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Deep Learning Technology: Sebastian Arnold, Betty van Aken, Paul Grundmann, Felix A. Gers and Alexander Löser. Learning Contextualized Document Representations for Healthcare Answer Retrieval. The Web Conference 2020 (WWW'20)
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In lactation mastitis, antibiotics are not needed in the overwhelming majority of cases and should be used only for bacterial infections. Dicloxacillin or cephalexin are sometimes recommended. The effects of antibiotics has not been well studied as of 2013.
In lactation mastitis, frequent emptying of both breasts by breastfeeding is essential. Also essential is adequate fluid supply for the mother and baby. Use of pumps to empty the breast is now considered somewhat controversial.
For breastfeeding women with light mastitis, massage and application of heat prior to feeding can help as this may aid unblocking the ducts. However, in more severe cases of mastitis heat or massage could make the symptoms worse and cold compresses are better suited to contain the inflammation.
Nonpuerperal mastitis is treated by medication and possibly aspiration or drainage (see in particular treatment of subareolar abscess and treatment of granulomatous mastitis). According to a BMJ best practice report, antibiotics are generally to be used in all nonpuerperal mastitis cases, with replacement of the antibiotics by an antifungal agent such as fluconazole in cases of deep fungal infections, and corticosteroids are to be used in case of granulomatous mastitis (with differential diagnosis to tuberculosis infection of the breast).
Treatment is problematic unless an underlying endocrine disorder can be successfully diagnosed and treated.
A study by Goepel and Panhke provided indications that the inflammation should be controlled by bromocriptine even in absence of hyperprolactinemia.
Antibiotic treatment is given in case of acute inflammation. However, this alone is rarely effective, and the treatment of a subareaolar abscess is primarily surgical. In case of an acute abscess, incision and drainage are performed, followed by antibiotics treatment. However, in contrast to peripheral breast abscess which often resolves after antibiotics and incision and drainage, subareaolar breast abscess has a tendency to recur, often accompanied by the formation of fistulas leading from inflammation area to the skin surface. In many cases, in particular in patients with recurrent subareolar abscess, the excision of the affected lactiferous ducts is indicated, together with the excision of any chronic abscess or fistula. This can be performed using radial or circumareolar incision.
There is no universal agreement on what should be the standard way of treating the condition. In a recent review article, antibiotics treatment, ultrasound evaluation and, if fluid is present, ultrasound-guided fine needle aspiration of the abscess with an 18 gauge needle, under saline lavage until clear, has been suggested as initial line of treatment for breast abscess in puerperal and non-puerperal cases including central (subareolar) abscess (see breast abscess for details). Elsewhere, it has been stated that treatment of subareolar abscess is unlikely to work if it does not address the ducts as such.
Duct resection has been traditionally used to treat the condition; the original Hadfield procedure has been improved many times but long term success rate remains poor even for radical surgery. Petersen even suggests that damage caused by previous surgery is a frequent cause of subareolar abscesses. Goepel and Pahnke and other authors recommend performing surgeries only with concomitant bromocriptine treatment.
Treatment protocol is not well established. Some sources report that approximately half of the patients will fully recover after lengthy (mean time 14.5 months, range 2–24 months) expectant management.
Treatment with steroids is lengthy and usually requires about 6 months. While some source report very good success with steroids most report a considerable risk of recurrence after a treatment with steroids alone. Steroids are known to cause elevation of prolactin levels and increase risk of several conditions such as diabetes, and other endocrinopathies which in turn increase the risk of IGM. Treatment with topical steroids to limit side effects was also reported in one case. For surgical treatment recurrence rates of 5-50% have been reported.
A 1997 literature review article recommended complete resection or corticosteroid therapy, stating also that long-term follow-up was indicated due to a high rate of recurrence.
Treatment with a combination of glucocorticoids and prolactin lowering medications such as bromocriptine or cabergoline was used with good success in Germany. Prolactin lowering medication has also been reported to reduce the risk of recurrence. In cases of drug-induced hyperprolactinemia (such as antipsychotics) prolactin-sparing medication can be tried.
Methotrexate alone or in combination with steroids has been used with good success. Its principal mechanism of action is immunomodulating activity, with a side effect profile that is more favorable for treating IGM.
Colchicine, azathioprine and NSAIDs have also been used.
The condition is usually self-limiting, and thus not indicated for surgery.
Treatment is possible with long-acting antibiotics, but milk from such cows is not marketable until drug residues have left the cow's system. Antibiotics may be systemic (injected into the body), or they may be forced upwards into the teat through the teat canal (intramammary infusion). Cows being treated may be marked with tape to alert dairy workers, and their milk is syphoned off and discarded. To determine whether the levels of antibiotic residuals are within regulatory requirements, special tests exist. Vaccinations for mastitis are available, but as they only reduce the severity of the condition, and cannot prevent reoccurring infections, they should be used in conjunction with a mastitis prevention program.
Most women with fibrocystic changes and no symptoms do not need treatment, but closer follow-up may be advised.
There is no widely accepted treatment or prevention strategy for fibrocystic condition. When treatment of symptoms is necessary it follows the same strategies as treatment for cyclical breast pain.
It is controversial whether benign breast conditions improve or worsen with oral contraceptives or hormone replacement therapy.
A few small-scale studies have indicated that the fibrocystic condition may be improved by dietary changes (especially by a reduced intake of caffeine and related methylxanthines or by a reduced intake of salt) and by vitamin supplements.
Small, preliminary studies have shown beneficial effects of iodine supplementation (such as reducing the presence of breast cysts, fibrous tissue plaques and breast pain) in women with fibrocystic breast changes, with elemental iodine (I) being more effective than iodide (I). It is noted that iodine supplementation, via an iodine-based modulation of estrogen influence in the breast, also appears to inhibit early cancer progression in small studies done on breast cancer cells in a lab.. Since treatment success in a lab is often not replicated in humans, more human research is necessary to determine if iodine supplementation prevents breast cancer
A U.S. National Institutes of Health fact sheet of 2011 reported on a randomized, double-blind, placebo-controlled clinical trial performed on 111 women affected by fibrosis and having a history of breast pain. In this trial, daily doses of iodine led to decreased in breast pain, tenderness and nodularity. It was emphasized that further research to clarify iodine's role in fibrocystic breast disease is needed and that large doses of iodine should only be used under the guidance of a physician.
Danazol, an estrogen biosynthesis inhibitor, tamoxifen, an antagonistic modulator of the estrogen receptor, and bromocriptine, a prolactin-lowering D receptor agonist, are the main drugs used in the treatment of mastodynia and are effective.
Other medications and supplements have been found to be of benefit. Spironolactone (Aldactone), low dose oral contraceptives, low-dose estrogen have helped to relieve pain. Topical anti-inflammatory medications can be used for localized pain. For anti hormonal treatment, danazol (Danocrine) can be helpful. Tamoxifen citrate is used in some cases of severe breast pain. Vitamin E is not effective in relieving pain nor is Evening primrose oil. Vitamin B and Vitamin A have not been consistently found to be beneficial. Flaxseed has shown some activity in the treatment of cyclic mastalgia.
Pain may be relieved by the use of nonsteroidal anti-inflammatory drugs or, for more severe localized pain, by local anaesthetic. Pain may be relieved psychologically by reassurance that it does not signal a serious underlying problem, and an active life style can also effect an improvement.
Information regarding how the pain is real but not necessarily caused by disease can help to understand the problem. Learning breast self-examination helps to orient the woman to normal and expected texture and structure of the breast and nipple. Yearly breast exams may be suggested. Counseling can also be to describe changes that vary during the monthly cycle. Women on hormone replacement therapy may benefit from a dose adjustment. Another non-pharmacological measure to help relieve symptoms of pain may be to use good bra support. Breasts change during adolescence and menopause and refitting may be beneficial. Applying heat and/or ice can bring relief. Dietary changes may also help with the pain. Methylxanthines can be eliminated from the diet to see if a sensitivity is present. Some clinicians recommending a reduction in salt, though no evidence supports this practice.
Practices such as good nutrition, proper milking hygiene, and the culling of chronically infected cows can help.
Ensuring that cows have clean, dry bedding decreases the risk of infection and transmission. Dairy workers should wear rubber gloves while milking, and machines should be cleaned regularly to decrease the incidence of transmission.
The term nonpuerperal mastitis describes inflammatory lesions of the breast (mastitis) that occur unrelated to pregnancy and breastfeeding.
It is sometimes equated with duct ectasia, but other forms can be described.
"Duct ectasia" in the literal sense (literally: duct widening) is a very common and thus rather unspecific finding, increasing with age. However, in the way in which the term is mostly used, duct ectasia is an inflammatory condition of the larger-order lactiferous ducts. It considered likely that the condition is associated with aseptic (chemical) inflammation related to the rupture of ducts or cysts. It is controversial whether duct dilation occurs first and leads to secretory stasis and subsequent periductal inflammation or whether inflammation occurs first and leads to an inflammatory weakening of the duct walls and then stasis. When the inflammation is complicated by necrosis and secondary bacterial infection, breast abscesses may form. Subareolar abscess, also called Zuska's disease (only nonpuerperal case), is a frequently aseptic inflammation and has been associated with squamous metaplasia of the lactiferous ducts.
The duct ectasia—periductal mastitis complex affects two groups of women: young women (in their late teens and early 20s) and perimenopausal women. Women in the younger group mostly have inverted nipples due to squamous metaplasia that lines the ducts more extensively compared to other women and produces keratin plugs which in turn lead to duct obstruction and then duct dilation, secretory stasis, inflammation, infection and abscess. This is not typically the case for women in the older group; in this group, there is likely a multifactorial etiology involving the balance in estrogen, progesterone and prolactin.
Treatment of mastitis and/or abscess in nonlactating women largely the same as that of lactational mastitis, generally involving antibiotics treatment, possibly surgical intervention by means of fine-needle aspiration and/or incision and drainage and/or interventions on the lactiferous ducts (for details, "see also" the articles on treatment of mastitis, of breast abscess and of subareolar abscess). Additionally, an investigation for possible malignancy is needed, normally by means of mammography, and a pathological investigation such as a biopsy may be necessary to exclude malignant mastitis. Although no "causal" relation with breast cancer has been established, there appears to be an increased statistical risk of breast cancer, warranting a long-term surveillance of patients diagnosed with non-puerperal mastitis.
Nonpuerperal breast abscesses have a higher rate of recurrence compared to puerperal breast abscesses. There is a high statistical correlation of nonpuerperal breast abscess with diabetes mellitus (DM). On this basis, it has recently been suggested that diabetes screening should be performed on patients with such abscess.
Cracked nipples can be treated with 100% lanolin. Glycerin nipple pads can be chilled and placed over the nipples to help soothe and heal cracked or painful nipples. If the cause of cracked nipples is from thrush, treatment is usually begun with nystatin. If the mother is symptomatic then the mother and the baby can be treated. Continuing to breastfeed will actually help the nipples heal. A little breast milk or purified lanolin cream or ointment helps the healing process. Breastfeeding professionals that include nurses, midwives and lactation consultants are able to assist in the treatment of cracked nipples.
Advice from others is abundant but there have been some treatments that have been identified as not being effective in healing or preventing cracked nipples. These ineffective treatments are keeping the breastfeeding short and using a nipple guard. Keeping the feedings short so that the nipples can rest is not effective in relieving the pain of cracked nipples and it could have a negative effect on the milk supply. Nipple shields do not improve latching on.
There are usually no adverse side effects to this condition. In almost all cases it subsides after menopause. A possible complication arises through the fact that cancerous tumors may be more difficult to detect in women with fibrocystic changes.
Other strategies for protracting inverted nipples include regularly stimulating the nipples to a protruding state, in an attempt to gradually loosen the nipple tissue. Some sex toys designed for nipple stimulation, such as suction cups or clamps may also cause inverted nipples to protract or stay protracted longer. There are special devices specifically designed to draw out inverted nipples, or a home-made nipple protractor can be constructed out of a 10 ml disposable syringe. These methods are often used in preparation for breast-feeding, which can sometimes cause inverted nipples to become protracted permanently.
Two methods which are now discouraged are breast shells and the Hoffman technique. Breast shells may be used to apply gentle constant pressure to the areola to try to break any adhesions under the skin that are preventing the nipple from being drawn out. The shells are worn inside the bra. The Hoffman technique is a nipple stretching exercise that may help loosen the adhesions at the base of the nipple when performed several times a day. Although both techniques are heavily promoted, a 1992 study found that not only do shells and the Hoffman technique not promote more successful breastfeeding, but they may also actually disrupt it.
Another method of protracting inverted nipples is to have the nipple pierced. This method will only be effective if the nipple can be temporarily protracted. If pierced when protracted, the jewellery may prevent the nipple from returning to its inverted state. The success of both of these methods, from a cosmetic standpoint, is mixed. The piercing may actually correct the overly taut connective tissue to allow the nipple to become detached from underlying connective tissue and resume a more typical appearance.
90% of cases are smokers, however only a very small fraction of smokers appear to develop this lesion. It has been speculated that either the direct toxic effect or hormonal changes related to smoking could cause squamous metaplasia of lactiferous ducts. It is not well established whether the lesion regresses after smoking cessation.
Extrapuerperal cases are often associated with hyperprolactinemia or with thyroid problems. Also diabetes mellitus may be a contributing factor in nonpuerperal breast abscess.
The clinical management of a cyst of Montgomery depends upon the symptoms of the patient.
If there are no signs of infection, a cyst of Montgomery can be observed, because more than 80% resolve spontaneously, over only a few months. However, in some cases, spontaneous resolution may take up two years. In such cases, a repeat ultrasonography may become necessary. If, however, the patient has signs of an infection, for example reddening (erythema), warmth, pain and tenderness, a treatment for mastitis can be initiated, which may include antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs). With treatment, inflammatory changes usually disappear quickly. In rare cases, drainage may become necessary. A surgical treatment of a cyst of Montgomery, i.e. a resection, may become necessary only if a cyst of Montgomery persists, or the diagnosis is questioned clinically.
The prognosis seems to be excellent. In one series, all adolescent patients with a cyst of Montgomery had a favourable outcome.
Antibiotics have been used to prevent and treat these infections however the misuse of antibiotics is a serious problem for global health. It is recommended that guidelines be followed which outline when it is appropriate to give antibiotics and which antibiotics are most effective.
Atelectasis: mild to moderate fever, no changes or mild rales on chest auscultation.
Management: pulmonary exercises, ambulation (deep breathing and walking)
Urinary tract infection : high fever, malaise, costovertebral tenderness, positive urine culture.
Management: antibiotics as per culture sensitivity (cephalosporine).
Endometritis: moderate fever, exquisite uterine tenderness, minimal abdominal findings.
Management: multiple agent IV antibiotics to cover polymicrobial organisms: clindamycin, gentamicin, addition of ampicillin if no response, no cultures are necessary.
Wound infection: persistent spiking fever despite antibiotics, wound erythema or fluctuance, wound drainage.
Management: antibiotics for cellulitis, open and drain wound, saline-soaked packing twice a day, secondary closure.
Septic pelvic thrombophlebitis: persistent wide fever swings despite antibiotics, usually normal abdominal or pelvic exams.
Management: IV heparin for 7–10 days at rates sufficient to prolong the PTT to double the baseline values.
Mastitis: unilateral, localized erythema, edema, tenderness.
Management: antibiotics for cellulitis, open and drain abscess if present.
The mother must remove the breast milk. If the baby can attach well and suckle, then she should breastfeed as frequently as the baby is willing. If the baby is not able to attach and suckle effectively, she should express her milk by hand or with a pump a few times until the breasts are softer, so that the baby can attach better, and then get them to breastfeed frequently.
She can apply warm compresses to the breast or take a warm shower before expressing, which helps the milk to flow. She can use cold compresses after feeding or expressing, which helps to reduce the oedema.
Engorgement occurs less often in baby-friendly hospitals which practise the Ten Steps and which help mothers to start breastfeeding soon after delivery.
Regular breastfeeding can be continued. The treatment for breast engorgement can be divided into non-medical and medical methods. The non-medical methods include hot/cold packs, Gua-Sha (scraping therapy), acupuncture and cabbage leaves whereas medical methods are proteolytic enzymes such as serrapeptase, protease, and subcutaneous oxytocin. Evidence from published clinical trials on the effectiveness of treatment options is of weak quality and is not strong enough to justify a clinical recommendation.
Antimetabolites, also categorized as steroid-sparing agents, such as azathioprine, methotrexate, mycophenolic acid, and leflunomide are often used as alternatives to corticosteroids. Of these, methotrexate is most widely used and studied. Methotrexate is considered a first-line treatment in neurosarcoidosis, often in conjunction with corticosteroids. Long-term treatment with methotrexate is associated with liver damage in about 10% of people and hence may be a significant concern in people with liver involvement and requires regular liver function test monitoring. Methotrexate can also lead to pulmonary toxicity (lung damage), although this is fairly uncommon and more commonly it can confound the leukopenia caused by sarcoidosis. Due to these safety concerns it is often recommended that methotrexate is combined with folic acid in order to prevent toxicity. Azathioprine treatment can also lead to liver damage. Leflunomide is being used as a replacement for methotrexate, possibly due to its purportedly lower rate of pulmonary toxicity. Mycophenolic acid has been used successfully in uveal sarcoidosis, neurosarcoidosis (especially CNS sarcoidosis; minimally effective in sarcoidosis myopathy), and pulmonary sarcoidosis.
Treatments for sarcoidosis vary greatly depending on the patient. At least half of patients require no systemic therapy. Most persons (>75%) only require symptomatic treatment with non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or aspirin. For persons presenting with lung symptoms, unless the respiratory impairment is devastating, active pulmonary sarcoidosis is observed usually without therapy for two to three months; if the inflammation does not subside spontaneously, therapy is instituted.
Major categories of drug interventions include glucocorticoids, antimetabolites, biologic agents especially monoclonal anti-tumor necrosis factor antibodies, and more recently, specific antibiotic combinations and mesenchymal stem cells. If drug intervention is indicated, a step-wise approach is often used to explore alternatives in order of increasing side effects and to monitor potentially toxic effects.
Corticosteroids, most commonly prednisone or prednisolone, have been the standard treatment for many years. In some people, this treatment can slow or reverse the course of the disease, but other people do not respond to steroid therapy. The use of corticosteroids in mild disease is controversial because in many cases the disease remits spontaneously.
Medical treatment of gynecomastia is most effective when done within the first two years after the start of male breast enlargement. Selective estrogen receptor modulators (SERMs) such as tamoxifen, raloxifene, and clomifene may be beneficial in the treatment of gynecomastia but are not approved by the Food and Drug Administration for use in gynecomastia. Clomifene seems to be less effective than tamoxifen or raloxifene. Tamoxifen may be used for painful gynecomastia in adults. Aromatase inhibitors (AIs) such as anastrozole have been used off-label for cases of gynecomastia occurring during puberty but are less effective than SERMs. A few cases of gynecomastia caused by the rare disorders aromatase excess syndrome and Peutz–Jeghers syndrome have responded to treatment with AIs such as anastrozole. Androgens/anabolic steroids may be effective for gynecomastia. Testosterone itself may not be suitable to treat gynecomastia as it can be aromatized into estradiol, but non-aromatizable androgens like topical androstanolone (dihydrotestosterone) can be useful.
The nipples of nursing mothers naturally make a lubricant to prevent drying, cracking, or infections. Cracked nipples may be able to be prevented by:
- Avoid soaps and harsh washing or drying of the breasts and nipples. This can cause dryness and cracking.
- Rubbing a little breast milk on the nipple after feeding to protect it.
- Keeping the nipples dry to prevent cracking and infection.
Roman chamomile can be applied directly to the skin for pain and swelling and is used to treat cracked nipples.
Medical treatment has not proven consistently effective. Medical regimens have included tamoxifen, progesterone, bromocriptine, the gonadotropin-releasing hormone agonist leuprolide, and testosterone. Gestational macromastia has been treated with breast reduction drugs alone without surgery. Surgical therapy includes reduction mammaplasty and mastectomy. However, breast reduction is not clinically indicated unless at least 1.8 kg (4 lb) of tissue per breast needs to be removed. In the majority of cases of macromastia, surgery is medically unnecessary, depending on body height. Topical treatment includes regimens of ice to cool the breasts.
Treatment of hyperprolactinemia-associated macromastia with D receptor agonists such as bromocriptine and cabergoline has been found to be effective in some, but not all cases. Danazol, an antiestrogen and weak androgen, has also been found to be effective in the treatment of macromastia.
When hypertrophy occurs in adolescence, noninvasive treatments, including pharmaceutical treatment, hormone therapy, and steroid use are not usually recommended due to known and unknown side effects. Once a girl's breast growth rate has stabilized, breast reduction may be an appropriate choice. In some instances after aggressive or surgical treatment, the breast may continue to grow or re-grow, a complete mastectomy may be recommended as a last resort.
Pregnancy is recognized as the second most common reason for hypertrophy. When secondary to pregnancy, it may resolve itself without treatment after the pregnancy ends.
A number of other conditions can cause fevers following delivery including: urinary tract infections, breast engorgement, atelectasis and surgical incisions among others.