Non-Communicable Diseases Manual 20-21 by ASSA Alexandria

Table of Contents Diabetes 1. Diabetes Mellitus 2. Diabetes Insipidus 3. Gestational Diabetes Cancer 1.

Breast Cancer

2. Prostate Cancer Cardiovascular Diseases 1. Cholesterol as a threat to Cardiovascular Disease 2. Arrhythmia 3.

Valve Stenosis

Respiratory Diseases COPD: 1. Asthma 2. Emphysema 3. Bronchitis 4. Bronchiectasis 3

Noncommunicable diseases (NCDs), such as heart disease, cancer, chronic respiratory disease, and diabetes, are the leading cause of death worldwide and represent an emerging global health threat. Deaths from NCDs now exceed all communicable disease deaths combined. On the light of that we created this manual to whoever would love to understand more about the topic. Hope you LoPH it.

Mariam Alaa Zaki LPO ASSA-Alex

Introduction Noncommunicable diseases (NCDs), also known as chronic diseases, tend to be of long duration and are the result of a combination of genetic, physiological, environmental and behavioral factors. The main types of NCDs are cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. NCDs disproportionately affect people in low- and middleincome countries where more than three-quarters of global NCD deaths – 32million – occur. People of all age groups, regions and countries are affected by NCDs. These conditions are often associated with older age groups, but evidence shows that 15 million of all deaths attributed to NCDs occur between the ages of 30 and 69 years. Of these "premature" deaths, over 85% are estimated to occur in low- and middle-income countries. Children, adults and the elderly are all vulnerable to the risk factors contributing to NCDs, whether from unhealthy diets, physical inactivity. Cardiovascular diseases account for most NCD deaths, 17.9 million people annually, followed by cancers (9.0 million), respiratory diseases (3.9million), and diabetes (1.6 million). These 4 groups of diseases account for over 80% of all premature NCD deaths. Detection, screening and treatment of NCDs, are key components of the response to NCDs. Thus in SCOPH it is our main mission to equip medical school students, and future health care professionals with sufficient knowledge about the various types of NCDs so that they are capable of spreading knowledge about these diseases to their loved ones. Where our vision is a world where everyone has the opportunity for a healthy life, free from preventable suffering, stigma and death caused by NCDs.

Diabetes Diabetes mellitus: The digestive system breaks down carbohydrates into glucose. This simple sugar is then transported to each cell via the bloodstream. The pancreas secretes the hormone insulin, which allows the glucose to migrate from the blood into the cells. Once inside a cell, the glucose is ‘burned’, along with oxygen, to produce energy. Without insulin, the glucose remains in the bloodstream at high levels. This condition is called (Diabetes Mellitus). The body recognizes the problem and tries to provide the cells with other sources of fuel, such as stored fats. Extensive fat burning can release products called ketones, which are dangerous in high amounts. The normal blood glucose levels should be between 80 and 130 mg/dL (4.44 to 7.2 mmol/L) before meals and no higher than 180 mg/dL (10mmol/L) two hours after eating. That’s why diabetes mellitus needs to be treated properly. There are two main types of diabetes mellitus: type 1 and type 2.

Type 1 diabetes It is an autoimmune disease that prevents the body from being able to produce enough insulin to adequately regulate blood glucose levels. It’s more likely to appear in children between 4 and 7 years old, and in children between 10 and 14 years old, but it also can appear at any age. (5)

Causes Autoimmune diseases are when the body incorrectly identifies it’s own useful cells as an attacking organism. In type 1 diabetes, it is the beta cells in the pancreas which produce insulin that is wrongfully targeted and killed off by specific antibodies created by the body’s immune system.

Researchers have been investigating what may cause the immune system to act in this way but till now researchers have theories but no concrete proof. There is likely to be an environmental factor that triggers the initial development of type 1 diabetes. Some of the possible triggers that have been suggested include: • Viral infection • Vaccines • Low levels of vitamin D • Increased insulin demand (6)

Risk factors • Family history. Anyone with a parent or sibling with type 1 diabetes has a slightly increased risk of developing the condition. • Genetics. The presence of certain genes indicates an increased risk of developing type 1 diabetes. • Geography. The incidence of type 1 diabetes tends to increase as you travel away from the equator. (5)

Symptoms They usually happen quickly, over a few days to weeks. Symptoms can include: • increased thirst and urination • increased hunger • blurred vision • fatigue • unexplained weight loss • cuts and grazes that are not healing Sometimes the first symptoms of type 1 diabetes are signs of a life-threatening condition called diabetic ketoacidosis (DKA). Some symptoms of DKA include: • breath that smells fruity • dry or flushed skin • nausea or vomiting

• stomach pain • trouble breathing • trouble paying attention or feeling confused • coma. (2,3)

Diagnosis and testing If you show signs of having diabetes, your doctor may use blood or urine tests to diagnose diabetes. Your doctor should consider which type of diabetes you have as this can affect how your diabetes is treated, so your doctor may decide to carry out one or more of the following tests:  Ketone test:  GAD autoantibodies test: A GAD test is a blood test that measures whether the body is producing a type of antibody that destroys its own GAD cells. In type1diabetes, some autoantibodies are thought to circulate including those that target glutamicaciddecarboxylase. The presence of these autoantibodies suggests type1diabetes.  C-peptide test: C-peptide is released at the same time as insulin. A Cpeptide test is a blood test That is carried out to find out how much insulin your body is producing. (1,7)

Treatment The impairment of the pancreas’ ability to produce insulin in type 1 diabetes means that insulin treatment is necessary. Most people will take insulin by injection with insulin pens. Insulin can also be delivered by wearing an insulin pump. The use of an insulin pump will be considered in people that express an interest in having one and that meet certain eligibility criteria. (1)

Checkups required and Life Style adjustments • self-monitoring of blood sugar levels by regularly testing droplets of blood in a glucose meter • self-testing of urine with a test strip for high levels of ketones – not routinely, but when problems are suspected • regulating diet so intake is matched to insulin and exercise

• increasing the amount of ‘slow’ carbohydrates in the diet, such as beans and fruits, which take longer to be absorbed by the body • regular exercise • maintaining regular checks for diabetes complications. The goal is to keep your blood sugar level as close to normal levels as possible to delay or prevent complications.

Complications Type 1 diabetes can lead to the development of the following long term diabetes complications:      

Heart disease Stroke Retinopathy (damage to the eyes) Kidney disease Neuropathy increased possibility of infections such as thrush and also more serious infections.  poor blood circulation in the legs and feet, potentially leading to lower limb amputation.  sexual impotence. So Consider Checking these things regularly with your doctor as well. (1,4,5)

Hypoglycemia If a person with type 1 diabetes skips a meal, exercises heavily or takes too much insulin, their blood sugar levels will fall. This can lead to a (hypoglycemic reaction). The symptoms include dizziness, sweating, hunger, headache and change in mood. This can be remedied with a quick boost of sugar (such as jellybeans or glucose tablets), then something more substantial such as fruit. A person with type 1 diabetes should have lollies on hand at all times, just in case. (4)

References: 1. https://www.diabetes.co.uk/type1-diabetes.html 2. https://www.niddk.nih.gov/health-information/diabetes/overview/what-isdiabetes/type-1-diabetes#whois

3. https://www.nhs.uk/conditions/type-1-diabetes/symptoms-and-getting-diagnosed/ 4. https://www.betterhealth.vic.gov.au/health/C onditionsAndTreatments/diabetes-type-1 5. https://www.mayoclinic.org/diseasesconditions/type-1-diabetes/diagnosistreatment/drc-20353017 6. https://www.diabetes.co.uk/causes-oftype1-diabetes.html 7. https://www.diabetes.co.uk/Diabetesscreening-test.html

Type 2 Diabetes It is characterized by the body being unable to metabolize glucose. This leads to high levels of blood glucose (hyperglycemia) which over time may damage the organs of the body. (1)

Causes Type 2 diabetes mellitus occurs when the hormone insulin is not used effectively by the cells in your body or when the pancreas is unable to produce enough insulin. Ineffective use of insulin results in the body becoming resistant to insulin, also known as insulin resistance, which in turn causes hyperglycemia.

In advanced stages, type 2 diabetes may cause damage to insulin-producing cells in the pancreas, leading to insufficient insulin production for your body’s needs. (1,5)

Risk factors Your chances of developing type 2 diabetes depend on a combination of risk factors including: • overweight or obesity • age (45 or older) • family history of diabetes • high blood pressure • low level of HDL (“good”) cholesterol, or high level of triglycerides • A history of gestational diabetes or gave birth to a baby weighing 9 pounds or more • not being physically active • a history of heart disease or stroke • depression • polycystic ovary syndrome also called PCOS • acanthosis nigricans; dark, thick, and velvety skin around your neck or armpits • Being pre-diabetic • Smoking Although you can’t change risk factors such as family history or age, you can change lifestyle risk factors around eating, physical activity, and weight, which can affect your chances of developing type 2 diabetes. (4,6)

Symptoms The most common symptoms of type 2 diabetes are:     

Excessive thirst Frequent urination Increased hunger Extreme tiredness Sudden loss of muscle mass

Some of these symptoms are the same for type 1 diabetes, but in type 2 diabetes they tend to develop more slowly over months or years, making it harder sometimes for people to recognize them as signs of an underlying illness. In fact, many people have type 2 Diabetes for a long time before being diagnosed with the disease. (1)

Testing Your doctor may need you to have some tests to make sure you are diabetic and to determine which type of diabetes you have, such as: 1. C-peptide test 2. GAD Antibodies test 3. Plasma glucose test: A fasting plasma glucose test, also known as a fasting glucose test (FGT), is a test that can be used to help diagnose diabetes or pre-diabetes by measuring your blood glucose level. The test is a simple blood test taken after several hours of fasting. 4. HbA1c test: An important blood test gives a good indication of how well your diabetes is being controlled. If your HbA1c test returns a reading of 6.0–6.4%, that indicates prediabetes. HbA1c of 48 mmol/mol (6.5%) or over means that you have Type 2 diabetes 5. Oral Glucose Tolerance: The test is used to determine whether the body has difficulty metabolizing the intake of sugar/carbohydrates. The patient is asked to take a glucose drink and their blood glucose level is measured before and at intervals after the sugary drink is taken. (7)

Treatment Management of type 2 diabetes includes: • Weight loss • Healthy eating • Regular exercise • Possibly, diabetes medication or insulin therapy • Blood sugar monitoring

These steps will help keep your blood sugar level closer to normal, which can delay or prevent complications. (1)

Checkups required and Life Style adjustments • Commit to managing your diabetes. • Schedule a yearly physical exam and regular eye exams. • Keep your vaccinations up to date. • Take care of your teeth. • Pay attention to your feet for any numbness, ulcers or infections. • Keep your blood pressure and cholesterol under control. • If you smoke or use other types of tobacco, ask your doctor to help you quit. • If you drink alcohol, quit or do so responsibly. (3,5)

References 1. https://www.diabetes.co.uk/type2-diabetes.html 2. https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/type-2diabetes#causes 3. https://www.nhs.uk/conditions/type-2-diabetes/going-regular-check-ups/ 4. https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/diabetes-type-2 5. https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/diagnosis-treatment/drc20351199 6. https://www.niddk.nih.gov/health-information/diabetes/overview/tests-diagnosis#who 7. https://www.diabetes.co.uk/Diabetes-screening-test.html

Diabetes Insipidus Diabetes insipidus (DI) is a condition in which the patient has excessive urination (polyuria) and increased thirst (Polydipsia) as a result of losing so much water, although it has similar symptoms to diabetes mellitus it isn’t related to blood sugar level. (1) DI is a rare disorder that occurs when a person's kidneys pass an abnormally large volume of urine that

is insipid—dilute and odorless the amount of urine can range from 3 liters in mild cases to up to 20 liters per day in severe cases. This can cause tiredness, irritability and difficulty concentrating, which can affect your daily life further. You may also feel generally unwell and "run down" much of the time for no apparent reason. (3,4)

Symptoms in children Excessive thirst can be difficult to recognize in children who are too young to speak, so you can depend on other obvious signs which include:        

Heavy, wet diapers Bed-wetting Trouble sleeping Fever Vomiting Constipation Delayed growth Weight loss (2)

In older children, symptoms of diabetes insipidus include:  Wetting the bed (enuresis) –although most children who wet the bed do not have diabetes insipidus loss of appetite  feeling tired all the time (fatigue) (4) A hormone called anti-diuretic hormone (ADH), or vasopressin, helps control how fast or slow fluids are excreted from our bodies. ADH is made in a part of the brain called the hypothalamus and stored in the pituitary gland. Your kidneys contain nephrons, that filter waste products from the blood and help produce urine. They also control how much water is reabsorbed into your body and how much is passed in the urine when you pee. In a healthy person, ADH acts as a signal to the nephrons to reabsorb water into the body. A problem with either the production or action, of the hormone vasopressin leads to diabetes insipidus. (2,4)

There are two main types of DI

1. Cranial diabetes insipidus In which the source of the problem is in the secretion of ADH. The most common causes of cranial DI are: • A damage of the hypothalamus or pituitary gland as a result of a brain tumor or a severe head injury • complications that occur during brain or pituitary surgery **No cause can be found for about a third of all cases of cranial diabetes insipidus. These cases, known as idiopathic, appear to be related to the immune system attacking the normal healthy cells producing ADH. It's unclear what causes the immune system to do this.

Less common causes of cranial diabetes insipidus include: • cancers that spread from another part of the body to the brain • Wolfram syndrome, a rare genetic disorder that also causes vision loss • brain damage caused by a sudden loss of oxygen, which can occur during a stroke or drowning • infections, such as (Meningitis) and (encephalitis) that can damage the brain (4)

2. Nephrogenic diabetes insipidus In which, the nephrons in the kidneys are not able to respond to ADH, leading to excessive water loss in large amounts of urine. Your thirst increases to try to balance this loss from the body. Nephrogenic diabetes insipidus can be present at birth (congenital) or develop later in life as a result of an external factor Causes of Congenital nephrogenic DI: Two abnormal changes in genes that lead to them not working properly (genetic mutations) have been identified that cause congenital nephrogenic diabetes insipidus.

The first known as the AVPR2 gene mutation is responsible for 90% of all cases of congenital diabetes insipidus. The AVPR2 gene mutation can only be passed down by mothers (who may appear to not be affected) to their sons (who are affected). But it's still rare, occurring in an estimated 1 in 250,000 births. The remaining 10% of cases of congenital nephrogenic diabetes insipidus are caused by the AQP2 gene mutation, which can affect both males and females. (4)

Risk factors Anything that could hurt your kidneys as Lithium or hypercalcemia (abnormally high levels of calcium). Lithium is used in some medications, particularly for bipolar disorder, and long term intake of lithium can cause damage to the nephrons in the kidneys. (1,5)

Diagnosis and testing See your doctor if you have the symptoms of diabetes insipidus. They’ll ask about your symptoms and carry out some tests as : 1. Water deprivation test A test involves not drinking any liquid for several hours to see how your body responds. During the test, the amount of urine you produce will be measured. Your blood and urine may also be tested for substances such as glucose, calcium and potassium. If you have diabetes insipidus, you'll continue to pee large amounts of very dilute urine with low levels of other substances. when normally you'd only pee a small amount of concentrated urine. (4)

2. Vasopressin test After the water deprivation test, you may be given a small dose of Vasopressin, usually as an injection. This will show how your body reacts to the hormone, which helps to identify the type of diabetes insipidus you have. If the dose of ADH stops you from peeing urine, it's likely your condition is the result of a shortage of ADH (cranial DI).

If you continue to pee despite the dose of ADH, this suggests there's already enough ADH in your body, but your kidneys are not responding to it (nephrogenic DI). (4) 3. MRI scan You may need an MRI scan if your endocrinologist thinks you have cranial diabetes insipidus as a result of damage to your hypothalamus or pituitary gland. If it’s the case, it may need to be treated too, along with treatment for diabetes insipidus. (4) 4. Blood test You may also need a blood test to assess the levels of (ADH) in your blood and to measure electrolyte levels. (4,6)

Treatment • Central (crania) diabetes insipidus. If you have mild diabetes insipidus, you may only need to increase your water intake. If the condition is caused by an abnormality in the pituitary gland or hypothalamus (such as a tumor), your doctor will first treat the abnormality. Typically, this form is treated with a man-made hormone called desmopressin (DDAVP, Minirin, others). This medication replaces the missing anti-diuretic hormone (ADH) and decreases urination. You can take desmopressin as a nasal spray, as oral tablets or by injection. Most people still make some ADH, though the amount can vary from day to day. So, the amount of desmopressin you need also may vary. Taking more desmopressin than you need can cause water retention and potentially serious low-sodium levels in the blood. Other medications may also be prescribed, such as indomethacin (Indocin, Tivorbex) and chlorpropamide. These drugs can enhance your body to produce more ADH. (2) • Nephrogenic diabetes insipidus. Since the kidneys don't properly respond to ADH in this form of diabetes insipidus, desmopressin won't help. Instead, your doctor may prescribe a low-salt diet to help

reduce the amount of urine your kidneys make. You'll also need to drink enough water to avoid dehydration. Treatment with the drug: hydrochlorothiazide (Microzide) may improve your symptoms. Although it is a type of drug that usually increases urine output (diuretic), in some people it can reduce urine output for people with nephrogenic diabetes insipidus. (2)

References: 1. https://www.diabetes.co.uk/Diabetes-insipidus.html 2. https://www.mayoclinic.org/diseases-conditions/diabetesinsipidus/symptomscauses/syc-20351269 3. https://www.niddk.nih.gov/health-information/kidney-disease/diabetesinsipidus 4. https://www.nhs.uk/conditions/diabetes-insipidus/ 5.https://www.pituitary.org.uk/information/pituitary-conditions/diabetesinsipidus/ 6. https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/diabetesinsipidus

Gestational Diabetes It is diabetes diagnosed for the first time during pregnancy (gestation). It happens when your body cannot produce enough insulin to meet your extra

needs in pregnancy. Like other types of diabetes, gestational diabetes affects how your cells use glucose. Gestational diabetes causes high blood sugar that can affect your pregnancy and your baby's health. In women with gestational diabetes, blood sugar usually returns to normal soon after delivery. But if you've had gestational diabetes, you have a higher risk of getting type 2 Diabetes. You'll need to be tested for changes in blood sugar more often. and it is very common Nearly 10 percent of pregnancies in the U.S. are affected by gestational diabetes every year. (1,2,4)

Causes During pregnancy, your body makes special hormones and goes through other changes, such as weight gain. Because of these changes, your body’s cells don’t use insulin well, a condition called insulin resistance. All pregnant women have some insulin resistance during late pregnancy. Most pregnant women can produce enough insulin to overcome insulin resistance, but some cannot. These women develop gestational diabetes. Women who are overweight or obese may already have insulin resistance when they become pregnant. (5)

Risk factors Some risk factors increase your chance of having gestational diabetes such as: • Overweight and obesity. • A lack of physical activity. • Previous gestational diabetes or prediabetes. • Polycystic ovary syndrome (PCOS). • Diabetes in an immediate family member. • Previously delivering a baby weighing more than 4.1 kilograms (9 pounds). • taking some types of anti-psychotic or steroid medications. (1)

Symptoms: Gestational diabetes does not usually cause any symptoms. Most cases are only discovered when your blood sugar levels are tested during screening for gestational diabetes.

Some women may develop symptoms if their blood sugar levels get too high (hyperglycemia), such as: • Increased thirst • Needing to pee more often than usual • A dry mouth • Tiredness However, some of these symptoms are common during pregnancy and are not necessarily a sign of gestational diabetes. Speak to your midwife or doctor if you're worried about any symptoms you're experiencing. (2)

Diagnosis and testing All women are screened for gestational diabetes at their 24 to 28-week routine check-ups. Women who are at higher risk may be tested more often. Doctors use blood tests to diagnose gestational diabetes. These tests show how well your body uses glucose: • Glucose Challenge Test You may have the glucose challenge test first. Another name for this blood test is the glucose screening test. In this test, a health care professional will draw your blood 1 hour after you drink a sweet liquid containing glucose. You do not need to fast for this test. If your blood glucose is too high (140 or more) you may need to return for an oral glucose tolerance test while fasting. If your blood glucose is 200 or more, you may have type 2 diabetes. • Oral Glucose Tolerance Test (OGTT)(5,6)

Treatment Treatment for gestational diabetes includes: • Lifestyle changes • Blood sugar monitoring • Medication, if necessary Managing your blood sugar levels helps keep you and your baby healthy. Close management can also help you avoid complications during pregnancy and delivery. (1)

Checkups required 1. Checking your blood sugar level 2. Monitoring your pregnancy Gestational diabetes can increase the risk of your baby developing problems, such as growing larger than usual. Because of this, you'll be offered extra antenatal appointments so your baby can be monitored. Appointments you should be offered include: • an ultrasound scan at around week 18 to 20 of your pregnancy to check your baby for abnormalities • Ultrasound scans at weeks 28, 32 and 36 to monitor your baby's growth and the amount of amniotic fluid, plus regular checks from week 38 onwards. (2)

Lifestyle adjustments 1. Eat Healthy Foods:  Polyunsaturated fats; Sunflower seeds, Fish (such as salmon, mackerel, herring, albacore tuna, and trout) Corn oil, Soybean oil, Safflower oil.  Fiber-rich foods; Wholegrain, Fruit (such as berries, pears, melon and oranges.), Vegetables (such as broccoli, carrots and sweetcorn.), Peas, Beans and Nuts. 2. Exercise Regularly 3. Lower your risk by maintaining normal weight (BMI 18.5 to 24.9) 4. Monitor your blood sugar 5. Close monitoring of your baby (4,3,7)

References 1. https://www.mayoclinic.org/diseasesconditions/gestationaldiabetes/symptoms-causes/syc20355339 2. https://www.nhs.uk/conditions/gestational-diabetes/ 3. https://www.cdc.gov/pregnancy/diabetes-gestational.html 4. https://www.diabetes.org/diabetes/gestational-diabetes 5. https://www.niddk.nih.gov/health-information/diabetes/overview/what-isdiabetes/gestational 6. https://www.pregnancybirthbaby.org.au/gestational-diabetes 7. https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/pregnancyweight-gain/art-20044360

Introduction to Cancer Cancer refers to any one of a large number of diseases characterized by the development of abnormal cells that divide uncontrollably and have the ability to infiltrate and destroy normal body tissue. Cancer often has the ability to spread throughout the body (metastasis). Cancer is caused by changes (mutations) to the DNA within cells. In this manual, we are going to discuss when the cancer originates from the breast and prostate specifically. Breast and prostate cancers are extremely prevalent around the globe as the incidence rates for both cancers are significantly high compared to other cancers’ incidence rates as shown by the following figure:

Breast Cancer Breast cancer is the second most common cancer after skin cancer in women. (1) Approximately 1 in 8 women (13%) will develop breast cancer in their lifetime. (2) Developed countries have a higher incidence of breast cancer, however, lower mortality rate than developing countries, due to awareness of earlier screening for breast cancer.

Types of Breast Cancers 1. Ductal Carcinoma in Situ (DCIS): Abnormal cells are found in the lining of the breast milk duct and not yet infiltrated outside of the ducts into the surrounding tissue. May develop into IDC if left untreated. 2. Invasive Ductal Carcinoma (IDC): Abnormal cancerous cells have begun to spread outside of ducts into the surrounding tissue. Can also be called infiltrative ductal carcinoma. Most commonly affect males. IDCs form 70 – 80 % of breast cancer diagnoses. 3. Lobular Carcinoma in Situ (LCIS): Abnormal cells are found in the lobules of the breast. LCIS may develop into ILC if left untreated. 4. Invasive Lobular Carcinoma (ILC): Abnormal cells that originate in breast lobules begin to spread beyond lobules to surrounding tissue. ILCs form 10 – 15 % of breast cancer diagnoses.

-In situ means in the original place while carcinoma means cancer. -Terms as lobular (deriving from lobules) and ducts are found in the figure above.

Other types of breast cancers include 1. Inflammatory breast cancer: A rare (accounts for only 1 to 5 % of all breast cancers) and very aggressive cancer that blocks the lymph vessels in the skin of the breast. The breast often looks swollen and red or inflamed hence the name.

2. Triple-negative breast cancer: Triple-negative cancers mean that the 3 most common types of receptors that accelerate the growth of breast cancer which are estrogen receptors (ER), progesterone receptors (PR), and epidermal growth factor receptor 2 (HER2) are not present in the cancerous tumor. Resulting in that certain forms of therapy used to combat the tumor as hormone therapy that targets estrogen, progesterone and HER2 become ineffective. Triple-negative breast cancers occur in 10-20% of diagnosed breast cancers.

3. Metastatic breast cancer: Known also as stage 4 breast cancer, can spread to other parts of the body which include the liver, lungs, bones or brain.

4. Paget’s disease of the breast or nipple: Rare type of breast cancer that affects the skin of the nipple and often the areola, most people with Paget have 1 or more tumors inside the same breast. Paget’s disease symptoms are often associated with other conditions affecting the skin of the nipple so, it is frequently misdiagnosed. (3)

Risk Factors for Breast cancer - Unmodifiable risk factors 1. Personal or familial history of breast cancer:

The presence of personal or familial history in first degree relatives (as mother or sister) increases the risk of developing breast cancer.

2. Gene changes: About 5% to 10% of breast cancer cases are thought to be hereditary, meaning that they result directly from gene changes (mutations) passed on from a parent. Inheritance of a mutated version of BRCA1 or BRCA2 increases the risk of developing breast cancer in the person’s lifetime as well as ovarian cancer in women and prostate cancer in men. Multiple other genes can also lead to the development of breast cancer but not as likely as BRCA1 and BRCA2. 3. Having dense breast tissue: Breasts contain glandular, connective, and fat tissue. Breast density is a term that describes the relative amount of these different types of breast tissue as seen on a mammogram. Dense breasts have relatively high amounts of glandular tissue and fibrous connective tissue and relatively low amounts of fatty breast tissue. Women with dense breasts have a risk of breast cancer that is about 1.5 to 2 times that of women with average breast density. Another problem is presented as dense breast tissue can also make it harder to view cancers on mammograms so, other screenings as ultrasound might be recommended. 4. Age: Chances of getting breast cancer increase as you get older. (4)

-Modifiable risk factors 1. Consuming exogenous hormones: As the use of estrogen combined with progestin to reduce symptoms of menopause increases the risk of developing breast cancer. 2. Treatment with radiation therapy to the breast or chest:

Prior radiation exposure, if the person was treated with radiation therapy to the chest for another cancer significantly, increases chances of developing breast cancer for younger women (below age 40 to 45). 3. Drinking Alcohol 4. Smoking 5. Obesity

Performing self or clinical breast exams If you are performing a self-breast exam and if you menstruate, pick a date in your cycle when your breasts are least tender, the best time to perform a self-exam for breast awareness is usually the week after your period ends every 28 days. 1. Visual examination of the breast: Sit or stand facing a mirror and inspect the following aspects with your hands resting once on your hips and once again with your arms raised overhead and the palms of your hands pressed together.  Look for puckering, dimpling, changes in size, shape or symmetry  Check to see if nipples are inverted  Lift your breasts to see if ridges along the bottom are symmetrical as well 2. Using your hands to examine your breasts: Lying down on a flat surface on your back or in the shower using soap to glide your fingers on your breasts.  Use pads of fingers (flat part) instead of tips of your three middle fingers, if you have any difficulty with the pads then, use a sensitive part of your hand as the palm or the back of your fingers.  Use different pressure levels at different parts: Light pressure to feel the tissue closest to the skin Medium pressure to feel a little deeper Firm pressure to feel the tissue closest to the chest and ribs Make sure to use each pressure level before moving on to the next spot. 3. Take your time: might take several minutes to examine each breast 4. Follow a pattern: using a circular motion, vertical sweep or wedge type motion from near the collarbone towards the nipple or in the reverse direction. *Some key points to remember: Breast tissue feels different at different stages of the menstrual cycle. Breasts often feel different at different places. A firm ridge along the bottom of each breast is normal.

The look and feel of your breasts will change as you age. Remember in self-breast exams to have an alert but not anxious mindset so, a better examination is achieved. (5)

Signs and Symptoms Consult with your doctor if you have any of the following:       



Change in size or shape of your breast. Lump or thickening in or near the breast or in the underarm region. A dimple or puckering in the skin of the breast. Fluid, other than breast milk especially if it’s bloody. Redness, warmth, swelling or pain Itching, scales, sores or rashes Dimples in the breast that look like the skin of an orange (called peau d’orange). A recent change in a nipple to become pushed in (inverted) instead of sticking out.

Tests and diagnosis Additional tests and procedures might be recommended as a clinical breast exam, mammograms, ultrasounds, and a biopsy: 1. Mammograms: Mammograms are x-ray images of the breast, used to detect early signs of breast cancer. Women might feel a bit of discomfort during the mammogram as the breast rests on a plastic plate and another plastic plate from above presses on the top of the breast to flatten it so the x-ray could be taken. A mammogram shows a four-picture view When should women get mammograms?

- Women ages 40 to 44: should have accessibility to get annual mammograms if they prefer. -Women ages 45 to 54: should get annual mammograms. -Women ages 55 and older: should get mammograms every 2 years or can continue annual screening. (6)

Some women because of their family history, a genetic tendency, or certain other high-risk factors should be screened with MRIs along with mammograms An abnormal result of a mammogram doesn’t automatically mean it is cancer. (7) 2. Ultrasounds Used in the following situations:  For screening for lumps that can be felt but not seen by mammograms  For women with dense breast tissue  Can often tell the difference between fluid-filled cysts (which are very unlikely to be cancer) and solid masses (which might need further testing to be sure they're not cancer).  Can guide biopsy needle so, cells can be extracted and tested for cancer. Ultrasounds can be preferred as they don’t involve X-rays as mammograms, cost less than other tests, widely available and don’t accompany any discomfort just a bit of pressure. (8) 3. Biopsy: A tissue and is a pathologist cancer cells A biopsy may detected in

sample is extracted analyzed in a lab by to determine whether are present. be done if a lump is imaging.

Staging and grading Once cancer is confirmed, staging and grading of the cancer occur to determine the extent of aggressiveness of the cancer. (9) Difference between staging and grading: Staging

Grading

Describes the size of a tumor and how far it has spread from where it originated

Describes the appearance of cancerous cells and how differentiated they are from non-cancerous cells and depends on how cells look underneath the microscope. A higher grade indicates a more aggressive cancer that is more likely to spread quickly.

Staging is determined by the TNM system: -Tumor size (T): The size and location of the tumor. - Lymph node (N): The size and location of lymph nodes where cancer has spread. -Metastasis (M): The spread of cancer to other parts of the body. Stages are from 0 to IV: Stage 0: indicates that the cancer is where it started (in situ) and hasn't spread.

Grades from I to III: - Grade I: cancer cells that resemble normal cells and aren't growing rapidly.

- Grade II: cancer cells that don't look like normal cells and are growing faster Stage I: the cancer is small and hasn't spread than normal cells. anywhere else - Grade III: cancer cells that look

Stage II: the cancer has grown, but hasn't spread

abnormal and may grow or spread more aggressively.

Stage III: the cancer is larger and may have spread to the surrounding tissues and/or the lymph nodes. Stage IV: the cancer has spread from where it started to at least one other body organ; also known as "secondary" or "metastatic" cancer. The stage and grade of a cancer are all used to determine the individualized treatment of the patient.

References 1. https://www.cancer.gov/types/breast 2. https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breastcancer.html 3. https://www.nationalbreastcancer.org/types-of-breast-cancer/ 4. https://www.cancer.org/cancer/breast-cancer/risk-and-prevention/breastcancer-risk-factors-you-cannot-change.html 5. https://www.mayoclinic.org/tests-procedures/breast-exam/about/pac20393237 6. https://www.cancer.org/cancer/breast-cancer/risk-and-prevention/breastcancer-risk-factors-you-cannot-change.html 7. https://www.cdc.gov/cancer/breast/basic_info/mammograms.htm 8. https://www.cancer.org/cancer/breast-cancer/screening-tests-and-earlydetection/breast-ultrasound.html 9. https://www.nhs.uk/common-health-questions/operations-tests-andprocedures/what-do-cancer-stages-and-grades-mean/

Prostate cancer Prostate cancer is the second most common cancer after skin cancer in men. About 1 man in 9 will be diagnosed with prostate cancer during his lifetime. (1) The prostate is a small walnut-shaped gland in males that is involved in the production of the seminal fluid that nourishes and transports sperm. (2)

Types of prostate cancers Adenocarcinomas form almost all prostate cancers, these cancers develop from the gland cells that make the prostate fluid that is added to the semen. Other types of prostate cancers: These other types of prostate cancer are rare. If you are told you have prostate cancer, it is almost certain to be an adenocarcinoma. • Small cell carcinomas • Neuroendocrine tumors (other than small cell carcinomas) • Transitional cell carcinomas • Sarcomas Some prostate cancers grow and spread quickly, but most grow slowly. (2)

Risk factors for Prostate cancer - Unmodifiable factors: 1. Age: Older men tend to have a higher chance of getting prostate cancer. Prostate cancer is rare in men younger than 40, but the chance of having prostate cancer rises rapidly after age 50. 2. Personal or familial history of prostate cancer: Prostate cancer appears to run in some families which leads to the conclusion that there is some inherited genetic factor involved yet, most prostate cancers occur in men without a family history in it. The risk is increased for those who: • Have a father or brother with prostate cancer where it increases the risk of developing prostate cancer to more than double. (The risk is higher for men who have a brother with the disease than for those who have a father with it.)

• The risk is much higher for men with several affected relatives, particularly if their relatives developed the cancer when they were young. 3. Gene changes: Several inherited mutations seem to raise prostate cancer risk but are only believed to cause 5% to 10% of cases of prostate cancer, some of these genetic variations include: • Inherited mutations of the BRCA1 or BRCA2 genes, not only increase the risk of acquiring breast cancer in both sexes but also, prostate cancer in men especially mutations in BRCA2. • Having lynch syndrome (also known as hereditary non-polyposis colorectal cancer, or HNPCC) increases the risk of developing many cancers including prostate cancer as this condition is caused by inherited gene changes 4. Geography: Prostate cancer is most common in North America, northwestern Europe, Australia, and on Caribbean islands. It is less common in Asia, Africa, Central America, and South America.

Modifiable Factors: 1. Diet: Men who eat a lot of dairy products appear to have a slightly higher chance of getting prostate cancer. 2. Obesity: Being obese does not seem to increase the overall risk of getting prostate cancer yet increases the risk of developing a more aggressive form (fast-growing) of prostate cancer and more likely to return after initial treatment. 3. Chemical exposure: There is some evidence showing that firefighters have a higher risk of developing prostate cancer. There is limited or suggestive evidence of an association between exposure to Agent Orange and the risk of getting prostate cancer.

Active research is being conducted to investigate the correlation between the following factors and the increased risk of getting prostate cancer: smoking, consuming too much calcium, having a prior inflammation of the prostate, sexually transmitted infections, or a vasectomy. However, they seem to contribute to more aggressive cases of prostate cancer because someone who has systemic health issues as a result of any of these factors is going to fare more poorly with any illness. (3)

Signs and Symptoms Early-stage prostate cancer: may cause no signs or symptoms and are found mainly through screening. More advanced prostate cancer: may cause these signs and symptoms: • Trouble urinating: Needing to urinate more frequently (often during the night) and straining or taking a long time while peeing or feeling a burning sensation when urinating. • Decreased force in the stream of urine (weak flow) • Blood in the urine • Blood in the semen • Bone pain • Unexplained weight loss • Erectile dysfunction • Weakness or numbness in the legs or feet, or even loss of bladder or bowel control from cancer pressing on the spinal cord. (4) If you experience any of these symptoms you should consult your physician, as these symptoms do not always mean you have prostate cancer. Many men's prostates get larger as they get older due to benign prostatic hyperplasia (BPH) causing symptoms similar and in common with those of prostate cancer. BPH is not linked to cancer and does not increase your risk of getting prostate cancer. (5)

Screening Prostate screening tests might include: 1. Digital rectal exam (DRE):

During a DRE, A doctor inserts a gloved, lubricated finger into the rectum to examine the prostate as the prostate is adjacent to the rectum. If the doctor finds any abnormalities in the texture, shape, or size of the gland, it may require further tests. 2.

Prostate-specific antigen (PSA) test: A blood sample is drawn from a vein in the arm and analyzed for PSA (a substance that's naturally produced by the prostate gland). However, if the level of PSA is higher than normal it may be an indication of prostate infection, inflammation, enlargement or cancer.

Tests and diagnosis If prostate cancer screening detects an abnormality, further tests are recommended to determine whether it’s prostate cancer or not, such as:

1. Ultrasounds: During a transrectal ultrasound (TRUS), a small probe (about the size and shape of a cigar) is inserted into the rectum to create a picture of your prostate gland using sound waves thus, can be used to measure the size of the prostate. It can be also used during a prostate biopsy to guide the needles into the correct area of the prostate. The procedure often takes less than 10 minutes and is done in a doctor’s office or outpatient clinic. It is usually not painful, there is just some pressure when the probe is inserted. The area may be numbed before the procedure.

2. Magnetic resonance imaging (MRI): MRIs are useful for: • Create a more detailed picture. • Help to plan procedure for a prostatic biopsy if needed.

3. Biopsy:

A prostate biopsy is often done using a thin needle that's inserted into the prostate to collect tissue. Once the tissue sample is extracted, it is analyzed in a lab by a pathologist to determine whether cancer cells are present. (6)

Staging and grading Once cancer is confirmed, staging and grading of the cancer occur to determine the extent of aggressiveness of the cancer. Difference between staging and grading: Staging: Describes the size of a tumor and how far it has spread from where it originated. Staging is determined by the TNM system: - Tumor size (T): The size and location of the tumor. - Lymph node (N): The size and location of lymph nodes where cancer has spread. - Metastasis (M): The spread of cancer to other parts of the body.

Stages are from 0 to IV: Stage 0: indicates that the cancer is where it started (in situ) and hasn't spread. Stage I: the cancer is small and hasn't spread anywhere else Stage II: the cancer has grown, but hasn't spread Stage III: the cancer is larger and may have spread to the surrounding tissues and/or the lymph nodes. Stage IV: the cancer has spread from where it started to at least one other body organ; also known as "secondary" or "metastatic" cancer.

Grading: Describes the appearance of cancerous cells and how differentiated they are from non-cancerous cells and depends on how cells look underneath the microscope. A higher grade indicates a more aggressive cancer that is more likely to spread quickly. Gleason score is used to determine the aggressiveness of the cancer. Gleason score: The most common scale used to evaluate the grade of prostate cancer cells. Using different grades to determine the level of differentiation of prostate cancerous cells: Grade 1: indicates that the cancer looks a lot like normal prostate tissue Grade 2-4: grades 2 through 4 have features in between the extremes of grade 1 to grade 5. Grade 5: indicates that the cancer looks very abnormal Almost all cancers are grade 3 or higher, grades 1 and 2 are not often used. However prostate cancers often have areas with different grades, a grade is assigned to the 2 areas that make up most of the cancer. These 2 grades are added to yield the Gleason score (also called the Gleason sum). Most Gleason scores used to assess prostate biopsy samples range from 6 to 10. • Score of 6: indicates well-differentiated or low-grade prostate cancer. • Score of 7: indicates moderately-differentiated or intermediate-grade prostate cancer. • Score 8-10: indicates poorly-differentiated or high-grade prostate cancer.

Treatment

Immediate treatment may not be necessary such as in low-grade prostate cancer, sometimes treatment may never be needed and only active surveillance is recommended. Active surveillance may also be considered for someone who: • Has another serious health condition • Is advanced in age which makes cancer treatment more difficult. • Has cancer that doesn’t present any symptoms, is very slow-growing and is confined to a small area of the prostate. Active surveillance includes: • Regular follow-up blood tests • Rectal exams • Prostate biopsies Which may be performed to monitor the progression of the cancer and in case, the cancer progresses to choose another method of treatment like surgery or radiation. (6)

References: 1. https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html 2. https://www.cancer.org/cancer/prostate-cancer/about/what-is-prostatecancer.html 3. https://www.cancer.org/cancer/prostate-cancer/causes-risksprevention/risk-factors.html 4. https://www.mayoclinic.org/diseases-conditions/prostate-cancer/symptomscauses/syc-20353087 5. https://www.nhs.uk/conditions/prostate-enlargement/ 6. https://www.mayoclinic.org/diseases-conditions/prostate-cancer/diagnosistreatment/drc-20353093

Cancer treatment Depending on your type of cancer, staging, how fast it is growing, whether it has spread and the person’s overall health. Your doctor can determine the most suitable plan of treatment, which may include one or more kind of treatment such as:

• Surgery: In the case of breast cancer:

Types of surgery: • Breast-conserving surgery: only cancer is removed and some of the normal tissue around it. Part of the chest wall lining may also be removed if the cancer is near it. Also called lumpectomy, partial mastectomy or breast-sparing surgery. • Total mastectomy: The whole breast that has the cancer is removed. Some of the lymph nodes under the arm may be removed and checked for cancer. Also called a simple mastectomy. • Modified radical mastectomy: The whole breast that has cancer, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes, part of the chest wall muscles are removed. ** Breast reconstruction surgery: a woman who has surgery to treat breast cancer might choose to have additional surgery to rebuild the shape and look of her breast but, it is advised to inform her surgeon before having the surgery to remove the tumor. In the case of prostatic cancer: Surgery is an option for treating cancer that's confined to the prostate. It's sometimes used to treat advanced prostate cancer in combination with other treatments. Radical prostatectomy: involves removing the prostate gland, some surrounding tissue and a few lymph nodes. **While surgery removes almost all of the cancerous cells, some cancerous cells are bound to remain so, some patients may be given radiation therapy, chemotherapy, targeted therapy, or hormone therapy after surgery, to kill any cancer cells that are left.

• Chemotherapy: Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, It is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body, the drugs will shrink the tumor and reduce the amount of tissue that needs to be removed during surgery either by killing the cells or by stopping them from dividing. It can be prescribed before the surgery (preoperative) or after the surgery (postoperative).

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

• Hormone therapy: Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing.

• Immunotherapy: Immunotherapy is a treatment that uses the patient’s immune system to fight cancer either by: - Genetically engineering the body’s immune cells: by modifying the cells in a laboratory to fight cancer and then injects the cells back into your body through a vein. - Helping your immune system cells identify cancer cells: using immunotherapy drugs, used for treating advanced cancers that no longer respond to hormone therapy.

• Targeted drug therapy: Targeted drug treatments focus on specific abnormalities present within cancer cells, by blocking these abnormalities, these treatments can cause cancer cells to die.

Special treatment for prostatic cancer: Freezing or heating prostate tissue: a. Freezing prostate tissue:

Cryoablation or cryotherapy for prostate cancer involves using a very cold gas to freeze the prostate tissue then, the tissue is thawed and the procedure repeats. The cycles of freezing and thawing kill the cancer cells and some surrounding healthy tissue. b. Heating prostate tissue: High-intensity focused ultrasound (HIFU) treatment uses concentrated ultrasound energy to heat the prostate tissue and cause it to die. **These treatments may be considered for treating very small prostate cancers when surgery isn't possible. (1, 2, 3)

Lifestyle adjustments, follow up and prevention What to expect and what lifestyle adjustments you need to make: • Follow-ups and doctor appointments as per your doctor’s instructions, the longer you have been free of cancer, the less often the appointments are needed. • Other tests you might need in the future, such as early detection (screening) tests for other types of cancer as having breast/prostatic cancer increases the risk of developing other types of cancers, or tests to look for long-term health effects from your cancer or its treatment. • Getting a list of possible late or long-term side effects from your treatment, including what to watch for and when you should contact your doctor.  Nutrition and diet: 1. Increase intake of fruits, vegetables and whole grains 2. Minimize intake of cured, pickled and smoked foods 3. Increase your intake of poultry, fish and vegetarian proteins (legumes and lentils). 4. Fat intake: -Decrease in food containing trans fatty acids. - Limit the intake of highly saturated foods. 4. Consuming moderate amount of calcium for healthy bone growth especially if on hormonal therapy but, not too much above 2000 mg per day

as evidence on increased intake of calcium and a higher risk of prostate cancer remains unclear.  Physical activity: Regular physical activity before cancer diagnosis and after treatment decreases the possibility for cancer to come back as exercising for 150 minutes per week.  Achieve and maintain a healthy weight.  Breastfeeding was found to decrease the risk of getting breast cancer.  Quitting smoking.  Getting emotional support: Feelings of depression, anxiety, or worry are normal when cancer is a part of your life. So, it is highly important to seek out help and create a support group for better mental and physical health as seeking out cancer survivorship groups or professional help. (4,5)

References: 1. https://prostatecanceruk.org/prostate-information/living-with-prostatecancer/your-diet-and-physical-activity/foods-to-eat-or-avoid 2. https://www.cancer.gov/types/breast/patient/breast-treatment-pdq 3. https://www.hopkinsmedicine.org/breast_center/treatments_services/nutrit ion.html 4. https://www.cancer.org/cancer/breast-cancer/living-as-a-breast-cancersurvivor/follow-up-care-after-breast-cancer-treatment.html 5. https://www.cancer.org/cancer/prostate-cancer/after-treatment/followup.html

Cardiovascular Diseases Cardiovascular disease (CVD) is the name for the group of disorders of heart and blood vessels. CVDs are the number one cause of death globally: more people die annually from CVDs than from any other cause. An estimated 17.3 million people died from CVDs in 2008, representing 30% of all global deaths. Low- and middle-income countries are disproportionally affected: over 80% of CVD deaths take place in low- and middle-income countries and occur almost equally in men and women. By 2030, almost 23.6 million people will die from CVDs, mainly from heart disease and stroke. These are projected to remain the single leading causes of death.

What are Cholesterol and Triglycerides? Cholesterol is a substance your body produces naturally. It is present in both the bloodstream and body’s cells Triglycerides are the most common type of fat in your body. They come from food, and your body also makes them. They also can build up within your artery walls and cause plaque, if not maintained in a certain range. (1)

The Normal Function of Cholesterol and Triglycerides Although elevated cholesterol & Triglyceride levels can lead to health problems, particularly cardiovascular diseases, both cholesterol and triglycerides have essential physiological roles to play in maintaining a healthy body. (2)  Cholesterol: 1. is an essential component of cell membranes. Without it cells would not maintain their cell membranes, thus rupture. 2. is also needed for the manufacture of steroid-based hormones, particularly sex hormones like testosterone and progesterone along with other hormones, produced mainly by the adrenal gland like Aldosterone (the hormone that makes the kidneys retain water) and cortisol (the hormone that is important in suppressing inflammation in the body) are two such examples. 3. must also be present for the skin to manufacture vitamin D, which plays a role in how the body handles calcium and assists in maintaining bone density.

4. enables the body to form bile acids, which are needed to help breakdown fats in the digestive tract so that they can be absorbed into the body. (2)  Triglycerides: 1. are an important source of energy for the body, particularly when glucose is deficient. (2) 2. They are stored in the body's fat cells. Being very overweight, eating a lot of fatty and sugary foods or drinking too much alcohol can make you more likely to have a high triglyceride level. Triglycerides can also contribute to the narrowing of the artery walls, increasing your risk. (5) Two types of lipoproteins carry cholesterol to and from cells. Low-density lipoprotein (LDL) transports cholesterol particles throughout your body. It is often called the “bad” kind of cholesterol. When you have too much LDL cholesterol in your blood, it can join with fats and other substances to build up in the inner walls of your arteries, creating a thick, hard substance called plaque. The arteries can become clogged and narrow, and blood flow is reduced or a piece may break off Having too much LDL in your blood will cause it to join with fats and other components creating a thick, hard Plaque. This causes the lumen to become narrower or even clogged thus reduce blood flow. If plaque accumulates a piece may break off and travel in the bloodstream, causing a heart attack or stroke. If the buildup of plaque ruptures a blood clot may form at this location; leading to Thrombus formation. (1,3) With LDL, lower is better High-density lipoprotein (HDL): The “good” kind of cholesterol is It removes the “bad” LDL cholesterol away from the arteries and back to the liver, so it can be removed from your body. HDL may also remove cholesterol from plaque in the arteries. (1)

Risk factors that can increase your risk of bad cholesterol include A: Controllable risk factors  Poor diet: 1. Eating saturated fat, found in animal products, and trans fats, found in some commercially baked cookies and crackers and microwave popcorn, can raise your cholesterol level.

2. Foods that are high in cholesterol, such as red meat and full-fat dairy products, will also increase your cholesterol.  Obesity: Having a body mass index (BMI) of 30 or greater puts you at risk of high cholesterol.  Lack of exercise: Exercise helps boost your body's HDL, or "good," cholesterol while increasing the size of the particles that make up your LDL, or "bad," cholesterol, which makes it less harmful.  Smoking: As it lowers your level of HDL, or "good," cholesterol levels.  Diabetes: High blood sugar contributes to higher levels of dangerous cholesterol called very-low-density lipoprotein (VLDL) and lower HDL cholesterol. (4, 16) B: Uncontrollable risk factors  Age: Particularly men above the age of 55-60 and women 65 and older. (8) as we age, our liver becomes less able to remove LDL cholesterol. (4)  Sex: Until around age 55 (or until menopause), women tend to have lower lowdensity lipoprotein (LDL, or “bad”) levels than men do. At any age, men tend to have lower high-density lipoprotein (HDL, or “good”) cholesterol than women do. (7)  Familial Hypercholesterolemia (FH): a condition that runs in the family where people have very high LDL cholesterol levels in their blood, above 190 mg/dL. Men and women are affected equally. Everyone’s cholesterol levels tend to rise with age, but people with FH are born with high cholesterol. As time passes, it gets worse. FH can’t be treated by diet and exercise alone. These lifestyle changes help will lower LDL, but when levels must be decreased by 50% or 75%, medication is needed. (1)  Kidney Diseases: such as Nephrotic syndrome (9)  Liver Conditions: Where the liver serves as the center for lipoprotein uptake, formation, and export to the circulation. Thus, chronic liver disease, such as nonalcoholic fatty liver disease (NAFLD) causes increased LDL particle concentrations, decreased LDL particle size, and decreased HDL levels. (10)  Underactive thyroid gland: Patients with hypothyroidism have higher cholesterol levels. (11)

High Cholesterol can increase the risk of developing:

 Coronary Heart Disease (CHD): When your cholesterol level is too high, it builds upon the walls of your arteries resulting in atherosclerosis, causing arteries to become narrowed and reduce blood flow to the heart. This narrowing leads to Hypertension (High blood pressure) This can result in angina (chest pain) from not enough blood flow getting to the heart, or a heart attack in cases when a blood vessel is blocked completely and the heart muscle begins to die.  Stroke: It occurs when a blood vessel that carries oxygen and nutrients to the brain becomes blocked or bursts. It occurs when the blood supply to the brain is reduced. When a stroke occurs, part of the brain cannot get the blood and oxygen it needs, so it starts to die.  Peripheral arterial disease: refers to diseases of blood vessels that are outside the heart and brain. In PAD, fatty deposits build up along artery walls and affect blood circulation, mainly in arteries leading to the legs and feet. The arteries of the kidney can also be affected. (12)

How To Get Your Cholesterol Tested? "Fasting" or "Non-fasting" lipoprotein profile. Fasting usually means not eating, drinking certain beverages and taking medications 9 to 12 hours before the cholesterol test. A sample of blood is taken by a needle then analyzed in a laboratory, where the levels of HDL cholesterol, LDL cholesterol and triglycerides are measured. If you don’t fast, only the values for total cholesterol and HDL cholesterol will be usable. The test report will show the cholesterol level in milligrams per deciliter of blood (mg/dL). (13) For the most accurate results, the test should be done at least two months after a heart attack, surgery, infection, injury or pregnancy to check LDL levels. (14)

Ideal cholesterol levels  Total cholesterol level – less than 200 mg/dL is best, but it depends on your HDL and LDL levels. Goal values:  75-169 mg/dL for those age 20 and younger  100-199 mg/dL for those over age 21  LDL cholesterol levels – less than 130 mg/dL is best, but this depends on your risk for heart disease. (6) Goal values:

 Less than 70 mg/dL for those with heart or blood vessel disease and other patients at very high risk of heart disease (those with metabolic syndrome)  Less than 100 mg/dL for high-risk patients (e.g., some patients who have multiple heart disease risk factors)  Less than 130 mg/dL for individuals who are at low risk for coronary artery disease  HDL cholesterol levels – 60 mg/dL or higher reduces your risk for heart disease.  Triglycerides – less than 150 mg/dL is best. (6, 14)

Treatment Plan & Lifestyle Changes A: Diet Adjustments: Eating a heart-healthy diet can help you improve your cholesterol and reach and maintain a healthy weight and blood pressure.  Focus on eating 1. A variety of fruits and vegetables. 2. A variety of whole-grain foods like whole-grain bread, cereal, pasta and brown rice. At least half of the servings should be whole grains. 3. Fat-free, 1% and low-fat milk products. 4. Poultry without skin and lean meats. When you choose to eat red meat and pork, select options labeled “loin” and “round.” These cuts usually have the least amount of fat. 5. Unsalted nuts, seeds, and legumes (dried beans or peas). 6. Non-tropical vegetable oils like canola, corn, olive or safflower oils.  Limit 1. 2. 3. 4. 5. 6. 7. 8. 9.

Foods with a lot of sodium (salt). Sweets and sugar-sweetened beverages. Red meats and fatty meats that aren’t trimmed. Full-fat dairy products such as whole milk, cream, ice cream, butter, and cheese. Baked goods made with saturated and trans fats like donuts, cakes and cookies. Foods that list the words “hydrogenated oils” in the ingredients panel. Tropical oils such as coconut, palm and palm kernel oils. Solid fats like shortening, stick margarine and lard. Fried foods. (1)

B: Life Style Changes 1. Exercise regularly. Aim for at least 30 minutes of physical activity on most or all days of the week. 2. Regular exercise can lower triglycerides and boost "good" cholesterol. Try to incorporate more physical activity into your daily tasks — for example, climb the stairs at work or take a walk during breaks. 3. Quit Smoking: By quitting, smokers can lower their LDL cholesterol and increase their HDL cholesterol levels. It can also help protect their arteries. Nonsmokers should avoid exposure to secondhand smoke. 4. Stop Drinking Alcohol (4, 15, 16) C: Medication: is prescribed to patients with borderline to intermediate risk and have risk enhancing factors or are at high risk for heart disease or stroke. These include:  Statins prevent the production of cholesterol in the liver. Their major effect is to lower LDL cholesterol. If the patient has CVD and is already taking the highest tolerated statin and his LDL is still 70 or above, one or more of the following medicines may be prescribed.  Ezetimibe (cholesterol absorption inhibitors) works by preventing cholesterol from being absorbed in the intestine. It is the most commonly used non-statin agent.  Bile acid sequestrants cause the intestine to get rid of more cholesterol.  PCSK9 Inhibitors are powerful LDL-lowering drugs. They bind to and inactivate a protein in the liver to lower LDL (bad) cholesterol.  Fibrates are especially good for lowering triglyceride (blood fat) levels and have a mild LDL-lowering action.

 Niacin (nicotinic acid) is a B vitamin that limits the production of blood fats in the liver. (1)

References 1. https://www.heart.org/-/media/files/health-topics/cholesterol/my-cholesterol-guideenglish.pdf?la=en 2. https://www.independentnurse.co.uk/clinical-article/the-role-of-cholesterol/63612/ 3. https://www.health.harvard.edu/heart-health/the-problem-with-plaque-evenlesser-amounts-are-stillrisky#:~:text=Once%20a%20plaque%20ruptures%2C%20platelets,of%20the%20 heart%20muscle%20dies. 4. https://www.mayoclinic.org/diseases-conditions/high-bloodcholesterol/symptoms-causes/syc-20350800 5. https://www.bhf.org.uk/informationsupport/risk-factors/high-cholesterol 6. https://familydoctor.org/condition/cholesterol/ 7. https://www.cdc.gov/cholesterol/risk_factors.htm 8. https://www.hendrickhealth.org/services/heart-vascular/risk-factors-warningsigns/ 9. https://www.kidney.org.uk/cholesterol-and-kidney-disease 10.

https://www.ncbi.nlm.nih.gov/books/NBK326742/

11. https://www.thyroid.org/patient-thyroid-information/ct-for-patients/august2017/vol-10-issue-8-p-9/ 12. https://my.clevelandclinic.org/health/articles/11918-cholesterol-highcholesteroldiseases#:~:text=Diseases%20that%20are%20tied%20to,diabetes%20and%20hi gh%20blood%20pressure.

13. https://www.heart.org/en/health-topics/cholesterol/how-to-get-your-cholesteroltested 14.

https://my.clevelandclinic.org/health/diagnostics/17176-lipid-blood-tests

15. https://www.bhf.org.uk/informationsupport/risk-factors/high-cholesterol/fourlifestyle-changes-to-lower-your-cholesterol 16. https://www.heart.org/en/health-topics/cholesterol/prevention-and-treatmentof-high-cholesterol-hyperlipidemia

Arrhythmia The heart is a pump made up of muscle tissue. The heart's pumping action is regulated by an electrical conduction system (SA node heart’s pacemaker) that coordinates the contraction of the various chambers of the heart. (1)

The normal rhythm of the heart The sinoatrial node (SA node) located in the right atrium, produces electrical impulses that normally start each heartbeat. These impulses cause the atria muscles to contract and pump blood into the ventricles. The electrical impulses then arrive atrioventricular (AV) node which slows down the electrical signal before sending it to the ventricles. This slight delay allows the ventricles to fill with blood. When electrical impulses reach the muscles of the ventricles, they contract, causing them to pump blood either to the lungs or to the rest of the body. (1, 3)

In a healthy heart, this process usually goes smoothly, resulting in a normal resting heart rate of 60 to 100 beats per minute. (3) Arrhythmia is a problem with the rate or rhythm of the heart and it has several types as tachycardia in which the heart beats too fast for a normal person, or bradycardia in contrary to tachycardia in which the heart beats too slow, or it can be irregular rhythm. (5)

Risk factors

Certain conditions may increase your risk of developing an arrhythmia. These include: Coronary artery disease:



Which can be due to narrowed heart arteries, a heart attack, abnormal heart valves, prior heart surgery, heart failure, cardiomyopathy and other heart damage. All of these diseases are risk factors for almost any kind of arrhythmia. High blood pressure:



This increases your risk of developing coronary artery disease. It may also cause the walls of your left ventricle to become stiff and thick, which can lead to arrhythmia. Changes in the heart muscle (cardiomyopathy) Valve disorders Electrolyte imbalances in the blood such as sodium or potassium

  

Electrolyte levels that are too high or too low can affect your heart's electrical impulses. Injury from a heart attack The healing process after heart surgery Thyroid problems (Hyper or hypothyroidism) Diabetes. Increases your risk of developing coronary artery disease and high blood pressure greatly increases with uncontrolled diabetes.

   

Obstructive sleep apnea. This disorder, in which your breathing is interrupted during sleep, can increase your risk of bradycardia, atrial fibrillation and arrhythmia. Infection with COVID-19

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Other risk factors that can cause an arrhythmia include: 

Smoking

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Drinking too much alcohol or caffeine

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Stress or anxiety

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Certain medications and supplements

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Genetics (3)

Signs and Symptoms

Arrhythmias may not cause any signs or symptoms. Noticeable signs and symptoms don't necessarily mean you have a serious problem, however. These signs are most common among patients suffering from arrhythmias.        

Palpitations: A feeling of skipped heartbeats, fluttering, "flip-flops" or feeling that the heart is "running away". Pounding in the chest Dizziness or feeling lightheaded Shortness of breath Chest discomfort Weakness or fatigue Blurred vision Foggy thinking (4)

Diagnosis and testing To diagnose arrhythmia, your doctor will ask you about your symptoms, your medical history, and any signs of arrhythmia in your family. Your doctor may also do an ECG and a physical exam as part of your diagnosis. 1.

Medical history.

Physical exam: your doctor may take these steps:  Check for swelling in your legs or feet, which could be a sign of a Cardiomegaly or heart failure  Check your pulse  Listen to the rate and rhythm of your heartbeat  Listen to your heart for a heart murmur (4)

Diagnostic tests and procedures:  Blood tests: to check the level of certain substances in the blood, such as potassium and thyroid hormone.  Cardiac catheterization: is a procedure used to diagnose and treat certain cardiovascular conditions. But it has some risks such as (bleeding, heart attack, stroke, damage to the area where the catheter was inserted).  Chest X-ray is usually taken after placement of

such medical devices (Pacemakers, defibrillators and catheters) to make sure everything is positioned correctly.  Echocardiography uses sound waves (ultrasound) to image the heart size, structure and function as well as detailed images of the heart valves.  Electrocardiogram (ECG): Electrocardiogram records the electrical signals in your heart used to detect heart problems. It is a common, painless and safe test used to quickly detect heart problems because it doesn’t produce electricity.  Electrophysiology study (EPS) is recommended in people with arrhythmias and other heart problems.  Ultrasound: This procedure is done in pregnant women to diagnose a suspected fetal arrhythmia in the womb. (2,4,6,7,8,9)

Types of arrhythmia Doctors classify arrhythmias not only by where they originate (atria or ventricles) but also by the speed of heart rate such as:

1. Bradyarrhythmia (bradycardia): It is defined as a heart rate that is slower than 60

beats per minute. 2. Tachycardia: It is defined as a heart rate that is faster than 100 beats per minute and includes:  Atrial fibrillation the heart can race at more than 400 beats per minute.  Atrial flutter the atria beat 250 to 350 times per minute.

   

Paroxysmal supraventricular tachycardia (PSVT): It is usually not dangerous Wolff-Parkinson-White syndrome: caused by an extra electrical pathway Ventricular fibrillation: it can be fatal. Long QT syndrome: it may lead to fainting and can be life-threatening.

3. Premature heartbeat: A premature heartbeat happens when the signal to a heartbeat comes earlier. It can feel like your heart skipped a beat and followed by a stronger beat. (3,4)

Complications Certain arrhythmias may increase your risk of developing conditions such as: Stroke: Heart arrhythmias are associated with an increased risk of blood clots. Blood clots can travel from your heart to your brain where it might block blood flow, causing a stroke. Heart failure: It can result if your heart is pumping ineffectively for a prolonged period due to bradycardia or tachycardia. (3)

Treatment Common arrhythmia treatments include hearthealthy lifestyle changes, medicines, surgically implanted devices that control the heartbeat, and other procedures that treat abnormal electrical signals in the heart. 1. Medicines: such as (Adenosine, Atropine, Betablockers, blood thinners, calcium channel blockers, sodium channel blockers, potassium channel blockers).

2. Procedures: If medications didn’t work and had no effect some procedures are made like: o Cardioversion it is usually done by sending electric shocks to your heart through electrodes placed on your chest. o Catheter ablation. o Implant cardioverter-defibrillator (ICDs) ICD can deliver electric shocks via one or more wires connected to your heart fixing abnormal heart rhythm. o Pacemaker is small device placed under the skin in your chest to help control your heartbeat.

Surgeries: In some cases, surgery may be the recommended treatment for heart arrhythmias such as: o Maze procedure: A surgeon makes series of surgical incisions in the atria creating a pattern or maze of scar tissue. Scar tissues don’t conduct electricity, so it interferes with stray electrical impulses that cause some types of arrhythmia. o Coronary bypass surgery (CABG): If you have severe coronary artery disease in addition to arrhythmias, this procedure may improve the blood flow to your heart. (2,4,10,11,12) Alternative medicine: Research is ongoing regarding the effectiveness of several forms of complementary and alternative medical therapies for arrhythmia such as: o Yoga o Meditation o Relaxation techniques (2)

Checkups required and Life Style adjustments To monitor your condition, your doctor may recommend the following tests:  Blood tests  Echocardiography (echo) to check your heart functions if you have underlying heart disease.  Monitors: to detect changes in the heart rhythm include the following: 1. Electrocardiograms (ECG) 2. Holter monitor: is a small, wearable device that records a continuous ECG, usually for 24 to 48 hours. 3. Event monitor: similar to Holter monitor. 4. Smartphone-based monitor (4) Your doctor may suggest that, in addition to other treatments, you make lifestyle changes that include:  Eat heart-healthy foods.

 Exercise regularly for at least 30 minutes on most days.  Quit smoking.  Maintain a healthy weight.  Keep blood pressure and cholesterol levels under control.  Drink alcohol in moderation.  Maintain follow-up care.  Using over-the-counter medications with caution, as some cold and cough medications contain stimulants that may trigger a rapid heartbeat. (2)

References 1. https://www.hopkinsmedicine.org/health/conditions-and-diseases/anatomyand-function-of-the-hearts-electrical-system 2. https://www.mayoclinic.org/diseases-conditions/heart-arrhythmia/diagnosistreatment/drc-20350674 3. https://www.mayoclinic.org/diseases-conditions/heart-arrhythmia/symptomscauses/syc-20350668 4. https://www.nhlbi.nih.gov/health-topics/arrhythmia 5. https://www.nhs.uk/conditions/arrhythmia/ 6. https://www.mayoclinic.org/tests-procedures/ep-study/about/pac-20384999 7. https://www.mayoclinic.org/departments-centers/echocardiographylaboratory/overview/ovc-20442326 8. https://www.mayoclinic.org/tests-procedures/cardiaccatheterization/about/pac-20384695 9. https://www.mayoclinic.org/tests-procedures/chest-x-rays/about/pac-20393494 10. https://www.mayoclinic.org/tests-procedures/cardioversion/about/pac20385123

11. https://www.mayoclinic.org/tests-procedures/implantable-cardioverterdefibrillators/about/pac-20384692 12. https://www.mayoclinic.org/tests-procedures/pacemaker/about/pac20384689

Cardiac stenosis Types of Stenosis  Aortic valve stenosis: when the heart's aortic valve narrows preventing the valve from opening fully, which reduces or blocks blood flow from the heart into the main artery to the body via the aorta.  Tricuspid Valve Stenosis: the narrowing of the tricuspid valve opening thus blood doesn’t flow easily from the right atrium to the right ventricle.  Pulmonary Stenosis: the narrowing of the pulmonary valve opening. As one or more of the cusps may be defective or too thick, or the cusps may not separate from each other properly. restricting blood flow from the right ventricle to the pulmonary arteries, which deliver blood to the lungs.  Mitral Stenosis: the narrowing of the mitral valve, which controls the flow of blood from the heart’s left atrium to the left ventricle. (1, 2, 5, 8)

Causes & Risk Factors  Congenital heart defect.  Calcium buildup on the valve These deposits may never cause any problems. However, in some people — particularly those with a congenitally abnormal aortic valve.  Rheumatic fever. A complication of strep throat infection, rheumatic fever may result in scar tissue forming on the aortic valve that can narrow the aortic valve and lead to aortic valve stenosis. Scar tissue can also create a rough surface on which calcium deposits can collect, contributing to aortic valve stenosis later in life. Rheumatic fever may damage more than one heart valve and in more than one way. A damaged heart valve may not open fully or close fully — or both.  Atherosclerosis. As calcium builds up on the valve over time (similar to atherosclerosis or hardening of the arteries), it can cause gradual wear and tear of the valve leaflets.  Infection of the valve (endocarditis). An infection of the valve is more likely to happen when you already have an abnormal heart valve or abnormal blood flow through the valve.  Together with mitral valve abnormalities. Tricuspid valve disease often happens at the same time as mitral valve disease and is usually treated at the same time, especially if surgery is needed.  Pulmonary valve stenosis usually occurs when the pulmonary valve doesn't grow properly during fetal development.  Calcium deposits with age around the ring (annulus) of the valve.  Other rare causes include radiation to the chest and some autoimmune diseases, such as lupus, especially in mitral valve stenosis.  Having cardiovascular risk factors, such as diabetes, high cholesterol and high blood pressure  Chronic kidney disease  History of radiation therapy to the chest (1, 4)

Signs & Symptoms    

Fatigue, low tolerance for exercise Fainting shortness of breath, Cold skin, fluttering sensations and palpitations.

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Heart murmur Chest pain or palpitations Swollen feet or legs Coughing up blood (3,5,7)

Complications           

Heart failure heart attack Stroke Heart rhythm abnormalities (arrhythmias) Cardiomegaly: Heart enlargement Atrial fibrillation. Lung congestion Swollen feet and ankles. Infections that affect the heart, such as Endocarditis. Right ventricular hypertrophy, in pulmonary stenosis. Pulmonary hypertension: This is a condition in which there's increased pressure in the pulmonary arteries. Occurs especially in mitral valve stenosis. (1,3, 6, 7)

Diagnostic Procedures for Stenosis in General Tests used to diagnose valve disease may include:  Electrocardiography (ECG): Is used to assess  heart rhythm  diagnose poor blood flow to the heart muscle (ischemia)  diagnose abnormalities of your heart, such as heart chamber  Abnormal electric conduction  Chest X-ray  Echocardiography: is a graphic outline of the heart's movement. During an echo test, ultrasound (high-frequency sound waves) from a hand-held wand placed on

your chest provides pictures of the heart's valves and chambers and helps the sonographer evaluate the pumping action of the heart. Echo is often combined with Doppler ultrasound (a noninvasive test that can be used to estimate the blood flow through your blood vessels by bouncing high-frequency sound waves (ultrasound) off circulating red blood cells.) and color Doppler to evaluate blood flow across the heart's valves. (10, 11)  Assess the overall function of your heart.  Determine the presence of many types of heart disease, such as valve disease, myocardial disease, pericardial disease, infective endocarditis, cardiac masses and congenital heart disease.  Follow the progress of valve disease over time.  Evaluate the effectiveness of your medical or surgical treatments. (10)  Transesophageal echocardiography: a type of echo that uses a long, thin, tube (endoscope) to guide the ultrasound transducer down the esophagus. This lets the doctor see pictures of the heart without the ribs or lungs getting in the way. A combination of Transesophageal echocardiography, Doppler ultrasound and color Doppler to get information about how blood flows across your heart’s valves. It is used to:  Check how well your heart’s valves and chambers are working.  Look for problems, such as valve disease, myocardial disease, pericardial disease, infective endocarditis, cardiac masses and congenital heart disease.  See how well your heart valves are working after surgery.  Check for abnormalities in the top left chamber of your heart (left atrium). (12)  Cardiac Catheterization (cardiac cath or angiogram): Where a long, narrow tube called a catheter is inserted through a plastic introducer sheath (a short, hollow tube that is inserted into a blood vessel in your leg or arm). The catheter is guided through the blood vessel to the coronary arteries with the aid of a special x-ray machine. Contrast material is injected through the catheter and x-ray movies are created as the contrast material moves through the heart’s chambers, valves and major vessels. (13)  Magnetic resonance imaging (MRI): a painless test that produces very clear images of the organs and structures within the body. MRI uses a large magnet, radio waves and a computer to produce these detailed images. It does not use Xrays (radiation). (13)

Medications generally recommended for Patients with Stenosis No medications can correct a valve defect. However, certain drugs can reduce symptoms by easing your heart's workload and regulating its rhythm. Your doctor might prescribe one or more of the following medications:  Diuretics to reduce fluid accumulation in your lungs or elsewhere.  Blood thinners (anticoagulants) to help prevent blood clots. Daily aspirin may be included.  Beta-blockers or calcium channel blockers to slow your heart rate and allow your heart to fill more effectively.  Anti-arrhythmics to treat rhythm disturbances associated with valve stenosis.  Antibiotics to prevent a recurrence of rheumatic fever if that's what caused your mitral stenosis.

Surgical Procedures for Patients with Stenosis Depends on the severity of the condition, whether the patient is experiencing signs and symptoms, and if the condition is getting worse.  Valve repair: Where surgeons either separate fused flaps of the valve, reposition or reshape it or otherwise fix the valve to connective tissue structures to support it.  Valve Replacement: Surgeon removes damaged valve which is beyond repair and replaces it with either; o Mechanical valve: a man-made valve. However, to prevent blood clots that may accompany a mechanical valve, the doctor may prescribe blood-thinning medications. o Biological valve: The replacement valve is made from cow, pig or human heart tissue. These valves may wear out over time, requiring another valve replacement.  Balloon Valvuloplasty: procedure using a long, thin tube (catheter) to repair valve stenosis. In this procedure, a

doctor inserts a catheter with a balloon on the tip into an artery in the patient arm or groin and guides it to the aortic valve. The doctor performing the procedure then inflates the balloon, which expands the opening of the valve. The balloon is then deflated, and the catheter and balloon are removed. In some cases, this procedure can treat valve stenosis in infants and children. However, the valve tends to narrow again in adults who've had the procedure, so it's usually only performed in adults who are too ill for surgery or who are waiting for a valve replacement, as they typically need additional procedures to treat the narrowed valve over time.  Commissurotomy: A special procedure for mitral stenosis If balloon valvuloplasty isn't an option, a cardiac surgeon might perform open-heart surgery to remove calcium deposits and other scar tissue to clear the valve passageway. The procedure requires that the patient is put on a heart-lung bypass machine during the surgery. The patient may need the procedure repeated if your mitral valve stenosis redevelops. N.B: For Pulmonary stenosis to decide what treatment to use, doctors consider: •

The location of the narrowing and the amount of narrowing

•

The child's age and size

•

How well the other valves in the heart are working

•

Whether the child has had previous heart surgery

•

Whether the child has other medical conditions (15, 16, 17)

Prevention of Stenosis in General includes  Taking steps to prevent rheumatic fever. You can do this by making sure you see your doctor when you have a sore throat. Untreated strep throat can develop into rheumatic fever. Fortunately, strep throat can usually be easily treated with antibiotics.  Addressing risk factors for coronary artery disease. These include high blood pressure, obesity and high cholesterol levels. These factors may be linked to aortic valve stenosis.  Taking care of your teeth and gums. There may be a link between infected gums (gingivitis) and infected heart tissue (endocarditis). Inflammation of heart

tissue caused by infection can narrow arteries and aggravate aortic valve stenosis.  Control your cholesterol and risks for heart disease. If you use tobacco, quit. It is one of the best things you can do for your health. Besides, follow these healthy living guidelines:      

Exercise regularly. Take medicines to lower your cholesterol if necessary. Eat a heart-healthy and low-fat diet. Control your blood pressure. Maintain your ideal weight if possible. Control your blood sugar if you have diabetes (1, 4)

References 1. https://www.mayoclinic.org/diseases-conditions/aortic-stenosis/symptomscauses/syc-20353139 2. https://carle.org/conditions/heart-and-vascular-conditions/tricuspid-valvestenosis 3. https://www.templehealth.org/services/conditions/tricuspid-valvestenosis/symptoms 4. https://mydoctor.kaiserpermanente.org/ncal/article/tricuspid-stenosis-195503 5. https://www.heart.org/en/health-topics/heart-valve-problems-and-disease/heartvalve-problems-and-causes/problem-pulmonary-valve-stenosis

6. https://www.mayoclinic.org/diseases-conditions/pulmonary-valvestenosis/symptoms-causes/syc-20377034 7. https://www.mayoclinic.org/diseases-conditions/mitral-valve-stenosis/symptomscauses/syc-20353159 8. https://www.mayoclinic.org/diseases-conditions/pulmonary-valvestenosis/symptoms-causes/syc-20377034 9. https://www.genome.gov/Genetic-Disorders/NoonanSyndrome#:~:text=is%20Noonan%20Syndrome%3F,Noonan%20syndrome%20is%20a%20disorder%20that%20involves%20unusu al%20facial%20characteristics,of%20several%20autosomal%20dominant%20g enes. 10. https://my.clevelandclinic.org/health/diagnostics/16947-echocardiogram 11. https://www.mayoclinic.org/doppler-ultrasound/expert-answers/faq-20058452 12. https://my.clevelandclinic.org/health/diagnostics/4992-echocardiogramtransesophageal-tee 13. https://my.clevelandclinic.org/health/diagnostics/16832-cardiac-catheterization

Asthma Asthma is a chronic disease involving the airways in the lungs. These airways, or bronchial tubes, allow air to come in and out of the lungs. If you have asthma, your airways are always inflamed. They become even more swollen and the muscles around the airways can tighten when something triggers your symptoms. This makes it difficult for air to move in and out of the lungs, causing what is called an "Asthma attack". (4)

Causes: Asthma tends to run in families and may be inherited, and environmental factors may also play a key role. Scientists continue to explore what causes asthma, but we do know that these factors play an important role in the development of asthma. (1)  Genetics. Asthma tends to run in families, if your mom or dad has asthma, then you are likely to have asthma too. More than one gene is likely to be involved.  Allergies. Some people are likely to develop allergies than others, especially if one of their parents has allergies. Certain allergic conditions are linked to people who get asthma.  Respiratory Infections. The lungs develop in infancy and early childhood, certain respiratory infections have been shown to cause inflammation and damage the lung tissue. The damage that is caused in infancy or early childhood can impact lung function long-term.

 Environment. Contact with allergens, certain irritants, or exposure to viral infections as an infant or in early childhood when the immune system isn't fully mature has been linked to developing asthma. Exposure to certain chemicals and dust in the workplace may also play a significant role in adult-onset asthma. (1)

Risk factors: Your environment or occupation, your family history or genes, other medical conditions, your race or ethnicity, or your sex may raise your risk for developing asthma. Asthma affects people of all ages, but it often starts during childhood. Sometimes asthma develops in adults, particularly women. This type of asthma is called adultonset or late-onset asthma. Environment or occupation: Things in your environment, including work or home, may raise your risk of developing asthma or make asthma symptoms worse. 

 



Exposure to cigarette smoke in the womb or a child’s first few years raises the risk of developing asthma symptoms early in life. This exposure may also affect lung growth and development. Exposure to different microbes in the environment, especially early in life, can affect how the immune system develops. Exposures that occur in the workplace, such as chemical irritants or industrial dust, may also raise the risk of developing asthma in susceptible people. This type of asthma is called occupational asthma. It may develop for years, and it often lasts even after you are no longer exposed. Poor air quality from pollution or allergens may make asthma worse. Pollutants may include traffic-related air pollution. Allergens in the air may include pollen, dust, or other particles. Other medical conditions: Asthma is often linked to other medical conditions, such as:



Allergies: Asthma is usually a type of allergic reaction. People who have asthma often have other types of allergies. They may have food allergies or get a runny or stuffy nose from pollen. You may be at higher risk for developing asthma if you had allergic reactions in early childhood to substances in the air, such as pollen, dander,



mold, or dust. The more things you are allergic to, the higher your risk of asthma will be. Obesity: can increase the chances of developing asthma or worsening asthma symptoms. This may be because people who have obesity can have inflammation or changes in the immune system. Respiratory infections and wheezing: Young children who often have respiratory infections caused by viruses are at the highest risk of developing asthma symptoms early in life. Race or ethnicity: African Americans and Puerto Ricans are at higher risk of asthma than people of other races or ethnicities. African American and Hispanic children are more likely to die from asthma-related causes than non-Hispanic white Americans. Sex: Among children, boys are likely to have asthma rather than girls. Among teens and adults, asthma is more common among women than men. (3)

The most common symptoms of asthma:    

Wheezing (a whistling sound when breathing). Breathlessness. A tight chest, that feels like a band tightening around it. Coughing, especially at night or early morning. (3)

Many things can cause these symptoms, but they're more likely to be asthma if they:    

Happen often and keep coming back. They start or get worse with viral infections, such as colds. (3) Are worse at night and early in the morning. Seem to happen in response to an asthma trigger like exercise, cold air, or an allergy (such as allergies to pollen or animal fur). (2,3)

Asthma attacks: Are episodes that occur when symptoms get much worse and require a change in a typical treatment. These can happen gradually or suddenly and may be lifethreatening. People who have severe asthma often get asthma attacks. (3) Signs of a severe asthma attack include:  

Wheezing, coughing, and chest tightness becoming severe and constant. Being too breathless to eat, speak, or sleep.

    

Rapid breath and heartbeat. Drowsiness, confusion, exhaustion, or dizziness. Blue lips or fingers. Fainting. Children may also complain of a tummy or chest ache. (2)

Diagnosis: To diagnose asthma, a doctor will evaluate these symptoms, ask for complete health history, conduct a physical exam, and look at test results. Today, asthma is no longer thought of as a single disease. Asthma is often categorized into different types based on the triggers identified by the doctor and the patient that cause breathing problems and make asthma symptoms worse. They include: 

Allergic asthma.



Aspirin-induced asthma.

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Cough-variant asthma.

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Exercise-induced asthma.

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Nighttime asthma.



Steroid-resistant asthma.

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Occupational asthma. Some people have asthma that is very difficult to be treated, as it does not respond well to inhaled corticosteroids. Depending on the type of asthma, there are different management steps and treatment options that can help. Researchers have started to look deeper at the role that inflammation plays in asthma. They believe that all people with asthma have some degree of inflammation of the airways. They have categorized these into four biological pathways of inflammation, or endotypes:



Eosinophilic.



Neutrophilic.



Mixed eosinophilic and neutrophilic.



Non-inflammatory (Paucigranulocytic). (1)

Health History. You will be asked for some medical history, which should include family members with asthma, allergies, smoking, and exposure to secondhand smoke as well as pollutants in your workplace. (1)

Breathing problems during exercise. If you have chest tightness, cough, wheeze, or shortness of breath during exercise, your doctor may perform extra tests to see if you have a type of asthma called: exercise-induced asthma or exercise-induced bronchospasm. For some people, they will only have asthma symptoms during exercise. There are many benefits of exercise, so work with your doctor to find the best management steps and treatment options for you. (1)

Diagnosing asthma in children. A young child who has frequent wheezing with colds or respiratory infections is more likely to have asthma if: 

A parent has asthma.



The child has signs of allergies, including allergic skin condition eczema.



The child wheezes even when he or she doesn't have a cold or other infection. To help your child's healthcare provider make a correct diagnosis, be prepared to provide information about family history of asthma or allergies, the child's overall behavior, breathing patterns, and responses to foods or possible allergy triggers. Lung function tests are often used to make an asthma diagnosis, but they are very hard to do with young children. The doctor may use a 4- to 6-week trial of asthma medicines to see if they make a difference in your child's symptoms. (1)

Treatment:

Symptoms can be controlled with effective asthma treatment and management. Treatment usually depends on your age, asthma severity, and response to a given treatment option. (3,4)

1. Inhalers: Inhalers devices that let you breathe in medicine, are the main treatment. Types of Inhalers: 1. Reliever inhalers that relieve symptoms when they occur. - Reliever inhalers have few side effects, but they can sometimes cause shaking or a fast heartbeat for a few minutes after they're used. 2. Preventer inhalers that stop symptoms from developing. - Preventer inhalers contain steroid medicine. - They are important to use even if you are asymptomatic. -They do not usually have side effects, but can sometimes cause:  Fungal infection of the mouth or throat (oral thrush).  A hoarse voice.  A sore throat. - You can help prevent these side effects by:  Using a spacer, which is a hollow plastic tube you attach to your inhaler,  Rinsing your mouth or cleaning your teeth after using your inhaler. 3. Combination inhalers: If using reliever and preventer inhalers does not control your asthma, you may need an inhaler that combines both. - They are important to use it even if you are asymptomatic. - Side effects of combination inhalers are similar to those of reliever and preventer inhalers.

2. Tablets: You may also need to take tablets if using an inhaler alone is not helping control your symptoms.

If you are using steroid tablets, you may experience long-term or frequent use of steroid tablets which can occasionally cause side effects such as: 

Increased appetite, leading to weight gain.



Easy bruising.



Mood changes.



Fragile bones (Osteoporosis).



High blood pressure.

3. Injections: For some people with severe asthma, injections are given every few weeks can help control the symptoms. These medicines are not suitable for everyone with asthma and can only be prescribed by an asthma specialist. - The main side effect is discomfort where the injection is given. Manage your asthma at home. As part of your asthma action plan, your doctor may show you how to monitor your asthma using a peak flow meter. You can compare your numbers over time to make sure your asthma is controlled. A low number can help warn you of an asthma attack, even before you notice symptoms. Prevent complications from asthma. Your doctor may recommend that you keep your medicine dose as low as possible to prevent long-term side effects. High doses of certain asthma medicines over time can increase your risk of cataracts (clouding of the lens in your eye) and osteoporosis. (3)

References: 1. https://www.lung.org/lung-health-diseases/lungdisease-lookup/asthma 2. https://www.nhs.uk/conditions/asthma/ 3. https://www.nhlbi.nih.gov/health-topics/asthma

4. https://www.aaaai.org/conditions-and-treatments/asthma

Emphysema Emphysema is a lung condition that causes shortness of breath. People with emphysema, have damaged alveoli, where the inner walls of the air sacs weaken and rupture — creating larger air spaces instead of many small ones. This reduces the surface area of the lungs and, in turn, the amount of oxygen that reaches your bloodstream. When the person exhales, the damaged alveoli don't work properly and old air becomes trapped, leaving no room for fresh, oxygen-rich air to enter. Most people with emphysema also have chronic bronchitis. Chronic bronchitis is inflammation of the tubes that carry air to your lungs (bronchial tubes), which leads to a persistent cough.

Risk Factors Smoking: Emphysema is most likely to develop in smokers. The risk for all types of smokers increases with the number of years and amount of tobacco smoked. Age: Lung damage that occurs in emphysema develops gradually, most people with tobacco-related emphysema begin to experience symptoms of the disease between the ages of 40 and 60. Exposure to secondhand smoke: Also known as passive or environmental tobacco smoke; which is smoke that you inadvertently inhale from someone else's cigarette. Occupational exposure to fumes or dust: If you breathe fumes from certain chemicals or dust from grain, cotton, wood or mining products, you're more likely to develop emphysema. This risk is even greater if you smoke.

Exposure to indoor and outdoor pollution. Breathing indoor pollutants, such as fumes from heating fuel Breathing outdoor pollutants: car exhaust, for instance increases your risk of emphysema. (1)

Symptoms At first, you may have no symptoms or only mild symptoms. As the disease gets worse, your symptoms usually become more severe. They can include:  Wheezing Breath  Coughing  Bringing up phlegm (contaminated mucus) when coughing  Tightness in the chest  Constant fatigue  Difficulty sleeping  Morning headaches  Weight loss  Ankle swelling may be present (1,2)

Complications The most frequently encountered complications of emphysema are:  Respiratory insufficiency or failure.  Pneumonia: is an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing.

 Pneumothorax: air leaks into the space between lung and chest wall. This air pushes on the outside of your lung and makes it collapse. Pneumothorax can be a complete lung collapse or a collapse of only a portion of the lung.  Chronic atelectasis: affected area is often characterized by a complex mixture of airlessness, infection, widening of the bronchi (bronchiectasis), destruction, and scarring (fibrosis).  Cor pulmonale: a condition that causes the right side of the heart to fail.  Interstitial emphysema: abnormal location of gas within the pulmonary interstitium and lymphatics usually due to rupture of overdistended alveoli.  Recurrent respiratory tract infections.  Respiratory acidosis, hypoxia, and coma.

Diagnosis In making a diagnosis of emphysema, your doctor will start by conducting a thorough medical examination, recording your medical history and asking about any symptoms you are experiencing. The following tests may then be conducted to make a definite diagnosis: Pulmonary Function Testing (PFT): This test involves a series of breathing maneuvers that measure the airflow and volume of air in your lungs. This allows your doctor to objectively assess the function of your lungs. High-Resolution Computed Tomography (HRCT): This is a special type of CT scan that provides high-resolution images of your lungs. Having a HRCT is no different than having a regular CT scan; they both are performed on an open-air table and take only a few minutes. Chest X-rays can help confirm a diagnosis of emphysema and rule out other lung conditions. Arterial Blood Gases Analysis These blood tests measure how well your lungs transfer oxygen to your bloodstream and remove carbon dioxide. Sputum Examination Analysis of cells in sputum can help determine the cause of some lung problems. (4)

Treatment

The goal of therapy for emphysema is to provide relief of symptoms, prevent complications and slow the progression of the disease. 1. Medications  Bronchodilator Medications: Inhaled as aerosol sprays or taken orally, bronchodilator medications may help to relieve symptoms of emphysema by relaxing and opening the air passages in the lungs.  Steroids: Inhaled as an aerosol spray, steroids can help relieve symptoms of emphysema associated with asthma and bronchitis. Over time, however, inhaled steroids can cause side effects, such as weakened bones, high blood pressure, diabetes and cataracts. It is important to discuss these side effects with your doctor before using steroids.  Antibiotics: used to help fight respiratory infections common in people with emphysema, such as acute bronchitis, pneumonia and the flu.

2. Vaccines Patients with emphysema should receive a flu shot annually and a pneumonia shot every five to seven years to prevent infections. 3. Oxygen Therapy As a patient's disease progresses, they may find it increasingly difficult to breathe on their own and may require supplemental oxygen. Oxygen could be given in various ways, including those you can use at home. 4. Surgery  Lung transplantation, if severe lung damage is present and other options have failed.  Lung volume reduction surgery, during which small wedges of damaged lung tissue are removed. This depends on the doctor’s advice in different cases.

5. Protein Therapy Alpha-1 antitrypsin (AAT) deficiency may be given infusions of AAT to help slow the progression of lung damage.

6. Pulmonary Rehabilitation An important part of treatment is pulmonary rehabilitation, which includes education, nutrition counseling, learning special breathing techniques, help with quitting smoking and starting an exercise regimen. Because people with emphysema are often physically limited, they may avoid physical activity. However, regular physical activity can improve a patient's health and wellbeing. (1, 3)

References 1. https://www.mayoclinic.org/diseases-conditions/emphysema/symptomscauses/syc-20355555 2. https://www.health.harvard.edu/a_to_z/emphysema-a-to-z 3. https://www.ucsfhealth.org/conditions/emphysema/treatment 4. https://www.ucsfhealth.org/conditions/emphysema/diagnosis#:~:text=Chest%2 0X%2DRay%20Chest%20X,bloodstream%20and%20remove%20carbon%20 dioxide

Bronchitis Bronchitis occurs when the bronchioles are inflamed and make too much mucus, which makes people who have bronchitis often cough up thickened mucus. It falls between the common cold and pneumonia in severity. (1,2)

Types of bronchitis: • Chronic bronchitis is defined as cough productive of sputum that persists for three months out of the year for at least two consecutive years. • Acute bronchitis is more common. Episodes of acute bronchitis can be related to and made worse by smoking. Acute bronchitis could last for 10 to 14 days, possibly causing symptoms for three weeks. (2)

Symptoms: For either acute bronchitis or chronic bronchitis, signs and symptoms may include: • Cough • Production of mucus (sputum), which can be clear, white, yellowish-grey or green — rarely, it may be streaked with blood • Fatigue • Shortness of breath • Slight fever and chills • Chest discomfort • A wheezing sound when breathing (may or may not be present). (2)

Causes: Usually, acute bronchitis is brought on by a viral infection (ex; The flu and colds), though it may be caused by a bacterial infection. That's why it can be contagious. Chronic bronchitis is caused by long-term irritation to the pulmonary system. The most common cause is cigarette smoking, air pollution and dust or toxic gases in the environment or workplace. (1)

Diagnosis and tests: During the first few days of illness, it can be difficult to distinguish the signs and symptoms of bronchitis from those of a common cold. In the physical exam, your doctor will use a stethoscope to listen closely to your lungs as you breathe. In some cases, the doctor may suggest the following tests: • Chest X-ray: A chest X-ray can help determine if you have pneumonia or another condition that may explain your cough. This is important if you ever were or currently are a smoker. • Sputum tests: Sputum can be tested to see if you have illnesses that could be helped by antibiotics. Sputum can also be tested for signs of allergies. • Pulmonary function test: During a pulmonary function test, you blow into a device called a spirometer, which measures how much air your lungs can hold and how quickly you can get the air out of your lungs. This test checks for signs of asthma or emphysema. (1)

Risk factors: • Cigarette smoke. People who smoke or who live with a smoker are at higher risk of both types of bronchitis. • Low resistance. This may result from another acute illness, such as a cold, or from a chronic condition that compromises your immune system. • Exposure to irritants on the job. Your risk of developing bronchitis is greater if you work around certain lung irritants, such as grains or textiles, or are exposed to chemical fumes. • Gastric reflux. Repeated bouts of severe heartburn can irritate your throat and make you more likely to develop bronchitis. (1)

Treatment: The treatment for bronchitis depends on which type the patient has. For acute bronchitis, you might not need any treatment. Or you might use drugs that break up mucus or that treat fever or pain. If you have a bacterial infection, your doctor might prescribe antibiotics. Chronic bronchitis, considered to be chronic obstructive pulmonary disease (COPD), is not curable. Symptoms can be treated using a variety of methods, including drugs, oxygen therapy, Pulmonary Rehabilitation (a supervised education and exercise program designed to help people with chronic lung diseases), surgery, or a combination of these. The doctor might prescribe a mucus clearing device, also called an airway clearance device, to help bring up mucus easily. (2)

References:

1. https://www.mayoclinic.org/diseases-conditions/bronchitis/diagnosistreatment/drc-20355572 2. https://my.clevelandclinic.org/health/diseases/3993-bronchitis

Bronchiectasis Bronchiectasis is a long-term condition where the airways of the lungs become abnormally widened, in bronchiectasis, your airways slowly lose their ability to clear out mucus. It builds up and creates an environment in which bacteria can grow. This leads to repeated, serious lung infections, each infection causes more damage to your airways. Over time, the airways lose their ability to move air in and out. This can prevent enough oxygen from reaching your vital organs. (1, 2)

Causes & Risk Factors Lung infections that can lead to bronchiectasis include:    

Severe pneumonia Whooping cough or measles Tuberculosis Fungal infections

Conditions that damage the airways and raise the risk of lung infections also can lead to bronchiectasis.      

Cystic fibrosis: It is a relatively common genetic disorder, where the lungs become clogged up with mucus. Immunodeficiency disorders: It's also possible to acquire an immunodeficiency after an infection such as HIV. Allergic bronchopulmonary aspergillosis (ABPA): This is an allergic reaction to a fungus called aspergillus. The reaction causes swelling in the airways. Disorders that affect cilia function, such as primary ciliary dyskinesia. Chronic pulmonary aspiration: This is a condition in which you inhale food, liquids, saliva, or vomited stomach contents into your lungs. Connective tissue diseases: such as rheumatoid arthritis, Sjögren’s syndrome, and Crohn’s disease. (1,2,5)

Signs and Symptoms Symptoms of bronchiectasis can take months or years to develop, and gradually become worse. The two primary symptoms are a cough and daily production of mucus (sputum). Other symptoms typically include: 1. Coughing up yellow or green mucus daily 2. Shortness of breath that gets worse during flare-ups

Flare-ups that usually include:    

Fatigue Fevers and/or chills Increased shortness of breath Night sweats

3. Fatigue, feeling run-down or tired, 4. Loss of weight 5. Fevers and/or chills 6. Wheezing or whistling sound while you breathe 7. Coughing up blood or mucus mixed with blood, a condition called hemoptysis 8. Chest pain from increased effort to breathe 9. Clubbing, or the thickening of the skin under nails 10. Problems with your sinuses (3,4,5)

Complications

Severe bronchiectasis can lead to other serious health conditions, such as respiratory failure and atelectasis.

Respiratory failure is a condition in which not enough oxygen passes from your lungs into your blood. The condition also can occur if your lungs can't properly remove carbon dioxide (a waste gas) from your blood. Respiratory failure can cause shortness of breath, rapid breathing, and air hunger (feeling like you can't breathe in enough air). In severe cases, signs and symptoms may include a bluish color on your skin, lips, and fingernails; confusion; and sleepiness. Atelectasis is a condition in which one or more areas of your lungs collapse or don't inflate properly. As a result, you may feel short of breath. Your heart rate and breathing rate may increase, and your skin and lips may turn blue. If bronchiectasis is so advanced that it affects all parts of your airways, it may cause heart failure. Heart failure is a condition in which the heart can't pump enough blood to meet the body's needs. The most common signs and symptoms of heart failure are shortness of breath or trouble breathing, tiredness, and swelling in the ankles, feet, legs, abdomen, and veins in the neck. (1)

Diagnosis and testing To find out whether you have bronchiectasis, your doctor may recommend tests to:   

Identify any underlying causes that require treatment Rule out other causes of your symptoms Find out how much your airways are damaged

Diagnostic Tests and Procedures  Chest CT Scan: A chest computed tomography scan, or chest CT scan, is the most common test for diagnosing bronchiectasis. a) This painless test creates precise pictures of your airways and other structures in your chest and it can show the extent and location of lung damage. This test gives more detailed pictures than a standard chest x-ray.

 Chest X-Ray: This painless test creates pictures of the structures in your chest, such as your heart and lungs. A chest x-ray can show areas of abnormal lung and thickened, irregular airway walls.



Bronchoscopy: If the condition doesn't respond to treatment, the doctor may recommend bronchoscopy. Doctors use this procedure to look inside the airways. b) During bronchoscopy, a flexible tube with a light on the end is inserted through your nose or mouth into your airways. It provides a video image of your airways. 

Other Tests 1. Blood test. It can show whether you have an infection or low levels of certain infection-fighting blood cells. 2. A sputum culture. Lab tests can show whether a sample of your sputum contains bacteria (such as the bacteria that cause tuberculosis) or fungi. 3. Lung function tests. These tests measure how much air you can breathe in and out, how fast you can breathe air out, and how well your lungs deliver oxygen to your blood. Lung function tests help show how much lung damage you have. 4. A sweat test or other tests for cystic fibrosis. (1)

Treatment Bronchiectasis often is treated with medicines, hydration, and chest physical therapy (CPT). Your doctor may recommend surgery if the bronchiectasis is isolated to a section of the lung or you have a lot of bleeding. The goals of treatment are to:  Treat any underlying conditions and lung infections.  Remove mucus (a slimy substance) from your lungs. Maintaining good hydration helps with mucus removal.  Prevent complications.

Medicines:

Antibiotics are the most common treatment for bronchiectasis. Oral antibiotics are suggested for most cases, but harder to treat infections may require intravenous (IV) antibiotics. Mucus Thinning Medication may be prescribed to help bronchiectasis’ patients cough up mucus. These medications are often given through a nebulizer, where it is mixed with hypertonic saline solution, turned into a mist, and inhaled deep into the lungs.

Hydration

Drinking plenty of fluid, especially water, helps prevent airway mucus from becoming thick and sticky. Good hydration helps keep airway mucus moist and slippery, which makes it easier to cough up. 3.

Chest Physical Therapy (CPT)

c) It involves the therapist pounding your chest and back over and over with his or her hands or a device. Doing this helps loosen the mucus from your lungs so you can cough it up. You can sit with your head tilted down or lie on your stomach with your head down while you do CPT. Gravity and force help drain the mucus from your lungs. 4.

Other Treatments

Bronchodilators Responsible for relaxing the muscles around your airways. This helps open your airways and makes breathing easier. Most bronchodilators are inhaled medicines. Inhaled Corticosteroids: Taken when patient has wheezing or asthma with your bronchiectasis. It used to treat inflammation in the airways 5.

Surgical Treatment

Surgery is recommended if no other treatments have helped and only one part of the airway is affected. Surgical procedure will be used to remove part of the faulty airway or to control the bleeding. In very rare instances of severe bronchiectasis, the doctor may recommend a lung transplant. (1, 5)

Management

Bronchiectasis is a long-term condition with symptoms that need to be managed over many years. Patients should work closely with a doctor to determine healthy habits that will limit flare-ups. Such as:  Be diligent about taking oral and inhaled medications and performing mucus clearance techniques daily.  Staying up to date on vaccinations.  Take antibiotics for one to two weeks during flare-ups only when prescribed by your doctor during the time of the flare-up. (5)

References 1234-

https://www.nhlbi.nih.gov/health-topics/bronchiectasis https://www.nhs.uk/conditions/bronchiectasis/treatment/ https://www.blf.org.uk/support-for-you/bronchiectasis/what-is-it https://my.clevelandclinic.org/health/diseases/21144bronchiectasis/management-and-treatment 5- https://www.lung.org/lung-health-diseases/lung-diseaselookup/bronchiectasis/treating-and-managing

Lifestyle adjustments for Patients with COPD These are several steps to halt progression or at least delay it and to protect from complications.  Quit smoking: This is the most important measure for overall health and the only one that might halt the progression of COPD and as much as possible, avoid secondhand smoke as well.  Avoid other respiratory irritants: These include fumes from paint and automobile exhaust, some cooking odors, certain perfumes, even burning candles and incense. Change furnace and air conditioner filters regularly to limit pollutants.  Regular exercise can significantly increase your lung capacity.  Protection from cold air as much as possible: Cold air can cause spasms of the bronchial passages, making it even more difficult to breathe so, using a face mask or wrapping a scarf would definitely help.  Recommended vaccinations Be sure to get an annual flu shot and pneumonia vaccinations as advised by your doctor.  Prevent respiratory infections by avoiding direct contact with people who have a cold or the flu. If you have to mingle with large groups of people during cold and flu season, wear a face mask, wash your hands frequently and carry a small bottle of alcohol-based hand sanitizer to use when needed. (1)  Drinking fluids every one to two hours to help prevent mucus build-up, unless the doctor has restricted fluid intake.  Rest and relieve body aches by taking prescribed pain relievers.  Use a humidifier: warm, moist air helps relieve coughs and loosens mucus in your airways and follow other doctor's instructions on ways to help you clear mucus. (2,3)

 Maintain a healthy diet: low in sodium, added sugars, saturated fats, refined grains and getting enough vitamin D  Manage stress. Learn breathing and relaxation techniques, which can help reduce COPD symptoms. Meet with a mental health professional if you have anxiety, depression, or panic attacks.  Try to get good quality sleep: Getting quality sleep can sometimes be difficult with COPD patients. Develop healthy sleep habits by going to sleep and getting up at regular times, following a calming bedtime routine, and keeping your bedroom cool and dark.

References 1. https://www.mayoclinic.org/diseases-conditions/emphysema/diagnosistreatment/drc-20355561 2. https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma 3. https://www.nhs.uk/conditions/asthma/