Worldwide, breast cancer accounts for 10.4% of all cancer cases among women, making it the second most common type of non-skin cancer (after lung cancer) and the fifth most common cause of cancer-related death.

Breast Cancer Causes

Previous history of breast cancer

A woman with breast cancer has a higher risk of developing breast cancer in the other breast.

Genetic causes

First-degree relatives (mother, sister, daughter) are the most important in estimating risk. A few second-degree relatives (grandmothers, aunts) with breast cancer may also increase the risk. Breast cancer in a man increases the risk for all close female relatives. The BRCA1 and BRCA2 genes increase the risk of breast cancer by about 40 to 80% when inherited. Women with the BRCA1 gene are more likely to develop breast cancer at an early age.

Hormonal causes

Reasons such as menstrual cycle, early pregnancy, hormonal replacement therapy, use of oral contraceptives can accelerate the process of breast cancer by changing hormone levels.

Lifestyle and nutrition reason

Sedentary lifestyle, high dietary fat intake, especially obesity can cause breast cancer in postmenopausal women. Alcohol use is another cause of breast cancer. The risk increases with the amount of alcohol consumed. It has been determined that women who consume two to five alcoholic beverages a day have approximately one and a half times the risk of developing breast cancer compared to non-drinkers.

Environmental cause

It is known that there is a slight increased risk in women who work with low-dose radiation for a long time, for example X-ray technicians.

Signs and symptoms

The classic symptom of breast cancer is a lump in the breast or armpit. Performing a monthly breast self-exam (BSE) is a good way to become familiar with the texture, cyclic changes, size and skin condition of the breasts. General stimulating properties of breast cancer; breast swelling or lump (mass), armpit swelling (lymph nodes), nipple discharge (clear or bloody), nipple pain, inverted (retracted) nipple, scaly or dimpled skin on the nipple, persistent breast tenderness, and unusual breast pain or discomfort; In the advanced stage of the disease (metastatic), axillary lymph nodes are present with symptoms such as bone pain (bone metastases), shortness of breath (lung metastases), loss of appetite (liver metastases), unintentional weight loss (liver metastases), headaches.

Breast cancer is divided into 3 main subtypes based on the presence or absence of molecular markers for estrogen or progesterone receptors and human epidermal growth factor 2 (ERBB2; formerly HER2): hormone receptor positive/ERBB2 negative (70% of patients), ERBB2 positive (15-20%) and tumors lacking these three standard molecular markers (15%).

Management of Breast Cancer

Operation

Depending on the stage and type of the tumor, lumpectomy (removal of the mass only) or surgical removal of the entire breast (mastectomy) are performed. Standard practice requires the surgeon to determine that the surgically removed tissue has cancer-free margins, indicating that the cancer has been completely excised. If the removed tissue does not have clear boundaries, further operations may be required to remove more tissue.

Radiation therapy

Radiation therapy involves the use of high-energy X-rays or gamma rays that target the tumor or the tumor site after surgery. These rays are highly effective in killing cancer cells that remain after surgery or that recur in the area where the tumor was removed. Radiation therapy for breast cancer is usually done after surgery. The radiation dose should be strong enough to destroy cancer cells. Treatments are typically given over a period of five to seven weeks, performed five days a week.

Chemotherapy

Chemotherapy is the use of anti-cancer drugs to treat cancerous cells. Specific treatment for breast cancer; general health, medical history, age (menstruation), type and stage of cancer, tolerance to certain drugs and procedures, etc. determined by its elements. Chemotherapy treatments are usually given in cycles; one treatment for a certain period of time, followed by a recovery period, then another treatment. Chemotherapy is most often given after surgery, and the dose can be given every three weeks or once every two weeks.

In 1994, Cremophor-EL-paclitaxel was approved by the United States Food and Drug Administration (FDA) for the treatment of metastatic breast cancer in patients who progressed after anthracycline-based combination chemotherapy or relapsed less than 6 months after adjuvant therapy. Docetaxel has a similar mechanism of action as paclitaxel, but is a more potent microtubule inhibitor in vitro.

Several groups of cytotoxic agents active against metastatic breast carcinoma include alkylating agents (cyclophosphamide, thiotepa), antimetabolites (5-fluorouracil, methotrexate), vinca alkaloids (vincristine and vinblastine), and antitumor antibiotics (doxorubicin, mitomycin, and others). In the late 1950s, the first attempts to combine two or more of these agents were initiated to manage metastatic breast carcinoma. The combination of cyclophosphamide, methotrexate, 5-fluorouracil, vincristine and prednisone (also known as the Cooper regimen) and its derivatives (CMF and CMFP) was developed. The antitumor antibiotic doxorubicin (Adriamycin, Adria Laboratories, Columbus, OH) was evaluated clinically and shown to have significant antitumor activity. Doxorubicin was also included in combinations with cyclophosphamide and 5-fluorouracil (CAF, FAC). These combinations were soon found to be the most effective systemic treatments for metastatic breast carcinoma. Therefore, the same combinations that proved effective in metastatic disease (CMF and FAC) were included as adjuvant therapy in lymph node positive and ultimately lymph node negative disease. Numerous clinical studies have shown that CMF and similar regimens produce a 50% or greater reduction in measurable tumor deposits in 40-50% of patients.

Cardiovascular disease (CVD) is a general term for conditions affecting the heart or blood vessels.

There are many different types of CVD. 4 of the main types are described on this page.

1. Coronary heart disease, Coronary heart disease occurs when the flow of oxygen-rich blood to the heart muscle is blocked or reduced.
2. Strokes and TIAs, A stroke is where the blood supply to part of the brain is cut off, which can cause brain damage and possibly death.
3. Peripheral arterial disease, Peripheral arterial disease occurs when there’s a blockage in the arteries to the limbs, usually the legs.
4. Aortic disease, Aortic diseases are a group of conditions affecting the aorta. This is the largest blood vessel in the body, which carries blood from the heart to the rest of the body.

The exact cause of CVD isn’t clear, but there are lots of things that can increase your risk of getting it. These are called “risk factors”.

This include; High blood pressure, Smoking, High cholesterol, Diabetes, Inactivity, Being overweight or obese, Family history of CVD, Ethnic background, Other risk factors.

The most important behavioural risk factors of heart disease and stroke are unhealthy diet, physical inactivity, tobacco use and harmful use of alcohol. The effects of behavioural risk factors may show up in individuals as raised blood pressure, raised blood glucose, raised blood lipids, and overweight and obesity. These “intermediate risks factors” can be measured in primary care facilities and indicate an increased risk of heart attack, stroke, heart failure and other complications.

Heart Failure

This term can be scary. It doesn’t mean your heart has “failed,” or stopped working. It means your heart doesn’t pump as strongly as it should. This will cause your body to hold in salt and water, which will give you swelling and shortness of breath.

Your valves sit at the exit of each of your four heart chambers. They keep blood flowing through your heart.

Sometimes, there are problems with these valves. Examples of heart valve problems include:

Aortic stenosis. Your aortic valve narrows. It slows blood flow from your heart to the rest of your body.

Mitral valve insufficiency. Your mitral valve doesn’t close tightly enough. This causes blood to leak backward, leading to fluid backup in the lungs.

Mitral valve prolapse. The valve between your left upper and left lower chambers doesn’t close right.

A healthy lifestyle can lower your risk of CVD. If you already have CVD, staying as healthy as possible can reduce the chances of it getting worse. The key to cardiovascular disease reduction lies in the inclusion of cardiovascular disease management interventions in universal health coverage packages, although in a high number of countries health systems require significant investment and reorientation to effectively manage CVDs

Basic medicines that should be available include: Aspirin,beta-blockers, angiotensin-converting enzyme inhibitors; and statins.

Medical devices are required to treat some CVDs. Such devices include pacemakers, prosthetic valves, and patches for closing holes in the heart.

Human monkeypox was first identified in humans in 1970 in the Democratic Republic of the Congo in a 9-year-old boy in a region where smallpox had been eliminated in 1968.

Monkeypox is a disease of global public health importance as it not only affects countries in west and central Africa, but the rest of the world. In 2003, the first monkeypox outbreak outside of Africa was in the United States of America and was linked to contact with infected pet prairie dogs. These pets had been housed with Gambian pouched rats and dormice that had been imported into the country from Ghana. This outbreak led to over 70 cases of monkeypox in the U.S. Monkeypox has also been reported in travelers from Nigeria to Israel in September 2018, to the United Kingdom in September 2018, December 2019, May 2021 and May 2022, and to the United States of America in July and November 2021. In May 2022, multiple cases of monkeypox were identified in several non-endemic countries. Studies are currently underway to further understand the epidemiology, sources of infection, and transmission patterns.  

 Signs and Symptoms

In humans, the symptoms of monkeypox are similar to but milder than the symptoms of smallpox. Monkeypox begins with fever, headache, muscle aches, and exhaustion. The main difference between symptoms of smallpox and monkeypox is that monkeypox causes lymph nodes to swell (lymphadenopathy) while smallpox does not. The incubation period (time from infection to symptoms) for monkeypox is usually 7−14 days but can range from 5−21 days.

The illness begins with:

• Fever, Headache, Muscle aches, Backache, Swollen lymph nodes, Chills, Exhaustion

Within 1 to 3 days (sometimes longer) after the appearance of fever, the patient develops a rash, often beginning on the face then spreading to other parts of the body.

Lesions progress through the following stages before falling off:

• Macules, Papules, Vesicles, Pustules, Scabs

The illness typically lasts for 2−4 weeks. In Africa, monkeypox has been shown to cause death in as many as 1 in 10 persons who contract the disease.

Vaccination

Vaccination against smallpox was demonstrated through several observational studies to be about 85% effective in preventing monkeypox. Thus, prior smallpox vaccination may result in milder illness. At the present time, the original (first-generation) smallpox vaccines are no longer available to the general public.

JYNNEOS^TM  (also known as Imvamune or Imvanex) is an attenuated live virus vaccine which has been approved by the U.S. Food and Drug Administration for the prevention of monkeypox. The Advisory Committee on Immunization Practices (ACIP) is currently evaluating JYNNEOS^TM for the protection of people at risk of occupational exposure to orthopoxviruses such as smallpox and monkeypox in a pre-event setting.

Description of the outbreak

As of 21 May, 13:00, 92 laboratory confirmed cases, and 28 suspected cases of monkeypox with investigations ongoing, have been reported to WHO from 12 Member States that are not endemic for monkeypox virus, across three WHO regions (Table 1). No associated deaths have been reported to date.

Table 1.Cases of monkeypox in non-endemic countries reported to WHO between 13 to 21 May 2022 as at 13:00.

To date, all cases whose samples were confirmed by PCR have been identified as being infected with the West African clade. Genome sequence from a swab sample from a confirmed case in Portugal, indicated a close match of the monkeypox virus causing the current outbreak, to exported cases from Nigeria to the United Kingdom, Israel and Singapore in 2018 and 2019.

The identification of confirmed and suspected cases of monkeypox with no direct travel links to an endemic area represents a highly unusual event. Surveillance to date in non-endemic areas has been limited, but is now expanding. Available information suggests that human-to-human transmission is occurring among people in close physical contact with cases who are symptomatic.

Prevention

There are number of measures that can be taken to prevent infection with monkeypox virus:

• Avoid contact with animals that could harbor the virus (including animals that are sick or that have been found dead in areas where monkeypox occurs).
• Avoid contact with any materials, such as bedding, that has been in contact with a sick animal.
• Isolate infected patients from others who could be at risk for infection.
• Practice good hand hygiene after contact with infected animals or humans. For example, washing your hands with soap and water or using an alcohol-based hand sanitizer.
• Use Personal Protective Equipment (PPE) when caring for patients.

Resource

https://www.who.int/news-room/monkeypox

https://www.cdc.gov/poxvirus/monkeypox

Diabetes is a group of deases in which the body doesn’t make any insulin or the body cannot make good use of insulin it produces. When any of these things happens, the body is unable to get sugar from the blood into cells. That lead to high blood sugar levels.

There are three main types of diabetes:

Type 1 Diabetes

Type 1 diabetes often develops more quickly and cause symptoms like weight loss, it can develop at any age. but occurs most frequently in children and adolescents. When you have type 1 diabetes, your body produces very little or no insulin, which means that you need daily insulin injections to maintain blood glucose levels under control.

Type 2 Diabetes

Type 2 diabetes is more common in adults and accounts for around 90% of all diabetes cases.it start as insulin resistance. This means your body does not make good use of the insulin that it produces. The cornerstone of type 2 diabetes treatment is healthy lifestyle, including increased physical activity and healthy diet. However, over time most people with type 2 diabetes will require oral drugs or insulin to keep their blood glucose levels under control.

Gestational Diabetes

Gestational Diabetes is a type of diabetes that can develop during pregnancy.it is usually diagnosed from a blood test 24 to 28 weeks into pregnancy. That means you have high blood glucose and its associated with complications to both of mother and fetus. this type of diabetes usually disappears after pregnancy but women affected and their children are at increased risk of developing type 2 diabetes later in life.

Types of diabetes treated

For all types of diabetes, you’ll need to work closely with your doctor to keep it under control. The main goal is to keep blood glucose levels within your target range. Your doctor will let you know what your target range should be. Targets vary with the type of diabetes, age, and presence of complications. If you have gestational diabetes, you blood glucoses targets will be lower than people with other types of diabetes.                                                       Physical activity is an important part of diabetes management. Ask your doctor how many minutes per week you should devote to exercise. Diet is also crucial to good control.

Treating type 1

All people with type 1 diabetes must take insulin to live because damage to the pancreas is permanent. There are different types of insulin available with different times of onset, peak, and duration. Insulin is injected just under the skin. Your doctor will show you how to properly inject and rotate injection sites. You can also use an insulin pump, which is a device worn outside your body that can be programmed to release a specific dose. There are now continuous blood glucose monitors as well that check your sugar 24 hours a day.                                        

Treating type 2

Type 2 diabetes is managed with diet and exercise, and can also be treated with a variety of medications to help control blood sugar. The most common tablet is metformin but if metformin doesn’t work, your doctor can add other medications or try something different.

Treatment for gestational diabetes

Controlling your blood sugar level is essential to keeping your baby healthy and avoiding complications during delivery. In addition to maintaining a healthy diet and exercising, your treatment plan may include monitoring your blood sugar and, in some cases, using insulin or oral medications.                                                                      Your doctor also will monitor your blood sugar level during labor. If your blood sugar rises, your baby may release high levels of insulin which can lead to low blood sugar right after birth

Sources:

• At a glance 2016: Diabetes. (2016).
  cdc.gov/chronicdisease/resources/publications/aag/pdf/2016/diabetes-aag.pdf

• Diabetic neuropathy. (n.d.).
  niddk.nih.gov/health-information/health-topics/Diabetes/diabetic-neuropathies-nerve-damage-diabetes/Pages/diabetic-neuropathies-nerve-damage.aspx
• Diabetes UK                                                                        https://www.diabetes.org.uk/diabetes-the-basics/diabetes-treatments

• Mayo Clinic Staff. (2017). Type 1 diabetes.
  mayoclinic.org/diseases-conditions/type-1-diabetes/basics/complications/con-20019573

Parallel trade or parallel import in pharmaceutical market simply refers to buy medicinal products in a country that sells them at a reasonable price and then to distribute such products outside the distribution channels set up by the drug manufacturer or its recognized distributor in one’s own country of origin. It is named ‘parallel’ as it takes place beside and usually in parallel to the producer’s distribution networks.

The EU Commission’s policy position is that parallel imports increased price competition, and that this in turn increases consumer welfare as the import of goods from a country with lower prices forces sellers in the country of destination to reduce prices. The commission’s overall approach is based on two principles (Competition Policy Newsletter 1, 2007):

1. The single market in pharmaceuticals requires the unhindered free movement of products – private companies cannot erect barriers to undermine this without distorting intra-brand competition.
2. The efficiency claims defence advanced by the research based pharmaceutical industry is unsubstantiated – i.e. there is no evidence that partitioning the common market would spur on global investment in inter-brand competition.

Parallel Trade in the Pharmaceutical Sector

The Reasons for Parallel Trade in the Pharmaceutical Sector The pharmaceutical industry is a special sector in two respects: Firstly, innovative pharmaceutical companies incur high research and development costs for novel medicines. Secondly, in many cases, the buyer of a pharmaceutical product does not directly pay for it but is reimbursed by a national health system. Prices and reimbursement schemes vary considerably between countries in Europe: Price differentiation allows companies to allocate contributions to research and development costs efficiently among different payers, which improves cost recovery.

1) This results in considerable price differences between Member States. A price comparison of pharmaceuticals in 16 EU Member States in 2013 shows differences between 25% and 100% for two thirds and between 100% and 251% for one third.

2) Such price differences are a strong incentive for parallel trade: An importer, usually a wholesaler, purchases pharmaceuticals in a low-price country and then sells them in a high-price country.

Parallel Trade of Pharmaceuticals and its Problems in the EU

Parallel trade, on the one hand, lowers expenditure on pharmaceuticals for high-price countries which is, of course, welcomed by them. The larger the share of parallel imported medicines, the greater this effect is. On the other hand, parallel trade adds to the non-transparency of price structures and may cause certain difficulties for pharmaceutical companies regarding cost calculations.

1) Shortages of Medicines

Parallel trade is exports of pharmaceuticals from low-price countries to high-price countries, may lead to shortages in the former unless the manufacturer is willing to make up for it and supply higher quantities of the product.

2) Risk to the safety of pharmaceuticals

Parallel trade can increase the potential risk of falsified pharmaceuticals because extra steps are added to the supply chain through parallel imports. Complex supply chains, routes of transport, changes of outer packaging and relabeling make it difficult for national authorities to trace the history of pharmaceuticals bought and sold by intermediaries in different EU Member States. The EU has taken measures against falsified medicines through the Falsified Medicines Directive. So far, however, this has not eliminated the problem completely.

3) Lack of transparency and calculation problems

Prices in the pharmaceutical sector are not transparent. The negotiated prices that health insurers pay are generally not published. Such lack of transparency protects the producers by blocking price signals to other insurers and other countries.

Result

Parallel trade is a form of arbitrage: A product, sold by the manufacturer in country A at a lower price than in country B, is bought by a dealer in country A and sold in country B. It is particularly relevant for pharmaceuticals in the internal market of the EU.

Parallel trade may lead to pharmaceutical shortages in low-price countries and increase the potential risk of falsified pharmaceuticals. It adds to the non-transparency of pricing of pharmaceuticals and can lead to calculation problems for manufacturers.

There are three basic options for addressing parallel trade: the exclusion of pharmaceuticals from the internal market rules, open redistribution among the national health systems by a subsidisation fund, and a unitary price that has to be paid everywhere in the EU.