'Early detection of cancer can save your life' by Jeannie Mulford

Original article from http://www.rediff.com/news/2007/oct/26spec.htm

Not everyone is as fortunate as David and I were 28 years ago -- to walk down the aisle of an airplane, glance to my left, take one look at each other and know that in an instant we had found each other after lifetimes of searching. My sister would later say it was the greatest case of destiny she had ever heard of, that we were two stars traveling through time who collided that day and found each other somewhere in the skies between Portland, Oregon, and Chicago, Illinois.
Little did I know that morning when I awakened that that would happen, and little did I know that 26 years later, after 55 years of being blessed with near perfect good health, I would return to the United States from our home in India to have a routine annual mammogram and learn that I had breast cancer. That was two and a half years ago, and the very best part of the journey through those years is what I have learned.
I thought I was afraid of cancer. I learned that I was not.
I learned something I already knew, that David would be my pillar of strength and love.
I actually thought my long hair was important (I had not had short hair since I was eight years old.)
What I learned was that for Lance Armstrong, who went on after brain and testicular cancer to win the Tour de France, it was not about the bike -- and that, certainly, for me was not about the hair.
I learned that we are not always given in life the opportunity to be courageous and strong, and I saw this as my opportunity.
I chose to have a double mastectomy so that I could avoid a possible reoccurrence, begin chemotherapy more quickly, and I would not need radiation. I learned how successful breast reconstruction can be, and I wish more women could know this as well. I feel it would give them comfort when faced with certain outcomes of breast cancer.
During many of the most difficult times, I would actually say to myself: 'How could I possibly be feeling so well, so strong?' I learned that the answer always was that someone somewhere would be thinking of me, saying a prayer, asking the Ambassador how I was doing, lighting a candle, giving him a wave across the parking lot or namaste across the garden -- all of which let him know they were thinking of me.
Every card, e-mail, flower sent, phone call, every word of encouragement, every small kind gesture -- not one went unnoticed, every single gesture was received and appreciated and will be remembered.
I would tell my sisters, my two guardian angels who looked after me when David needed to return to the Embassy in India, that I would suddenly have the feeling of being elevated, somehow lifted by the goodwill, the prayers and thoughts of others and carried through the most difficult times.
At the very beginning of the process I resolved not to spend even one moment thinking a sad thought.
I learned that I could change in an instant a negative thought into a positive thought.
I learned that early detection of cancer can save your life and I encourage all of you, women and men alike, to do your annual exams, learn the early warning signs of some cancers, do self-examination, take the time from your busy schedule, save the money for tests if you must pay yourself, spend it on something that can and will save your life. However unpleasant you think the test is, it is nothing compared to what you could go through if you put if off.
A month after breast surgery I learned that I needed to have open-heart surgery to correct an anomaly that might have interfered with my chemotherapy. I learned that because I had such a squeaky clean heart and had never smoked that I could walk two 14-minute miles a day, only six days after surgery. Two weeks after heart surgery, I was in Washington for the White House State Dinner for Prime Minister Manmohan Singh.
My captive audience of doctors and nurses in Cleveland and New York gave me the chance to tell them of my life here in India and what I have learned that I wish so many more Americans and people worldwide could know, that our Embassy is filled with hard-working, talented, wonderful people, both Americans and Indians working side-by-side on so many fronts of endeavour to improve mankind and our important friendship with this remarkable country.
Four weeks after finishing the chemotherapy on my 56th birthday, I returned to India to welcome the President of the United States George Bush and Mrs Laura Bush to India for their historic visit wearing my wig, and considering myself the most grateful person in the world to be feeling so well and to be back in India.
When David and I sat down to discuss our plan for dealing with my breast cancer, I initially said, 'I am going to do whatever it takes to overcome this and we are not going to tell anyone except my family.' I remember David looking sympathetically but incredulously at me and saying, 'In our present circumstances in India, how do you suggest we do that?'
I understood immediately that it could not be kept a secret. I learned since then that it should not. What I learned was that if I could speak openly about breast cancer, as I have done so today, and if only one woman is moved to have an exam that exposes breast cancer in an early, treatable stage that saves her life, it will have been worth every minute of the journey for me.
(The writer is the wife of the US Ambassador to India David C Mulford. She spoke at a US Embassy briefing to mark the International Breast Cancer Awareness Month on Thursday, October 25, 2007 in New Delhi)

Fever – Fact Sheet

Fever (also known as pyrexia, or a febrile response from the Latin word febris, meaning fever, and archaically known as ague) is a frequent medical symptom that describes an increase in internal body temperature to levels that are above normal (the common oral measurement of normal human body temperature is 36.8±0.7 °C or 98.2±1.3 °F). Fever is most accurately characterized as a temporary elevation in the body’s thermoregulatory set-point, usually by about 1-2°C. Fever differs from hyperthermia, which is an increase in body temperature over the body’s thermoregulatory set-point (due to excessive heat production or insufficient thermoregulation, or both). Carl Wunderlich discovered that fever is not a disease but a symptom of disease.

The elevation in thermoregulatory set-point means that the previous "normal body temperature" is considered hypothermic, and effector mechanisms kick in. The person who is developing the fever has a cold sensation, and an increase in heart rate, muscle tone and shivering attempt to counteract the perceived hypothermia, thereby reaching the new thermoregulatory set-point.

When a patient has or is suspected of having a fever, that person's body temperature is measured using thermometer. At a first glance, fever is present if:

Ø temperature in the anus (rectum/rectal) or in the ear (otic) is at, or higher than 38 degrees Celsius (100.4 degrees Fahrenheit)

Ø oral temperature (in the mouth) is at, or higher than 37.5 degrees Celsius (99.5 degrees Fahrenheit)

Ø axillary temperature (underarm) is at, or higher than 37.2 degrees Celsius (99 degrees Fahrenheit)

However, there are many variations in normal body temperature, and this needs to be considered when measuring fever. The values given are for an otherwise healthy, non-fasting adult, dressed comfortably, indoors, in a room that is kept at a normal room temperature, during the morning, but not shortly after arising from sleep. Furthermore, for oral temperatures, the subject must not have eaten, drunk, or smoked anything in at least the previous fifteen minutes.

Body temperature normally fluctuates over the day, with the lowest levels at 4A.M. and the highest at 6P.M. Therefore, an oral temperature of 37.5C would strictly be a fever in the morning, but not in the afternoon. Normal body temperature may differ as much as 0.4C (0.7F) between individuals or from day to day. In women, temperature differs at various points in the menstrual cycle, and this can be used for family planning (although it is only one of the variables of temperature). Temperature is increased after meals, and psychological factors (like the first day in the hospital) also influence body temperature.

There are different locations where temperature can be measured, and these differ in temperature variability. Tympanic membrane thermometers measure radiant heat energy from the tympanic membrane (infrared). These may be very convenient, but may also show more variability.

Children develop higher temperatures with activities like playing, but this is not fever because their set-point is normal. Elderly patients may have a decreased ability to generate body heat during a fever, so even a low-grade fever can have serious underlying causes in geriatrics.

Mechanism

Temperature is regulated in the hypothalamus, in response to PGE2. PGE2 release, in turn, comes from a trigger, a pyrogen. The hypothalamus generates a response back to the rest of the body, making it increase the temperature set-point.

Pyrogens

Substances that induce fever are called pyrogens. These are both internal or endogenous, and external or exogenous, such as the bacterial substance LPS.

Endogenous

The cytokines (such as interleukin 1) are a part of the innate immune system, produced by phagocytic cells, and cause the increase in the thermoregulatory set-point in the hypothalamus. Other examples of endogenous pyrogens are interleukin 6 (IL-6), and the tumor necrosis factor-alpha.

These cytokine factors are released into general circulation where they migrate to the circumventricular organs of the brain, where the blood-brain barrier is reduced. The cytokine factors bind with endothelial receptors on vessel walls, or interact with local microglial cells. When these cytokine factors bind, they activate the arachidonic acid pathway.

Exogenous

One model for the mechanism of fever caused by exogenous pyrogens includes lipopolysaccharide (LPS), which is a cell wall component of gram-negative bacteria. An immunological protein called Lipopolysaccharide-Binding Protein (LBP) binds to LPS. The LBP-LPS complex then binds to the CD14 receptor of a nearby macrophage. This binding results in the synthesis and release of various endogenous cytokine factors, such as interleukin 1 (IL-1), interleukin 6 (IL-6), and the tumor necrosis factor-alpha. In other words, exogenous factors cause release of endogenous factors, which, in turn, activate the arachidonic acid pathway.

PGE2 release

PGE2 release comes from the arachidonic acid pathway. This pathway (as it relates to fever), is mediated by the enzymes phospholipase A2 (PLA2), cyclooxygenase-2 (COX-2), and prostaglandin E2 synthase. These enzymes ultimately mediate the synthesis and release of PGE2.

PGE2 is the ultimate mediator of the febrile response. The set-point temperature of the body will remain elevated until PGE2 is no longer present. PGE2 acts on neurons in the preoptic area (POA) through the EP3 subtype of PGE receptors and the EP3-expressing neurons in the POA innervate the dorsomedial hypothalamus (DMH), the rostral raphe pallidus nucleus in the medulla oblongata (rRPa) and the paraventricular nucleus of the hypothalamus (PVN). Fever signals sent to the DMH and rRPa lead to stimulation of the sympathetic output system, which evokes non-shivering thermogenesis to produce body heat and skin vasoconstriction to decrease heat loss from the body surface. It is presumed that the innervation from the POA to the PVN mediates the neuroendocrine effects of fever through the pathway involving pituitary gland and various endocrine organs.

Hypothalamus response

The brain ultimately orchestrates heat effector mechanisms. These may be

Ø increased heat production by increased muscle tone, shivering and hormones like epinephrine.

Ø prevention of heat loss, such as vasoconstriction.

The autonomic nervous system may also activate brown adipose tissue to produce heat (=non-exercise associated thermogenesis, also known as non-shivering thermogenesis), but this seems mostly important for babies. Increased heart rate and vasoconstriction contribute to increased blood pressure in fever.

Types

Pyrexia (fever) can be classed as

Ø low grade: 38 - 39 °C (100.4 - 102.2 °F)

Ø moderate: 39 - 40 °C (102.2 - 104 °F)

Ø high-grade: > 40 °C (> 104 °F)

Ø Hyperpyrexia: > 42 °C (> 107.6 °F)

The last is clearly a medical emergency because it approaches the upper limit compatible with human life.

Most of the time, fever types can not be used to find the underlying cause. However, there are specific fever patterns that may occasionally hint the diagnosis:

Ø Pel-Ebstein fever is a specific kind of fever associated with Hodgkin's lymphoma, being high for one week and low for the next week and so on. However, there is some debate whether this pattern truly exists.

Ø Continuous fever: temperature remains above normal throughout the day and does not fluctuate more than 1 degree C in 24 hours. Eg: lobar pneumonia, typhoid, urinary tract infection, brucellosis, typhus, etc. Typhoid fever may show a specific fever pattern, with a slow stepwise increase and a high plateau.

Ø Intermittent fever: temperature is present only for some hours of the day and becomes normal for remaining hours.Eg: malaria, kala-azar, pyaemia, septicemia etc In malaria, there may be a fever with a periodicity of 24 hours (quotidian) 48 hours (tertian fever) or 72 hours (quartan fever, indicating Plasmodium vivax). These patterns may be less clear in travelers.

Ø Remittent fever: temperature remains above normal throughout the day and fluctuates more than 1 degree C in 24 hours.Eg: infective endocarditis etc

Febricula is a mild fever of short duration, of indefinite origin, and without any distinctive pathology.

Causes

Fever is a common symptom of many medical conditions:

Ø infectious disease, e.g. influenza, common cold, HIV, malaria, infectious mononucleosis, gastroenteritis, etc..

Ø Various skin inflammations such as boils, pimples, acne, abscess, etc.

Ø Immunological diseases like lupus erythematosus, sarcoidosis, inflammatory bowel diseases, etc..

Ø Tissue destruction, which can occur in hemolysis, surgery, infarction, crush syndrome, rhabdomyolysis, cerebral hemorrhage, etc..

Ø Drug fever

1. directly caused by the drug (e.g. lamictal, progesterone, chemotherapeutics causing tumor necrosis)

2. as an adverse reaction to drugs (e.g. antibiotics, sulfa drugs, etc.)

3. after drug discontinuation, like with heroin withdrawal

Ø Cancers such as Hodgkin disease (with Pel-Ebstein fever)

Ø Metabolic disorders like gout, porphyria, etc..

Ø Thrombo-embolic processes (i.e. pulmonary embolism, deep venous thrombosis)

Persistent fever which cannot be explained after repeated routine clinical inquiries, is called fever of unknown origin.

Usefulness of fever

There are arguments for and against the usefulness of fever, and the issue is controversial. There are studies using warm-blooded vertebrates and humans in vivo, with some suggesting that they recover more rapidly from infections or critical illness due to fever.

Theoretically, fever has been conserved during evolution because of its advantage for host defense. There are certainly some important immunological reactions that are sped up by temperature, and some pathogens with strict temperature preferences could be hindered. The overall conclusion seems to be that both aggressive treatment of fever and too little fever control can be detrimental. This depends on the clinical situation, so careful assessment is needed.

Fevers may be useful to some extent since they allow the body to reach high temperatures. This causes an unbearable environment for some pathogens. White blood cells also rapidly proliferate due to the suitable environment and can also help fight off the harmful pathogens and microbes that invaded the body.

Treatment

Fever should not necessarily be treated. Fever is an important signal that there's something wrong in the body, and it can be used for follow-up. Moreover, not all fevers are of infectious origin.

Even when treatment is not indicated, however, febrile patients are generally advised to keep themselves adequately hydrated, as the dehydration produced by a mild fever can be more dangerous than the fever itself. Water is generally used for this purpose, but there is always a small risk of hyponatremia if the patient drinks too much water. For this reason, some patients drink sports drinks or products designed specifically for this purpose.

Most people take medication against fever because the symptoms cause discomfort. Fever increases heart rate and metabolism, thus potentially putting an additional strain on elderly patients, patients with heart disease, etc. This may even cause delirium. Therefore, potential benefits must be weighed against risks in these patients. In any case, fever must be brought under control in instances when fever escalates to hyperpyrexia and tissue damage is imminent.

Treatment of fever should be based primarily on lowering the setpoint, but facilitating heat loss may also contribute. The former is accomplished with antipyretics. Wet cloth or pads are also used for treatment, and applied to the forehead. Heat loss may be an effect of (possibly a combination of) heat conduction, convection, radiation or evaporation (sweating, perspiration). This may be particularly important in babies, where drugs should be avoided. However, if water that is too cold is used, it induces vasoconstriction and prevents adequate heat loss.

New Diseases Arise as Environments Destroyed, Says UN

Changes to the environment that are sweeping the planet are bringing about a rise in infectious diseases, the United Nations Environment Program (UNEP) has warned.

Loss of forests; the building of roads and dams; urban growth; the clearing of natural habitats for agriculture; mining; and pollution of coastal waters are promoting conditions under which new and old pathogens can thrive, according to research published today in UNEP's Global Environment Outlook Year Book for 2004/2005.

Ailments previously unknown in human beings are appearing, such as the Nipah virus, which until recently was found normally in Asian fruit bats, according to the report.

Nipah's emergence in the late 1990s as an often fatal disease in humans has been linked to a combination of forest fires in Sumatra and the clearance of natural forests in Malaysia for palm plantations. In searching for fruit, bats were forced into closer contact with domestic pigs, giving the virus its chance to spread to humans.

Climate change in particular may aggravate the threats of infectious diseases in three ways, the report suggests. First, by increasing the temperatures under which many diseases and their carriers flourish.

Second, by further stressing and altering habitats. For example, the geographic range and seasonality of two of the world's most serious mosquito-borne infections, malaria and dengue fever, are very sensitive to changes in climate. Also, Neissseria meningitidis, a common cause of meningitis, can be spread many miles in the dusty conditions that occur following prolonged drought in the Sahel.

Third, climate change may increase the number of environmental refugees who are forced to migrate to other communities, or even countries. This in turn will also favor the spread of diseases from one location to another. Overall, it seems that intact habitats and landscapes tend to keep infectious agents in check.

The issue of environmental degradation and a rise of many new and old infectious diseases is a complex, sometimes subtle one that is causing increasing concern among scientists and disease specialists.

Many scientists are now convinced that ecological disruption, dramatic environmental change, and poor handling of human and animal wastes are playing an important part in the spread of diseases such as malaria, bilharzia, Japanese encephalitis, and dengue haemorrhagic fever.

The report is based on research by some of the leading specialists. They include Tony McMichael of the Australian National University, Bernard Goldstein of the University of Pittsburgh and Jonathan Patz of the University of Wisconsin

Source : http://www.commondreams.org/headlines05/0222-02.htm