CVD Risk Total Cholesterol HDL Cholesterol LDL Cholesterol Total-to-HDL Ratio
Normal 200 or lower 60 or higher 100 or lower 3 or less
Moderate 200 to 239 41 to 59 100 to 159 3 to 4
interact with medications taken for heart disease, particularly ANTIHYPERTENSIVE MEDICATIONS.
Blood cholesterol levels tend to rise with advancing age, probably due to a combination of changes in metabolism and slowed physical activ- ity. When considered in conjunction with other CVD risk factors, including family history of early heart disease, smoking, and the presence of health conditions such DIABETES and hypertension, blood cholesterol levels help to form a man’s risk profile for heart attack. The higher the risk profile, the more critical it becomes to moderate blood choles- terol levels. Over time the arterial plaque accumu- lations of atherosclerosis can become thick enough to block the flow of blood through an artery, and brittle enough that fragments can break away and lodge in an artery to stop the flow of blood.
See also GARLIC; NUTRITION AND DIET. cholesterol, dietary See NUTRITION AND DIET.
cholesterol-lowering medications See LIPID-
LOWERING MEDICATIONS.
chordee A congenital deformity in which the penis has an extreme curvature. Surgery generally is performed to correct chordee during infancy or early childhood, as it often interferes with urina- tion. Untreated chordee in an adult man can make sexual intercourse difficult and painful.
See also HYPOSPADIAS; PEYRONIE’S DISEASE. Christmas disease See BLEEDING DISORDERS.
chronic A health condition that extends over a prolonged period of time or that recurs over time. Some chronic conditions evolve from acute health problems (conditions that arise suddenly), for example, back pain that begins as an injury (acute back pain). Generally, the symptoms of chronic health conditions change little from day to day or follow a pattern. Though chronic health conditions can improve over time, most have symptoms that ebb and flow. Treatment generally focuses on man- aging symptoms and making lifestyle adaptations.
ARTHRITIS, DIABETES, and HYPOTHYROIDISM, are
examples of chronic health conditions.
chronic fatigue syndrome (CFS) A debilitating disorder characterized by persistent or recurrent fatigue and a constellation of other symptoms. CFS is frustrating for people who have it as well as for doctors trying to diagnose it, as it lacks distinctive diagnostic markers. Diagnosis is a combination of time (length of symptoms) and elimination of other possible health conditions. Though health experts have recognized the existence of the symp- toms of CFS since the mid-1980s, and the disorder was formally defined as a diagnostic category in 1988, there remains confusion and disagreement around its diagnosis, causes, and treatments—and even whether it exists as a unique disorder. In 1993 the Centers for Disease Control and Preven- tion (CDC) convened a consensus panel of researchers and health care providers that arrived at these criteria for diagnosis:
1. Clinically evaluated, unexplained persistent or relapsing chronic fatigue that is of new or defi- nite onset (not lifelong), is not the result of ongoing exertion, is not substantially alleviated by rest, and results in substantial reduction in previous levels of occupational, educational, social, or personal activities.
2. The concurrent occurrence of four or more of the following symptoms: substantial impair- ment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain; multi-joint pain without swelling or redness; headaches of a new type, pattern, or severity; unrefreshing sleep; and post-exertional malaise lasting more than 24 hours. These symptoms must have persisted or recurred during 6 or more consecutive months of illness and must not have predated the fatigue.
CFS typically begins with a minor infection or other illness and follows a pattern of remission and recurrence of symptoms over a course of years. There are as yet no clear demographic data about how many people have CFS, though researchers believe it affects men somewhat less commonly than women and typically develops in people age 30 and older. The cause of CFS remains unknown; it does not appear linked to the Epstein-Barr virus, as once believed, nor does it appear to be a disorder chronic fatigue syndrome 85
of the immune system. As best scientists under- stand CFS, it is not contagious nor the consequence of environmental exposure, though some people who have CFS also have allergies or sensitivities to environmental chemicals such as perfumes. Because there is no definitive cause for CFS, there are no known ways to prevent the disorder.
Symptoms and Diagnosis
For most people the diagnostic journey begins with the effort to identify the cause for persistent and debilitating fatigue, which doctors define as the reduced ability or inability to participate in cus- tomary or everyday activities, not related to sleep inadequacy or intensified physical exertion. A man with chronic fatigue may feel like sleeping all the time, yet does not feel rested with adequate sleep. Demands on physical stamina may result in flulike symptoms or “sick” (malaise) feelings, such as headaches, aching in the joints or throughout the body, and sore throat. The doctor’s examination may detect tender and slightly swollen lymph glands, especially in the neck.
The majority of people who ultimately receive a diagnosis of CFS have a history of repeated health care evaluations, often over several years, for the various symptoms that comprise the syndrome as doctors attempt to rule out likely conditions such as
HYPOTHYROIDISM (underactive thyroid), multiple
sclerosis (a degenerative disorder of the nervous system), chronic HEPATITIS, mononucleosis, CANCER, HIV/AIDS, early RHEUMATOID ARTHRITIS, medication side effects, or other health conditions that could be present depending on the person’s health history. Many undergo extensive blood and urine tests, neurological examinations, immunological evalua- tions, and imaging studies that produce results within normal limits and thus are helpful only to the extent that they can eliminate other illnesses.
Treatment
Because doctors do not know what causes CFS, treatment targets specific symptoms such as joint pain, as well as aims to improve overall well-being. Medical treatments might include over-the-counter or prescription NONSTEROIDAL ANTI-INFLAMMATORY
DRUGS(NSAIDs) to reduce pain and swelling or for
headache. Some people benefit from low-dose
therapy with tricyclic antidepressant medications, which are sometimes used to treat chronic pain syndromes. Others benefit from taking a different kind of antidepressant, selective serotonin reup- take inhibitor (SSRI) medications, or from a central nervous system stimulant such as methylphenidate (Ritalin). Most people do not experience improve- ment with medications such as CORTICOSTEROIDS
(hydrocortisone), narcotic pain relievers, sleep medications, or ANTI-ANXIETY MEDICATIONS. Doctors may try various treatments that are reported to provide relief for some people, such as DEHY-
DROEPIANDROSTERONE (DHEA), even though such
treatments have no proven scientific basis for suc- cess or failure. Researchers continue to investigate treatments with reported anecdotal success.
The treatments that seem to provide the great- est relief for nearly everyone who has CFS are nonmedical therapies such as ACUPUNCTURE, MAS-
SAGE THERAPY, CHIROPRACTIC, COGNITIVE THERAPY,
and MEDITATION. Regular physical activity, to what-
ever extent the person can tolerate without increasing fatigue, is highly beneficial. Some peo- ple find relief in nutritional supplements such as adenosine monophosphate, COENZYME Q-10, glu- tathione, melatonin, vitamin B12, vitamin C, vita-
min A, and the minerals magnesium and zinc. Some doctors report success in delivering these nutrients intravenously or as intramuscular injec- tions. Herbal preparations that improve symptoms in some people with CFS include evening primrose oil, echinacea, quercetin, and adrenal boosters such as Siberian GINSENGand rhodiola. It is impor- tant to discuss taking any of these products with the doctor, as they can cause undesired side effects and interactions with other medications.
Course of Disease and Outlook for Recovery The syndrome’s loosely defined diagnostic criteria make it difficult for researchers and doctors to track the progress and outcome of CFS. Anecdo- tally, it seems that CFS becomes a lifelong chronic condition with alternating periods of improvement and exacerbation in symptoms for about half of the people who have it. Of the remainder, half seem to improve to the point at which they consider them- selves “cured,” and half become disabled and unable to return to their jobs and regular activities. 86 chronic fatigue syndrome
There does not appear to be any pattern to distin- guish which course the disorder will take for a given individual; the outcome seems unrelated to the kind or duration of symptoms.
CFS can be particularly disabling in a man because this illness threatens the traditional image of a man. The CFS sufferer looks normal but feels very exhausted and powerless inside. This can lead to severe self-esteem issues and social wihdrawal at work and from activities that are bonding with other men.
These resources can provide information about current developments in CFS research and recom- mendations:
Centers for Disease Control and Prevention
National Center for Infectious Diseases
Office of Health Communication, Mailstop C-14 1600 Clifton Road
Atlanta, GA 30333
http://www.cdc.gov/ncidod/diseases/cfs
The CFIDS Association of America
PO Box 220398
Charlotte, NC 28222-0398 704-365-2343
http://www.cfids.org
National Chronic Fatigue Syndrome and Fibromyalgia Association National Headquarters PO Box 18426 Kansas City, MO 64133 816-313-2000 http://www.ncfsfa.org
See also HERBAL REMEDIES; FIBROMYALGIA; SLEEP
DISORDERS.
chronic obstructive pulmonary disease (COPD) A disease of the lungs and airways in which the alveoli where oxygen exchange takes place become damaged and scarred, limiting their ability to allow oxygen to transfer to the blood and reduc- ing the lung’s elasticity (ability to expand and con- tract during breathing). COPD is sometimes divided into emphysema (characterized by air trapped around the damaged alveoli and the inability to exhale easily) and chronic bronchitis (recognized by the heavy secretions in the lungs and bronchi, leading to a chronic cough). Most men with COPD have a preponderance of one form or the other.
Most COPD occurs as a consequence of cigarette smoking, though some people develop COPD as a result of exposure to industrial or environmental toxins that damage lung tissue. The body cannot repair or replace the destroyed alveoli. COPD is a progressive disease for which there is no cure; it is the fourth-leading cause of death in the United States. About 16 million Americans have COPD.
Persistent cough and shortness of breath with physical exertion are the key early symptoms of COPD, though even they do not occur until con- siderable damage compromises lung function. As these are generalized symptoms that can reflect numerous minor health ailments or even being out of shape, many men fail to recognize them as sig- nificant until they begin to interfere with daily activities, by which time the damage to the lungs often is substantial. Diagnosis is by X-ray, which shows the increased density of the scarred lung tis- sue. A man may be asked to breathe into a device to measure pulmonary function, including the capacity of the lungs to expand and to exhale. A
COMPUTED TOMOGRAPHY (CT) SCAN and MAGNETIC
RESONANCE IMAGING (MRI) can provide further
detail about the extent of damage.
Another sign of COPD that often shows on an X-ray is an enlarged heart, an early sign that the heart’s workload has increased. COPD increases the work of the heart to circulate oxygenated blood through the body. It also forces the heart to pump with greater force to get blood into the lungs, as the scar tissue from the COPD increases resistance within the lungs. In combination these conse- quences typically lead to heart failure, in which the heart cannot keep pace with the body’s needs.
As most people are well into the course of the disease by the time their COPD is diagnosed, the COPD already has caused lifestyle changes and lim- itations. The first aspect of treatment is to stop the exposure responsible for the damage, such as ciga- rette smoking. This slows, though unfortunately cannot entirely halt, the progression of disease. Medications that activate adrenergic receptors in the bronchi help to dilate the lung’s passageways to allow greater volumes of air to enter and leave the lungs with each breath. DIURETIC MEDICATIONShelp to minimize the accumulation of fluid in the lungs and in body tissues, reducing the strain COPD chronic obstructive pulmonary disease 87
places on the heart as well as on the lungs. Regu- lar physical exercise, such as walking and swim- ming, that improves aerobic fitness helps the lungs and the CARDIOVASCULAR SYSTEMto function more efficiently. Combined with medical therapies to improve cardiopulmonary function, these lifestyle modifications can slow the progression of the COPD and extend quality of life.
See also HEART DISEASE; SMOKING CESSATION. chronic liver disease See LIVER DISEASE.
chronic pain See PAIN AND PAIN MANAGEMENT.
circulatory system See CARDIOVASCULAR SYSTEM.
circumcision Surgical removal of the FORESKIN, a hood of tissue that covers the end of the penis. In the United States about half of newborn boys are circumcised within two weeks of birth, primarily for religious, hygienic, or personal preference rea- sons. Though routine circumcision has been the norm in the United States since the 1950s, the cur- rent medical consensus is that there are few health reasons to support the practice.
Circumcision as an Ancient Custom The heritage of circumcision is ancient, with evi- dence of its practice appearing in mummified remains, drawings, and religious and medical texts from Egypt as well as cultures in Africa (the Masai), South America (the Aztecs and Mayans), Australia (the Aboriginal tribes), North America (Native American tribes), and Samoa. Circumci- sion represented a rite of passage or a religious rit- ual in these cultures, much as it remains today in the Jewish and Islamic faiths. In Judaism circumci- sion represents the fulfillment of the covenant between Abraham and God, carried out by the infant’s father or in the father’s stead the mohel, typically a rabbi trained to perform circumcision. A Jewish circumcision is done when the infant boy is eight days old in a ceremony called a Bris, per- formed by the mohel. In Islam, circumcision stems from the same covenant that in Islam is known as having taken place between Ibraheem and Allah. Muslim circumcision, the khitaan, represents the decree of the prophet Muohammad to maintain
the tradition of Ibraheem. It is performed by a qualified practitioner, who can be a physician or nonphysician, generally before the boy becomes an adolescent and often in infancy.
Circumcision as a Hygienic and Medical Practice In Western cultures circumcision generally has hygienic underpinnings, arising from the observa- tion that cleanliness is easier to maintain when the penis is circumcised (though it takes little addi- tional attention to personal hygiene to maintain cleanliness when the penis is not circumcised). Cir- cumcision came into vogue in Western Europe during the Victorian era, a time noted for its emphasis on hygiene and propriety, and fell to the domain of the surgeon or physician most qualified to carry out the procedure. Boys typically were cir- cumcised as infants because the risks of bleeding and infection were minimal, and because the med- ical consensus of the time was that this afforded the child the benefit of good hygiene from the beginning of his life. There also was an element of social status attached to circumcision in this era, as only the affluent could afford to have their sons circumcised. Circumcision continued as a hygienic/ medical practice among many of those who emi- grated from Europe to the “new world” of the North American continent. In the 1950s a new surge of interest in the correlation between hygiene and health swept the United States, and it became common practice to routinely circumcise male infants within days of birth.
For several decades the medical community sup- ported the hygienic and health benefits of circum- cision based on observations that health problems such as BALANITIS(yeast infection of the penis), URI-
NARY TRACT INFECTION(UTI), and cancer of the penis
occurred more frequently in uncircumcised men. Subsequent scientific analysis of any correlation between circumcision and these health conditions failed to support these observations, however, and in the 1980s doctors began to question the practice of routine circumcision. However, in the United States routine circumcision remains the standard. Physicians find that parents making circumcision decisions tend to opt for circumcision when the infant’s father is circumcised, primarily so the father and son have similar physical appearance.
cochlear implant 89
Risks and Benefits of Circumcision
Circumcision performed on an infant by a qualified physician has few risks. Though bleeding and infec- tion are risks with any surgery, there is little bleeding and little likelihood of infection when the procedure is done under sterile conditions. Methods for per- forming circumcision usually employ a clamp-type of device, particularly for infants, under the prem- ise that this is the least traumatic approach. Healing generally is complete within 10 days to two weeks. Critics of routine infant circumcision note that few physicians use adequate anesthetic under the belief that the infant’s nerve endings are not yet developed enough to sense pain in the way an adult’s nerve endings do—a practice that subjects the infant to significant trauma. There is consider- able debate about this position; in reality, there is no means for objectively assessing the amount of pain an infant experiences during circumcision, though studies suggest the newborn’s pain sensory mechanisms are far more sophisticated in their level of development than previously assumed. Most health experts agree performing circumcision on a boy older than infancy can have significant psychological consequences. Adult circumcision is a significant procedure, generally performed by a urologist under a local nerve block for conditions involving the penis that do not respond to more conservative treatment approaches.
See also PARAPHIMOSIS; PHIMOSIS. cirrhosis See LIVER DISEASE.
cochlear implant A device that aids in sound transmission for those who are profoundly deaf. Cochlear implant systems integrate internally implanted electrodes with external amplification and transmittal units to convey sound into electri- cal signals that stimulate nerves within the inner ear. In normal hearing the outer ear collects sound waves and channels them to the middle ear, where they vibrate the eardrum. The vibration sets in motion the ossicles, three tiny bones between the middle ear and the inner ear. The primary struc- ture of the inner ear is the fluid-filled cochlea, a spiral structure that resembles a snail shell. The motions of the ossicles cause ripples in the fluid of the cochlea, which in turn activates thousands of
tiny sensors lining the cochlea. These sensors send electrical impulses along the cochlear nerve to the brain; the brain then interprets the impulses as sounds. Deafness, partial or complete, can arise from problems at any stage of this process.
A cochlear implant can benefit those who lose hearing as a result of damage to the inner ear (nerve deafness). The implant substitutes for the sensor cells, called hair cells, that sound normally