Hepatitis A

This is caused by eating infected food or water. The food or water is infected with a virus called HAV (hepatitis A virus). Anal-oral contact during sex can also be a cause. Nearly everyone who develops Hepatitis A makes a full recovery – it does not lead to chronic disease.

Hepatitis B

This is an STD (sexually transmitted disease). It is caused by the virus HBV (hepatitis B virus) and is spread by contact with infected blood, semen, and some other body fluids. You get hepatitis B by:

• Unprotected sexual intercourse with an infected person (unprotected sex means without using a condom) Using a syringe that was previously used by an infected person (most commonly happens with drug addicts and people who inject steroids).
• Having your skin perforated with unsterilized needles, as might be the case when getting a tattoo, or being accidentally pricked. People who work in health care risk becoming infected by accident in this way. Sharing personal items, such as a toothbrush or razor, with an infected person.
• A baby can become infected through his mother’s milk if she is infected.
• Being bitten by someone who is infected.

The liver of a person infected with hepatitis B swells. The patient can suffer serious liver damage due to infection, resulting in cancer. For some patients the hepatitis becomes chronic (very long-term or lifelong). Donated blood is always tested for hepatitis B.

Hepatitis C

Hepatitis C is usually spread through direct contact with the blood of a person who has the disease. It is caused by the virus HCV (hepatitis C Virus). The liver can swell and become damaged. In hepatitis C, unlike hepatitis B, liver cancer risk is only increased in people with cirrhosis and only 20% of hep C patients get cirrhosis. Feces is never a route of transmission in hepatitis C. Donated blood is also tested for hepatitis C.

Misuse of anesthesia can result in the transmission of hepatitis B and hepatitis C viruses, researchers reported in the journal Gastroenterology. The cause of infection tends to be from anesthesia contamination, and not endoscopy contamination. Experts say that more effort is needed to better educate the health care community about the importance of strict sterile techniques when using any type of anesthesia.

Hepatitis D

Only a person who is already infected with hepatitis B can become infected with hepatitis D. It is caused by the virus HDV (Hepatitis D Virus). Infection is through contact with infected blood, unprotected sex, and perforation of the skin with infected needles. The liver of a person with Hepatitis D swells.

Hepatitis E

A person can become infected by drinking water that contains HEV (hepatitis E virus). The liver swells but there is no long-term consequence. Infection is also possible through anal-oral sex.

Hepatitis X

If a hepatitis cannot be attributed to the viruses of hepatitis A, B, C, D, or E, it is called hepatitis X. In other words, hepatitis of an unknown virus.

Hepatitis G

This is a type of hepatitis caused by the hepatitis G virus (HGV). Usually there are no symptoms. When there are symptoms, they are very mild.

What exactly are PNET?  Are they the same as medulloblastomas?

Yes and no. Under a microscope, PNET tumors appear to be similar to a tumor called medulloblastoma, and some will classify medulloblastoma as “PNET (cerebellum).” However, it has been demonstrated that medulloblastomas behave differently than PNET in other locations in the brain.

According to the World Health Organization (WHO), all undifferentiated tumors—regardless of location—are derived from common cells and are therefore classified as PNET.  To differentiate, their location is frequently indicated in parentheses. This separates medulloblastoma (PNET cerebellum) and pineoblastoma (PNET in the pineal region) from other PNET such as PNET in the supratentorial compartment (meaning occurring in the cerebrum) or in the spine.

What causes a PNET?

Researchers have not been able to find an identifiable cause or risk factors for PNET. There doesn’t appear to be a genetic predisposition, meaning the disease does not seem to run in families.

What are the symptoms of a PNET?

The symptoms of a PNET depend on the location of the tumor, and each child may experience symptoms differently.  Symptoms of a PNET in the supratentorial compartment usually arise quickly and last up to several weeks. These tumors are often seen in the older child or teenager.

Some common symptoms occur due to increased pressure within the brain, including:

• headache (generally upon awakening in the morning)
• vomiting
• fatigue/lethargy
• seizures

Pineoblastomas (PNET in the pineal region, a tiny organ near the center of the brain) are usually seen in young children. Common symptoms may include increased pressure in the brain, resulting in:

• headache (generally upon awakening in the morning)
• vomiting
• fatigue/lethargy
• eye movement problems and/or complaints of double vision, since the tumor is close to the nuclei (centers in the brain) that regulate eye movements and coordination

Symptoms of PNET of the spine may include:

• back and/or leg pain
• slow development of weakness in the legs
• impairment of bowel and/or bladder function, including incontinence

The symptoms of a PNET may resemble other conditions or medical problems. Always consult your child’s physician for a diagnosis.

 What are the treatments for PNET?

What is myopathy?

Myopathy refers to any disease that affects muscle tissue. Diseases of the muscle result in weakness, inflammation, tetany (spasms), or paralysis. Myopathy can be the result of either inherited or acquired causes.

Acute “acquired” myopathies, such as acute stiffness, spasm, or cramp, are common. Others are linked to exposure to an infectious agent, such as viruses or bacteria, or are inherited. However, certain cases of myopathy have no known associated risk factors.

What are the symptoms of myopathy?

Myopathy causes dysfunction of the muscles due to inflammation or disease and can cause a number of symptoms. The symptoms can vary in intensity among individuals.

What is HIPEC?

Hyperthermic intraperitoneal chemotherapy (HIPEC) is a highly concentrated, heated chemotherapy treatment that is delivered directly to the abdomen during surgery.

Unlike systemic chemotherapy delivery, which circulates throughout the body, HIPEC delivers chemotherapy directly to cancer cells in the abdomen. This allows for higher doses of chemotherapy treatment. Heating the solution may also improve the absorption of chemotherapy drugs by tumors and destroy microscopic cancer cells that remain in the abdomen after surgery.

How it works

Before patients receive HIPEC treatment, doctors perform cytoreductive surgery to remove visible tumors within the abdomen. Cytoreductive surgery is accomplished using various surgical techniques. Once as many tumors as possible have been removed, the heated, sterilized chemotherapy solution is delivered to the abdomen to penetrate and destroy remaining cancer cells. The solution is 41 to 42 degrees Celsius, about the temperature of a warm bath. It’s circulated throughout the abdomen for approximately 1 ½ hours. The solution is then drained from the abdomen and the incision is closed.

HIPEC is a treatment option for people who have advanced surface spread of cancer within the abdomen, without disease involvement outside of the abdomen.

Advantages of HIPEC

• Allows for high doses of chemotherapy
• Enhances and concentrates chemotherapy within the abdomen
• Minimizes the rest of the body’s exposure to the chemotherapy
• Improves chemotherapy absorption and susceptibility of cancer cells
• Reduces some chemotherapy side effects

When Is Fetal Echocardiography

Not all pregnant women need a fetal echocardiogram. For most women, a basic ultrasound will show that all four chambers of their baby’s heart have developed. Your obstetrician may recommend that you have this procedure done if previous tests detected an abnormal heartbeat in the fetus.

You may also need this test if:

• your unborn child is at risk for a heart abnormality or other disorder present at birth
• you have a family history of heart disease
• you already have a child with a heart condition
• you’ve used drugs or alcohol during your pregnancy
• you’ve taken certain medications or been exposed to medications that can cause heart defects, such as medications used to treat epilepsy or prescription acne drugs
• you have other medical conditions, including rubella, type 1 diabetes, lupus, or phenylketonuria, which is an inability to break down an important amino acid called phenylalanine

Some obstetricians can perform this test themselves. Usually, an experienced ultrasound technician, or ultrasonographer, performs the test. A cardiologist who specializes in pediatric medicine will then review the results after your test is finished.

What Happens During the Examination?

This test is similar to a routine pregnancy ultrasound. If it’s performed through your abdomen, it’s called an abdominal echocardiography. If it’s performed through your vagina, it’s called a transvaginal echocardiography.

Abdominal Echocardiography

An abdominal echocardiography is very much like an ultrasound. You’ll be asked to lie down and expose your belly. An ultrasound technician will apply a special lubricating jelly to your skin. This prevents friction so that the ultrasound transducer, which is a device that sends and receives sound waves, can be rubbed on your skin. The jelly also helps transmit the sound waves.

The transducer sends high-frequency sound waves through your body. The waves echo as they hit a dense object, such as your unborn child’s heart. Those echoes are then reflected back into a computer. The sound waves are too high-pitched for the human ear to hear.

The technician will move the transducer all around your stomach to get images of different parts of your baby’s heart.

After the procedure, the gel will be cleaned off your abdomen. You can then continue with your normal activities.

Transvaginal Echocardiography

For a transvaginal echocardiography, you’ll be asked to undress from the waist down and lie on the exam table. A technician will insert a small probe into your vagina. From there, the probe will use sound waves to create an image of your baby’s heart.

A transvaginal echocardiography is typically used in earlier stages of pregnancy. It may provide a clearer image of the fetal heart.

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Are There Any Risks Associated with This Exam?

There are no risks associated with the echocardiogram because it uses ultrasound technology and no radiation.

What Do the Results Mean?

During your follow-up appointment, your doctor will explain the results to you, answer any questions you might have, and refer you to any appropriate resources or specialists needed to treat your unborn child’s condition.

Generally, normal results mean that no cardiac abnormality was found. If your doctor finds an issue, such as a heart defect, rhythm abnormality, or other problem, you may need to have more tests, such as a fetal MRI or other high-level ultrasounds. You may also need to have this test done more than once or go in for additional testing if your doctor thinks something else could be wrong.

It’s important to remember that an echocardiography can’t always be used to diagnose every condition. Some problems, such as a hole in the heart, are difficult to see even with advanced equipment. Your doctor will explain what the test can and cannot di

Why Is This Test Important?

Abnormal results from a fetal echocardiography can be inconclusive or require that you get more testing to figure out what might be wrong. Once a diagnosis is determined, you can better manage your pregnancy and prepare for delivery. Information from this test will help you and your doctor plan any treatments that may need to happen after delivery, such as correctional surgery. You can also get the support and counseling you need to make good decisions for the remainder of your pregnancy.

 

Double vision is the perception of two images of a single object seen adjacent to each other (horizontally, vertically, or obliquely) or overlapping. Double vision is medically termed diplopia. Polyplopia is the perception of three or more images of a single object overlapping each other.

Most causes of monocular diplopia stem from poor focusing of light by the eye. Refractive errors (myopia, hyperopia, astigmatism) are common. Dry eye (from a variety of causes such as meibomitis, Sjögren’s syndrome, and decreased tear production following refractive surgery) can produce diplopia that varies with blinking. Cataracts (clouding of the natural lens) and posterior capsule opacification (after cataract surgery) are common in people over 60 years of age. Other conditions that interfere with proper focusing of light include corneal irregularity from swelling or scars and retinal conditions, such as epiretinal membranes. Rarely is the underlying cause a medical emergency in cases of monocular diplopia.

Binocular diplopia on the other hand is produced by a misalignment of the eyes, which can be caused by life-threatening conditions. For example, aneurysms, strokes, trauma (head injury), and brain swelling (such as from brain cancer) can interfere with the nerves that control the extraocular muscles. The extraocular muscles move the eyes in different direction of gaze, much like the strings on a marionette, and when one or more muscle is weakened or paralyzed, it is referred to as cranial nerve palsy. In multiple sclerosis, lesions in regions of the brain that control eye alignment may result in diplopia that varies over time. Guillain-Barré syndrome can produce diplopia from restricted eye movement due to nerve damage. Migraineheadaches can cause a sudden but temporary eye misalignment. Diseases such as myasthenia gravis can interfere with the communication between the nerves and the eye muscles to cause diplopia. And the eye muscles themselves can be damaged or compressed by conditions such as Graves’ disease (often associated with thyroid disease), orbital inflammations, vascular disease (as seen with diabetes and high blood pressure), and others. Following traumatic fracture of the orbital bones, muscles and orbital tissue may be trapped in the fracture, leading to restriction of eye movement in certain directions of gaze. Sometimes the cause is relatively harmless, such as when the eye muscles or neurologic signals to the muscles weaken with fatigue or illness. Inability to align the eyes when focusing on a near object (convergence insufficiency) is a common benign cause of intermittent binocular diplopia that can often be treated with prism glasses.

Images may appear to overlap each other or may appear adjacent to each other. Diplopia may vary depending on the direction of gaze or with tilting or turning of the head.

One of the most critical features to determine is whether the diplopia is monocular or binocular. In monocular diplopia, the double vision is caused by a condition within one or both eyes and does not resolve when one eye is covered. In binocular diplopia, the eyes are misaligned. Each eye sees a single image when working alone, as when one eye is covered, but when both eyes are open the brain perceives two adjacent images.

How do health-care professionals diagnose the cause of double vision?

A thorough evaluation of double vision begins with a detailed history of the diplopia, including onset (gradual or sudden), duration, frequency (intermittent or constant), and variability with head position or eye gaze, noting any associated symptoms (pain, headache, nausea, and weight loss among others), and a complete history of past and current medical conditions. The physical examination includes measuring the visual acuity in each eye and assessing whether the diplopia is monocular or binocular. Careful examination of the eyes’ alignment in various head positions is performed if the diplopia is binocular. A complete eye examination, which may include dilating the eyes, is performed to look for any ocular or orbital abnormalities. Particular attention is paid to the pupils and eyelid position if a neurologic cause is suspected. In some instances, specialized imaging (topography, CT, MRI, etc.) and other tests are needed to further investigate possible causes. When a life- or vision-threatening cause is suspected, time may is of the essence.

Diplopia stemming from refractive errors (myopia, hyperopia, astigmatism) can be corrected with glasses or contact lenses. Dry eyes are treated with artificial tears, punctal plugs, warm compresses, and a variety of other treatments. Cataracts are removed with surgery, and posterior capsule opacification (after cataract surgery) is treated with laser. It is uncommon for the cause of monocular diplopia to be a medical emergency.

Binocular diplopia on the other hand can be caused by life-threatening conditions, and emergency treatment may be necessary. This is particularly the case with aneurysms, head trauma, stroke, and other neurologic conditions. Any onset of diplopia with accompanying neurologic symptoms such as headache, nausea, dizziness, loss of balance, etc., should be evaluated immediately.

Diplopia produced by chronic diseases (see causes above) may subside with treatment of the underlying disease. If eye muscles are engorged (such as from Graves’ disease) or entrapped (as after traumatic orbital fracture), surgery of the muscles or surrounding tissue may correct the problem.

Convergence insufficiency, or inability to align the eyes when focusing on a near object, is a common benign cause of intermittent binocular diplopia when reading. It can improve with eye exercises (“pencil pushups” prescribed by the eye doctor).

Often glasses with prisms can be worn to correct binocular diplopia. If the diplopia is expected to resolve, temporary prisms (Fresnel prisms) can be added to glasses and later removed when the eyes realign.

What are the different types of fibroids?

There are many different types of fibroids. Depending on their size and location, fibroids can present with a wide range of symptoms.

Fibroids can be divided into submucosal, intramural or subserosal:

• Submucosal fibroids: These fibroids are located just underneath the endometrium, or lining of the uterus, and protrude into the uterine cavity.  Submucosal fibroids can vary in how much of the fibroid protrudes into the uterine cavity and how much is in the muscle of the uterus. They often cause heavy bleeding and long periods, but they can also cause irregular bleeding.
  
  
• Intramural fibroids:  These fibroids are found predominantly in the myometrium, or muscle of the uterus. Depending on their size and location, these fibroids can also extend toward and distort the uterine cavity or protrude outside the uterus.  Intramural fibroids can be asymptomatic (causing no symptoms), cause bleeding abnormalities, or cause pressure and bulk symptoms.
• Subserosal fibroids: These fibroids are located near the outside of the uterus.  They can be partially in the myometrium (muscle of the uterus) or hanging off the outside of the uterus. They can cause bulk symptoms such as bladder or rectal pressure.

What symptoms do fibroids cause?

Most fibroids cause no symptoms at all. Depending on their size, location and number, fibroids can become significantly problematic.

Some common symptoms associated with fibroids include:

• Abnormal uterine bleeding, heavy or long periods
• Bulk and pressure symptoms
• Bladder pressure, frequent urination
• Rectal pressure, constipation
• Infertility or recurrent miscarriages/pregnancy loss
• Pregnancy complications
• Pain
• Anemia

What are the treatment options for fibroids?

There is a wide range of treatment options for fibroids.  Many factors influence treatment choice.  These include symptoms, fibroid location, size and number, age, reproductive plans and a woman’s preferences.

There is medical management:

• Gonadotropin-releasing hormone agonists (GnRH agnosits):This medication is given as an injection (shot), either every month or every three months, and puts you in a temporary state of menopause. While on the medication the fibroids shrink. Once the medication is stopped, the fibroids usually re-grow and symptoms return. GnRH agonists are usually used to prepare women for surgery or to bridge women close to their natural menopause. GnRH agonists are not usually used for long-term treatment.

Other hormone treatments, including:

• Progestins (oral, by injection or intra-uterine device [IUD]), oral contraceptive pills, androgenic agents (such as danazol) and anti-estrogens (such as raloxifene) have been used to try to control heavy bleeding in women with fibroids. However, these medications do not consistently decrease the size of the fibroids or uterus and are usually ineffective in reducing the amount of bleeding.

There is surgical management:

• The surgical procedures provided at the MIGS Center combine current technology, and medical and surgical expertise to treat fibroids on an outpatient basis.
• Myomectomy is a surgical procedure in which only the fibroids are removed, preserving the uterus. As an alternative to hysterectomy, one advantage of a myomectomy is that with the uterus in place, childbearing remains an option. A disadvantage of a myomectomy is that when the uterus remains in place, fibroids can recur, sometimes requiring additional surgery.

Fibroids can be removed by hysteroscopic myomectomy, laparoscopic myomectomy or an open abdominal myomectomy.

• Hysteroscopic myomectomy is a technique used to remove fibroids that are submucosal. A hysteroscope, a thin tube containing a video camera, is passed through the cervix and into the uterus. The fibroid is then removed by shaving it out. There are no incisions with a hysteroscopic myomectomy. It is a day surgery procedure (you typically leave the hospital 1 hour after the completion of the procedure) with a 1-day recovery period.
• Laparoscopic myomectomy is a technique used to remove fibroids that are intramural (deep in the muscle of the uterine wall), subserosal or pedunculated(on the outside of the uterus).  This minimally invasive technique uses a laparoscopic technique to remove the fibroids through very small incisions. It is a day surgery procedure (you typically leave the hospital 1-2 hours after the completion of the procedure) with a 1-2 week recovery period.
• Open myomectomy uses a traditional large abdominal incision to remove the fibroids. Most fibroids can be removed by minimally invasive techniques; the use of the open method is limited to women with specific situations where laparoscopic or hysteroscopic removal of fibroids is not appropriate.

• Uterine Artery Embolization/Uterine Fibroid Embolization (UAE/UFE) is performed by an interventional radiologist.  The blood flow to the uterus and/or fibroid is blocked, leading to necrosis and a gradual shrinkage of the fibroid.
• MR-Guided Focused Ultrasound uses ultrasound energy to heat and destroy the fibroid causing gradual shrinkage of the fibroid.
• Fibroids can be treated with a hysterectomy, which involves removing the uterus with the fibroids. The hysterectomy can typically be done in a minimally invasive way.

If you have intestinal failure, you may receive all or most of your nutrients and calories intravenously through total parenteral nutrition (TPN). TPN is given through a catheter placed in the arm, groin, neck or chest. Patients on TPN may live for many years, but long-term use of TPN can result in serious complications, such as bone disorders, central venous catheter infections and liver disease. Our goal is to restore intestinal function to minimize and ultimately eliminate the need for TPN. Unfortunately, not every patient can be weaned from TPN. In these cases, we work to optimize the use of TPN and decrease the risk of complications.