SYSTEMIC SCLEROSIS. Systemic sclerosis (ssc) /Scleroderma is a rare chronic disease of unknown etiology characterised by diffuse fibrosis. Degenerative changes and Vascular abnormalities in the skin ,joints and internal organs. COMMON SYMPTOMS. Raynaud's phenomenon. Polyarthritis. Dysphagia. Heartburn. Swelling of fingers. Skin tightening and contracture of fingers. Lung ,kidney and heart involved. ETIOLOGY. Heridity and immunological mechanisms play a role in etiology. Scleroderma like syndrome can also result from exposure to vinyl chloride ,bleomycin ,pentazocine , epoxy ,aromatic hydrocarbons ,contaminated rapeseed oil or L -tryptophan. PATHOPHYSIOLOGY Pathophysiology involves vascular damage and activation of fibroblasts. Changes in the skin. *skin develops compact collagen fibers in the reticular dermis, *epidermal thinning. *loss of rete pegs. *atrophy of dermal appendages. *accumulation of T cells. *extensive fibrosis of the subcutaneous and dermal layers. *capillary loops are dilated and microvascular loops are lost kn the nail bed. *chronic inflammation and fibrosis of synovial membranes. Changes in the GIT. *esophageal motility is impaired. *lower esophageal sphincter becomes incompetent. *secondary strictures develop. *intestinal muscularis mucosa degenerates. leading to pseudo diverticula in thecolon and ileum. Changes in respiratory tract. *interstitial and peri bronchiolar fibrosis. *intimal hyperplasia of small pulmonary atteries. *pulmonary hypertension. Changes in heart. *diffuse myocardial fibrosis. *cardiac conduction abnormalities. There are Two types of systemic sclerosis. 1) LIMITED CUTANEOUS SYSTEMIC SCLEROSIS / LIMITED SCLERODERMA. Thid is also known as CREST SYNDROME Calcinosis. Raynaud's phenomenon. Esophageal dysmotility. Sclerodactyly. Telangiectasia. 2)DIFFUSE CUTANEOUS SYSTEMIC SCLEROSIS. OR DIFFUSE SCLERODERMA. SYMPTOMS AND SOGNS. The most common symptoms are Raynaud's phenomenon and insidious swelling of distal exyremities. SKIN AND NAIL MANIFESTATIONS *Symmetric swelling of the skin which progresses to induration. *Sclerodactyly. *salt and pepper appearance of skin. *subcutaneous calcifications. *digital ulcers. *skin becomes shiny ,taut ,hypopigmented or hyperpigment JOINT MANIFESTATIONS. *Polyarthralgia. *flexion contractures . GI MANIFESTATIONS. *Esophageal dysfunction. *Retro sternal Dysphagia. *diverticula in the colon. CARDIO PULMONARY MANIFESTATIONS. *Lung fibrosis. Acute alveolotis. Pericarditis with pleural effusion. *Cardiac arrhythmias. RENAL MANIFESTATIONS. Renal disease. DIAGNOSIS *Clinical evaluation Usually ANTI NUCLEAR ANTIBODIES (ANA ), Scl.-70 (topoisomerase. Anti centromere antibodies. PROGNOSIS. Slow progression of diseasr. 10 yr survival rate is 65 % TREATMENT. Treatment is directed at symptoms and dysfunctional organs. KEY POINTS. Pathologic changes include skin and joint changes. Raynaud's phenomenon. Esophageal dysfunction. Involvement of lung,heart and kidneys. Consider the diagnosis in Raynaud's phenomenon. Typical musculoskeletal or skin manifestations. Unexplained Dysphagia. Malabsorption. Pulmonary fibrosis. Pulmonary hypertension. Cardiomyopathies. Conduction disturbances. Test for ANA ,Scl-70 (topoisomerase), and anti centromere antibodies. Because there is no clear disease modifying therapy ,treatment is directed at the involved organs.

✍️✍️Late Effects Of Blood And Marrow Transplantation ___________________________________________ Abstract Hematopoietic cell transplantation is a curative treatment for a variety of hematologic diseases. Advances in transplantation technology have reduced early transplant-relatedmortality and expanded application of transplantation to older patients and to a wider variety of diseases. Management of late effects after transplantation is increasingly important for a growing number of long-term survivors that is estimated to be half a million worldwide. Many studies have shown that transplant survivors suffer from significant late effects that adversely affect morbidity, mortality, working status and quality of life. Late effects include diseases of the cardiovascular, pulmonary, and endocrine systems, dysfunction of the thyroid gland, gonads, liver and kidneys, infertility, iron overload, bone diseases, infection, solid cancer, and neuropsychological effects. The leading causes of late mortality include recurrent malignancy, lung diseases, infection, secondary cancers and chronic graft-versus-host disease. The aim of this review is to facilitate better care of adult transplant survivors by summarizing accumulated evidence, new insights, and practical information about individual late effects. Further research is needed to understand the biology of late effects allowing better prevention and treatment strategies to be developed. Introduction Hematopoietic cell transplantation (HCT) is a curative treatment for a variety of hematologic diseases.1 The safety of HCT has improved over the decades,2 indications for HCT have expanded to older patients,3 and almost all patients are able to find suitable allogeneic donors by the growing use of cord blood4 and haploidentical transplantation.5 These current conditions have contributed to a growing number of HCT survivors, estimated to be half a million worldwide.6 Patients who are disease-free at two or five years after HCT have a greater than 80% subsequent 10-year survival rate,7–10 but many studies show that HCT survivors suffer from significant late effects that adversely affect morbidity, mortality, working status and quality of life.7–13 A prospective observational study of 1022 survivors who underwent HCT between 1974 and 1998 showed that 66% of the survivors had at least one chronic condition and 18% had severe or life-threatening conditions.14 A retrospective study of 1087 contemporary survivors also showed that the cumulative incidence of any non-malignant late effect at five years after HCT was 45% among autologous and 79% among allogeneic recipients, and 2.5% of autologous and 26% of allogeneic recipients had three or more late effects.15 Life expectancy among 5-year survivors remained 30% lower compared with the general population, regardless of their current ages and years since HCT.9 The leading causes of excess deaths in 5-year survivors included secondary malignancies (27%) and recurrent disease (14%), followed by infections (12%), chronic graft-versus-host disease (GvHD) (11%), cardiovascular diseases (11%), and respiratory diseases (7%).9 The aim of this review is to facilitate better care of adult HCT survivors by summarizing accumulated evidence, new insights, and practical information about individual late effects (Figure 1). Recurrent disease and chronic GvHD are not discussed and readers are referred to other reviews.16–20 Figure 1. Download figure Open in new tab Download powerpoint Figure 1. Late effects of blood and marrow transplantation. Cardiovascular diseases Cardiovascular diseases (CVD) after HCT include cardiomyopathy, congestive heart failure, valvular dysfunction, arrhythmia, pericarditis, and coronary artery disease.21 Their cumulative incidences were 5%–10% at ten years after HCT,22–24 accounting for 2%–11% of mortality among long-term survivors.8,9,25 The incidence of CVD and its associated mortality were 1.4–3.5-fold higher compared with the general population.8,9,24,25 HCT survivors are more likely to have conventional risk factors such as dyslipidemia and diabetes than the general population.26 Early diagnosis and treatment of modifiable risk factors is important. We usually treat hypertension more than 140/90 mmHg on 2 separate visits or more than 130/80 mmHg for patients with diabetes or renal disease.27 The first step is lifestyle modification including weight reduction, dietary sodium reduction and regular physical activity, followed by initiating antihypertensive drugs such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). Anthracycline exposure and chest radiation are the major risk factors for CVD after HCT.21 Several studies showed that dexrazoxane, ACE inhibitors, ARBs and beta-blockers can prevent anthracycline-related cardiomyopathy in the non-HCT setting.28–32 Once cardiomyopathy is established, it is important to initiate appropriate treatment. ACE inhibitors and beta-blockers have been effective in improving left ventricular function.33 Pulmonary diseases Non-infectious late complications of the lung include bronchiolitis obliterans syndrome (BOS), cryptogenic organizing pneumonia (COP) and pulmonary hypertension. BOS represents chronic GvHD of the lung, and is characterized by the new onset of fixed airflow obstruction after allogeneic HCT.34 According to the strict 2005 National Institutes of Health (NIH) diagnostic criteria for chronic GvHD, incidence of BOS was 5.5% and its prevalence was 15% among patients with chronic GvHD.35 Symptoms of BOS include dyspnea on exertion, cough and wheezing, but early BOS may be asymptomatic until significant lung function is lost.36 One study showed rapid decline in %FEV1 during the six months before BOS diagnosis, with a lower %FEV1 at diagnosis associated with worse survival.37 In our practice, we perform pulmonary function tests every three months including %FEV1 and FEV1/FVC among patients with active chronic GvHD. When testing shows significant new airflow obstruction, we repeat testing every month until stability is confirmed.38 Plasma matrix metalloproteinase 3 levels39 and parametric response mapping from CT scans40 might be useful diagnostic tests for BOS but these have not yet entered clinical practice. Standard treatment of BOS is prednisone at 1 mg/kg per day, followed by a taper to reach a lower, alternate-day regimen.38 A multicenter prospective study showed that addition of FAM (inhaled fluticasone propionate at 440 μg twice a day, azithromycin at 250 mg taken 3 days per week, and montelukast at 10 mg nightly) to prednisone treatment stabilized pulmonary function in 70% of patients with newly diagnosed BOS and permitted systemic steroid exposure to be reduced.41 Cryptogenic organizing pneumonia is a disorder involving bronchioles, alveolar ducts, and alveoli, the lumen of which become filled with buds of granulation tissue consisting of fibroblasts.42 Clinical symptoms include dry cough, shortness of breath, and fever. Bronchoalveolar lavage is performed to exclude infection. Lung biopsy is required for definitive diagnosis, but an empiric diagnosis is often based on radiographic findings of diffuse, peripheral, fluffy infiltrates consistent with airspace consolidation. Pulmonary function testing shows restrictive changes and low diffusing capacity of the lungs for carbon monoxide. The incidence of COP is 2%–10%,43,44 and it is strongly associated with acute and chronic GvHD.45 COP usually responds within 5–7 days to prednisone at 1 mg/kg per day, which is continued for one month followed by a slow taper over five months because COP can often recur. Small case series suggest potential benefits of macrolides for treatment of COP.46 Pulmonary hypertension is an uncommon but potentially fatal complication after HCT, with a reported prevalence of 2.4%.47 The most common symptoms are hypoxia, tachypnea, dyspnea, and acute respiratory failure,48 and if untreated, pulmonary hypertension can result in a progressive increase in pulmonary vascular resistance, right ventricular failure and death. Since initial symptoms are non-specific, it is likely to be underdiagnosed after HCT. Although cardiac catheterization is the gold standard for diagnosis of pulmonary hypertension, high-resolution chest computed tomography and echocardiography are non-invasive and useful diagnostic modalities. The most common types are pulmonary arterial hypertension and pulmonary veno-occlusive disease, sometimes associated with transplant-associated microangiopathy and inherited or acquired hemolytic anemia.48 First-line therapies are supplemental oxygen and phosphodiesterase-5 inhibitors, followed by inhaled nitric oxide, diuretics, bipyridine inotropes and after-load reducing agents.48 Endocrine diseases Major late effects in the endocrine system include thyroid dysfunction, diabetes, dyslipidemia, and adrenal insufficiency. Hypothyroidism occurs in 30% of patients by 25 years after HCT.49 Risk factors include age under ten years, conditioning containing radiation, busulfan or cyclophosphamide, and hematologic malignancies.49,50 The international guidelines recommend checking serum thyroid-stimulating hormone and free thyroxine levels every year.21 For patients who received radiolabeled iodine antibody therapy, thyroid function should be checked earlier starting at three and six months after HCT, and other times as clinically indicated. Standard criteria are used to initiate replacement therapy for hypothyroidism. Some patients develop hyperthyroidism after HCT as a rare complication.51 Diabetes occurs in 8%–41% of patients after allogeneic HCT and in 3% of patients after autologous HCT.15,52,53 Its incidence after allogeneic HCT is 3.65 times higher compared with their siblings.54 Initial treatment is therapeutic lifestyle counseling, but many patients require hypoglycemic agents or insulin. Dyslipidemia occurs in 9%–61% of HCT survivors.53,55 Despite no established consensus for management of dyslipidemia after HCT, our practice is to initiate therapeutic lifestyle counseling followed by statin therapy when LDL cholesterol exceeds 130–190 mg/dL according to the estimated risk of CVD, based on the National Cholesterol Education Program Adult Treatment Panel III guidelines56 and the recently suggested approach after allogeneic HCT.57 The 2013 ACC/AHA guidelines do not specify the targeted levels for LDL cholesterol, and addition of statin therapy is based on calculated risk for future cardiovascular events.58 Addition of omega-3-acid ethyl esters or fibrate is considered when fasting triglycerides exceed 200–499 mg/dL. Adrenal insufficiency occurs in 13% of patients after allogeneic HCT and 1% of patients after autologous HCT,15 and can be confirmed by a cortisol-stimulation test. Once adrenal insufficiency is diagnosed, physiological glucocorticoid replacement and a very slow terminal taper is needed. Patients should carry notification that they have adrenal insufficiency to alert emergency medical providers. For chronic GvHD therapy, the risk of adrenal insufficiency is lower with alternate-day administration of corticosteroids than with daily dosing,59 although patients with brittle diabetes need daily dosing to allow for optimal glucose control. Male gonadal dysfunction and infertility Hypogonadism is common after HCT. Impaired spermatogenesis, erectile dysfunction, low testosterone, and low libido occur in male patients. Erectile dysfunction and low libido have been associated with both physical and psychosocial factors.60,61 Testosterone replacement may be considered for patients with low testosterone levels and has improved sexual function, libido and bone mass, although monitoring prostate-specific antigen and testosterone levels is necessary.62,63 Azoospermia occurred in 70% of male patients, and spermatogenesis recovered in 90% of patients conditioned with cyclophosphamide alone, in 50% of patients conditioned with cyclophosphamide plus busulfan or thiotepa, and in 17% of patients conditioned with total body irradiation (TBI).64 Semen banking or cryopreservation of testicular tissue should be discussed before HCT with patients desiring fertility. Female gonadal dysfunction, infertility and pregnancy Ovarian insufficiency, vaginal changes and low libido occur in female patients. A historical study showed that ovarian failure occurred in more than 90% of female patients after HCT and recovered in 92% of patients conditioned with cyclophosphamide alone, but only in 24% of patients conditioned with cyclophosphamide and TBI.65 A pilot study showed that only 10% of patients had ovarian failure after reduced-intensity allogeneic HCT.66 The use of hormone replacement therapy for premature ovarian failure should be individualized based on the patient age, severity of menopausal symptoms, low bone density, risk of breast cancer, clotting predisposition and liver abnormalities.67 Since efficacy of gonadotropin-releasing hormone agonists in preserving fertility in cancer patients is controversial,68,69 cryopreservation of oocytes, ovarian tissue, or embryos should be discussed with patients desiring fertility.70 The largest study of pregnancy after HCT showed that 0.87% of patients or their partners had pregnancies after allogeneic HCT, and 0.36% of those after autologous HCT.71 We generally recommend that women wait 2–5 years after HCT before attempting conception since rates of relapse are generally highest in the first two years after HCT. Another concern is the theoretical risk of recurrent malignancy because of disturbance of the graft-versus-leukemia effect, and some cases of recurrent chronic myeloid leukemia after conception have been reported.71 Pregnancy outcomes are generally good with no increase in the risk of fetal malformations, although these pregnancies are considered high risk because of higher maternal risks of pregnancy complications.71 Iron overload Iron overload is rare after autologous HCT72 but common after allogeneic HCT.73,74 Previous prospective studies showed that 30%–60% of long-term survivors of allogeneic HCT had elevated serum ferritin levels and 25%–50% had elevated liver iron concentration on T2* magnetic resonance imaging (MRI).73,74 Since serum ferritin does not specifically reflect iron overload and can be elevated in hepatic and systemic inflammation, additional testing is required if the ferritin is elevated. We favor transferrin saturation, which is widely available and defined as the ratio of serum iron concentration divided by total iron-binding capacity.75 Normal transferrin saturation is less than 50% in males and less than 45% in females. Patients with iron overload usually have saturation more than 60%. HFE genotyping is considered in patients with a family history of hemochromatosis and in patients of Northern or Western European ethnicity. When saturation is not elevated, other etiologies for an elevated ferritin including inflammation, metabolic syndrome, and alcoholism should be ruled out. The most accurate test of tissue iron concentration is liver biopsy, but the procedure is invasive and may cause serious complications. Thus, T2* MRI and other modalities (FerriScan and superconducting quantum interference device) have been increasingly used.76 Importantly, liver tests are often normal among long-term survivors with iron overload, so hepatitis and GvHD should also be considered when results of liver tests are elevated.77 Iron overload may cause cardiomyopathy. Studies of thalassemia patients showed that cardiomyopathy typically took more than ten years to be clinically evident,78 and that many patients improved with intensive chelation therapy.79 Although a prospective study and a meta-analysis showed no statistical association of liver iron concentration with mortality after allogeneic HCT,80,81 our practice is to start phlebotomy of 5 mL/kg or 250–300 mL every 3–4 weeks as long as hematocrit is more than 35% until serum ferritin falls below 1000 ng/mL. Deferasirox, an oral chelating agent, is considered for patients with anemia precluding phlebotomy. Liver diseases Late liver diseases include chronic hepatitis B, chronic hepatitis C, liver cirrhosis, nodular regenerative hyperplasia and focal nodular hyperplasia.77 Hepatitis B-infected patients have an increased risk of fulminant liver failure. One study reported a 35% risk of HBV reactivation after HCT even among patients with isolated anti-HBc antibodies, mostly during steroid treatment for GvHD.82 Patients treated with anti-CD20 antibodies have an increased risk of HBV reactivation. Antiviral prophylaxis using entecavir or lamivudine will prevent almost all fulminant cases if initiated before the start of conditioning regimens in patients with positive blood HBV DNA levels.83 Patients with latent HBV (i.e. anti-HBc+/HBV DNA−) should be monitored monthly with HBV DNA levels after HCT and antiviral treatment should be initiated when viremia is detected.83 Hepatitis C virus infection in HCT survivors almost always results in chronic hepatitis.84,85 Typically, asymptomatic elevation of alanine aminotransferase occurs 2–4 months after HCT, coinciding with tapering of immunosuppressive medications. There may be little liver-related mortality in the first ten years after HCT,84 but liver cirrhosis occurs later with a cumulative incidence of 4%–24% at 20 years.85,86 A large retrospective study showed that hepatitis C-infected patients had an increased risk of 2-year non-relapse mortality due to hepatic problems and bacterial infection.87 Antiviral therapy for HCV has not been given early after HCT, but may improve both oncological and hepatic outcomes after HCT.88 Ribavirin and interferon-based therapy have been used for patients who have discontinued all immunosuppressive medications without active GvHD, but it can cause pancytopenia and GvHD. Recently, highly effective and well tolerated direct acting antiviral agents with more than 90% rates of sustained virological response have been developed, and interferon-free regimens are now the treatments of choice.89,90 Nodular regenerative hyperplasia is a rare liver condition characterized by a widespread benign transformation of the hepatic parenchyma into small regenerative nodules.77 This process is usually asymptomatic unless portal hypertension develops. Focal nodular hyperplasia occurs in 12% of HCT survivors, and possibly reflects sinusoidal injury caused by myeloablative conditioning regimens.91 Kidney diseases Chronic kidney disease (CKD) is defined as an elevated serum creatinine level, or a decreased glomerular filtration rate (GFR) less than 60 mL/min/1.73 m2 for three months or longer.92 CKD occurs in approximately 20% of HCT recipients.93–95 There are three major etiologies of CKD after HCT: thrombotic microangiopathy (TMA), nephrotic syndrome and idiopathic CKD. Other etiologies include persistent acute kidney injury and BK virus nephropathy.96 Whenever possible, renal biopsy should be considered to accurately diagnose the etiology of CKD and to provide appropriate management.97 Thrombotic microangiopathy occurs in 2%–21% of patients after HCT, and is characterized by renal dysfunction, thrombocytopenia, neurological dysfunction, hemolytic anemia with schistocytes, elevated lactate dehydrogenase and decreased haptoglobin.98,99 Risk factors of TMA include TBI, calcineurin inhibitors, and acute and chronic GvHD.100–102 TMA-related kidney injury often improves with tapering or stopping calcineurin inhibitors, but full renal function is rarely restored.103 In some cases TMA did not improve until GvHD was treated.104 Efficacy of plasma exchange is limited.105 Nephrotic syndrome occurs in 6%–8% of patients after allogeneic HCT.106,107 Membranous nephropathy comprised 61% of cases, and minimal change disease comprised 22% of cases, with a median onset of 14 months and eight months after HCT, respectively.108 Mechanisms of membranous nephropathy are thought to be formation of immune complexes through allo- or auto-antibodies recognizing antigens expressed by the podocyte, while T cells are implicated with minimal change disease.109 Nephrotic syndrome after HCT is often associated with chronic GvHD and tapering of immunosuppressive medications. Initial treatment is prednisone 1 mg/kg/day in addition to calcineurin inhibitors. Complete response was observed in 90% of patients with minimal change in disease, but only in 27% of patients with membranous nephropathy.108 Refractory cases may be treated with rituximab or mycophenolate mofetil.110 Idiopathic CKD comprises most cases of CKD. Risk factors include acute GvHD, chronic GvHD, acute kidney injury, long-term use of calcineurin inhibitors and previous autologous HCT,94,111 suggesting that GvHD, accompanying treatment and inflammatory conditions may have pathogenic roles in this entity. Associations of TBI with risk of CKD have been controversial.94,112 ACE inhibitors and ARBs have been used to treat CKD and hypertension associated with CKD.113 Bone diseases Late complications of bone include osteopenia, osteoporosis and avascular necrosis (AVN).114 Osteoporosis has been reported in as many as 50% of HCT recipients.115,116 The diagnoses of osteopenia and osteoporosis are made by measuring T-scores with dual-energy X-ray absorptiometry. A T-score between −1.0 and −2.5 indicates osteopenia, and a T-score less than −2.5 or presence of a fragility fracture indicates osteoporosis.117 Multiple risk factors are implicated including chemotherapy, radiation, corticosteroids, calcineurin inhibitors, vitamin D deficiency, and gonadal failure.116,118 Bone loss occurs within 6–12 months after HCT, and recovery of bone mineral density (BMD) begins from the lumber spine, followed by a slower recovery in the femoral neck. The use of corticosteroids is the strongest risk factor for osteoporosis. General preventative recommendations include adequate intake of calcium of 1200 mg per day or over and vitamin D of 1000 IU (25 μg) per day or over, regular weight-bearing exercise, and avoidance of smoking and excessive alcohol. Bisphosphonates are the primary treatment for bone loss.119 Patients who are taking 5 mg or more daily prednisone-equivalent steroids for three months or more should have screening BMD tests for osteoporosis, and bisphosphonate treatment may be indicated until corticosteroid treatment is discontinued or for up to five years.120 Second-line treatment includes calcitonin, raloxifene, denusomab, romosozumab, and blosozumab, though their reported use in HCT recipients is limited and adverse effects may be more prominent than with the bisphosphonates. Avascular necrosis occurs in 4%–19% of HCT survivors with a cumulative incidence of 3%–10% at five years after HCT.121,122 AVN causes severe bone pain and bone destruction, causing significant impairment in quality of life. AVN typically affects the femoral heads, but sometimes affects other joints such as the knee and shoulders.21 Risk factors for AVN include corticosteroids, calcineurin inhibitors, older age and TBI conditioning.114 When AVN is suspected, diagnostic MRI should be performed. Early involvement of an orthopedic specialist is important for management of AVN, including conservative treatment, joint-preserving surgery and joint replacement surgery.21,114 Infectious diseases All HCT survivors have some degree of immunodeficiency, particularly during the first year after HCT.123 If patients are able to stop immunosuppressive medications without GvHD or recurrent disease, many recover adequate immune function by one year after HCT. Patients with chronic GvHD, however, remain immunodeficient and have a high risk of infections. Common late infections are caused by Pneumocystis jirovecii, encapsulated bacteria, fungi, varicella-zoster virus (VZV), cytomegalovirus, and respiratory viruses. Patients may report more frequent episodes of upper respiratory infections and sinusitis. All patients should receive prophylaxis against Pneumocystis jirovecii for at least one year after HCT or until 3–6 months after all immunosuppressive medication is discontinued, whichever occurs later. The preferred drug is trimethoprim-sulfamethoxazole, but dapsone or atovaquone could be substituted for patients who are allergic to or intolerant of trimethoprim-sulfamethoxazole. In particular, patients with chronic GvHD are highly susceptible to encapsulated bacteria such as Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis due to low levels of opsonizing antibodies, low CD4+ T-cell counts, poor reticuloendothelial function and suppressive effects of immunosuppressive medications on phagocytosis. Vaccination against these bacteria is recommended.124 Efficacy of vaccination in increasing antibody levels has been shown in several prospective studies.125,126 Chemoprophylaxis is always recommended due to the unpredictable protection provided by vaccination. The first-line drug is trimethoprim-sulfamethoxazole, but if it is not tolerated, penicillin or azithromycin is substituted until 3–6 months after discontinuation of all immunosuppressive medications. Invasive fungal infection occurs in 1% of patients after autologous HCT and in 6%–8% of patients after allogeneic HCT.127 GvHD and long-term use of corticosteroids have been a major risk factor associated with onset of invasive fungal infection.128 As recommended in the European guidelines, mold prophylaxis with posaconazole or voriconazole may be considered for patients with GvHD requiring high-dose corticosteroid treatment.129 Varicella-zoster virus-seropositive patients should receive prophylaxis with acyclovir or valacyclovir during the first year after HCT or until six months after discontinuation of immunosuppressive medications. A standard dose of acyclovir is 800 mg twice daily,130 but some studies showed that 200 mg once daily was effective in preventing VZV reactivation.131 Acyclovir should be started empirically if the patient presents with an acute abdomen or hepatitis typical of fulminant visceral VZV infection.132 CMV monitoring in blood is continued beyond 100 days after HCT until one year for patients at risk of late CMV disease, including CMV-seropositive patients receiving high-dose corticosteroids, those who have already experienced CMV reactivation, and cord blood transplantation.133 Pre-emptive therapy is usually considered for CMV levels of 250 IU/mL or more (equivalent to ≥1000 copies/mL) or a positive antigenemia test. Community-acquired respiratory virus infections are an important cause of morbidity and mortality after HCT. The most frequent viruses include rhinovirus, respiratory syncytial virus (RSV), parainfluenza viruses (PIV), human metapneumovirus, and influenza viruses as these frequently cause lower respiratory tract disease associated with 12%–100% mortality.134 An immunodeficiency scoring index can predict severity of RSV infection.135 Aerosolized ribavirin showed efficacy in treating lower tract RSV after HCT.136 Combination therapy with immunomodulators such as intravenous immunoglobulin or palivizumab has been seen to have variable success.137 Treatment for PIV infection has not been established. Efficacy of ribavirin has been limited for patients with lower respiratory tract infection of PIV.138 Novel drugs such as a recombinant sialidase fusion protein and a hemagglutinin-neuraminidase inhibitor are under investigation.138 Solid cancers There is an increased risk of solid cancers following both autologous and allogeneic HCT compared with the general population. The cumulative incidence is 1%–6% at ten years after HCT, and continues to rise over time without a plateau.139–142 The most common sites include oral cavity, skin, breast and thyroid, but rates are also elevated in esophagus, liver, nervous system, bone and connective tissues compared with the general population.143 Myeloablative TBI, young age at HCT, chronic GvHD and prolonged immunosuppressive medications beyond two years are well-documented risk factors for many types of cancers.143 All HCT recipients should be advised of the risk of second cancers and should be encouraged to undergo recommended screening tests based on their predisposition.143 The 5-year overall survival rates after diagnosis of solid cancers varied by cancer site, with 88%–100% for thyroid, testis and melanoma, approximately 50% for breast, mouth, soft tissue and female reproductive organs, and 20% or less for bone, lower gastrointestinal tract, and central nervous system.144 These rates were similar to those of de novo cancers, except that rates were lower for female reproductive organs, bone, colorectum, and central nervous system, although further studies are warranted to confirm this observation. There is emerging evidence that human papilloma virus (HPV) is involved in the pathogenesis of squamous cell cancer after HCT.145,146 The efficacy of HPV vaccination in preventing squamous cell cancer after HCT remains to be determined in prospective studies.147 Neuropsychological effects Neuropsychological effects after HCT are being increasingly recognized and include, among others, depression, post-traumatic stress disorder, and neurocognitive deficits. Depression occurs in 12%–30% of HCT survivors and is more frequent in female patients, younger patients and those with poor social support, history of recurrent disease, chronic pain, and chronic GvHD.148 Post-traumatic stress disorder occurs in 28% of patients at six months after HCT and may persist for 5%–13% of cases, although its risk factors are not yet clear.148–150 Neurocognitive deficits, so called “chemo brain”, have adverse functional impacts on HCT survivors who return to work and daily activities that require short-term memory, information-processing speed, multitasking and co-ordination.151 Neuropsychological tests can help identify neurocognitive deficits. Most evidence is derived from studies of breast cancer survivors, with estimated rates of deficits ranging from 16% to 50% up to ten years after treatment.152,153 Potential mechanisms for chemotherapy-induced neurocognitive changes include cytokine and immune dysregulation, damage to DNA and telomere length through cytotoxic agents, oxidative stress and hormonal changes.154 In cases of HCT survivors, there may be additional deficits derived from neurological complications including nervous system infection (HHV-6, fungi, etc.), immune-mediated damage, and toxicities of calcineurin inhibitors such as TMA and posterior reversible encephalopathy syndrome. A prospective observational study showed that neurocognitive function declined substantially at 80 days after HCT, returned to pre-transplantation levels at one year, and continued to improve between one and five years after HCT, except for motor dexterity and verbal learning and retention.155 Mostly mild, neurocognitive dysfunction according to the Global Deficit Score persisted at five years in 42% of long-term survivors.155 Rehabilitation programs have succeeded in improving neurocognitive functions,156 and methylphenidate and modafinil have demonstrated variable efficacies to improve neurocognitive function in non-HCT cancer patients.157,158 Efficacies of these interventions remaine to be determined among HCT survivors. Influence of newer practices on late effects An understanding of the influence of newer practices such as cord blood transplantation, non-TBI or reduced-intensity conditioning regimens and older patients on the incidence and severity of late effects awaits longer follow up. For example, TBI is associated with an increased risk of many late effects such as cardiovascular diseases, COP, hypothyroidism, diabetes, dyslipidemia, infertility, TMA-related kidney injury, bone density loss, avascular necrosis, and secondary solid cancer.49,54,100,102,114,118,143,159,160 The use of non-TBI conditioning regimens might reduce the burden of these late effects among HCT survivors. Some studies found that cumulative incidences of late effects did not differ much after reduced-intensity regimens compared with myeloablative regimens,15,161 and reduced-intensity conditioning was associated with a higher risk of recurrent malignancy among patients with myeloid malignancy.162 One study showed that the risk of AVN was elevated after cord blood transplantation, but graft source had a limited influence on other long-term health status and QOL.163 Consensus guidelines for late effects and prevention behaviors Incidence, mortality, morbidity and management of individual late effects are summarized in Tables 1 and 2. Recognizing the importance of managing late effects after HCT, the Center for International Blood and Marrow Transplant Research (CIBMTR), the European Group for Blood and Marrow Transplantation (EBMT), and the American Society for Bone Marrow Transplantation (ASBMT) developed recommendations in 2006 for screening and prevention practices for HCT survivors.164 Consensus recommendations were up-dated in 2011 including other international transplant communities.21 The NIH convened working groups to formulate late effects initiatives in 2015.148,165–169 View inlineDownload powerpoint Table 1. Late effects after blood and marrow transplantation View inlineDownload powerpoint Table 2. Tests, preventive approaches and treatment of late effects. Despite higher levels of engagement with health care providers, HCT survivors had similar health and prevention behaviors as matched untransplanted controls, suggesting the need for further education of both HCT survivors and health practitioners.170 Major modifiable predictors of lower adherence to preventive care practices were concerns about medical costs and lack of knowledge.171 Conclusion While the number of HCT survivors is growing, there is no evidence that the burden of late effects is lessening. HCT survivors face myriad late effects that can limit their functioning, require prolonged or life-long medical treatment, reduce their quality of life and also shorten their survival. To the extent that the HCT procedure itself causes these late effects, the transplant community has a responsibility to appropriately monitor, treat and ultimately try to prevent late effects. Given the dispersion of survivors and the varied structure of health care, hematologists, oncologists, primary care physicians and medical subspecialists are all involved in providing this care. Further research is needed to understand the biology of late effects to help identify better prevention and treatment strategies

Friends today I am discussing about a problem known as Thyroid Disease & Pregnancy. Thyroid disease is a group of disorders that affects the thyroid gland. The thyroid is a small, butterfly-shaped gland in the front of your neck that makes thyroid hormones. Thyroid hormones control how your body uses energy, so they affect the way nearly every organ in your body works—even the way your heart beats. The thyroid is a small gland in your neck that makes thyroid hormones. Sometimes the thyroid makes too much or too little of these hormones. Too much thyroid hormone is called hyperthyroidism and can cause many of your body’s functions to speed up. “Hyper” means the thyroid is overactive. Too little thyroid hormone is called hypothyroidism and can cause many of your body’s functions to slow down. “Hypo” means the thyroid is underactive. If you have thyroid problems, you can still have a healthy pregnancy and protect your baby’s health by having regular thyroid function tests and taking any medicines that your doctor prescribes. What role do thyroid hormones play in pregnancy? Thyroid hormones are crucial for normal development of your baby’s brain and nervous system. During the first trimester—the first 3 months of pregnancy—your baby depends on your supply of thyroid hormone, which comes through the placenta . At around 12 weeks, your baby’s thyroid starts to work on its own, but it doesn’t make enough thyroid hormone until 18 to 20 weeks of pregnancy. Two pregnancy-related hormones—human chorionic gonadotropin (hCG) and estrogen—cause higher measured thyroid hormone levels in your blood. The thyroid enlarges slightly in healthy women during pregnancy, but usually not enough for a health care professional to feel during a physical exam. Thyroid problems can be hard to diagnose in pregnancy due to higher levels of thyroid hormones and other symptoms that occur in both pregnancy and thyroid disorders. Some symptoms of hyperthyroidism or hypothyroidism are easier to spot and may prompt your doctor to test you for these thyroid diseases. Another type of thyroid disease, postpartum thyroiditis, can occur after your baby is born. Hyperthyroidism in Pregnancy Some signs and symptoms of hyperthyroidism often occur in normal pregnancies, including faster heart rate, trouble dealing with heat, and tiredness. Other signs and symptoms can suggest hyperthyroidism: fast and irregular heartbeat shaky hands unexplained weight loss or failure to have normal pregnancy weight gain Causes of hyperthyroidism in pregnancy Hyperthyroidism in pregnancy is usually caused by Graves’ disease and occurs in 1 to 4 of every 1,000 pregnancies in the United States.1 Graves’ disease is an autoimmune disorder. With this disease, your immune system makes antibodies that cause the thyroid to make too much thyroid hormone. This antibody is called thyroid stimulating immunoglobulin, or TSI. Graves’ disease may first appear during pregnancy. However, if you already have Graves’ disease, your symptoms could improve in your second and third trimesters. Some parts of your immune system are less active later in pregnancy so your immune system makes less TSI. This may be why symptoms improve. Graves’ disease often gets worse again in the first few months after your baby is born, when TSI levels go up again. If you have Graves’ disease, your doctor will most likely test your thyroid function monthly throughout your pregnancy and may need to treat your hyperthyroidism.1 Thyroid hormone levels that are too high can harm your health and your baby’s. Pregnant woman having her blood drawn If you have Graves’ disease, your doctor will most likely test your thyroid function monthly during your pregnancy. Rarely, hyperthyroidism in pregnancy is linked to hyperemesis gravidarum —severe nausea and vomiting that can lead to weight loss and dehydration. Experts believe this severe nausea and vomiting is caused by high levels of hCG early in pregnancy. High hCG levels can cause the thyroid to make too much thyroid hormone. This type of hyperthyroidism usually goes away during the second half of pregnancy. Less often, one or more nodules, or lumps in your thyroid, make too much thyroid hormone. Untreated hyperthyroidism during pregnancy can lead to miscarriage premature birth low birthweight preeclampsia—a dangerous rise in blood pressure in late pregnancy thyroid storm—a sudden, severe worsening of symptoms congestive heart failure Rarely, Graves’ disease may also affect a baby’s thyroid, causing it to make too much thyroid hormone. Even if your hyperthyroidism was cured by radioactive iodine treatment to destroy thyroid cells or surgery to remove your thyroid, your body still makes the TSI antibody. When levels of this antibody are high, TSI may travel to your baby’s bloodstream. Just as TSI caused your own thyroid to make too much thyroid hormone, it can also cause your baby’s thyroid to make too much. Tell your doctor if you’ve had surgery or radioactive iodine treatment for Graves’ disease so he or she can check your TSI levels. If they are very high, your doctor will monitor your baby for thyroid-related problems later in your pregnancy. An overactive thyroid in a newborn can lead to a fast heart rate, which can lead to heart failure early closing of the soft spot in the baby’s skull poor weight gain irritability Sometimes an enlarged thyroid can press against your baby’s windpipe and make it hard for your baby to breathe. If you have Graves’ disease, your health care team should closely monitor you and your newborn. How do doctors diagnose hyperthyroidism in pregnancy? Your doctor will review your symptoms and do some blood tests to measure your thyroid hormone levels. Your doctor may also look for antibodies in your blood to see if Graves’ disease is causing your hyperthyroidism. Learn more about thyroid tests and what the results mean. How do doctors treat hyperthyroidism during pregnancy? If you have mild hyperthyroidism during pregnancy, you probably won’t need treatment. If your hyperthyroidism is linked to hyperemesis gravidarum, you only need treatment for vomiting and dehydration. If your hyperthyroidism is more severe, your doctor may prescribe antithyroid medicines, which cause your thyroid to make less thyroid hormone. This treatment prevents too much of your thyroid hormone from getting into your baby’s bloodstream. You may want to see a specialist, such as an endocrinologist or expert in maternal-fetal medicine, who can carefully monitor your baby to make sure you’re getting the right dose. Doctors most often treat pregnant women with the antithyroid medicine propylthiouracil (PTU) during the first 3 months of pregnancy. Another type of antithyroid medicine, methimazole , is easier to take and has fewer side effects, but is slightly more likely to cause serious birth defects than PTU. Birth defects with either type of medicine are rare. Sometimes doctors switch to methimazole after the first trimester of pregnancy. Some women no longer need antithyroid medicine in the third trimester. Small amounts of antithyroid medicine move into the baby’s bloodstream and lower the amount of thyroid hormone the baby makes. If you take antithyroid medicine, your doctor will prescribe the lowest possible dose to avoid hypothyroidism in your baby but enough to treat the high thyroid hormone levels that can also affect your baby. Antithyroid medicines can cause side effects in some people, including allergic reactions such as rashes and itching rarely, a decrease in the number of white blood cells in the body, which can make it harder for your body to fight infection liver failure, in rare cases Stop your antithyroid medicine and call your doctor right away if you develop any of these symptoms while taking antithyroid medicines: yellowing of your skin or the whites of your eyes, called jaundice dull pain in your abdomen constant sore throat fever If you don’t hear back from your doctor the same day, you should go to the nearest emergency room. You should also contact your doctor if any of these symptoms develop for the first time while you’re taking antithyroid medicines: increased tiredness or weakness loss of appetite skin rash or itching easy bruising If you are allergic to or have severe side effects from antithyroid medicines, your doctor may consider surgery to remove part or most of your thyroid gland. The best time for thyroid surgery during pregnancy is in the second trimester. Radioactive iodine treatment is not an option for pregnant women because it can damage the baby’s thyroid gland. Hypothyroidism in Pregnancy Symptoms of an underactive thyroid are often the same for pregnant women as for other people with hypothyroidism. Symptoms include extreme tiredness trouble dealing with cold muscle cramps severe constipation problems with memory or concentration Woman with a coat shivering outdoors You may have symptoms of hypothyroidism, such as trouble dealing with cold. Most cases of hypothyroidism in pregnancy are mild and may not have symptoms. What causes hypothyroidism in pregnancy? Hypothyroidism in pregnancy is usually caused by Hashimoto’s disease and occurs in 2 to 3 out of every 100 pregnancies.1 Hashimoto’s disease is an autoimmune disorder. In Hashimoto’s disease, the immune system makes antibodies that attack the thyroid, causing inflammation and damage that make it less able to make thyroid hormones. How can hypothyroidism affect me and my baby? Untreated hypothyroidism during pregnancy can lead to preeclampsia—a dangerous rise in blood pressure in late pregnancy anemia miscarriage low birthweight stillbirth congestive heart failure, rarely These problems occur most often with severe hypothyroidism. Because thyroid hormones are so important to your baby’s brain and nervous system development, untreated hypothyroidism—especially during the first trimester—can cause low IQ and problems with normal development. How do doctors diagnose hypothyroidism in pregnancy? Your doctor will review your symptoms and do some blood tests to measure your thyroid hormone levels. Your doctor may also look for certain antibodies in your blood to see if Hashimoto’s disease is causing your hypothyroidism. Learn more about thyroid tests and what the results mean. How do doctors treat hypothyroidism during pregnancy? Treatment for hypothyroidism involves replacing the hormone that your own thyroid can no longer make. Your doctor will most likely prescribe levothyroxine , a thyroid hormone medicine that is the same as T4, one of the hormones the thyroid normally makes. Levothyroxine is safe for your baby and especially important until your baby can make his or her own thyroid hormone. Your thyroid makes a second type of hormone, T3. Early in pregnancy, T3 can’t enter your baby’s brain like T4 can. Instead, any T3 that your baby’s brain needs is made from T4. T3 is included in a lot of thyroid medicines made with animal thyroid, such as Armour Thyroid, but is not useful for your baby’s brain development. These medicines contain too much T3 and not enough T4, and should not be used during pregnancy. Experts recommend only using levothyroxine (T4) while you’re pregnant. Some women with subclinical hypothyroidism—a mild form of the disease with no clear symptoms—may not need treatment. Pregnant woman with a pill in one hand and a glass of water in the other Your doctor may prescribe levothyroxine to treat your hypothyroidism. If you had hypothyroidism before you became pregnant and are taking levothyroxine, you will probably need to increase your dose. Most thyroid specialists recommend taking two extra doses of thyroid medicine per week, starting right away. Contact your doctor as soon as you know you’re pregnant. Your doctor will most likely test your thyroid hormone levels every 4 to 6 weeks for the first half of your pregnancy, and at least once after 30 weeks.1 You may need to adjust your dose a few times. Postpartum Thyroiditis What is postpartum thyroiditis? Postpartum thyroiditis is an inflammation of the thyroid that affects about 1 in 20 women during the first year after giving birth1 and is more common in women with type 1 diabetes. The inflammation causes stored thyroid hormone to leak out of your thyroid gland. At first, the leakage raises the hormone levels in your blood, leading to hyperthyroidism. The hyperthyroidism may last up to 3 months. After that, some damage to your thyroid may cause it to become underactive. Your hypothyroidism may last up to a year after your baby is born. However, in some women, hypothyroidism doesn’t go away. Not all women who have postpartum thyroiditis go through both phases. Some only go through the hyperthyroid phase, and some only the hypothyroid phase. What are the symptoms of postpartum thyroiditis? The hyperthyroid phase often has no symptoms—or only mild ones. Symptoms may include irritability, trouble dealing with heat, tiredness, trouble sleeping, and fast heartbeat. Symptoms of the hypothyroid phase may be mistaken for the “baby blues”—the tiredness and moodiness that sometimes occur after the baby is born. Symptoms of hypothyroidism may also include trouble dealing with cold; dry skin; trouble concentrating; and tingling in your hands, arms, feet, or legs. If these symptoms occur in the first few months after your baby is born or you develop postpartum depression , talk with your doctor as soon as possible. What causes postpartum thyroiditis? Postpartum thyroiditis is an autoimmune condition similar to Hashimoto’s disease. If you have postpartum thyroiditis, you may have already had a mild form of autoimmune thyroiditis that flares up after you give birth. Woman holding her baby. Postpartum thyroiditis may last up to a year after your baby is born. How do doctors diagnose postpartum thyroiditis? If you have symptoms of postpartum thyroiditis, your doctor will order blood tests to check your thyroid hormone levels. How do doctors treat postpartum thyroiditis? The hyperthyroid stage of postpartum thyroiditis rarely needs treatment. If your symptoms are bothering you, your doctor may prescribe a beta-blocker, a medicine that slows your heart rate. Antithyroid medicines are not useful in postpartum thyroiditis, but if you have Grave’s disease, it may worsen after your baby is born and you may need antithyroid medicines. You’re more likely to have symptoms during the hypothyroid stage. Your doctor may prescribe thyroid hormone medicine to help with your symptoms. If your hypothyroidism doesn’t go away, you will need to take thyroid hormone medicine for the rest of your life. Is it safe to breastfeed while I’m taking beta-blockers, thyroid hormone, or antithyroid medicines? Certain beta-blockers are safe to use while you’re breastfeeding because only a small amount shows up in breast milk. The lowest possible dose to relieve your symptoms is best. Only a small amount of thyroid hormone medicine reaches your baby through breast milk, so it’s safe to take while you’re breastfeeding. However, in the case of antithyroid drugs, your doctor will most likely limit your dose to no more than 20 milligrams (mg) of methimazole or, less commonly, 400 mg of PTU. Thyroid Disease and Eating During Pregnancy What should I eat during pregnancy to help keep my thyroid and my baby’s thyroid working well? Because the thyroid uses iodine to make thyroid hormone, iodine is an important mineral for you while you’re pregnant. During pregnancy, your baby gets iodine from your diet. You’ll need more iodine when you’re pregnant—about 250 micrograms a day.1 Good sources of iodine are dairy foods, seafood, eggs, meat, poultry, and iodized salt—salt with added iodine. Experts recommend taking a prenatal vitamin with 150 micrograms of iodine to make sure you’re getting enough, especially if you don’t use iodized salt.1 You also need more iodine while you’re breastfeeding since your baby gets iodine from breast milk. However, too much iodine from supplements such as seaweed can cause thyroid problems. Talk with your doctor about an eating plan that’s right for you and what supplements you should take. Learn more about a healthy diet and nutrition during pregnancy . Homeopathy provides remedies which treat not just the above symptoms but the person as a whole. Sepia Officinalis: Used when the patient presents with the following symptoms. Weak, slightly yellow appearance Tendency to faint, especially when in cold temperatures Extreme intolerance to cold, even in warm surroundings Increased irritability Hair loss Increased menstrual flow that occurs ahead of schedule Constipation Increased desire for pickles and acidic foodstuff Calcarea Carbonica: This popular medicine is useful when patients present with the following symptoms. Fat, flabby, fair person Increased intolerance to cold Excessive sweating, especially in the head Aversion to fatty foods Peculiar food habits including craving for eggs, chalk, pencils, lime, Increased menstruation that is also prolonged and is associated with feet turning cold Lycopodium Clavatum: Useful in patients who present with these symptoms: Physically weakened Increased irritability Excessive hair fall Face is pale yellow with blue circles around the eyes Craving for foods that are hot and sweet Acidity that is worse in the evenings Gastric issues including excessive flatulence Constipation with painful, hard, incomplete stooling Graphites: Presenting symptoms where Graphites are mainly used include: Obesity Intolerance to cold Depressed emotionally, timid, indecisive, weeping, listening to music Bloated, gassy abdomen Chronic constipation with hard, painful stooling process Lodium: Good appetite but lose weight quickly Tendency to eat at regular intervals Excessive warmth and need to stay in a cool environment Anxiety about present Excessive palpitations Lachesis Mutus: These patient present with the following symptoms: Feeling extremely hot, so inability to wear tight clothes Generally sad with no inclination to do any work Tendency to stay aloof and alone Excessive talkativeness Women around menopausal age

21 years old female c/o dryness and tightening of skin b/L foot since childhood and hands*5yrs. Numbness and pain of fingers with cold+,mouth ulcers ,nausea and regurgitation *3 months. No dysnoea . No similar family history. o/E Afebrile pR -80 spo2-98 BP- 130/80mmhg clubbing+ chest - b/l clear S1,S2+

Friends I am sure u must have enjoyed green Diwali. Today I am discussing about a major problem known as Asthma. Asthma is a chronic disease of the airways that transport air to and from the lungs. No full cure is available, but management methods can help a person with asthma lead a full and active life. In a person with asthma, the inside walls of the airways, known as bronchial tubes, become swollen or inflamed. This swelling or inflammation makes the airways extremely sensitive to irritations and increases their susceptibility to an allergic reaction. In an allergic reaction, the airways swell, and the muscles around the airway tighten, making it difficult for air to move in and out of the lungs. What is asthma? asthma attack lady Asthma is a chronic respiratory disease that often leads to severe attacks of symptoms. Asthma is an incurable illness of the airways. The disease causes inflammation and narrowing inside the lung, restricting air supply. The symptoms of asthma often present in periodic attacks or episodes of tightness in the chest, wheezing, breathlessness, and coughing. During the development of asthma, the airways swell and become extremely sensitive to some of the substances a person might inhale. When this increased sensitivity causes a reaction, the muscles that control the airways tighten. In doing so, they might restrict the airways even further and trigger an overproduction of mucus. Asthma attacks The set of inflammatory events in the respiratory system can lead to the severe symptoms of an asthma attack. Worldwide, around 250,000 people die every year as a result of asthma. Asthma attacks occur when symptoms are at their peak. They might begin suddenly and can range from mild to severe. In some asthma attacks, swelling in the airways can completely prevent oxygen from reaching the lungs, which also stops it entering the bloodstream and traveling to vital organs. This type of asthma attack can be fatal and requires urgent hospitalization. At the start of an asthma attack, the airways allow enough air into the lungs, but it does not let the carbon dioxide leave the lungs at a fast enough rate. Carbon dioxide is poisonous if the body does not expel the gas, and a prolonged asthma attack might lead to a build-up of the gas in the lungs. This might further reduce the amount of oxygen entering the bloodstream. People with clear symptoms of asthma should visit a doctor. They will provide treatments and advise on management techniques, as well as identifying potential triggers for asthma symptoms and how to avoid them. The doctor will also prescribe medications to help reduce the frequency of attacks asthma. Effective asthma control reduces the impact of the condition on everyday living. Types As many different factors come together to cause asthma, there are many different types of the disease, separated by age and severity. Adults and children share the same triggers for symptoms that set off an allergic response in the airways, including airborne pollutants, mold, mildew, and cigarette smoke. Childhood asthma Children are more likely to have an intermittent form of asthma that presents in severe attacks. Some children might experience daily symptoms, but the common characteristic among children with asthma is a heightened sensitivity to substances that cause allergy. Second-hand tobacco smoke causes severe problems for children with asthma. Between 400,000 and 1 million children experience worsening asthma symptoms as a result of second-hand smoke, according to the American Lung Association. The Centers for Disease Control and Prevention (CDC) advise that children experience more emergency visits and admissions for asthma than adults. Mild asthma might resolve without treatment during childhood. However, there is still a risk that the condition might return later on, especially if symptoms are moderate or severe. Adult-onset asthma Asthma in adults is often persistent and requires the daily management of flare-ups and preventing symptoms. Asthma can begin at any age. Allergies lead to at least 30 percent of adult presentations of asthma. Obesity is a strong risk factor for adult-onset asthma, and women are more likely to develop the condition after the age of 20 years. People over 65 years of age make up a large number of deaths from asthma. Occupational asthma This is a type of asthma that occurs as a direct result of a job or profession. Symptoms will become apparent after attending a particular workplace. Industries with regular associations to occupational asthma include baking, laboratory work, or manufacturing. In this type, the work environment leads to the return of childhood asthma or the start of adult-onset asthma. Other symptoms might include a runny nose and red eyes. Difficult-to-control and severe asthma These types involve consistent, debilitating asthma symptoms and breathing difficulties. Around 12 percent of people with asthma have difficult-to-control or severe asthma. With the correct medication and effective trigger avoidance, those in this category can bring asthma symptoms back under control. Roughly 5 percent of people with asthma do not see improvements after using the standard asthma medications. These people have severe asthma, and there are several types of severe asthma depending on the cause. Newer medications are becoming available to address the different forms of severe asthma, such as eosinophilic asthma that does not link to any allergic reactions. Seasonal asthma This type occurs in response to allergens that are only in the surrounding environment at certain times of year, such as cold air in the winter or pollen during hay fever season. People still have asthma for the rest of the year but do not experience symptoms. Causes Many different aspects of a person's environment and genetic makeup can contribute to the development of asthma. Asthma is the most common chronic disease among children. The first symptoms become clear at around 5 years of age in the form of wheezing and regular infections in the respiratory tracts. The following are the primary causes of asthma. Allergies A strong link exists between allergies and asthma. One 2013 study in the Annals of Asthma, Allergy, and Immunology suggests that over 65 percent of adults with asthma over the age of 55 years also have an allergy, and the figure is closer to 75 percent for adults between the ages of 20 and 40 years. Common sources of indoor allergens include animal proteins, mostly from cat and dog dander, dust mites, cockroaches, and fungi. Smoking tobacco Research has linked tobacco smoke to an increased risk of asthma, wheezing, respiratory infections, and death from asthma. In addition, the children of parents who smoke have a higher risk of developing asthma. Smoking makes the effects of asthma on the airways worse by adding coughing and breathlessness to its symptoms, as well as increasing the risk of infections from the overproduction of mucus. Environmental factors Air pollution both in and out of the home can impact the development and triggers of asthma. Allergic reactions and asthma symptoms often occur because of indoor air pollution from mold or noxious fumes from household cleaners and paints. pollen Anything from pollen to pollution can trigger an asthma attack and inflame the airways. Other asthma triggers in the home and environment include: pollution sulphur dioxide nitrogen oxide ozone cold temperatures high humidity Heavy air pollution tends to cause a higher recurrence of asthma symptoms and hospital admissions. Smoggy conditions release the destructive ingredient known as ozone, causing coughing, shortness of breath, and even chest pain. These same conditions emit sulfur dioxide, which also results in asthma attacks by constricting the airways. Changes in the weather might also stimulate attacks. Cold air can lead to airway congestion, constricted airway, extra secretions of mucus, and a reduced ability to clear that mucus. Humidity might also lead to breathing difficulties for populations in some areas. Obesity Some studies, such as this report from 2014, suggest a link between obesity and asthma, although the American Academy of Asthma, Allergies, and Immunology does not recognize obesity as a formal risk factor for asthma. However, the report in question suggests that the inflammatory mechanisms that drive asthma also link to obesity. Pregnancy If a woman smokes tobacco or illicit substanes while pregnant, an unborn child might grow less in the womb, experience complications during labor and delivery, and have a low birth weight. These newborns might be more prone to medical problems, including asthma. Stress People who undergo stress have higher asthma rates. Increases in asthma-related behaviors during stressful times, such as smoking, might explain these increased rates. Emotional responses, including laughter and grief, might trigger asthma attacks. Genetics A parent can pass asthma on to their child. If one parent has asthma, there is a 25 percent chance that a child will develop asthma. Having two parents with asthma increase the risk to 50 percent. Many genes are involved in passing on asthma. These genes can interact with the environment to become active, although confirming these findings may require further research. Atopy Atopy is a general class of allergic hypersensitivity that leads to allergic reactions in different parts of the body that do not come in contact with an allergen. Examples include eczema, hay fever, and an eye condition called allergic conjunctivitis. During atopy, the body produces more immunoglobin (IgE) antibodies than usual in response to common allergens. The most common type of asthma is atopic asthma, and atopy plays a key role in its development. Environmental allergens lead to overproduction of IgE antibodies and trigger asthmatic reactions. The menstrual cycle One type of asthma, known as perimenstrual asthma (PMA), leads to acute symptoms during the menstrual cycle and a particular sensitivity to aspirin. The sex hormones that circulate during menstruation, such as luteinizing hormone (LH) and follicle-stimulating hormone (FSH), impact immune activity. This increased immune action can cause hypersensitivity in the airways. Diagnosis Three main components comprise an accurate asthma diagnosis: Medical history, observations during a physical exam, and results from breathing tests. A primary care physician will administer these tests and determine the level of asthma as mild, intermittent, moderate, or severe in people who show signs of the condition, as well as identifying the type. A detailed family history of asthma and allergies can help a doctor make an accurate diagnosis. A personal history of allergies is also important to mention, as many share mechanisms with asthma and increase the risk. Keep a note of any potential triggers of asthma symptoms to help guide treatment, including information about any potential irritants in the workplace. Be sure to identify any health conditions that can interfere with asthma management, such as: a runny nose sinus infections acid reflux psychological stress sleep apnea Young children who develop asthma symptoms before the age of 5 years find it more difficult to receive a clear diagnosis. Doctors might confuse asthma symptoms with those of other childhood conditions. If children experience wheezing episodes during colds or respiratory infections in early life, they are likely to develop asthma after 6 years of age. Physical exam A physical examination will generally focus on the upper respiratory tract, chest, and skin. A doctor will listen for signs of wheezing, or a high-pitched whistle on breathing out, in the lungs during a breath using a stethoscope. Wheezing is a key sign of both an obstructed airway and asthma. Physicians will also check for a runny nose, swollen nasal passages, and soft growths on the inside of the nose and check for skin conditions including eczema and hives. These are allergic conditions that link to asthma and suggest heightened immune activity that could be causing any wheezing. People with asthma do not always show physical symptoms, and it is possible to have asthma without presenting any physical maladies during an examination. Asthma tests Lung function tests are another component of an asthma diagnosis. They measure how much air a person inhales and exhales and the speed with which a person can expel air from the lungs. A spirometry test can provide an indication of lung function. spirometry A spirometry can help assess lung function. Spirometry is a non-invasive test that requires deep breaths and forceful exhalation into a hose. The hose links to a machine called a spirometer that displays two key measurements: forced vital capacity (FVC), or the maximum amount of air a person can inhale and exhale forced expiratory volume (FEV-1), the maximum amount of air a person can exhale in one second The doctor then compares these measurements against what would be normal for another person of the same age. Measurements below normal indicate obstructed airways and probable asthma. A doctor will often administer a bronchodilator drug to open air passages before retesting with the spirometer to confirm the diagnosis. If results improve after using the drug, the risk of an asthma diagnosis increases. Children under 5 years of age are difficult to test using spirometry, so asthma diagnoses will rely mostly on symptoms, medical histories, and other parts of the physical examination process. In younger children, doctors commonly prescribe asthma medicines for 4 to 6 weeks to gauge physical response. Other Tests A bronchoprovocation test, also known as a "challenge test" involves the administration an airway-constricting substance, such as cold air, to deliberately trigger airway obstruction and asthma symptoms. Similarly, a challenge test for exercise-induced asthma would consist of vigorous exercise with the aim of triggering symptoms. The doctor then conducts a spirometry, and if measurements are still normal, they are not likely to reach a diagnosis of asthma. Physicians might use allergy tests to identify substances that may be causing asthma or making it worse. These tests do not fully diagnose asthma, but they might help a doctor understand the nature of asthma symptoms. Doctors may also test for other diseases with similar symptoms, such as: gastroesophageal reflux disease (GERD) heartburn hay fever sinusitis sleep apnea chronic obstructive pulmonary disease (COPD) airway tumors airway obstruction bronchitis pneumonia a blood clot in the lung, or pulmonary embolism congestive heart failure vocal cord dysfunction viral lower respiratory tract infection A doctor may test for these using the following methods: a chest x-ray electrocardiogram (ECG) complete blood counts CT scans of the lungs gastroesophageal reflux assessment the induction and examination of sputum, or phlegm Many people with asthma will not need to visit a specialist, as most primary care physicians have training for asthma diagnosis. People who require special asthma tests or have had life-threatening asthma attacks in the past may need to visit an asthma specialist Specialists can also be useful for people who need more than one kind of medication or higher, more concentrated doses in order to control asthma. A visit may also be necessary for people with difficult-to-control asthma, or people receiving treatment for other allergies. Takeaway Asthma is a chronic, inflammatory condition that causes swelling and blockage in the airways. It can range in severity, and there are several types, depending on the cause and the age at which asthma begins. Anyone of any age can develop asthma. Women are more likely to develop the condition after the age of 20 years, and smoking and air pollution heavily contribute to the issue. The immune system and asthma share a strong link, and people with asthma often have other allergies. A young child might find that asthma seems to resolve without treatment but returns in adult life. However, moderate and severe cases often require treatment. Asthma attacks involve a sudden and severe recurrence of symptoms, and these are how younger children normally experience asthma. Adult-onset asthma tends to be more constant and persistent. Diagnosing asthma involves testing lung function and immune response, as well as assessing an individual for other condition with similar symptoms to asthma risk of asthma for young children. Can asthma develop into other harmful lung diseases, such as COPD or emphysema? Asthma is a risk factor for COPD, and people with long-standing asthma have a high risk of developing COPD, especially if they had severe asthma as children. Emphysema on the other hand, is not related to asthma even though their symptoms may be similar. Cigarette smoking almost always causes this. Homoeopathic treatment for Asthma Carbo Vegetabilis: This is a homeopathic asthma treatment which is generally prescribed when the person has violent bouts of coughing which may cause a gag reflex to set in. Extremities might be cold, but there is a need for air or breeze. Feels dyspeptic, burping gives relief. Chamomilla: This is most often prescribed for asthma attacks that are brought on by emotional stress, anxiety or over excitement. The person displays behaviour that is irritable, angry and hypersensitive. In some cases, this is accompanied by a racking cough. Arsenicum Album: A person needing this homeopathic asthma remedy may often feel a combination of exhaustion and uneasiness. Breathing problems are exacerbated when supine, better when upright. The person often finds that ease of breathing deteriorates at night, accompanied by wheezing and a constant thirst. He/she may also experience violent chills accompanied by shivering, heat may bring relief. Natrum Sulphuricum: When asthma attacks are precipitated by mould and dampness, this homeopathy remedy is especially efficacious. Nux Vomica: Persons feeling constricted in the chest and stomach, brought on by having spicy food, alcohol and sweets. Warmth and sleep along with this remedy bring relief. Pulsatilla: Excessive warmth especially indoors along with and heavily spiced food bring on wheezing as a result of exertion and chest congestion. This remedy is useful for children suffering from asthma.