Peripheral arterial disease – Treatment
Posted by on Sunday, 17th February 2013
Introduction
Peripheral arterial disease (PAD) is a common condition in which a build-up of fatty deposits in the arteries restricts blood supply to leg muscles. It is also known as peripheral vascular disease (PVD).
Although many people with PAD have no symptoms, some people have painful aching in their legs brought on by walking. These aches will usually disappear after a few minutes of resting.
If you experience recurring leg pain with exercise, see Dr B C Shah. PAD is usually diagnosed through a physical examination by Dr B C Shah.
They will also measure the blood pressure in your leg, using the ankle brachial pressure index (ABPI). This involves comparing blood pressure readings from your arm and your ankle. A difference between these readings may indicate PAD.
Why does it happen?
Peripheral arterial disease is a cardiovascular disease, meaning it affects blood vessels. It’s usually caused by a build-up of fatty deposits in the walls of the leg arteries. The fatty deposits, called atheroma, are made up of cholesterol and other waste substances.
The build-up of atheroma on the walls of the arteries makes the arteries narrower and restricts the flow of blood to the legs. This process is called atherosclerosis.
Who is affected?
Rates of cases of PAD are strongly associated with older age. It is estimated that it develops in:
2.5% of people under 60
8.3% of people aged 60–69
19% of people over 70
Men are more likely to develop the symptoms of PAD earlier in life than women.
There are certain things that can increase your chances of developing PAD and other cardiovascular diseases, including:
Smoking –by far the single most significant risk factor
Diabetes – both type 1 and type 2 diabetes
High blood pressure
High cholesterol
Treating and preventing peripheral arterial disease
PAD is largely treated through medication and lifestyle changes.
Completely stopping smoking and exercising regularly are the main lifestyle changes that can ease the symptoms of PAD and reduce the chances of the condition worsening.
The underlying causes should also be treated, such as reducing high blood pressure and cholesterol and treating diabetes. Medication can be used to improve blood flow. In some cases, surgery may be needed to treat PAD.
Complications of peripheral arterial disease
While PAD is not immediately life-threatening, the process of atherosclerosis that caused it can lead to serious problems.
Having PAD means you have a much higher risk of developing other serious cardiovascular diseases, such as:
coronary heart disease – a condition where the supply of blood to the heart is restricted, putting you at risk of a heart attack
stroke
Also, if the symptoms of PAD worsen, there is a risk that tissue of the lower leg will begin to die (this is known as gangrene), which in severe cases requires the lower leg to be amputated.
If treatment is successful, and lifestyle changes are maintained, your situation will usually improve.
However, if you are unable or unwilling to make lifestyle changes, especially if your leg pain is getting worse, it is estimated there is a:
One-in-five chance you will experience a non-fatal heart attack or stroke
5% chance that one or both of your legs will need to be amputated
One-in-three chance you will die prematurely
Symptoms of peripheral arterial disease
Many people with peripheral arterial disease (PAD) do not have any symptoms. However, you may feel painful aching in your leg muscles triggered by physical activity such as walking or climbing stairs.
The pain usually develops in your calves, but sometimes your hip, buttock or thigh muscles can be affected. The pain can range from mild to severe.
The pain will usually go away after 5–10 minutes when you rest your legs. Other symptoms of PAD may include:
Hair loss on your legs and feet
Numbness or weakness in the legs
Brittle, slow-growing toenails
Ulcers (open sores) on your feet and legs, which do not heal
Changing skin colour on your legs, turning pale or bluish
Shiny skin
The muscles in your legs may shrink
Men may develop impotence (erectile dysfunction)
When to seek medical advice
If you experience recurring episodes of leg pain, make an appointment with Dr. B C Shah, especially if you are a smoker or have a confirmed diagnosis of diabetes, high blood pressure and/or high cholesterol.
Many people mistakenly think recurring episodes of leg pain are part of growing older. This is not the case. There is no reason why an otherwise healthy person should experience leg pain.
When to seek urgent medical advice
Some symptoms may suggest the supply of blood to your legs has become severely restricted and you may need to see a doctor urgently. These include:
Being unable to move muscles in the affected leg
A sudden loss of normal sensation in the affected leg
Feeling a burning or prickling sensation in the affected leg
Your toes or leg suddenly turns white or blue
The skin on your toes or lower limbs becomes cold and numb, and turns reddish and then black or begins to swell and produce foul-smelling pus, causing severe pain
Causes of peripheral arterial disease
Peripheral arterial disease (PAD) is usually caused by a build-up of fatty deposits on the walls of the arteries inside the legs. The fatty deposits, called atheroma, are made up of cholesterol and other waste substances.
The build-up of atheroma on the walls of the arteries makes the arteries narrower and restricts the flow of blood to the legs. This process is called atherosclerosis.
People with PAD can experience painful aching in their leg muscles during physical activity because the muscles are not receiving the blood supply they need.
Like all tissue in your body, muscles in your legs need a constant supply of blood to function properly. When you are using your leg muscles, the demand for blood increases four-fold. But if the arteries in your legs are blocked, the supply of available blood cannot meet the demand.
This shortfall between supply and demand causes your muscles to experience painful aches which usually get better when you rest your legs.
Increased risk of PAD
There are some things that cannot be changed which may increase your chances of developing PAD, such as a family history of heart disease and atherosclerosis, or your age.
As you get older, your arteries naturally begin to harden and get narrower, which can lead to atherosclerosis and then PAD.
However, there are many things that can dangerously speed up this process. These are described below.
Smoking
Smoking is the single most important thing that increases your risk of PAD. Smoking can damage the walls of your arteries. Tiny blood cells, known as platelets, will then form at the site of the damage to try to repair it. This can cause your arteries to narrow.
It is estimated that smokers are six times more likely to develop PAD than non-smokers and more than 80% of people who develop PAD are current or former smokers.
Diabetes
If you have poorly controlled type 1 or type 2 diabetes, the excess glucose in your blood can damage your arteries.
People with diabetes are two to four times more likely to develop PAD, and having a combination of poorly controlled diabetes and PAD is a major risk factor for amputation. People with diabetes and PAD are 15 times more likely to need an amputation than people with PAD who do not have diabetes.
High cholesterol
Cholesterol is a type of fat essential for the body to function.
There are two main types of cholesterol:
Low-density lipoprotein (LDL) is the main cholesterol transporter and carries cholesterol from your liver to cells that need it. If there is too much cholesterol for the cells to use, this can cause a harmful build-up in your blood and lead to atherosclerosis. For this reason, LDL cholesterol is known as "bad cholesterol", and lower levels are better.
High-density lipoprotein (HDL) carries cholesterol away from the cells and back to the liver, where it is either broken down or passed from the body as a waste product. For this reason, it is referred to as "good cholesterol", and higher levels are better.
Most of the cholesterol your body needs is made by your liver. However, if you eat foods high in saturated fat, the fat is broken down into LDL ("bad cholesterol").l.
High blood pressure
Your arteries are designed to pump blood at a certain pressure, and if blood pressure is too high (known as hypertension), the walls of the arteries can become damaged. High blood pressure can be caused by:
Being overweight
Drinking excessive amounts of alcohol
Stress
Smoking
A lack of exercise
Homocysteine
Homocysteine is a type of amino acid (molecule that makes up protein) found in the blood. Research has found that 30%–40% of people with PAD have higher-than-average levels of homocysteine in their blood. And one-in-four people who develop leg pain have extremely high levels.
It has been suggested that high levels of homocysteine may damage the walls of the arteries, leading to atherosclerosis, but this has not been proven.
Vitamin B supplements and eating foods high in folic acid, such as green leafy vegetables or wholegrains, are known to lower homocysteine levels. However, researchers found no significant reduction in risk of cardiovascular disease when people with PAD increased the amount of vitamin B and folic acid in their diet.
Diagnosing peripheral arterial disease
If Dr. B C Shah suspects a diagnosis of peripheral arterial disease (PAD), he will carry out a physical examination of your leg.
PAD can cause a number of noticeable signs and symptoms, such as:
Shiny skin
Brittle toenails
Hair loss
The pulse in your leg being very weak or undetectable
Leg ulcers
Dr B C Shah may also ask about your symptoms and personal and family medical histories.
The ankle brachial pressure index
The ankle brachial pressure index (ABPI) test is widely used to diagnose PAD, as well as assessing how well you are responding to treatment.
While you rest on your back, Dr B C Shah will measure the blood pressure in your upper arm and your ankle. These measurements are taken with a Doppler probe, which uses sound waves to determine the flow of blood in your arteries.
They then divide the second result (from your ankle) by the first result (from your arm).
If your circulation is healthy, the blood pressure in both parts of your body should be exactly or almost the same and the result of your ABPI would be 1.
But if you have PAD, the blood pressure in your ankle will be lower due to a reduction in blood supply, so the results of the ABPI would be less than 1.
In some cases, ABPI may be carried out after getting you to run on a treadmill or cycle on an exercise bike. This is a good way of seeing the effect of physical activity on your circulation.
Further testing
In most cases, Dr B C Shah will be able to confirm a diagnosis of PAD by doing a physical examination, asking about your symptoms and checking your ABPI score.
Further testing is usually only required if:
There is uncertainly about the diagnosis – for example, if you have symptoms of leg pain but your ABPI score is normal.
You do not fit the expected profile of somebody with PAD; for example, you are under 40 and have never smoked.
The restriction of blood supply in your leg is severe enough that treatment may be required.
Additional hospital-based tests that can be used include:
Ultrasound scan – where sound waves are used to build up a picture of arteries in your leg. This can identify exactly where in your arteries there are blockages or narrowing.
Angiogram – a special liquid known as a contrast agent is injected into a vein in your arm. The agent shows up clearly on a computerised tomography (CT) scan or magnetic resonance imaging (MRI) scan and produces a detailed image of your arteries.
In some cases, the contrast agent may be injected directly into the arteries of your leg and X-rays may be used to produce the images.
Treating peripheral arterial disease
There are two main types of treatment used in the management of peripheral arterial disease (PAD).
These are:
Making lifestyle changes to improve symptoms and reduce your risk of developing a more serious cardiovascular disease (CVD), such as coronary heart disease
Taking medication to address the underlying cause of PAD and reduce your risk of developing another CVD. For example, a statin can be used to lower your cholesterol levels.
Surgery may be used in some cases. For example, if you experience pain in your leg while resting or if there is tissue loss. These treatment types are discussed in more depth below.
Lifestyle changes
The two most important lifestyle changes you can make if you are diagnosed with PAD are:
If you currently smoke, you should stop.
Take regular exercise.
Smoking
Quitting smoking will reduce your risk of PAD getting worse and another serious cardiovascular disease developing.
Research has found people who continue to smoke after receiving their diagnosis are five times more likely to have a heart attack and seven times more likely to die from a complication of heart disease than people who quit after receiving their diagnosis.
People who stop smoking usually notice an improvement in their symptoms and an improvement in their ankle brachial pressure index (ABPI) score.
Exercise
Evidence suggests regular exercise helps reduce the severity and frequency of PAD symptoms, while at the same time reducing the risk of developing another CVD.
Research has found that after six months of regular exercise, a person can::
Walk for two to three times longer before experiencing pain
Walk a lot further before experiencing pain
see a 20% improvement in their ABPI score
If you are diagnosed with PAD, it is likely you have not taken part in regular exercise for many years (although this is not true for everyone, such as previously fit people with type 1 diabetes).
The exercise programme usually involves two hours of supervised exercise a week for three months. But ideally, over time, you should be aiming to exercise daily for the rest of your life, as the benefits of exercise are quickly lost if it is not frequent and regular.
The preferred exercise is walking. It is normally recommended you walk as far and as long as you can before the symptoms of pain become intolerable. Once this happens, rest until the pain goes and begin walking again until the pain returns. Keep using this "stop-start" method until you have spent at least 30 minutes walking.
You will probably find the exercise course challenging, as the frequent episodes of pain can be upsetting and off-putting. But if you persevere, you should gradually notice a marked improvement in your symptoms and you will begin to go longer and longer without experiencing any pain.
Medication
Different medications can be used to treat the underlying causes of PAD while reducing your risk of developing another CVD.
Some people may only need to take one or two of the medications discussed below, while others may need all of them.
Statins
If blood tests show that your levels of LDL cholesterol ("bad cholesterol") are high, you will be prescribed a type of medication called a statin.
Statins work by helping to reduce the production of LDL cholesterol by your liver.
Common side effects of statins include:
Digestive disorders, such as constipation and diarrhoea
Difficulty sleeping (insomnia)
Pain in the muscles and joints
Feeling sick (nausea)
Antihypertensives
Antihypertensives are a group of medications used to treat high blood pressure (hypertension).
It is likely you will be prescribed an antihypertensive drug if your blood pressure is higher than 140/90mmHg if you do not have diabetes, or 130/80mmHg if you do have diabetes.
A widely used type of antihypertensive is an angiotensin-converting enzyme (ACE) inhibitor.
ACE inhibitors block the actions of some hormones that help regulate blood pressure. They help to reduce the amount of water in your blood and widen your arteries, which will both decrease your blood pressure.
Side effects of ACE inhibitors include:
Dizziness
Tiredness or weakness
Headaches
A persistent dry cough
Most of these side effects pass in a few days, although some people find they still have a dry cough.
If side effects become particularly troublesome, a medication that works in a similar way to ACE inhibitors, known as an angiotensin-2 receptor antagonist, may be recommended.
ACE inhibitors can cause unpredictable effects if taken with other medications, including some over-the-counter ones, so check with Dr B C Shah before taking anything in combination with this medication.
Antiplatelets
One of the biggest potential dangers if you have atherosclerosis is a piece of fatty deposit (plaque) breaking off from your artery wall. This can cause a blood clot to develop at the site of the broken plaque.
If a blood clot develops inside an artery that supplies the heart with blood (a coronary artery) it can trigger a heart attack. Similarly, if a blood clot develops inside any of the blood vessels going to the brain, it can trigger a stroke.
You will probably be prescribed an antiplatelet medication to reduce your risk of blood clots. This medication reduces the ability of platelets (tiny blood cells) to stick together, so if a plaque does break apart, you have a lower chance of a blood clot developing.
Low-dose aspirin (usually 75mg a day) is usually recommended.
Common side effects of aspirin include:
Irritation of the stomach or bowel
Indigestion
Nausea (feeling sick)
If you are unable to take aspirin (for example, if you have a history of stomach ulcers or you are allergic to aspirin), an alternative antiplatelet called clopidogrel can be used.
Side effects of clopidogrel include:
Diarrhoea
Pains in your stomach and bowel
Nosebleeds
Bruising
Blood in your urine
Blood in your stools
Naftidrofuryl oxalate
Naftidrofuryl oxalate improves blood flow in the body, and is often used if you prefer not to have surgery or your supervised exercise programme has not led to satisfactory improvement in your condition.
Side effects of naftidrofuryl oxalate include:
Dizziness
Headache
Stomach pains
Diarrhoea
Rashes
Surgery
There are two main types of surgical treatment for PAD:
Angioplasty – where a blocked or narrowed section of artery is widened by inflating a tiny balloon inside the vessel
Bypass graft – where blood vessels are taken from another part of your body and used to bypass the blockage in an artery
Angioplasty vs bypass surgery
Both types of surgery have their own set of pros and cons.
An angioplasty is less invasive (it does not involve making major incisions in your body). It is usually performed under a local anaesthetic as a day procedure. This means you will be able to go home the same day you have the operation. You also feel less pain after an angioplasty. However, the improvement in symptoms varies from person to person and may only last for around 6-12 months.
Bypass surgery, which is usually only used when angioplasty is not suitable or if it has failed, has a longer recovery time (around two to three weeks). However, the improvement in symptoms usually lasts for longer than a year.
However, after two years, both techniques have broadly the same success rate of improving symptoms.
Both techniques carry a risk of causing serious complications such as a heart attack, stroke and even death. One study found that the risk of death for angioplasty was around one person in every 200, and the risk for bypass graft was slightly higher – around two to three people in every 100.
Before recommending treatment, a team of specialist surgeons, doctors and nurses will discuss the options with you – including the potential risks and benefits.
Surgery is not always successful in treating PAD and is usually only recommended under the following circumstances:
Your leg pain is so severe it prevents you from carrying out everyday activities.
Your symptoms have failed to respond to treatments discussed above.
The results of tests, such as ultrasound scans, show surgery is likely to improve symptoms.
Both techniques are discussed in more detail below.
Angioplasty
A tiny hollow tube known as a catheter is inserted into one of the arteries in your groin. The catheter is then guided to the site of the blockage.
On the tip of the catheter is a balloon which is inflated when the catheter is in place. This helps widen the vessel. Sometimes a hollow metal tube known as a stent may be left in place to help keep the artery open.
Read more about angioplasty.
Bypass graft
If angioplasty is unsuccessful or unsuitable, a bypass graft may be performed. During surgery a length of a healthy vein in your leg is removed. The vein is then joined (grafted) above and below the blocked vein so the blood supply can be rerouted, or bypassed, through the healthy vein. Sometimes a section of artificial tubing can be used as an alternative to a grafted vein.
Complications of peripheral arterial disease
The build up of fat in the arteries (atherosclerosis) that causes peripheral arterial disease (PAD) can also lead to other serious conditions.
Critical limb ischemia (CLI)
Critical limb ischemia (CLI) is a condition that occurs when blood flow to the limbs is severely restricted from atherosclerosis.
Symptoms of CLI include:
A severe burning pain in your legs and feet even when you are resting; the pain often occurs at night and episodes of pain can last several hours. You may find you have to hang your legs out of bed to get relief.
Your skin turns pale, shiny, smooth and dry.
You may develop wounds and ulcers (open sores) in your feet and legs that show no sign of healing.
The muscles in your legs begin to waste away.
The skin on your toes or lower limbs becomes cold and numb and turns reddish and then black or begins to swell and produce foul-smelling pus, causing severe pain.
If you think you are developing the symptoms of CLI, contact Dr. B C Shah immediately.
CLI is treated using an angioplasty or bypass graft (Read about treating peripheral arterial disease for more information on these operations). However, these may not always be successful and you may be advised to have an amputation below the knee. Around one-third of people with CLI will require an amputation.
CLI is an extremely serious complication that can be challenging to treat. Around one in four people will die from a complication of CLI, such as infection.
Heart attack and stroke
The build up of fat in the arteries in the legs that causes PAD can also affect other areas of your body too, such as the arteries supplying the heart and brain.
Blockages in these arteries can cause a heart attack or a stroke
Preventing peripheral arterial disease
The most effective way to prevent peripheral arterial disease (PAD) or stop your symptoms of PAD worsening is to tackle the build up of fat in your arteries (atherosclerosis).
There are five main ways you can achieve this:
Stop smoking
Eat a healthy diet
Take regular exercise
Lose weight (if you are overweight or obese)
Moderate your consumption of alcohol
These lifestyle changes are discussed in more detail below.
Smoking
If you smoke, it is strongly recommended you quit as soon as possible. T
It is recommended you use an anti-smoking treatment such as nicotine replacement therapy (NRT) or bupropion (a medication used to reduce cravings for cigarettes). People who use these treatments have a much greater success rate in permanently quitting than people who try to quit using willpower alone.
It is recommended you eat two to four portions of oily fish a week. Oily fish contains a type of fatty acid called omega-3, which can help lower your cholesterol levels.
Good sources of omega-3 include:
Herrings
Sardines
Mackerel
Salmon
Trout
Tuna
If you are unable or unwilling to eat oily fish, Dr B C Shah may recommend you take an omega-3 food supplement. However, never take a food supplement without first consulting Dr B C Shah. Some supplements, such as beta-carotene, can be harmful.
It is also recommended you eat a Mediterranean-style diet. This means you should eat more bread, fruit, vegetables and fish and less meat. Replace butter and cheese with products that are vegetable and plant-oil based, such as olive oil.
Weight management
If you are overweight or obese, aim to lose weight and maintain a healthy weight by using a combination of regular exercise and a calorie-controlled diet.
Alcohol
If you drink alcohol, do not exceed recommended daily limits (three to four units a day for men and two to three units a day for women).
A unit of alcohol is roughly half a pint of normal-strength lager, a small glass of wine or a single measure (25ml) of spirits. Regularly exceeding recommended alcohol limits will raise your blood pressure and cholesterol level, which will increase the risk of your PAD symptoms worsening and increase your risk of developing another more serious type of cardiovascular disease.
Contact Dr. B C Shah if you find it difficult to moderate your drinking. Counselling services and medication can help you reduce your alcohol intake.
Regular exercise
If you do not have PAD, then a minimum of 150 minutes of vigorous exercise a week is recommended. The exercise should be strenuous enough to leave your heart beating faster, and you should feel slightly out of breath afterwards.
Activities that you could incorporate into your exercise program include:
Brisk walking
Hill climbing
Running
Cycling
Swimming
If you find it difficult to achieve 150 minutes of exercise a week, start at a level you feel comfortable with. For example, you could do 5–10 minutes of light exercise a day and then gradually increase the duration and intensity of your activity as your fitness begins to improve.
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Coronary angioplasty
Posted by on Saturday, 16th February 2013
Introduction
A coronary angioplasty is a procedure used to widen blocked or narrowed coronary arteries.
A short wire-mesh tube, called a stent, is inserted into an artery to allow blood to flow more freely through it.
Coronary angioplasty is sometimes known as percutaneous transluminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI).
Why is a coronary angioplasty necessary?
Like all organs in the body, the heart needs a constant supply of blood. This is supplied by two large blood vessels called the left and right coronary arteries. In older people, these arteries can become narrowed and hardened. This is known as atherosclerosis.
Hardening of the coronary arteries can restrict the flow of blood to the heart, which can lead to angina.
The most common symptom of angina is chest pain, which is usually triggered by physical activity. While many cases of angina can be treated with medication, a coronary angioplasty may be required to restore the blood supply to the heart in severe angina.
Coronary angioplasties are also often used as an emergency treatment after a heart attack.
What are the benefits of a coronary angioplasty?
If you have angina, an angioplasty can:
Relieve your pain
Reduce your need for angina medication
Ease symptoms such as breathlessness
Enable you to be more active
Improve your ability to do everyday activities, such as climbing stairs and walking any distance
Make you feel generally better so you're more able to do the things you want to do, such as going to work and enjoying a social life
If you've had a heart attack, an angioplasty can:
Increase your chances of surviving by one-third more than clot-busting treatment (thrombolysis) can
Reduce your chances of having another heart attack
How is it performed?
You may have a pre-assessment of your health a few days before the operation. This may involve blood tests and a general health check. Being as fit as you can be before the procedure can help your recovery from a coronary angioplasty.
During an angioplasty, a flexible tube called a catheter is used to insert a mesh tube, known as a stent, into the coronary artery.
A small balloon is inflated to open the stent, which pushes against the artery walls. This widens the artery, squashing fatty deposits against the artery wall so that blood can flow through it more freely.
The procedure usually takes around 30 minutes, but it can take longer depending on how many sections of your artery need treatment. You will normally be able to go home the day after a coronary angioplasty. You will need to avoid driving for around a week.
How safe is a coronary angioplasty?
A coronary angioplasty is one of the most common types of treatment for the heart. Coronary angioplasties are most commonly performed in people who are 65 years of age or older as they are more likely to have angina.
A coronary angioplasty does not involve making major incisions in the body and is usually carried out safely in most people. Doctors refer to this as a minimally invasive form of treatment.
The risk of complications from a coronary angioplasty varies depending on individual circumstances. The risk increases slightly with age and if you have certain conditions. If you have an unrelated serious health condition, such as canceror liver failure, the risks of treatment may outweigh the benefits.
Are there any alternatives?
A coronary angioplasty may not be technically possible if your arteries are different from normal, for example if there are too many narrow sections.
In this circumstance, an alternative surgical procedure, known as a coronary artery bypass graft (CABG), may be considered.
Why do I need a coronary angioplasty?
A coronary angioplasty is necessary when hardening and narrowing of the coronary arteries prevents the heart from getting enough blood to function normally.
Atherosclerosis
Hardening of the arteries is known as atherosclerosis. Your arteries harden and narrow naturally as you get older, but this process can be dangerously sped up by:
Eating a high-fat diet
Smoking
Having high blood pressure (hypertension)
Having diabetes
Your ethnicity (where you were born and your cultural background)
For reasons that are not fully understood, high blood pressure and atherosclerosis are more common among people of African-Caribbean and south Asian (Indian, Pakistani, Bangladeshi and Sri Lankan) origin.
Angina
Once the hardening and narrowing of your coronary arteries reaches a certain point, your heart no longer receives the blood supply it needs to work properly. This can trigger the symptoms of angina, including:
Pain or discomfort in your chest
Breathlessness
When the symptoms of angina start, it is sometimes called an angina attack.
There are two types of angina:
Stable angina, where symptoms only last a few minutes, are triggered by physical activity and can be relieved with medication
Unstable angina, where symptoms develop even when you are resting, last longer than five minutes and cannot usually be relieved with medication
If your symptoms do not respond to angina medication, a coronary angioplasty may be recommended.
Heart attack
A coronary angioplasty can be used as an emergency treatment for a heart attack if the heart attack was caused by an interruption to your heart’s blood supply.How a coronary angioplasty is performed
You may have a pre-assessment of your health a few days before the operation. This will give you an opportunity to discuss any concerns with your Dr. B C Shah.
Before a coronary angioplasty is carried out, the arteries near your heart need to be assessed to make sure the operation is technically possible. This is done using a test called coronary angiography.
During coronary angiography, a long, flexible plastic tube called a catheter (about the width of the lead in a pencil) is inserted into a blood vessel, either in your groin or arm.
The tip of the catheter is guided using an X-ray to your heart or the arteries that supply your heart. A special fluid that shows up on X-rays, known as contrast medium, is injected through the catheter. The resulting pictures are called angiograms.
You may be asked not to eat or drink anything for four hours before a coronary angioplasty. You will usually be able to take most medications as normal up to the day of the procedure, with the exception of blood-thinning medication (anticoagulants), such as warfarin. You may also need to alter the timing of any diabetes medication you take.
The operation
A coronary angioplasty usually takes place in a room called a catheterisation laboratory, rather than in an operating theatre. A catheterisation laboratory is a room that is fitted with X-ray video to allow the doctor to monitor the procedure on a screen.
Coronary angioplasty usually takes about 30 minutes, although it may take longer depending on how many sections of your artery need to be treated.
You will be asked to lie on your back on an X-ray table. You will be linked up to a heart monitor and given a local anaesthetic to numb your skin. An intravenous (IV) line will also be inserted into a vein, in case you need to have painkillers or a sedative.
Dr. B C Shah will make a small incision in the skin of your groin or wrist and will insert a catheter. He will guide the catheter through the artery in your groin or arm, passing it through the main artery in your body (the aorta) and into the opening of your left or right coronary artery.
A thin, flexible wire is then passed down the inside of the blood vessel being treated to beyond the narrowed area. A small, sausage-shaped balloon is passed over the wire to the narrowed area and inflated for up to 60 seconds. This squashes the fatty material on the inside walls of the artery to widen it. This may be done several times.
While the balloon is inflated, the artery will be completely blocked and you may have some chest pain. However, this is normal and is nothing to worry about. The pain should go away when the balloon is deflated. Ask your cardiologist for pain medication if you find it uncomfortable.
You should not feel anything else as the catheter moves through the artery, but you may feel an occasional missed or extra heartbeat. This is nothing to worry about and is completely normal.
If you are having a stent inserted (see below), it will open up as the balloon is inflated and will be left inside your artery.
When the operation is finished, the cardiologist will check that your artery is wide enough to allow blood to flow through more easily. This is done by monitoring a small amount of contrast dye as it flows through the artery.
The balloon, wire and catheter are then removed and any bleeding is stopped with a dissolvable plug or firm pressure.
Going home
A coronary angioplasty often involves an overnight stay in hospital, but many people can go home on the same day if the procedure is straightforward. After the operation, you will not be able to drive for one week so you will need to arrange for someone to drive you home from hospital.
What type of stent?
A stent is a short, wire-mesh tube that acts like a scaffold to help keep your artery open. There are two main types of stent:
Bare metal (uncoated) stent
Drug-eluting stent, which is coated with medication that reduces the risk of the artery becoming blocked again
The biggest drawback of using bare metal stents is that, in around 30% of cases, the arteries begin to narrow again. This is because the immune system sees the stent as a foreign body and attacks it, causing swelling and excessive tissue growth around the stent.
Many cardiologists avoid this problem by using drug-eluting stents. These are coated with medication that reduces the body’s abnormal response and tissue growth.
Once the stent is in place, the medication is released over time into the area that is most likely to become blocked again. The two most researched types of medication are:
"-limus" drugs (such as sirolimus, everolimus and zotarolimus), which have previously been used to prevent rejection in organ transplants
paclitaxel, which inhibits cell growth and is commonly used in cancer chemotherapy
The use of drug-eluting stents has reduced the rate of arteries re-narrowing from around 30% to below 10%. However, as drug-eluting stents are still a relatively new technology, it is uncertain how effective or safe they are in the long term.
Before your procedure, discuss the benefits and risks of each type of stent with your cardiologist.
If you have a stent, you’ll also need to take certain anti-platelet drugs to help reduce the risk of blood clots forming around the stent. These include:
Aspirin, taken every morning for life
Clopidogrel, taken for 11 or 12 months depending on whether you have had a bare metal or drug-eluting stent, or whether you have had a heart attack
Prasugrel, which is used as an alternative to clopidogrel in some hospital
Recovering from a coronary angioplasty
You will normally be able to leave hospital the day after a coronary angioplasty. Arrange for a friend or family member to take you home.
Before you leave hospital, you should be told about any medication you need to take. You may also be given advice on improving your diet and lifestyle. You will be given a date for a follow-up appointment to check on your progress.
You may have a bruise under the skin where the catheter was inserted. This is not serious, but it may be sore for a few days. Occasionally, the wound can become infected. Keep an eye on it to check that it's healing properly. Tell Dr. B C Shah if it becomes red and sore.
Returning home
After having a coronary angioplasty, avoid doing any heavy lifting for about a week or until the wound has healed.
Do not drive for a week after the operation. If you drive a heavy vehicle for a living, such as a lorry or a bus, you must inform Dr. B C Shah that you have had a coronary angioplasty. He will arrange further testing before you can return to work. You should be able to drive again as long as:
You meet the requirements of an exercise/function test
You do not have another disqualifying health condition
If you have had a planned coronary angioplasty, you should be able to resume your normal activities within a week. However, if you have had an emergency angioplasty following a heart attack, it may be several weeks or months before you recover fully.
Sex
If your sex life was previously affected by angina, you may be able to have a more active sex life as soon as you feel ready after a coronary angioplasty. If you have any concerns, speak to Dr. B C Shah. According to experts, having sex is the equivalent of climbing a couple of flights of stairs in terms of the strain that it puts on your heart.
Further treatment
Most people need to take blood-thinning medications for up to one year after having an angioplasty. This is usually a combination of low-dose aspirin and a medication called clopidogrel. It is very important to follow your medication schedule as stopping medication early greatly increases the risk of the stent becoming blocked suddenly and causing a heart attack.
Clopidogrel blocks one of the chemicals that the body uses to trigger blood clotting.
Side effects of clopidogrel include:
diarrhoea
indigestion
abdominal pain
excessive or unusual bleeding, such as bleeding when injected, nosebleeds or blood in your urine (the loss of blood is usually minimal and nothing to worry about)
skin that may bruise more easily
Because of the side effect of excessive bleeding, men may prefer to shave with an electric razor.
The course of clopidogrel will be withdrawn after the agreed period, but most people need to continue taking low-dose aspirin for the rest of their life.
You may need to have another angioplasty if your artery becomes blocked again and your angina symptoms return. Alternatively, you may need a coronary artery bypass graft(CABG).
Risks of coronary angioplasty
As with all surgery, coronary angioplasty carries a risk of complications. Several factors increase your risk of experiencing these complications.
Who's at risk?
Factors that increase your chance of having complications include:
Your age – the older you are, the higher the risk. For example, a 60-year-old man with no other risk factors has a less than 1% risk of developing complications, while an 80-year-old has a 3% risk.
Whether the surgery was planned for angina or emergency treatment after a heart attack – emergency surgery is always riskier because there is less time to plan it.
Whether you have kidney disease – the intravenous dye used during an angioplasty can occasionally cause further damage to your kidneys.
Whether more than one coronary artery has become blocked – this is known as multi-vessel disease.
Whether you have a history of serious heart disease – this could include heart failure.
Dr. B C Shah can give you more information about your individual circumstances and level of risk.
Complications
Complications that can occur after an angioplasty include:
a heart attack, which is estimated to occur in 1 in 100 cases
a stroke, which is estimated to occur in 1 in 200 cases
excessive bleeding after the operation, which is estimated to occur in 1 in 200 cases and requires a blood transfusion
death, which is estimated to occur in 1 in 500 cases
Other heart surgery options
The most widely used surgical alternative to a coronary angioplasty is a coronary artery bypass graft (CABG).
Coronary artery bypass graft
A coronary artery bypass graft (CABG) is surgery to bypass a blockage in an artery. This is done using segments of healthy blood vessel, called grafts, taken from other parts of the body. Segments of vein from your legs or chest are used to create a new channel through which blood can be directed past the blocked part of the artery. This allows more blood to get through into the heart muscle.
Complications of CABG are uncommon, but are potentially serious. They include:
A heart attack, which is estimated to occur in 1 in 50 cases
A stroke, which is estimated to occur in 1 in 50 cases
You may not always be able to choose between having a coronary angioplasty or a CABG.
A CABG is usually recommended when multiple coronary arteries have become blocked and narrowed. However, it is invasive surgery so may not be suitable for people who are particularly frail and in poor health.
A coronary angioplasty may not be possible if the anatomy of the blood vessels near your heart is abnormal.
Coronary angioplasty or CABG?
If you can choose between having a coronary angioplasty or a CABG, be aware of the advantages and disadvantages of each technique.
As a coronary angioplasty is minimally invasive, you will recover from the effects of the operation quicker than you will from a CABG. The procedure also has a lower complication rate, but research has shown that up to one person in four who has a coronary angioplasty requires further treatment because the widened artery narrows again.
However, in the future, the number of people who need further surgery will probably fall sharply because of the use of drug-eluting stents.
CABG has a longer recovery time than coronary angioplasty and a higher complication rate. However, only 1 person in 10 who has a CABG requires further treatment. Also, research published in 2009 found that CABG is usually a more effective treatment option for people who are over 65 years of age and for people with diabetes.
Discuss the benefits and risks of both types of surgery with your surgical team.
Percutaneous transluminal coronary rotational atherectomy (PTCRA)
Percutaneous transluminal coronary rotational atherectomy (PTCRA) is a similar technique to coronary angioplasty. However, rather than using a balloon and a stent to expand the artery, a small diamond cutter is first used to remove the fatty deposit that is blocking the artery
It is usually used when the coronary artery has a high level of calcium in it. Calcium makes the artery very hard and can prevent balloons or stents expanding properly to relieve the narrowing. Once the small diamond cutter has been used, the artery is then treated with balloons and stents as normal.
Evidence has found that PTCRA is no more effective than a coronary angioplasty, so it is usually only carried out in people who are not suitable for conventional coronary angioplasty.
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Chickenpox
Posted by on Friday, 15th February 2013
Introduction
Chickenpox is a mild and common childhood illness that most children catch at some point.
It causes a rash of red, itchy spots that turn into fluid-filled blisters. They then crust over to form scabs, which eventually drop off.
Some children have only a few spots, but in others they can cover the entire body. The spots are most likely to appear on the face, ears and scalp, under the arms, on the chest and belly and on the arms and legs.
Chickenpox (medically known as varicella) is caused by a virus called the varicella-zoster virus. It's spread quickly and easily through the coughs and sneezes of someone who is infected.
Chickenpox is most common in children under 10. In fact, chickenpox is so common in childhood that 90% of adults are immune to the condition because they've had it before.
Children usually catch chickenpox in winter and spring, particularly between March and May.
What to do
To prevent spreading the infection, keep children off nursery or school until all the spots have crusted over.
Chickenpox is most infectious from one to two days before the rash starts, until all the blisters have crusted over (usually five to six days after the start of the rash).
If your child has chickenpox, try to keep them away from public areas to avoid contact with people who have not had it, especially people who are at risk of serious problems, such as newborn babies, pregnant women and anyone with a weakened immune system (for example, people having cancer treatment or taking steroid tablets).
Chickenpox treatment
Chickenpox in children is considered a mild illness, but expect your child to feel pretty miserable and irritable while they have it.
Your child is likely to have a fever at least for the first few days of the illness. The spots can be incredibly itchy.
There is no specific treatment for chickenpox, but there are pharmacy remedies which can alleviate symptoms, such as paracetamol to relieve fever and calamine lotion and cooling gels to ease itching.
In most children, the blisters crust up and fall off naturally within one to two weeks.
When to see Dr. B C Shah
For most children, chickenpox is a mild illness that gets better on its own.
But some children can become more seriously ill with chickenpox. They need to see a doctor.
Contact Dr. B C Shah straight away if your child develops any abnormal symptoms, for example:
If the blisters on their skin become infected
If your child has a pain in their chest or has difficulty breathing
Chickenpox in adults
Chickenpox may be a childhood illness, but adults can get it too. Chickenpox tends to be more severe in adults than children, and adults have a higher risk of developing complications.
As with children, adults with chickenpox should stay off work until all the spots have crusted over. They should seek medical advice if they develop any abnormal symptoms, such as infected blisters.
Adults with chickenpox may benefit from taking antiviral medicine if treatment is started early in the course of the illness.
Who's at special risk?
Some children and adults are at special risk of serious problems if they catch chickenpox. They include:
Pregnant women
Newborn babies
People with a weakened immune system
These people should seek medical advice as soon as they are exposed to the chickenpox virus or they develop chickenpox symptoms.
They may need a blood test to check if they are immune (protected from) chickenpox..
Chickenpox in pregnancy
Chickenpox occurs in approximately three in every 1,000 pregnancies. It can cause serious complications for both the pregnant woman and her baby.
Chickenpox and shingles
One you have had chickenpox, you usually develop antibodies to the infection and become immune to catching it again. However, the virus that causes chickenpox, the varicella virus, remains dormant (inactive) in your body's nerve tissues and can return later in life as an illness called shingles.
It is possible to catch chickenpox from someone with shingles, but not the other way around.
Is there a vaccine against chickenpox?
There is a chickenpox vaccine but it is not part of the routine childhood vaccination schedule. The vaccine is only offered to children and adults who are particularly vulnerable to chickenpox complications.
Symptoms of chickenpox
The most commonly recognised chickenpox symptom is a red rash that can cover the entire body.
However, even before the rash appears, you or your child may have some mild flu-like symptoms including:
Feeling sick
A high temperature (fever) of 38ºC (100.4ºF) or over
Aching, painful muscles
Headache
Generally feeling unwell
Loss of appetite
These flu-like symptoms, especially the fever, tend to be worse in adults than in children.
Chickenpox spots
Soon after the flu-like symptoms, an itchy rash appears. Some children and adults may only have a few spots, but others are covered from head to toe.
The spots normally appear in clusters and tend to be:
Behind the ears
On the face
Over the scalp
Under the arms
On the chest and belly
On the arms and legs
But the spots can be anywhere on the body, even inside the ears and mouth, on the palms of the hands, soles of the feet and inside the nappy area.
Although the rash starts as small, itchy red spots, after about 12-14 hours the spots develop a blister on top and become intensely itchy.
After a day or two, the fluid in the blisters gets cloudy and they begin to dry out and crust over.
After one to two weeks, the crusting skin will fall off naturally.
New spots can keep appearing in waves for three to five days after the rash begins. Therefore different clusters of spots may be at different stages of blistering or drying out.
Unusual symptoms
Most healthy children (and adults) recover from chickenpox with no lasting ill-effects simply by resting, just as with a cold or flu.
But some children and adults are unlucky and have a more severe bout than usual.
Contact Dr. B C Shah straight away if you or your child develop any abnormal symptoms, for example:
If the skin surrounding the blisters becomes red and painful
If you or your child start to get pain in the chest or have difficulty breathing
In these cases, prescription medicine, and possibly hospital treatment, may be needed.
Causes of chickenpox
Chickenpox is caused by the varicella-zoster virus. You catch it by coming into contact with someone who is infected with the virus.
It's a very contagious infection. About 90% of people who have not previously had chickenpox will become infected when they come into contact with the virus.
How you catch the virus
The chickenpox virus is spread in the same ways as colds as flu. It's contained in the millions of tiny droplets that come out of the nose and mouth when an infected person sneezes or coughs. You can then become infected with the virus by breathing in these droplets from the air.
You can also become infected by handling a surface or object that these droplets have landed on, then transferring the virus to yourself by touching your face.
It takes seven to 21 days for the symptoms of chickenpox to show after you have come into contact with the virus. This is called the ‘incubation period’.
Someone with chickenpox is most infectious from one to two days before the rash appears until all the blisters have crusted over. This usually takes five to six days from the start of the rash.
Shingles
If you have not had chickenpox before, you can also catch chickenpox from someone with shingles (an infection caused by the same virus). However, it's not possible to catch shingles from someone who has chickenpox.
Diagnosing chickenpox
You or your child should not usually need any medical tests to diagnose chickenpox. You can be pretty sure that it is chickenpox if there are the key symptoms of a mild fever followed by an itchy rash, blisters and scabs.
Chickenpox spots are usually distinctive enough to distinguish from other rashes, although occasionally they can be easily confused with other conditions that affect the skin, such as insect bites or scabies (a contagious skin condition that causes intense itching).
If you're still uncertain about what is causing the symptoms, Dr. B C Shahcan carry out a simple blood test to identify the virus.
When to contact Dr. B C Shah
1. See Dr. B C Shah if you're not sure whether you or your child have chickenpox.
2. Contact Dr. B C Shah urgently if you have been in contact with someone who has chickenpox or you have chickenpox symptoms and:
You are pregnant
You have a weakened immune system (the body’s defence system)
Your baby is less than four weeks old
Chickenpox in these instances can cause serious complications if left untreated. It is essential to seek medical advice so that you can receive any necessary treatment.
3. Contact Dr. B C Shah if you have chickenpox and are breastfeeding. They can advise about whether you should continue breastfeeding your baby.
Having a blood test
Once you have contacted Dr. B C Shah, you may need a test to see if you're already immune from chickenpox.
If you have had chickenpox in the past, then it is extremely unlikely that you will develop chickenpox for a second time. If you've never had chickenpox, or you're unsure whether you've had it, then you may need an immunity test.
This is a blood test that checks whether you are producing the antibodies to the chickenpox virus.
If your blood test result shows that you have the antibodies, you'll be naturally protected from the virus.
Treating chickenpox
There is no cure for chickenpox, and the virus usually clears up by itself without any treatment.
However, there are ways of easing the itch and discomfort, and there are important steps you can take to stop chickenpox spreading.
Painkillers
If your child is in pain or has a fever (high temperature), you can give them a mild painkiller, such as paracetamol. Paracetamol is available over-the-counter in pharmacies. Always read the manufacturer's dosage instructions.
You should avoid giving your child ibuprofen if they have chickenpox. This is because there have been some cases where using ibuprofen and other non-steroidal anti-inflammatory drugs(NSAIDs) has caused serious skin infections.
Ibuprofen should also be avoided if you or your child hasasthma, or a history of stomach problems, such as stomach ulcers.
If you're not sure whether ibuprofen is suitable, check with Dr. B C Shah. If your child is younger than three months old, always speak to Dr. B C Shah before you give your child any kind of pain relief.
If you're pregnant and need to take painkillers, then paracetamol is the first choice. You can use it at any stage of pregnancy. Only take ibuprofen during the second trimester (weeks 14-27 of the pregnancy).
If you're pregnant and you have chickenpox, you should visit Dr. B C Shah as soon as possible. You may need to have antiviral medicine or immunoglobulin treatment to prevent your symptoms from getting worse (see below).
Keeping hydrated
It is important for children (and adults) with chickenpox to drink plenty of water to avoid dehydration. Sugar-free ice-lollies are a good way of getting fluids into children. They also help to soothe a sore mouth that has chickenpox spots in it.
Avoid any food that may make the mouth sore, such as salty foods. Soup is easy to swallow as long as it is not too hot.
Stop the scratching
Chickenpox can be incredibly itchy, but it's important for children (and adults) to not scratch the spots so as to avoid future scarring.
One way of stopping scratching is to keep fingernails clean and short. You can also put socks over your child's hands at night to stop them scratching the rash as they sleep.
If your child's skin is very itchy or sore, try using calamine lotion or cooling gels. These are available in pharmacies and are very safe to use. They have a soothing, cooling effect.
A stronger medicine called chlorphenamine can also help to relieve the itching. It's available from your pharmacist over the counter or it can be prescribed by Dr. B C Shah. Chlorphenamine is taken by mouth and is suitable for children over one year old.
Cool clothing
If your child has a fever, or if their skin is sore and aggravated, dress them appropriately so that they don't get too hot or too cold. Loose-fitting, smooth, cotton fabrics are best and will help stop the skin from becoming sore and irritated.
If your child has chickenpox, avoid sponging them down with cool water. This can make your child too cold, and it may make them shiver.
Stronger treatments
Antiviral medicine
Aciclovir is an antiviral medicine that is sometimes given to people with chickenpox.
Aciclovir may be prescribed to:
Pregnant women
Adults, if they visit Dr. B C Shah within 24 hours of the rash appearing
Newborn babies
People with a weakened immune system (the body’s defence system)
Ideally, aciclovir needs to be started within 24 hours of the rash appearing. It does not cure chickenpox, but it makes the symptoms less severe. You normally need to take the medicine as tablets five times a day for seven days.
If you are taking aciclovir, make sure you drink plenty of fluids. Side effects are rare but can include nausea and diarrhoea.
Immunoglobulin treatment
Immunoglobulin is a solution of antibodies that is taken from healthy donors. Varicella-zoster immunoglobulin (VZIG) contains antibodies to the chickenpox virus.
Immunoglobulin treatment is given by drip. It is not used to treat chickenpox but to protect people who are at high risk of developing a severe chickenpox infection. This includes:
Pregnant women
Newborn babies
People with weakened immune systems
In the case of pregnant women, immunoglobulin treatment also reduces the risk of the unborn baby becoming infected.
As the supply of VZIG is limited, it will only be considered if a high-risk person has:
Been significantly exposed to the virus – significant exposure could be face-to-face contact with someone who has chickenpox
Been in the same room for 15 minutes with someone who has chickenpox
Had a blood test to confirm that they've not had chickenpox before
In some cases, newborn babies may be given immunoglobulin treatment without having a blood test first.
Complications of chickenpox
Complications of chickenpox are rare in healthy children. The most common complication is where the blisters become infected with bacteria.
A sign that the blisters have become infected is when the surrounding skin becomes red and sore.
If you think that your child's blisters have become infected, contact Dr. B C Shah as the child may need a course of antibiotics.
The people who are most at risk of developing chickenpox complications are:
Adults
Pregnant women
Babies under four weeks old
People with a weakened immune system
Adults
Chickenpox can be more serious in adults than in children. Adults with the virus are more likely to be admitted into hospital. Approximately 5-14% of adults with chickenpox develop lung problems, such as pneumonia. If you smoke, your risk of developing lung problems is much greater.
Although it is more serious in adults, most people will still make a full recovery from the chickenpox virus.
Pregnant women
If you're pregnant, chickenpox can occasionally cause complications.
For example, your risk of developing pneumonia is slightly higher if you're pregnant, especially if you smoke. The further you are into your pregnancy, the more serious the risk of pneumonia tends to be.
If you get chickenpox while you're pregnant, there is also a small but significant risk to your unborn baby.
If you are infected with chickenpox during the first 20 weeks of your pregnancy, there is a risk that your unborn baby could develop a condition known as foetal varicella syndrome.
This syndrome is rare. The risk of it occurring in the first 12 weeks of pregnancy is less than 1%. Between 13 and 20 weeks, the risk is 2%.
Foetal varicella syndrome can cause serious complications, including:
Scarring
Eye defects, such as cataracts
Shortened limbs
Brain damage
There have been reports of damage to the unborn baby from foetal varicella syndrome when a pregnant woman catches chickenpox after week 20. But the risk at this late stage in pregnancy is thought to be much less than 1%.
However, there are other risks from catching chickenpox after week 20 of pregnancy.
It is possible that your baby may be born prematurely (before week 37 of the pregnancy).
And if you are infected with chickenpox seven days before or seven days after giving birth, your newborn baby may develop a more serious type of chickenpox. In a few severe cases, this type of chickenpox can be fatal.
See Dr. B C Shah urgently if you're pregnant or have given birth in the last seven days and you think you may have chickenpox, or if you've been exposed to someone who has chickenpox.
People with a weakened immune system
Your immune system is your body's way of defending itself against disease, bacteria and viruses.
If your immune system is weak or does not work properly, you are more susceptible to developing infections such as chickenpox. This is because your body produces fewer antibodies to fight off the infection.
You may have a weakened immune system if you take immunosuppressive medication. This is medicine that works by damping down your immune system.
Immunosuppressive medication such as steroid tablets may be used if, for example, you have an inflammatory condition such as rheumatoid arthritis, lupus or certain blood conditions.
If you have a weakened immune system, you're also more at risk of developing complications from chickenpox. These complications include:
pneumonia
septicaemia (blood poisoning)
meningitis
See Dr. B C Shah urgently if you have a weakened immune system and you've been exposed to the chickenpox virus.
Preventing the spread of chickenpox
If your child has chickenpox, inform their school or nursery and keep them at home while they are infectious, which is until the last blister has burst and crusted over. This usually takes five or six days after the rash begins.
If you have chickenpox, stay off work and at home until you're no longer infectious.
If either you or your child has chickenpox, it is also a good idea for you, or them, to avoid contact with:
Pregnant women
Newborn babies
Anyone who has a weak immune system, such as people who are having chemotherapy (a treatment for cancer) or taking steroid tablets
If you or your child have recently been exposed to the chickenpox virus, you may not be able to visit friends or relatives in hospital. Telephone the ward to check first.
Travelling on a plane
If you or your child have chickenpox, you may not be allowed to fly until six days after the last spot has appeared.
You and your child should be safe to fly once you're past the infectious stage and all of the blisters have crusted over. But it's best to check the policy of your airline first. Inform the airline as soon as chickenpox is diagnosed.
It is also important to let your travel insurer know if you or your child have chickenpox. You need to make sure that you'll be covered if you have to delay or cancel your holiday, or if you need to extend your stay until your child is well enough to fly home.
Stop the virus spreading
Chickenpox can sometimes be spread through contact with objects that have been infected with the virus, such as children's toys, bedding or clothing.
If someone in your household has chickenpox, you can help stop the virus spreading by wiping any objects or surfaces with a sterilising solution and making sure that any infected clothing or bedding is washed regularly.
Vaccination
There is a chickenpox vaccine that is used to protect people who are most at risk of a serious chickenpox infection or of passing the infection on to someone who is at risk.
People who may be considered for chickenpox vaccination include:
healthcare workers who are not already immune – for example, a nurse who has never had chickenpox and who may pass it to someone they are treating if they become infected
people living with someone who has a weakened immune system – for example, the child of a parent receiving chemotherapy
The vaccine is not suitable for pregnant women. Avoid getting pregnant for three months after having the vaccine. The vaccine is also not suitable for people with weakened immune systems.
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Chemotherapy
Posted by on Thursday, 14th February 2013
Introduction
Chemotherapy is a type of treatment for cancer where medicine is used to kill cancer cells. It can be given either as a tablet, or as an injection or infusion directly into a vein.
Cancer
Cancer refers to a number of conditions where the body’s cells grow and reproduce uncontrollably. The rapid growth of cancerous cells is known as a malignant tumour. These cells can spread out of the tumour and into other parts of the body to form new tumours.
How chemotherapy is used
There are four main ways that chemotherapy can be used:
To try to cure cancer completely – this is known as curative chemotherapy
To help make other treatments more effective – for example, chemotherapy can be combined with radiotherapy (where radiation is used to kill cancerous cells), or it can be used before surgery
To relieve symptoms – a cure may not be possible for advanced cancer, but chemotherapy may be used to relieve the symptoms and slow the spread of the condition. This is known as palliative chemotherapy
To reduce the risk of the cancer returning after surgery or radiotherapy.
Side effects
Chemotherapy is a very effective cancer treatment and has helped save millions of lives. However, it does cause side effects.
The medications used in chemotherapy are not very good at telling the difference between fast-growing cancer cells and other types of fast-growing cells. These include blood cells, skin cells, the cells on the scalp and the cells inside the stomach.
This means that most chemotherapy medications have a poisonous effect on the body's cells. Common side effects include:
Feeling tired and weak all the time
Feeling sick
Being sick
Hair loss, although this can sometimes be prevented using a technique called a cold cap
Some people only have minimal side effects. However, for most people, a course of chemotherapy can be very unpleasant and upsetting.
In many cases, having chemotherapy will make you feel worse than the cancer you are being treated for.
Living with and adapting to the side effects of chemotherapy can be challenging. But it's important to realise that most, if not all, side effects will disappear once the treatment is complete.
Some people who are about to start chemotherapy are concerned that the harmful effects of chemotherapy can be passed to other people, particularly people who are vulnerable, such as children or pregnant women. However, there is no risk associated with coming into close contact with someone who is having chemotherapy.
How chemotherapy works
There are over 50 different types of chemotherapy medication which can be used to treat hundreds of different types of cancer.
However, they all work in one of the following two ways:
They stop cells from reproducing, which can be very useful in preventing the spread of cancer.
They essentially "trick" cells into self-destructing.
All human cells have a limited lifespan. They eventually die and are replaced by new cells. Chemotherapy medications make the cancer cells "think" that their lifespan has finished.
Depending on the type of cancer you have, you may be given:
Monotherapy – where only one chemotherapy medication is used
Combination therapy – where a combination of different medications is used
When is chemotherapy given?
Depending on the type and severity of your cancer, chemotherapy will be given at different stages of your treatment. You may receive chemotherapy:
Before having surgery to remove a tumour or radiotherapy to shrink it, so that other treatments can then begin (this is known as neo-adjuvant therapy)
In combination with radiotherapy, which is known as chemoradiation
After having surgery or radiotherapy, which is known as adjuvant therapy
Chemotherapy protocols
You will need to have regular chemotherapy over a set period of time for it to be effective.
Dr. B C Shah will draw up a treatment plan that gives details of how many sessions you will need, how long the course should last, and how much time should pass between each session. It is common for there to be a break after each session to allow your body to recover from the effects of the medication.
This treatment plan is known as a chemotherapy protocol. Chemotherapy protocols vary depending on the type of cancer you have and how advanced it is.
An example of a chemotherapy protocol is:
One day of treatment
Seven days of rest
One day of treatment
21 days of rest
This cycle will then be repeated six times over 18 weeks.
Who can use chemotherapy?
Delaying treatment or, in some cases, not having chemotherapy may be recommended if you:
Are in the first three months of pregnancy – using chemotherapy during this time has a very high risk of causing birth defects
Have low levels of blood cells – chemotherapy can lower your blood cell count more, so it could make you feel very ill and, in some cases, vulnerable to infection. Medication and sometimes a blood transfusion may be required to raise your blood cell count
Have severe kidney or liver disease – most chemotherapy medications are processed by your liver and kidneys, so this could have a very harmful effect if your liver and kidneys are already damaged
Have had recent surgery or a wound – chemotherapy can disrupt the body’s ability to heal wounds, so it's usually recommended that the wound heals before treatment begins
Have an ongoing infection – chemotherapy can make you more vulnerable to the effects of infection, increasing your risks of developing serious complications
As chemotherapy is a potentially life-saving treatment, it is usually recommended for most people with cancer, even if they are in poor health and the treatment is likely to make them feel worse.
How chemotherapy is performed
Dr. B C Shah
Many hospitals use multi-disciplinary teams (MDTs) to provide chemotherapy treatment.
MDTs are teams of specialists that work together. Members of your MDT may include a:
Medical oncologist – a specialist in the non-surgical treatment of cancer using techniques such as radiotherapy and chemotherapy
Pathologist – a specialist in diseased tissue
Haematologist – a blood specialist
Psychologist – who can provide support and advice about the psychological and emotional impact of chemotherapy
Clinical nurse specialist (CNS) – who will offer you support throughout your care, from diagnosis.
As well as having a specialist MDT, you may also be assigned a key worker (this is often the CNS). You will be given their details so that you can get in touch with your team at any point during your treatment. They will also be involved in coordinating your care.
Deciding what treatment is best for you can often be confusing. Dr. B C Shah will recommend what they think is the best treatment option, but the final decision will be yours.
Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask Dr. B C Shah.
For example, you may want to find out:
What the purpose of your chemotherapy is – for example, whether it's being used to cure your cancer, relieve your symptoms or make other treatments more effective
What side effects you're likely to experience and whether anything can be done to prevent or relieve them
How effective the chemotherapy is likely to be at curing your cancer or at least slowing it down
Whether any alternative treatments can be used instead of chemotherapy
Blood tests
Before chemotherapy begins, you will need to have a number of blood tests to assess your health and to make sure you can cope with any side effects.
Blood tests are useful for assessing the health of your liver and kidneys. This is important because chemotherapy medications will pass through your liver and kidneys, where they will be broken down. The medication can harm the liver. Therefore, if you have liver damage, it may not be suitable for you until your liver and kidneys have recovered.
Another important role of blood testing is to assess your blood count. This is a measurement of how many blood cells you have.
There are three types of blood cell:
Red blood cells – which carry oxygen around your body
White blood cells – which help fight infection
Platelets – which help the blood to clot (thicken)
Chemotherapy reduces the number of all three types of blood cells.
If you have a low blood count, treatment may be delayed until your blood count has returned to normal. Alternatively, medication can be used to raise your blood count. In some cases, a blood transfusion may be required.
You will have regular blood tests during your chemotherapy so that your liver, kidneys and blood count can be carefully monitored.
You may also need other tests to check how well the cancer is responding to treatment. The tests you require will depend on the type of cancer you have.
Types of chemotherapy
Chemotherapy is usually given in one of two ways:
as a tablet – which is known as oral chemotherapy
injected directly into a vein – which is known as intravenous chemotherapy
The type of chemotherapy you have will depend on the type of cancer and how advanced it is.
Oral chemotherapy
If you are in good health, you may be able to take your tablets at home. However, you will still need to go to hospital for regular check-ups.
It is very important that you only take your tablets on the days specified in your chemotherapy protocol. If you forget to take a tablet, contact Dr. B C Shah for advice. Also contact Dr. B C Shah if you are sick shortly after taking a tablet.
Intravenous chemotherapy
A number of different devices can be used to give chemotherapy medication into a vein.
The type of device used will often depend on the type of cancer you have and your general health. You may be able to choose which device you have, although this is not always possible.
Intravenous chemotherapy is not like having a vaccine, where you are given one quick injection. Instead, chemotherapy medications are slowly released into a vein over a period of time. The time it takes to give one dose can range from several hours to several days.
Occasionally, some people need a continuous low dose of chemotherapy medication over several weeks or months. If this is the case, you may be given a small portable pump that you can take home with you.
The devices used for intravenous chemotherapy are described below.
Cannula
A cannula is a small tube that is placed into a vein on the back of your hand or lower arm. Chemotherapy medication is slowly injected through the tube into your vein. Once the dose of medication has been delivered, the tube can be removed.
Skin-tunnelled catheter
A skin-tunnelled catheter is a fine tube that is inserted into your chest and connected to one of the veins near your heart. The catheter can be left in place for several weeks or months, so that you do not have to have repeated injections. The catheter can also be used to carry out blood tests.
Peripherally inserted central catheter
A peripherally inserted central catheter (PICC) is similar to a skin-tunnelled catheter except the tube is connected to your arm rather than your chest.
Implanted port
An implanted port is a chamber that can be inserted under your skin and connected to a nearby vein. A special needle is placed into the chamber and connected to a drip or used for blood tests.
Other medication
If you are having chemotherapy, check with Dr. B C Shah before you take any other medication, including over-the-counter (OTC) medicines and herbal remedies. Other medication could react unpredictably with your chemotherapy medication.
Pregnancy
You should avoid becoming pregnant while having chemotherapy. This is because many medications used in chemotherapy can cause birth defects.
You will need to use a barrier method of contraception, such as condoms, while having chemotherapy and for a year after your treatment has finished.
Contact Dr. B C Shah immediately if you think you may have become pregnant while having chemotherapy.
Side effects of chemotherapy
It is difficult to predict exactly what side effects you will experience while having chemotherapy. Different people react to treatment in different ways.
A small number of people have very few or even no side effects.
The common side effects of chemotherapy are listed below, although it is unlikely that you will experience them all.
Dr. B C Shah is there to help you cope with the physical and psychological side effects.
When to get urgent medical advice
While the side effects of chemotherapy can be distressing, most do not pose a serious threat to your health.
However, occasionally some side effects can be very serious. For example, if you have a rapid fall in white blood cells, you may be vulnerable to a serious infection.
People having chemotherapy for cancer that developed inside their blood cells or bone marrow are most at risk of serious infections. This is because this type of cancer will already have caused a reduction in white blood cell numbers.
Symptoms of serious infection include:
a high temperature of 38C (100.4F) or above
shivering
breathing difficulties
chest pain
flu-like symptoms, such as muscle aches and pain
bleeding gums or nose
bleeding from other parts of the body that does not stop after applying pressure for 10 minutes
mouth ulcers that stop you eating or drinking
vomiting that continues despite taking anti-sickness medication
four or more bowel movements a day, or diarrhoea
If you have any of these symptoms, contact Dr. B C Shah immediately.
Fatigue
Fatigue or tiredness is a common side effect of chemotherapy. Almost everyone who has chemotherapy will experience fatigue. You may feel generally tired or you may tire very easily after doing normal, everyday tasks.
While having chemotherapy, it is important to get plenty of rest. Do not carry out tasks or activities that you do not feel up to.
Light exercise, such as walking or yoga, can help boost your energy levels, but be careful not to push your body too hard.
If you are working, you may need to ask your employer to let you work part time until your chemotherapy has finished.
Contact your Dr. B C Shah if you are suddenly significantly more tired than usual and you also feel out of breath. Extreme fatigue and shortness of breath can be a sign of anaemia. This is a condition caused by having a low number of red blood cells.
Nausea and vomiting
Nausea (feeling sick) and vomiting (being sick) are common side effects of chemotherapy. They affect around half of all people being treated.
If you have nausea and vomiting, you will be given medication to help control your symptoms. This type of medication is known as an anti-emetic.
Anti-emetics can be given in a number of different ways, including:
as a tablet or capsule, which can either be swallowed or placed under your tongue to dissolve
as an injection or drip
as a suppository, which is a capsule that you put into your rectum (back passage) so that it can dissolve
through a patch that you place on your skin
Continue to take your anti-emetics even if you do not feel sick because they will help prevent your symptoms from returning.
Side effects of anti-emetics include:
Constipation
Flushing of the skin
Problems sleeping (insomnia)
Indigestion
Headaches
There are several different types of anti-emetics. If the one you are taking doesn't work or if it causes too many troublesome side effects, contact Dr. B C Shah. There may be an alternative anti-emetic that works better for you.
Hair loss
Hair loss is a common side effect of some chemotherapy. It usually begins one to three weeks after the first chemotherapy dose. The hair that grows on the side of your head, near your ears, becomes more brittle and thin. Most people have significant hair loss after one to two months.
The scalp is most commonly affected, although hair loss can occur on other parts of the body. These include the arms, legs and face.
Hair loss can be very traumatic, particularly for women.
If you find hair loss particularly difficult to cope with, talk to Dr. B C Shah. They understand how distressing it can be and will be able to give you support and counselling.
You may decide that you want to wear a wig.
Hair loss due to chemotherapy is almost always temporary, and your hair should begin to grow back soon after your treatment has finished.
Around three-quarters of people no longer need to wear a wig or use a head covering six months after their chemotherapy treatment has finished.
Many people find that their newly grown hair is different than before. For example, it may be a different colour or it may be curlier or straighter than it used to be.
Cold cap
It may be possible to prevent hair loss due to chemotherapy by using a cold cap.
A cold cap looks similar to a bicycle helmet. It is designed to cool your scalp while you receive a dose of chemotherapy. In cooling the scalp, the cold cap reduces the amount of blood flow to the scalp. This reduces the amount of chemotherapy medication that reaches it.
Whether or not you can use a cold cap during treatment will depend on the type of cancer you have.
For example, a cold cap cannot be used if you have:
various types of leukaemia, such as acute lymphoblastic leukaemia, which is cancer of the blood cells and mainly affects children
multiple myeloma, which is a cancer that develops inside the bone marrow
non-Hodgkin's lymphoma, which is a cancer that develops inside the lymphatic system (a series of glands and vessels that help protect the body against infection)
With these types of cancers, there is a good chance that cancerous cells could have spread to your skull. Therefore, it would be too dangerous to cool your skull.
Cold caps work better with certain types of chemotherapy medications, and they may not always prevent hair loss.
Increased risk of infection
Chemotherapy lowers the amount of white blood cells in your body. The main function of white blood cells is to fight infection. If the number of white blood cells is reduced, your immune system will be weakened and you will be more vulnerable to infection.
You may be given a course of antibiotics to reduce your risk of developing an infection. You will also need to take extra precautions to protect yourself against infection. For example, you should:
Have good personal hygiene – take daily baths or showers and make sure that clothes, towels and bed linen are washed regularly.
Avoid contact with people who have an infection, such as chickenpox or flu.
Wash your hands regularly with soap and hot water, particularly after going to the toilet and before preparing food and eating meals.
Take extra care not to cut or graze your skin – if you do, clean the area thoroughly with warm water, dry it and cover it with a sterile dressing.
The regular blood count tests that you will have during chemotherapy mean that your Dr. B C Shah should be able to tell you when you are most vulnerable to infection.
You may be advised to take extra precautions, such as avoiding crowded places and using public transport at busy times.
Anaemia
Chemotherapy will lower the amount of red blood cells. These cells carry oxygen around the body. If your red blood cell count drops too low, your body will be deprived of oxygen and you will develop anaemia.
Symptoms of anaemia include:
tiredness – you will feel much more tired than the general level of fatigue associated with chemotherapy
lack of energy
shortness of breath (dyspnoea)
irregular heartbeat
If you have any of these symptoms, contact your Dr. B C Shah as soon as possible.
You may need to have a blood transfusion to help increase the number of red blood cells. Alternatively, a medication called erythropoietin (EPO) can stimulate the production of red blood cells.
It is important to eat a diet that is high in iron. This is because iron helps red blood cells carry more oxygen. Foods that are high in iron include:
dark-green leafy vegetables, such as spinach
iron-fortified bread
beans
nuts
meat
apricots
prunes
raisins
Bruising and bleeding
Chemotherapy can lower the amount of platelets in your body. Platelets are blood cells that help blood to clot (thicken). This prevents excessive bleeding or bruising.
Most chemotherapy medications do not seriously affect the number of platelets. However, a small number of people experience a significant drop in their platelet count.
Symptoms of a low platelet count include:
easily bruised skin
nose bleeds
bleeding gums
Report any of these symptoms to Dr. B C Shah as you may need a blood transfusion to raise your platelet count.
You may need to take extra precautions to avoid damaging your skin and gums including:
using an electric razor to shave
using a soft toothbrush
taking extra care when using knives or other sharp instruments
wearing a thick pair of gloves when gardening
Oral mucositis
In some cases, chemotherapy can cause pain and inflammation of the surface of the inside of your mouth. This is known as oral mucositis.
The severity of your symptoms usually depends on the strength of your medication. People having high-dose chemotherapy usually have more severe symptoms.
The symptoms of oral mucositis usually begin 7 to 10 days after you start chemotherapy.
If you develop oral mucositis, the inside of your mouth will feel sore, as if you have burnt it by eating very hot food. You will probably develop ulcers on the lining of your mouth and, in some cases, on your tongue or around your lips.
The ulcers can be very painful and make it difficult to eat, drink and talk. They may also bleed and become infected.
The symptoms of oral mucositis should clear up a few weeks after your chemotherapy finishes, although a number of medications are available to relieve the symptoms.
Loss of appetite
Some people who have chemotherapy lose their appetite and do not feel like eating or drinking. If you lose your appetite, it is still important to make an effort to eat healthily and drink plenty of liquids.
You may find eating smaller, more frequent meals better than eating three large meals a day. Try sipping drinks slowly through a straw rather than drinking them straight from a glass.
If you have serious problems eating and drinking due to symptoms such as mouth ulcers, you may need to be admitted to hospital and attached to a feeding tube.
You will probably be given a nasogastric tube. This is a tube that passes down your nose and into your stomach. The tube can be removed once you are able to eat and drink normally.
Skin
Some chemotherapy medications can cause your skin to become dry and sore, particularly on your hands or feet. Your nails may become brittle and flakier than usual and white lines may develop across them.
During chemotherapy and for some time after treatment has finished, your skin may become more sensitive to sunlight. Therefore, it is important to take extra precautions to protect your skin from the sun:
Avoid going out in the sun when it is at its hottest – this is usually between 10am and 2pm, although the sun can also damage skin before and after these times.
Use a sunscreen that blocks both ultraviolet A (UVA) and B (UVB) radiation and has a sun protection factor (SPF) of at least 15.
Dress to protect your skin from the sun – for example, wear a wide-brimmed hat to protect your face and scalp and sunglasses to protect your eyes.
Memory and concentration
Some people who have chemotherapy have problems with their short-term memory, concentration and attention span. You may find that routine tasks take much longer than usual.
Exactly why these symptoms appear is unclear. They may be due to a combination of factors, such as fatigue and anxiety. However, the symptoms usually improve after your treatment has finished.
Sleep problems
Sleep problems are a common side effect of chemotherapy. They are thought to affect around half of all people being treated with chemotherapy.
Sleep problems can include difficulty falling asleep (insomnia), and waking up in the middle of the night and being unable to get back to sleep.
The following advice may help to improve your sleep:
Go to bed only when you are sleepy.
If you cannot sleep, leave the bedroom and only return when you feel sleepy.
Only use your bedroom for sleeping and having sex.
Avoid napping during the day. If this is not possible, try to limit your naps to about half an hour.
Avoid stimulants, such as caffeine, for at least six hours before you plan to go to bed.
If this advice does not work, contact your Dr.B C Shah. You may need additional treatment. A type of talking therapy called cognitive behavioural therapy (CBT) has proved to be effective in treating insomnia associated with chemotherapy.
Sexuality and fertility
Many people find that their interest in sex decreases during chemotherapy. However, this is usually temporary and your interest in sex should gradually return after your treatment has finished.
Some chemotherapy medications can stop women being able to conceive and can prevent men from producing healthy sperm. Loss of fertility is usually temporary, although in some cases a person can become permanently infertile.
If there is a risk that you could become permanently infertile, your Dr. B C Shah will discuss the possibility with you before treatment begins.
A number of options are available. Women can have their eggs frozen to be used later in IVF (in-vitro fertilisation). Men can have a sample of their sperm frozen to be used at a later date for artificial insemination.
Diarrhoea and constipation
You may have diarrhoea or constipation a few days after you begin chemotherapy. Dr. B C Shah can recommend suitable medication to help control the symptoms.
Depression
Living with the effects of chemotherapy can be frustrating, stressful and traumatic. It is natural to feel ongoing anxiety and concern about whether your treatment will be successful.
Stress and anxiety can increase your risk of getting depression. You may be depressed if you have been feeling particularly down for two weeks or more and you no longer take pleasure in the things that you used to enjoy.
Contact Dr. B C Shah if you have psychological and emotional difficulties. They will be able to recommend treatments to help improve the symptoms of stress, anxiety and depression.
Joining a support group for people who are having chemotherapy may also help. Talking to other people in a similar situation can often reduce feelings of isolation and stress.
Refusing or withdrawing treatment
In some circumstances, you may think that the benefits of chemotherapy are not worth the poor quality of life due to the side effects of treatment.
For example, if chemotherapy offered no hope of a cure and could only extend your life by a few months, you may feel that the extra few months are not worth undergoing treatment.
However, if you were looking forward to an event such as the birth of a grandchild or the wedding of a son or daughter, you may want to extend your life whatever the cost to your wellbeing.
There is no right answer or recommendation about when chemotherapy should be refused or withdrawn. Dr. B C Shah can give you advice about the likely benefit of continuing with treatment, but the final decision will be yours.
This is obviously a very sensitive topic that you should discuss fully with Dr. B C Shah, family, friends and loved ones. You always have the right to refuse a particular treatment or to ask for the treatment to be stopped if you do not feel it is benefiting you.
Stopping chemotherapy does not mean that any symptoms you have will go untreated. Dr. B C Shah will still provide support and pain relief. This type of care is known as palliative care.
If it's thought that you do not have long to live, it may be recommended that you are admitted to a hospice. Hospices provide care for people from the point at which their illness is diagnosed as terminal to the end of their life, however long that may be.
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Radiotherapy
Posted by on Wednesday, 13th February 2013
Introduction
Radiotherapy, also known as radiation treatment, is the controlled use of high energy X-rays to treat many different types of cancer. About 4 out of 10 people with cancer have radiotherapy.
In some cases, radiotherapy can also be used to treat benign (non-cancerous) tumours.
The length of each course of radiotherapy will depend on the size and type of cancer and where it is in the body.
Uses of radiotherapy
Radiotherapy may be used:
To cure an illness - for example, by destroying a tumour (abnormal tissue)
To control symptoms - for example, to relieve pain
Before surgery - to shrink a tumour to make it easier to remove
After surgery - to destroy small amounts of tumour that may be left
Radiotherapy is sometimes used to treat thyroid disease, as well as some blood disorders and other benign conditions. This topic focuses mainly on the use of radiotherapy as a treatment for cancer.
Types of radiotherapy
Radiotherapy can be given in two ways. It can be given from:
Outside the body (external radiotherapy) – using X-rays, small particles called electrons or, in rare cases, other particles such as protons; external radiotherapy is usually given once a day as a course of treatment over a number of days or weeks
Within the body (internal radiotherapy, also known as brachytherapy) – either by drinking a liquid that is absorbed by the cancerous cells or by putting radioactive material into, or close to, the tumour, usually for a small number of treatments (brachytherapy) or by injecting or drinking a liquid that is absorbed by the cancerous cells – for example, radioiodine for thyroid cancer
Courses of radiation
Radiotherapy is usually given as a course of treatment that lasts for a number of days or weeks.
Most people who have radiotherapy to treat a serious condition, such as cancer, have five treatments a week (one treatment a day, Monday to Friday) with a break at the weekend. Taking a break allows the normal, non-cancerous cells to recover.
In some cases, treatment may be given more than once a day or over the weekend.
Fractions
Radiation treatment is divided into a number of small doses called fractions, which are usually given over a number of weeks. Fractions are used to reduce the side effects of a full dose of radiation. The number of fractions required will depend on the type of cancer being treated.
Combination therapy
Radiotherapy is often used in combination with other treatments, such as chemotherapy (powerful medication that is used to treat cancer). This is known as chemoradiotherapy.
Chemoradiotherapy can be used to try to cure a cancerous tumour, to shrink a tumour before it is removed using surgery, or after surgery to reduce the risk of relapse.
How radiotherapy works
External radiotherapy
During external radiotherapy, a machine called a linear accelerator focuses high-energy X-rays or other high-energy beams at the cancer. Radiation kills the cancerous cells but also causes temporary damage to healthy, non-cancerous cells, resulting in side effects, most of which are temporary because normal tissues are able to repair themselves.
If radiotherapy is recommended, you will be referred to a specialist radiotherapy (oncology) department where you will receive your treatment. The type of machine that is used will depend on the reason for your treatment and the condition that you are being treated for.
You will not feel any pain during the treatment, but later you may experience some discomfort from the side effects of the treatment. Most side effects do not usually last long.
Internal radiotherapy
Internal radiotherapy uses radioactive materials (metal implants or liquids) to treat cancer. The two types of radioactive material are described below.
Radioactive implants (brachytherapy)
Radioactive implants are usually metal wires, seeds or tubes. They are inserted into or close to the cancerous tumour in a procedure that is known as brachytherapy.
The length of time that the radioactive implant is left inside your body will depend on the type and nature of your cancer. It could be a few minutes or a few days. In some cases, radioactive implants may be left inside the body permanently.
Radioactive metals, such as caesium and iridium, are sometimes used to treat prostate cancer, cancer of the womb, cervical cancer and vaginal cancer.
Radioactive liquids
Radioactive liquids to treat cancer are given either as a drink or an injection. The radioactive part of the liquid is known as an ‘isotope’.
Radioactive liquids include:
Phosphorous - which is used to treat blood disorders
Strontium - which is used to treat secondary bone cancers
Iodine - which is used to treat benign (non-cancerous) thyroid conditions and thyroid cancer
Safety
Health risks associated with radiotherapy are usually minimal because the radiation dose received by the rest of the body is usually very low.
However, as internal radiotherapy involves placing radioactive substances inside your body, there are some safety issues that you will need to discuss with your treatment team.
How radiotherapy is performed
Radiotherapy is only used if the benefits outweigh the risks. Your treatment team will discuss the risks of any radiotherapy procedures that are recommended for you.
Before having radiotherapy, you will be asked to sign a consent form to confirm that you agree to the treatment and understand any risks involved.
Treatment plan
Your treatment will be carefully planned to ensure that the radiotherapy destroys as many cancerous cells as possible, while affecting as few healthy cells as possible.
The amount of radiotherapy you have will depend on:
Where the cancer is in your body
The type and size of the cancer
Your general state of health
In planning your treatment, a radiotherapist (radiotherapy specialist or clinical oncologist) will use all the information gathered during your diagnosis. They may also carry out some additional tests to find out more about the size and site of the cancer and to get a clearer understanding of the area of your body to be treated.
Once your oncologist has all the relevant information, they will calculate the total dose of radiotherapy that you need and the number of individual doses (fractions) required.
If you are having external radiotherapy, a simulator machine will be used as part of your treatment planning. The simulator moves in the same way as the machine that will be used for your treatment. It uses X-rays to take pictures so that the radiographer knows how to position your body when you have your treatment. A radiographer is a healthcare professional who is trained in taking X-rays.
Many patients will also have a computerised tomography scan (CT) scan to help the oncologist to target their tumour accurately.
After the exact area of your body to be treated has been established, the radiographer will put small but permanent ink marks on your skin to ensure that the same area is treated each time.
If you are having external radiotherapy to your head or neck, or if it is difficult for you to keep the part of your body having treatment still, a plastic mould will be made for you to wear during treatment. In this case, the ink markings will be made on the mould rather than on your skin.
External radiotherapy
If you are having external radiotherapy, you will usually receive your treatment as an outpatient, which means that you will not have to stay in hospital overnight. You may need to stay in hospital if you are having chemotherapy in combination with radiotherapy (chemoradiotherapy), or if you are unwell.
During the procedure, you will be positioned on a treatment table and a radiotherapy machine (linear accelerator) will direct high-energy rays at the area being treated.
You will need to keep as still as possible throughout the treatment. The procedure only takes a few minutes and is completely painless. You will be able to breathe normally during your treatment.
While you are having treatment, you will be left alone in the treatment room. A radiographer will operate the machine from outside the room and will watch you through a window or on closed circuit television. If necessary, you will be able to talk to the radiographer during the procedure using an intercom.
Internal radiotherapy
Internal radiotherapy can be given as an implant, drink or injection. Depending on the type of treatment being used, you may need to stay in hospital for a short period of time.
Radioactive implants
If you have a radioactive implant or radioactive liquid, your hospital will have a number of safety guidelines in place to ensure that hospital staff and visitors are not exposed to radiation. Hospital staff will explain the safety procedures to you before your treatment.
Radioactive implants are placed into, or next to, the cancerous tumour so that it gets the highest possible dose of radiation. Although the area close to the implant will also get a high dose of radiation, other parts of your body will receive a very small amount of radiation which is not a risk to your health.
If you are having a radioactive implant, you may need to stay in hospital for a few days until the radioactive source is removed. After the implant has been removed, you are not a risk to others.
Permanent implants do not present a risk because they produce a very small amount of radiation that gradually decreases over time.
Liquid radiotherapy
After having liquid radiotherapy, you may be radioactive for a few days. This will not cause any long-term harm to your body, but you will probably have to stay in hospital until the radioactivity decreases. This is a precautionary measure to reduce other people’s exposure to radiation.
You will be able to leave hospital after the radiation has fallen to a safe level. Dr. B C Shah may give you some safety advice to follow for a few days when you get home.
If there is anything about your treatment that you do not understand, or if there is anything you are unsure about, you should ask a member of your treatment team to explain it to you in more detail.
Common side effects of radiotherapy
Following radiotherapy, it is highly likely that you will have some side effects. Side effects occur because radiotherapy temporarily damages some of the healthy cells as well as destroying the cancerous ones.
Side effects will depend on:
The part of your body being treated
The dose of radiotherapy
How quickly the healthy cells are able to repair the damage
Radiotherapy affects different people in different ways and it is difficult to know exactly how you will react to the treatment.
Some people experience mild side effects following radiotherapy, while others experience more severe effects. Some side effects begin during treatment whereas others can appear weeks or months afterwards.
Before starting treatment, you should discuss the possible side effects with your treatment team.
Common side effects of radiotherapy include:
Sore skin
Tiredness
Feeling sick
Dry mouth
Loss of appetite
Diarrhoea
Dair loss
discomfort on swallowing
a lack of interest in sex
stiff joints and muscles
These are explained in more detail below.
Sore skin
Your skin may become red and sore in the area being treated towards the end of a course of radiotherapy, or for a couple of weeks afterwards.
Depending on the area being treated, and the individual’s reaction to radiation, some people’s skin may peel after having a course of radiotherapy. This usually heals within a couple of weeks.
Dr. B C Shah will be able to give you advice about the best way of caring for your skin during treatment. If your skin becomes sore, you should try not to irritate it further.
You should avoid shaving and using perfumed soap in the affected area. Protect your skin from cold winds and wear a high-factor sunscreen (SPF 15 or above) to protect your skin from the sun.
Tiredness
You will probably feel tired both during and after having radiotherapy. Doing some gentle exercise may help to relieve the symptoms of tiredness.
Tiredness is particularly common towards the end of a course of radiotherapy and it can last for some time afterwards. It usually occurs as a result of the body repairing the damage to healthy cells.
A shortage of red blood cells (anaemia) can also contribute to tiredness during radiotherapy.
For some cancers, regular blood tests may be required during radiotherapy to ensure that you are not becoming anaemic. If you have anaemia, you may need to have a blood transfusion (where you receive blood that is removed from another person who is known as a donor).
Feeling sick (nausea)
Most people are not sick during radiotherapy. However, some people feel sick (are nauseated) at the start of, during, or for a short time after, their treatment. If you experience nausea, your doctor may be able to prescribe medication to help control it.
Radiotherapy to your abdomen (tummy area) or pelvic area may make you sick. This can last a few days after your treatment stops. Again, medication or complementary therapies can help.
Loss of appetite
The combination of feeling sick and tired during radiotherapy can make you lose your appetite. You may have difficulty swallowing if you are having radiotherapy to your head, neck or chest.
If you have difficulty eating, you may find it easier to eat several small meals throughout the day, rather than a few larger meals. You can also speak to your radiotherapist who may refer you to a dietitian (nutritional specialist).
Diarrhoea
Diarrhoea is a common side effect of radiotherapy to the abdomen or pelvic area. It usually starts a few days after treatment begins and gradually gets worse as treatment continues. You should tell your doctor if you notice any blood in your stools (faeces).
After your treatment has finished, diarrhoea should disappear within a few weeks. You should tell your doctor if your symptoms have not improved after a few weeks.
Hair loss
Hair loss is a common side effect of radiotherapy to your head or neck. Radiotherapy will only cause hair loss in the area being treated.
Many people find losing their hair stressful and difficult to cope with. Losing your hair can affect your self-confidence and it may make you feel depressed.
Talk to your family and friends about how you are feeling so that they can support you. After a few weeks of finishing treatment, your hair should start to grow back.
You may consider getting a synthetic (man-made) wig or a wig that is made from human hair.
Inpatients (those who need to stay in hospital overnight for treatment)
Those under 16 years of age
Those between 16 and 19 years of age who are in full-time education
Discomfort on swallowing
Radiotherapy to the chest can cause the tube through which food passes (the oesophagus) to become temporarily inflamed, which may cause temporary discomfort when swallowing. If required, Dr. B C Shah will be able to prescribe medication to help soothe your throat.
Effects on sex and fertility in women
Having radiotherapy may cause you to lose interest in sex, particularly if you have other side effects, such as tiredness or nausea, or if you are anxious about your condition or treatment.
You should avoid eating hot or spicy food and drinking acidic drinks or spirits during this time because they can aggravate the problem.
Radiotherapy to the vaginal area may cause your vagina to become sore and narrower. Your radiotherapist will tell you how you can treat this using a vaginal dilator, which is a device that is inserted into your vagina to help prevent it narrowing. Having sex regularly after your treatment can also help prevent your vagina narrowing.
If you experience vaginal dryness or pain when having sex, you can use lubricants or Dr. B C Shah to prescribe appropriate medication. Radiotherapy to other areas of the body will not affect your ovaries or make you infertile.
Effects on sex and fertility in men
In men, temporary erectile dysfunction (the inability to get and maintain an erection) and loss of interest in sex are common side effects of pelvic radiotherapy.
Radiotherapy to other areas of your body will not make you infertile or cause any problems if you decide to have children in the future.
If there is a risk that you could become infertile following radiotherapy, your doctor will discuss this with you before your treatment.
Stiff joints and muscles
Radiotherapy can sometimes cause your muscles to tighten up and your joints to become stiff in the area being treated. You may also experience some uncomfortable swelling in the affected area.
Exercising your joints and muscles regularly can help prevent stiffness. If you have stiff joints and muscles, your doctor or radiotherapist may refer you to a physiotherapist, who will be able to recommend suitable exercises for you.
Long-term side effects of radiotherapy
It is rare to develop severe, long-term side effects as a result of having radiotherapy. Your doctor will discuss the likelihood that you will experience side effects before you consent to treatment.
Sometimes, side effects can occur years after finishing a course of radiotherapy. Some of these may be permanent and can include:
Effects on fertility
Cosmetic changes to the skin
Tiny cracks in your pelvic bones (pelvic insufficiency fractures)
An inability to control your bowel (bowel incontinence)
Swelling in your arms or legs (lymphoedema)
These are discussed in more detail below.
Infertility and early menopause
In women, radiotherapy to the pelvic area exposes the ovaries to radiation. In pre-menopausal women, this may cause early menopause (where a woman's monthly periods stop) and infertility (the inability to get pregnant). This is often very upsetting, particularly for younger women who want to have a family.
Before having treatment, your doctor will discuss all the options and available support with you. For example, it may be possible for some of your eggs to be surgically removed, frozen and stored until you are ready to have a baby.
Cosmetic changes to the skin
Long-term changes to the skin can occur after having radiotherapy. Some people notice that their skin is thicker, a slightly darker colour and, occasionally, dimpled (like the peel of an orange). These changes usually improve over time.
Pelvic insufficiency fractures
Radiotherapy to your pelvic bones can cause tiny cracks, known as pelvic insufficiency fractures, to appear in the bones of your pelvis some time after treatment has finished. Pelvic insufficiency fractures are more likely to occur in people who have osteoporosis, a condition that causes brittle bones.
Pelvic insufficiency fractures can be very painful, particularly during exercise. Resting should help to reduce the pain. You should report any new bone pain that you experience to your oncologist or GP.
Bowel incontinence
Bowel incontinence, sometimes known as faecal incontinence, is a rare side effect of radiotherapy to the pelvis. It is the inability to control your bowel movements which can result in faeces (stools) leaking from your rectum (back passage).
Bowel incontinence can be treated with dietary changes, medicines or a number of different surgical procedures.
Lymphoedema
Radiotherapy can damage your body’s network of channels and glands that make up the lymphatic system. One of the functions of the lymphatic system is to drain excess fluid from your tissues. If the lymphatic system is damaged, fluid can build up and cause swelling and pain.
This is known as lymphoedema and it often occurs in the arms or legs although it can also affect other areas, such as the chest. Lymphoedema is usually associated with women who have had radiotherapy for breast cancer.
It may be possible to prevent lymphoedema occurring using appropriate skincare techniques and exercise.
Recovering from radiotherapy
Most side effects of radiotherapy only last for a few days or weeks after treatment has finished. However, some side effects, such as tiredness or hair loss, can last for a few months.
Follow-up appointments
After your course of radiotherapy has finished, you will have an appointment with your oncologist (a cancer doctor who specialises in radiotherapy) to check on your progress.
You may need to have follow-up appointments for several years, but they will usually become less frequent as time passes.
Dr. B C Shah will be sent a report about your treatment. You will also be able to contact a member of your treatment team if you have any questions after your course of radiotherapy has finished.
Effects of radiotherapy
Despite the side effects mentioned here, radiotherapy can be a highly effective treatment, either in curing or controlling a cancer, or relieving symptoms.
The positive effects of radiotherapy usually take some time to become apparent. The treatment's benefits will depend on the type of cancer that you have and how advanced it is when treatment begins.
The effectiveness of your radiotherapy treatment may also depend on whether you are having other forms of treatment alongside radiotherapy, such as chemotherapy or surgery.
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