and black British communities. However, as these are
inherited genetic diseases, it is impossible to automatically exclude
anyone. Cases have been found in people who are of Portuguese,
Spanish, French Corsican, Sardinian, Sicilian, Italian, Greek and
Turkish descent.
People who inherit one of the mutated genes are known as having
the sickle cell trait. Their bodies make both normal and sickle
shaped blood cells. Usually, they have no obvious symptoms, unless
they are in an environment where the oxygen levels are lower - such
as on top of a mountain, or ballooning at high altitude.
If two people who have the sickle cell trait have a child, there is a
chance that the child will inherit a pair of genes that both have the
sickle cell trait. This means they are unable to make normal
hemoglobin and have sickle cell anaemia. The chances of the sickle
cell trait being passed on are outlined below.

• 25% chance that the baby will receive a pair of normal
haemoglobin genes,
• 50% chance that the baby will receive one normal gene and
one mutated gene. In this case, they will not have sickle cell
anaemia, but they will have the sickle cell trait, and
• 25% chance that the baby will receive a pair of mutated genes
- they will have sickle cell anaemia.

If one parent has the sickle cell trait, and the other parent has
normal haemoglobin their baby will not get sickle cell anaemia. But,
there is a 50% chance that the baby will receive the sickle cell trait.

74
Diagnosis
Sickle cell anaemia can be diagnosed by a blood test. The blood can
be checked for the presence of the defective haemoglobin. A small
level of defective haemoglobin would suggest that you have the
sickle cell trait, but not sickle cell anaemia. A high level would
suggest sickle cell anaemia.
Antenatal and newborn screening
The purpose of antenatal screening is to check for inherited
disorders, such as sickle cell anaemia, and to provide parents with
the information they need to make informed decisions.
Antenatal screening for the sickle cell trait is available in areas
where the condition is most prevalent. These are typically cities and
towns that have large black communities. In low prevalence areas a
questionnaire looking at family origin is used as an initial screen to
assess risk for sickle cell disorders.
Pregnant women are routinely screened for the sickle cell trait. If
they test positive for the sickle cell trait, then their partner is also
offered the test. If both parents have the sickle cell trait, there is a
25% chance that the baby will have sickle cell anaemia.
Newborn babies are now also routinely screened for sickle cell
anaemia. This is because sickle cell anaemia can increase the risks
of infection. Newborn babies with sickle cell anaemia are at
particular risk of dangerous infections, such as pneumonia, and
need treatment with antibiotics.

Treatment
Living with sickle cell anaemia
Most of the treatment for sickle cell anaemia involves preventing
sickling crises and complications.
If you, or you child, is diagnosed with sickle cell anaemia, you will
normally be referred to a specialised sickle cell clinic. A detailed
plan of future medical care will be drawn up, and you will be
provided with information and support to help you manage the
condition.
It is important that you, or your child, attend all of your medical
appointments, as regular checkups are required to monitor the level
of red blood cells, and check for possible organ damage.
Crisis
Minor crises can normally be managed at home using over-the-
counter (OTC) painkillers. However, if the pain is severe, or you are
experiencing the symptoms of a possible dangerous complication,
such as chest pain, or problems breathing, you may need hospital
treatment. Hospital treatment can involve pain relief, blood
transfusions, supplemental oxygen and antibiotics.
Sickle-crisis in children should always be treated under medical
supervision due to the risk of infection.
Pain management

75
The pain experienced during crises can very from mild to extremely
painful. Mild pain can be treated using over-the-counter (OTC)
medications, such as paracetamol. More severe pain may require
stronger prescription painkillers and, in the most severe cases,
injections of opiates, such as morphine.
Pain that lasts for a few days is known as acute pain. However, in
some cases pain can last for up to six months, and continue after
the other symptoms of the crisis have gone. This is known as
chronic pain. This may require the long term use of painkillers.
Many people worry that long term use of painkillers, particularly
strong opiate-based painkillers, such as morphine, will make them
become addicted. Your specialist, or clinic, will carefully regulate the
dosage you receive to minimise the chances of addiction. People
with sickle cell anaemia are no more likely to become addicted to
opiates than anyone else.
Children can become very upset and frightened during a painful
crisis. However, using distractions, such as a favourite video game,
or DVD, can help.
Some studies have shown that a type of therapy called Cognitive
Behavioural Therapy (CBT) can help in the management of chronic
pain.
CBT is based on the principle that the way we feel is partly
dependent on the way we think about things. People who train
themselves to react differently to their pain - using relaxation
techniques, and maintaining a positive attitude - reported that the
levels of pain experienced went down. They were also more likely to
maintain a healthy lifestyle and diet, reducing the risks of further
crises occurring.
Blood transfusions
Blood transfusions increase the number of healthy red blood cells in
your body. The procedure is used to help relieve the symptoms of
anaemia.
Blood transfusions are sometimes used for children with sickle cell
anaemia who have a high risk of stroke. The healthy red blood cells
help the passage of oxygen to the brain, reducing the risk of a
stroke.
As blood contains iron, regular blood transfusions can build up the
level of iron in your blood which could cause damage to your
organs. Therefore, if you are receiving regular transfusions, you will
also need to have treatment to reduce your iron levels. This is
normally achieved by using a medicine called desferrioxamine. This
works by helping to remove the iron from your body through your
urine and faeces.
Hydroxyurea
Hydroxyurea is a medicine that was first used in chemotherapy. It
can be used by adults who have a high number of painful sickle
crises. It appears to work by stimulating the production of foetal
haemoglobin - a type of haemoglobin that is normally only found in

76
new born babies. Foetal haemoglobin helps prevent the frequency of
sickle cells.
Hydroxyuera does increase your risk of infections and can cause
fatigue, so may not be suitable for everyone. Your clinic, or
specialist, will be able to advise you it if is suitable for you.
Bone marrow transplantation
The only current cure for sickle cell anaemia is a bone marrow
transplant. The procedure involves replacing the affected bone
marrow with bone marrow donated from somebody who does not
have sickle cell anaemia. Following a bone marrow transplant, the
new bone marrow begins producing healthy blood cells.
There are some significant risks involved in having a bone marrow
transplant. The new bone marrow can start producing cells that
attack parts of your body. This is known as graft-versus-host disease
(GVHD).
GVHD can affect many parts of your body, although the eyes, skin,
stomach, and intestines are most commonly affected. Symptoms
include rashes, nausea, weight-loss, irritation of the eyes, and
jaundice.
Other risks that are related to bone marrow transplants include an
increased chance of strokes, seizures and tumours.
Due to the associated risks, bone marrow transplants are normally
only recommended in the following circumstances:

• if the patient is under 17 years of age, because children often
have less organ damage from their sickle cell disease than
adults, which improves their chances of survival,
• if the patient has a brother, or sister, with healthy bone
marrow, because a close family connection reduces the risks
of developing GVHD, and
• if the patient has one, or more, serious complications caused
by sickle cell anaemia, such as acute chest syndrome, which is
a life-threatening condition where the airways of your lungs
become blocked.

Prevention
Sickle cell anaemia cannot be prevented. However, many of the
symptoms and complications of the condition can be prevented
using the right treatment.
Preventing infection
It is important that children with sickle cell anaemia receive
specialised treatment as they have a much higher risk of infection.
Typically, children should start taking penicillin at the age of 3
months, and continue until they are five years old.
They will also require annual vaccinations for influenza (flu) and
regular vaccinations for pneumonia

77
Some older children, teenagers, or adults continue to use antibiotics
if they are prone to infections.
Preventing strokes
Children with sickle cell anaemia also have an increased risk of a
stroke, as the oxygen supply to their brain can be blocked, which
can cause damage to the brain.
It is recommended that children with sickle cell anaemia receive an
annual Transcranial Doppler scan. This involves using a machine
that produces ultrasound waves to measure the flow of blood
through the brain. If the scan reveals that there is a high risk of a
stroke, the child can be treated with blood transfusions.
Preventing sickle cell crises
Often the cause of a sickle cell crisis is unknown, or there can be
more than one cause. However, by following the lifestyle advice
outlined below, you can reduce the risk of a crisis occurring.

• Drink plenty of water, particularly in hot weather because
dehydration increases the likelihood that sickle cells will form.
The recommended daily amount (RDA) of water is 1.2 litres
which is the equivalent of between 6-8 glasses.
• Exercise regularly, although not so much that you become
tired, or seriously out of breath. Your GP will be able to
recommend an appropriate level of exercise for you.
• Do not smoke. If you do smoke, quit. The NHS Smoking
Helpline will be able to offer you advice or encouragement.
You can call on 0800 169 0 169, or visit the NHS's 'Go
smokefree' website at http://www.gosmokefree.co.uk. Your GP
or pharmacist will also be able to provide help and advice.
• Eat a healthy, balanced diet - your GP may recommend
taking folic acid supplements which increase the production of
red blood cells.
• Limit the amount of alcohol your drink - the
recommended daily levels are between 3-4 units of alcohol for
men, and between 2-3 units for women. A unit of alcohol is
equal to about half a pint of normal strength lager, a pub's
shot of spirits, or a small glass of wine.

As well as making healthy changes to your diet and lifestyle, you
should also avoid:

• extremes of temperature, because exposure to extreme
heat, or cold, can trigger the formation of sickle cells,
• high altitude areas, because the lack of oxygen at high
altitudes could trigger a crisis, and
• stress, because stressful events have been shown to trigger a
crisis. Learning relaxation techniques, talking about your
problems with your friends and family, or joining a support
group, have all been shown to be help reduce stress in people
living with sickle cell anaemia.

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Flying with sickle cell anaemia
Flying in commercial airliners should not be a problem as the
airplanes are completely pressurised, but you should make sure you
drink plenty of fluids and do not become dehydrated.
Smaller airplanes, military planes, and helicopters may not be
pressurised and flying in them could cause a sickle cell crisis. You
should check before you start your flight.

Complications
The fact that sickle cell anaemia can block the flow of oxygen to
parts of your body means that it can lead to a number of serious
complications which are outlined below.
Stroke
A stroke is one of the most serious complications of sickle cell
anaemia. It can happen when the sickle cells block the flow of
oxygen to your brain, damaging it. Symptoms of strokes include
weakness or numbness of your arms and legs, seizures, sudden
difficulty with speech, and a loss of consciousness. If you, or your
child, are experiencing any of these symptoms seek immediate
medical help. Strokes can be treated by blood transfusions. (Blood
transfusions are not effective in treating strokes in people without
sickle cell anaemia, as the causes are different, such as a blood clot
or burst artery.)
Acute chest syndrome
Acute chest syndrome is a life-threatening condition that causes
breathing problems, chest pain, and fever. The exact cause of acute
chest syndrome is unknown, but it is thought that an infection in
lungs, already damaged by sickle cell anaemia, can cause problems
with the air circulating in the lungs. It requires emergency medical
treatment with antibiotics, blood transfusions, oxygen and
intravenous fluids (where liquids are pumped directly into your veins
to help re-hydrate your body).
Organ damage
If sickle cells prevent the flow of oxygen-rich blood to your organs, it
can damage them. If left untreated, organ damage can be fatal. The
symptoms and treatment will vary depending on the organ. It is the
increased potential for organ damage that means people with sickle
cell anaemia require regular medical appointments, so that any
damage can be spotted early.
Blindness
If you have sickle cell anaemia, the blood vessels that lead to your
eyes can get blocked by sickle cells. This can lead to damage of the
retina (a layer of cells that process the light you see to your brain),
leading to blindness. If you notice deterioration in your eyesight,
contact your clinic, or specialist

Thalassaemia

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Introduction
Thalassaemia is an inherited blood disorder.
The incidence of thalassaemia carriers varies greatly from country
to country throughout the world. It's very common in the Middle
East, the Indian sub-continent and through out South East Asia, in a
region including Southern China, Thailand, Malaysia and parts of the
southern Mediterranean. These regions coincide with areas where
malaria occurs. Thalassaemia trait is believed to offer some
resistance to malaria. Thalassaemia is common in those parts of the
world where malaria is endemic.
Blood is made up of plasma (fluid), red blood cells, white blood cells
and platelets. The white cells protect your body against and fight
infection and the platelets are responsible for normal blood clotting.
The red blood cells carry red blood protein called haemoglobin.
Haemoglobin contains iron and transports oxygen from your lungs
around the body. Anaemia is caused by reduced haemoglobin. If the
anaemia is mild it does no harm and may not be noticeable.
A normal haemoglobin molecule contains four protein (globin)
chains (two alpha globin chains and two beta globin chains)
Different genes are responsible for producing each chain. In
thalassaemia there is an inherited defect in one of these genes. If
the alpha chain is affected this causes alpha thalassaemia. If the
beta chain is affected this causes beta thalassaemia.
There are a number of different types of thalassaemia within these
groups, alpha thalassaemia being less diverse than beta
thalassaemia.
Alpha plus thalassaemia is the mildest type of thalassaemia. It
will not affect your health but you may pass it on to your children,
who will also be perfectly healthy. This form of thalassaemia is very
common in people who come from, or have ancestors from Africa,
including many Afro-Caribbeans, India, Pakistan or Bangladesh.
Alpha zero thalassaemia is a rare type of alpha thalassaemia.
This form of thalassaemia may occur if you or your ancestors
originally came from South East Asia, China, the Mediterranean
area, and the Middle East. You will be healthy but if you have
children and your partner also has Alpha Zero Thalassaemia, your
baby has a 1 in 4 chance of having a very serious anaemic disorder
called alpha zero thalassaemia major, which is life threatening.
Babies who have alpha thalassaemia major are unlikely to survive
pregnancy.
Beta thalassaemia is seen most commonly in people who
originate from Mediterranean Islands, Asia, Middle and the Far East.
Because of migration and intermarriage it is also seen in other parts
of the world including the UK.
Beta Thalassaemia Trait (Carrier) If you have beta Thalassaemia
trait you will be healthy but if you have children and your partner
also has beta Thalassaemia trait then there is a 1 in 4 chance of
each child having the much more serious disorder Beta
Thalassaemia major or Beta Thalassaemia Intermedia.

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Also if you have children and you partner has another blood disorder
(Hb E, Hb O Arab or Hb Lepore) your child may have symptoms of
beta thalassaemia intermedia or beta thalassaemia major. If your
partner has the gene for sickle cell your child may have a serious
anaemia, sickle cell/beta thalassaemia. Therefore although carriers
are healthy, if there is any family history of the condition it is
extremely important to have a special blood test to detect this
poorly functioning beta gene.
Beta Thalassaemia Intermedia and Beta Thalassaemia major
If you have beta thalassaemia intermedia or Thalassaemia major,
you have inherited a poorly functioning beta gene from both
your parents. This usually causes Thalassaemia major, which is a
serious condition requiring regular blood transfusions and many
associated problems. Sometimes this causes thalassaemia
intermedia, which is a less serious condition and you can often keep
well without the need of regular blood transfusions. This is because
the inherited genes may be mildly affected.

Symptoms
Alpha plus Thalassaemia This is very common in some ethnic
groups. There are no symptoms and it usually goes unnoticed. There
may be slight iron deficiency (anaemia) if the blood is tested for
some reason. Sometimes people may be mistakenly diagnosed as
having iron deficiency anaemia and be treated with iron medications
unnecessarily.
Alpha Zero Thalassaemia There are no symptoms and you are
perfectly healthy. However if both parents have alpha zero
thalassaemia they have a 1 in 4 chance of having a baby who has
alpha zero thalassaemia major which is incompatible with life; the
baby is often born prematurely and is dead or dies shortly after
birth.
Beta Thalassaemia Trait (Carrier) There are usually no
symptoms and you are perfectly healthy, however there are an
increased number of cells and they are smaller than those without
the condition. It can cause mild anaemia because slightly less
haemoglobin is produced than normal. This usually does not usually
cause you any symptoms and cannot be treated by increased iron
intake.
Beta Thalassaemia major Between birth and three to six months,
your baby with Beta thalassaemia major will seem normal and quite
healthy. Your baby will then begin to show symptoms of anaemia
(they become pale) there may be shortness of breath, jaundice and
an enlarged spleen.
Without treatment your childs bones will grow abnormally and death
will occur early in childhood. Also if the condition is poorly treated or
between transfusions your child will be pale, lethargic and
breathless. There may be yellowing (jaundice) of the eyes and skin
due to excessive breakdown of red blood cells. Also with poor

81
treatment growth may be delayed, there may be osteoporosis of the
bones and the spleen may be damaged.

Causes
Thalassaemia is an inherited disorder of the haemoglobin, (the
substance in the blood that carries oxygen to the tissues). It is
caused by an abnormal gene inherited from one or both your
parents.
The haemoglobin chains, i.e. alpha or beta globin chain are affected.
There is a decrease in the production of alpha globin chains in alpha
thalassaemia due to a deletion (missing) or mutation (abnormal
change) of one or more of the four alpha globin genes located on
chromosome 16.
Beta thalassaemia is more varied due to the diversity of the
mutations (abnormal changes) in the beta globin gene. Beta
thalassemias are caused by mutations on chromosome 11.

Diagnosis
Many people who carry thalassaemia do not know that they carry it.
It is diagnosed by having a simple blood test, to measure the size of
red blood cells and the amount of a type of haemoglobin in the
blood.
Antenatal screening is offered on the NHS, this allows you to
undergo a blood test to detect carrier couples and provide genetic
counselling. You should also be offered a choice of prenatal
diagnosis, to allow an informed choice concerning continuation or
termination of any affected pregnancy. Specialist counselling should
also be available. Chorionic villus sampling (CVS) is done at 10
weeks of pregnancy. Foetal blood sampling is done between 18-20
weeks, and the more rarely done amniocentesis test between 14-18
weeks.
Testing of babies, at one year old is recommended in some areas in
the UK to give a clear diagnosis of carrier status.
If a member of your family tests positive as a carrier for
thalassaemia or you suspect you may be a carrier then it is sensible
that you get tested and have genetic counselling if planning a baby.
It is also important that you are tested to avoid the mistaken
diagnosis of iron deficiency.

Treatment
Treatment for Beta thalassaemia major involves you having regular
blood transfusions, which take place every six to eight weeks,
depending on the severity of the anaemia. Excess iron builds up in
your body from these regular transfusions. This is called iron
overload. If this is left untreated, iron will build up in your body,
leading to a condition called haemosiderosis. This can cause serious
long-term damage such as heart failure and liver failure.
Iron overload is kept under control by treatment with a medicine
called desferrioxamine, to achieve a more normal level of iron in the

82
body. Desferrioxamine works by binding (the chemical term is
chelating) with the iron in your blood and the chelated iron is then
removed by the kidneys (excretion) from the body. Desferrioxamine
has to be given by injection, usually by a slow injection under the
skin via a small device or pump over eight to twelve hours. You may
be taught how to do this yourself at home. The amount of
desferrioxamine and how often it is given depends on the how much
iron you have in your body i.e. the amount of iron overload.
As you will be receiving this medicine regularly (often daily), it can
become tiresome for you or your carer. So, it is important to
understand why desferrioxamine doses should not be missed.
Sticking to desferrioxamine treatment routines helps protect against
serious complications in later life, such as diabetes and heart
disease. There are also more immediate benefits such as prevention
of nausea and sickness caused by iron overload.
Deferipone is another medicine used to treat iron overload. It works
in a similar way to desferrioxamine but is given by mouth. This
medicine is only given to patients in whom desferrioxamine is not
suitable or is not tolerated.
Like all medicines, both desferrioxamine and deferipone may have
side effects. You should refer to the manufacturers patient
information leaflet for further information as well as talk to your
doctor or pharmacist if you have any particular concerns. If you are
receiving either of these medicines you need to be closely
monitored by having regular blood tests and eye and ear
examinations. Checks on body weight and height every three
months may be carried out in children because their growth can be
affected by the condition and, in some cases, by the medicines.
Beta thalassaemia intermedia treatment may be the same as for
Beta major but as the anaemia is less severe, the need for
transfusions or the frequency of tranfusions and need for iron
overload treatment will be different according to the severity of the
anaemia.
Supplementary treatment
The time taken for iron to be removed from your body by
desferrioxamine is improved by taking a daily dose of ascorbic acid
(vitamin C). This is prescribed by your doctor according to your age
and is usually started one month after starting desferrioxamine
treatment. Ascorbic acid prescribed for this purpose should be taken
separately from food because it also increases the absorption of iron
in food, which you must avoid.
If you have heart problems, you will not be given ascorbic acid
because its combined effect with the iron in the blood may make the
heart problem worse. Any other multivitamin and mineral
supplements should not be taken unless prescribed by a doctor
because they can increase or decrease absorption of iron and other
minerals.
Other Treatments

83
Venesection - therapeutic removal of blood from the body - to help
deal with excess iron build -up
Surgery removal of the spleen (splenectomy) is sometimes
required if the spleen is damaged because it has to remove a larger
number of abnormal red cells from the circulation.
Management and reduction of iron in the diet - usually only a
small amount of iron is absorbed from the diet, however the
absorption is increased when haemoglobin in the blood is low, as in
beta Thalassaemia major. This is especially true between
transfusions. Therefore iron in the diet should be low (red meat is
especially high in iron). You should be referred to a dietician for
advice on diet.
Bone marrow transplantation this can provide a cure for Beta
thalassaemia major. Bone marrow is transplanted from a matched
unaffected sibling or unrelated donor. It is best done when the child
is very young. However, the procedure is painful and, although
success rates are improving, they are unpredictable.
There are many emotional, psychological and social effects for the
person with thalassaemia and their family, particularly as self-
management is so important. Psychological support is important in
managing chelation therapy and other aspects of the condition. You
may find getting involved with local support groups and voluntary
organisations helpful.

Toxic shock syndrome

Introduction
Toxic shock syndrome (TSS) is a rare, acute and serious illness,
affecting around 40 people in the UK each year. Anyone can get
TSS - men, women and children. Younger people are at greater risk,
as older people are more likely to have built up the antibodies
needed to protect them from the toxins. However, it is so rare that
most doctors will not see a case of TSS during their medical career.
The toxins involved are poisons made by bacteria named
Staphylococci or Streptococci. Staphylococcus aureus normally live
harmlessly on the skin and in the nose, armpit, groin or vagina of
one in every three people.
Shock is a condition caused by the effect of these toxins in some
situations, where the blood pressure falls dramatically. A number of
clinical problems including fever and rash, as well as shock, must
also be present in order for this diagnosis to be made.

Symptoms
Symptoms of TSS may be similar to severe 'flu, initially. They
include:

• vomiting
• diarrhoea
• a sunburn-like rash

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• muscle aches
• a sudden high temperature (fever)
• drowsiness or confusion
• fainting and/or dizziness, and
• collapse.

Patients look pale, and have a high pulse rate. Children with shock
will often show confusion as an early sign.

Diagnosis
For doctors to reach a diagnosis of Toxic Shock Syndrome, there
must be:

• shock (low blood pressure),
• a high fever,
• a sunburn-like rash,
• problems with the gut such as vomiting or diarrhoea
• damage to other organs such as muscles (with pain), the liver
(with jaundice) or the kidneys (with changes in the urine).

However, there is no specific blood test for toxic shock syndrome.
For this reason the diagnosis of toxic shock syndrome must
represent a collection of problems that might have different causes.
The organs requiring the most blood - the brain, the lungs and the
kidneys - will be damaged if shock is not treated rapidly. Shock is
accompanied by changes in the signalling systems of immune cells
and the blood clotting system; ideal treatment involves tackling
these disorders too.
Long term studies of TSS suggest that if patients survive the initial
illness - the shock in particular - there should be very few long-term
physical effects. Women who have contracted TSS as an association
of using tampons often find that their fertility has been unaffected.
However it is also known that TSS may recur, perhaps because
those who develop TSS have difficulties protecting themselves
against the toxins.

Treatment
First of all, it is important to give oxygen to any shocked patient.
The blood volume needs to be increased.
Patients should receive fluids directly into the bloodstream
(intravenous) for this. In hospital other measures may be used to
improve blood pressure and heart function.
The source of toxins - the bacteria - needs to be removed using
antibiotics. The antibiotic clindamycin is preferred over others as it
stops bacteria making proteins including these toxin molecules.
The toxins themselves can be neutralised using intravenous
immunoglobulins. These are antibodies from blood donors, some of
which are likely to stop the activity of the toxin molecules.

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If the patient is using a tampon, it should be removed immediately
at the first sign of a fever or rash. If TSS is diagnosed, this action
may help to prevent symptoms from worsening.

Prevention
The toxins made by Streptococci and Staphylococci are powerful.
They are being used to make vaccines against Staphylococci and
Streptococci themselves, which might be of considerable value to
many patients in the future.
The link between TSS and tampon use is unclear. Research suggests
that for cases which occur in women using tampons, tampon
absorbency is a factor. For this reason it is important that women:

• always use a tampon with the lowest absorbency suitable for
period flow
• use a sanitary towel or panty liner from time to time during
their period
• wash their hands before and after inserting a tampon
• change tampons regularly, as often as directed on the pack
• never insert more than one tampon at a time
• when using at night, insert a fresh tampon before going to bed
and remove it on waking
• remove a tampon at the end of a period.

Cancer

• Brain tumour
• Cancer
• Cancer of the bile duct
• Cancer of the bladder
• Cancer of the bone
• Cancer of the breast, female
• Cancer of the breast, male
• Cancer of the cervix
• Cancer of the colon, rectum or bowel
• Cancer of the kidney
• Cancer of the larynx
• Cancer of the liver
• Cancer of the lung
• Cancer of the mouth
• Cancer of the oesophagus
• Cancer of the ovary
• Cancer of the prostate
• Cancer of the skin
• Cancer of the stomach
• Cancer of the testicle
• Cancer of the thyroid
• Cancer of the uterus

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• Cancer of the vagina
• Chemotherapy
• Lymphoma
• Malignant melanoma
• Multiple myeloma

Contraception and family planning

• Abortion
• Combined contraceptive pill
• Condoms (male and female)
• Contraception
• Contraceptive implants and injections
• Contraceptive patch
• Diaphragms and caps
• Emergency contraception
• Female sterilisation
• Intrauterine device (IUD)
• Intrauterine system (IUS)
• Male contraceptive pill
• Natural family planning
• Progestogen-only pill

Digestive disorders

• Cancer of the colon, rectum or bowel
• Cancer of the oesophagus
• Coeliac disease
• Colostomy
• Constipation
• Crohn's disease
• Diarrhoea
• Diverticular problems
• Dysentery
• Flatulence
• Gastroesophageal reflux disease
• Giardiasis
• Heartburn
• Ileostomy
• Indigestion
• Irritable bowel syndrome
• Lactose intolerance
• Laxatives
• Norovirus

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• Ulcerative colitis

Family support

• Carers
• Domestic violence
• Family support
• Respite care

Genetic disorders

• Alzheimer's disease
• Androgen insensitivity syndrome
• Ataxia
• Charcot-Marie-Tooth disease
• Congenital heart disease
• Cystic fibrosis
• Down's syndrome
• Dyslexia
• Epidermolysis bullosa. (EB)
• Genetics
• Huntington's disease
• Marfan syndrome
• Muscular dystrophy
• Neurofibromatosis
• Noonan syndrome
• Phenylketonuria
• Sickle cell anaemia
• Spinal muscular atrophy
• Tay-Sachs disease
• Thalassaemia

Gynaecology

• Dilatation and curettage (D&C)
• Gonorrhoea
• Gynaecologists and obstetricians
• Hysterectomy
• Infertility
• IVF
• Miscarriage
• Ovarian cyst
• Pelvic inflammatory disease
• Periods

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• Periods, absent
• Periods, heavy
• Periods, painful
• Polycystic ovarian syndrome
• Pregnancy
• Premenstrual syndrome
• Prolapse of the uterus
• Sexually transmitted infections
• Syphilis
• Vaginismus

Infection

• Abscess
• Amoebiasis
• Anal fistula
• Aspergillosis
• Avian flu
• Balanitis
• Blepharitis
• Boils
• Botulism
• Bronchiectasis
• Bronchiolitis
• Cellulitis
• Chest infection
• Chickenpox
• Chlamydia
• Clostridium difficile
• Cold sore
• Croup
• Cytomegalovirus
• Dental abscess
• Diphtheria
• Ear infection
• Flu
• Fungal nail infection
• Gastroenteritis
• Genital herpes
• Giardiasis
• Glandular fever
• Glue ear
• Gonorrhoea
• Hand, foot and mouth disease
• HIV and AIDS
• How do I avoid viral infections?
• How often should I have an epilepsy review?
• Impetigo
• Kidney infection
• Labyrinthitis

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• Laryngitis
• Legionnaire's disease
• Leptospirosis
• Listeriosis
• Lyme disease
• Malaria
• Measles
• Meningitis
• Molluscum contagiosum
• MRSA
• Mumps
• Oral thrush
• Osteomyelitis
• Pandemic flu
• Peritonitis
• Pneumococcal infections
• Pneumonia
• Poliomyelitis
• Q Fever
• Quinsy
• Rabies
• Respiratory tract infection
• Ringworm
• Rubella
• SARS
• Scarlet fever
• Sexually transmitted infections
• Shingles
• Sinusitis
• Slapped cheek syndrome
• Staphylococcal infections
• Streptococcal infections
• Syphilis
• Tetanus
• Thrush
• Thrush, men
• Tonsillitis
• Toxic shock syndrome
• Toxocariasis
• Toxoplasmosis
• Trachoma
• Trichomoniasis
• Tuberculosis
• Typhoid fever
• Urinary tract infection
• What are the incubation periods for infections?
• When do tetanus symptoms show up after an injury?
• Whooping cough
• Yellow fever

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Medicines, treatments and drugs

• Anaesthesia
• Anti-inflammatories, non-steroidal
• Anticoagulant drugs
• Antidepressant drugs
• Antifungal drugs
• Antihistamine drugs
• Bronchodilator drugs
• Chemotherapy
• Corticosteroid (drugs)
• Corticosteroid preparations (topical)
• Decongestant drugs
• Emollients
• Laxatives
• Painkillers
• Radiotherapy
• Tranquillisers
• Travel Immunisation

Mental health

• Addictions
• Agoraphobia
• Anorexia nervosa
• Anxiety
• Bipolar disorder
• Bulimia
• Cognitive behavioural therapy
• Counselling
• Dementia
• Depression
• Eating disorders
• Gender dysphoria
• Insomnia
• Mental health
• Mental health services
• Mental health specialist services
• Munchausen’s syndrome
• Obsessive compulsive disorder
• Panic disorder

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• Phobias
• Post-traumatic stress disorder
• Psychosis
• Schizophrenia
• Seasonal affective disorder
• Self-injury
• Stress
• Suicide

Muscles, joints and bones

• Ankylosing spondylitis
• Arthritis
• Arthroscopy
• Back pain
• Baker's cyst
• Bone cyst
• Broken bones
• Bursitis
• Cancer of the bone
• Carpal tunnel syndrome
• Cartilage damage
• Charcot-Marie-Tooth disease
• DEXA scan
• Exercise
• Falls
• Fibromyalgia
• Frozen shoulder
• Gout
• Hip replacement
• Irritable hip
• Joint hypermobility
• Knee replacement
• Kyphosis
• Muscular dystrophy
• Osteoarthritis
• Osteomyelitis
• Osteoporosis
• Paget's disease
• Physiotherapy
• Polymyalgia rheumatica
• Reiter's syndrome
• Repetitive strain injury
• Restricted growth
• Rheumatic fever
• Rheumatoid arthritis
• Rickets
• Scoliosis

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• Slipped disc
• Spina bifida
• Spinal muscular atrophy
• Sports injuries
• Tendonitis
• Tennis elbow
• Tics
• Traction
• Tremor (essential)

Babies' health

• Avian flu
• Babies crying
• Babies, weaning
• Bottle feeding
• Breastfeeding
• Bronchiolitis
• Cleft lip and palate
• Colic
• Cradle cap
• Craniosynostosis
• Croup
• Dental care for babies and children
• Immunisation
• Jaundice - newborn
• Nappy rash
• Pneumococcal infections
• Sudden infant death syndrome
• Talipes

Men's health

• Balanitis
• Cancer of the prostate
• Cancer of the testicle
• Domestic violence
• Ejaculation problems
• Erectile dysfunction
• Male contraceptive pill
• Priapism
• Testicular lumps, benign
• Thrush, men
• Vasectomy

Children's health

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• Accidents to children in the home
• Asthma - children
• Autistic spectrum disorder
• Bedwetting
• Chickenpox
• Children in care
• Dyspraxia (childhood)
• Glue ear
• Head lice
• Hearing and vision tests for children
• Hospitals, children
• Kawasaki disease
• Lazy eye
• Measles
• Meningitis
• Mumps
• Molluscum contagiosum
• Poliomyelitis
• Puberty
• Reye's syndrome
• Rickets
• Rotavirus
• Rubella
• Scabies
• Scarlet fever
• Slapped cheek syndrome

Senior health

• Alzheimer's disease
• Arthritis
• Cervical spondylosis
• Dementia
• Ectropion
• Macular degeneration
• Neuralgia
• Osteoarthritis
• Osteoporosis
• Paget's disease
• Parkinson's disease
• Pneumococcal infections
• Pneumonia
• Polymyalgia rheumatica
• Rheumatoid arthritis
• Varicose veins

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GLOSSARY

Homoeopathy
A complementary therapy based on giving patients very dilute
amounts of a substance that, in larger amounts, would produce
similar symptoms to the illness being treated.

Hormones
Chemical substances produced by glands, which circulate in the
blood and help to control growth, reproduction and other functions.

Hormone therapy
Treatment with hormones to control cancer growth, usually for
cancer of the breast, prostate, thyroid and uterus (womb).

Immune system
The body's main defence system against infections or foreign
substances.

Incontinence
An inability to control the muscles that control the passing of urine
or faeces.

Inoperable
Refers to a cancer that can't be removed by surgery, either because
the cancer has spread to nearby organs or because removal might
cause too much damage to normal tissue.

In situ
The earliest stage of cancer, when it's localised to its area of origin.

Intramuscular
Given by injection into a muscle.

Intravenous
Given into a vein by injection or infusion.

Isotope scan
A scan involving the injection of a very weak radioactive substance,
which collects in the organ being investigated so it can be viewed
more easily with a special camera.

Local therapy
Use of treatments such as radiotherapy and surgery that are
concentrated on particular areas of the body.

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Lumpectomy
The surgical removal of a lump.

Lymphangiogram
A special X-ray procedure carried out to display the lymphatic
system.

Lymphatic system
The system of lymph nodes and the vessels or small tubes that
connect them. Lymph nodes are located throughout the body,
filtering out dangerous substances and producing infection-fighting
cells called lymphocytes.

Lymphoedema
Swelling, usually in the arms or legs, that occurs because the lymph
vessels are damaged or blocked. This can occur following some
treatments for cancer or because of the cancer itself.

Malignant
Cancerous. Malignant tumours can invade and destroy surrounding
tissue, and have the capacity to spread.

Mammogram
A specialised X-ray that shows up breast tissue and can detect
breast cancer at a very early stage.

Mastectomy
The removal by surgery of all or part of the breast.

Metastasis
The spread of cancer from one part of the body to another, via the
lymphatic system or bloodstream.

MRI (magnetic resonance imaging) scan
Uses radio waves rather than X-rays to produce pictures, which are
then analysed by computer.

Nausea
The feeling of sickness.

Occupational therapists
Health professionals, also known as OTs, who find ways to help
people live at home and be independent, despite their illness.

Oncologist
A doctor who specialises in treating cancer. A clinical oncologist, or
radiotherapist, specialises in treating cancer with radiation, and a
medical oncologist specialises in treating cancer with drugs.

Orally
Given by mouth.

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Orchidectomy
Surgical removal of a testicle.

Palliative care
Palliative care concentrates on the quality of life of the person
affected by cancer and their family. It focuses on controlling pain
and other symptoms, and meeting a person's social, emotional and
spiritual needs.

Pathology
The branch of medicine concerned with the examination of diseased
tissues.

Peripheral stem cell transplant (PSCT)
Stem cells collected from the patient's blood are removed, stored
and then reintroduced into the bloodstream.

Physiotherapists
Health professionals who help people stay mobile and free of pain
by teaching exercises, giving advice, and providing massage and
other treatments.

Primary cancer
The first malignant tumour to develop in a particular part of the
body.

Prognosis
An assessment of the expected future course and outcome of a
person's disease.

Prosthesis
A specially made replacement for a part of the body that's been
removed, such as a breast or limb.

Radiographer
The member of the healthcare team who takes X-rays and scans
(diagnostic radiographer) or gives radiotherapy (therapeutic
radiographer).

Radiologist
A doctor who understands and interprets a scan or an X-ray.

Radiology
The use of X-rays in the diagnosis and treatment of disease.

Radiotherapist
A doctor specialising in the treatment of cancer with radiation. Also
known as a clinical oncologist.

Radiotherapy

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The treatment of cancer by X-rays or gamma rays to destroy cancer
cells.

Reflexology
A relaxing massage technique using pressure to the feet to improve
the blood supply to various parts of the body.

Secondaries
New tumours, or metastases, formed because cancer cells from the
original tumour have broken off and been carried to other parts of
the body in the bloodstream.

Shiatsu
A form of massage that works on the energy flow around the body. It
can be helpful for stress-related conditions.

Social workers
Social service professionals who can help organise practical help,
emotional help and financial support.

Speech and language therapist
Health professionals who can help people with problems chewing
and swallowing, as well as speech problems.

Staging
Determining the extent of cancer in an individual, using strict
measures. It helps doctors to decide on the best treatment.

Stoma
An artificial opening between an organ and the skin surface, formed
by surgery. There are different types including a tracheostomy
(formed from the windpipe), ileostomy (formed from the small
bowel) colostomy (formed from the large bowel) and urostomy
(formed from the bladder).

Subcutaneous
Given by injection beneath the skin.

Syringe drivers
A means of administering painkilling or chemotherapy drugs under
the skin.

Systemic therapy
Use of treatments, such as chemotherapy, that affect the whole
body.

Terminal care
Care of a person in the last days or weeks before they die that
focuses on making the person free of pain and as comfortable as
possible.

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Terminal illness
Active and progressive disease that can't be cured. Curative
treatment isn't appropriate but palliative care is.

Therapy
A word often used to mean treatment.

Thoracic
Referring to the chest area.

Tumour
A lump or mass of cells that can be either benign or malignant. Also
known as a neoplasm.

Tumour markers
Substances produced by some cancers that can be traced in the
blood.

Ultrasound scan
Use of sound waves to build up an image of internal organs.

Visualisation
A way of becoming relaxed, involving seeing an image in your mind
and altering it as you wish.

Yoga
A combination of relaxation, breathing techniques and exercise that
combats stress, and helps circulation and movement of the joints.

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By Ben Mpanzu

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Copyright © 2007

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