Antiphospholipid syndrome

What is it? Antiphospholipid syndrome (APS) is the name given to a disease which involves the immune system. Normally antibodies are good and they help fight germs or viral infections from outside, however, occasionally the immune system makes the wrong kind a type that acts against the body itself. !hese unusual auto antibodies in APS are detected by a blood test and when they are present make a person more likely to get specific problems. APS doesn"t make you feel unwell or stop your immune system from working to fight disease. #ou can"t catch it or give it to someone else and it certainly isn"t a terminal disease or anything like that. $any people go throughout life without even knowing their body makes these antibodies. %ts &ust that there"s more chance of certain problems. Sometimes APS is associated with a disease called systemic lupus erythematosis (S'(). #our doctor will have tested for this. %t is only recently that these antibodies were discovered and their significance understood, so the information available is somewhat limited, but more research is being carried out on this all the time. )e still don"t know e*actly how the antibodies bring about the effects described below, although we have some good ideas. What problems can it cause? !he manifestations of APS are very variable and most people will not have more than one of these problems. %t is associated with+ ,ecurring miscarriage in early pregnancy 'oss of a baby after the first trimester (-. weeks) Pre eclampsia in pregnancy /ne*pectedly small babies !hrombosis in a vein or artery

Part of the definition of APS is that one of these must have occurred along with a positive antibody test. Can these be prevented? !his is a 0uestion that much research is trying to answer, and we know that some treatments can significantly reduce the chances of these things happening. Pregnancy 1ne of the most common and distressing problems with APS is that of recurrent miscarriage. A promising treatment which helps prevent this is the use of low dose aspirin in early pregnancy. !his is sometimes combined with another drug called heparin, which is given by in&ection. 2nowing that someone has APS means that the pregnancy can be monitored much more closely than usual, for e*ample with ultrasound scans to watch for poor growth. %ndeed, it may be that aspirin or heparin can help prevent these problems too. Thrombosis A thrombosis is a blood clot which forms when it shouldn"t do, such as in a

deep vein of the leg (34!) or in an artery. 5lots from the leg can dislodge and move to more dangerous places such as the lung (pulmonary embolism). APS can make someone more likely to get thrombosis, but there are times when this is particularly important and thrombosis is already a risk, for e*ample after ma&or surgery, during prolonged illness or bed rest, during pregnancy and for a short time after delivery. 3uring these times, e*tra clot prevention may be needed. !his might mean some tight medical stockings or heparin treatment. %n more severe cases of thrombosis, it may mean long term treatment with tablets to thin the blood. )omen with APS shouldn"t take the combined (oestrogen containing) contraceptive pill and a doctor can suggest safer alternatives. How common is APS? !he auto antibodies are found in about 67 of women. Not all of these will have had one of the problems above, so they do not necessarily have the disease. !he levels of antibody can go up and down, and even disappear, so to definitely say someone has APS, the blood tests need to repeated at least 8 weeks from the first and still be positive. !he decision on treatment at a particular time (such as pregnancy) depends upon the levels and what previous medical problems there were. APS may run in families, although not all members are necessarily affected. %t isn"t e*actly clear to what e*tent this happens, but it is certainly suggestive, for e*ample, if several people have had a series of miscarriages or thromboses. What can I do? )hen you get pregnant it is important to be referred to your 1bstetrician as early as possible to decide on the need for treatment with aspirin or heparin. %f you have had a thrombosis, you will have received specific advice on treatment, but probably everyone should be encouraged to address other risk factors for thrombosis. !his includes stopping smoking, not using the combined contraceptive pill, treating high blood pressure and cholesterol levels. Antiphospholipid Antibody Syndrome There are many causes that have been linked to recurrent pregnancy loss. One of the less frequently seen associations is known as the antiphospholipid antibody syndrome. What are antiphospholipid antibodies? Under normal circumstances, antibodies are proteins made by your immune system to fight substances recognized as foreign by your body. Some e amples of foreign substances are bacteria and viruses. Sometimes the body!s own cells are recognized as foreign. "n the antiphospholipid antibody syndrome the body recognizes phospholipids #part of a cell!s membrane$ as foreign and produces antibodies against them. %ntibodies to phospholipids #antiphospholipid antibodies$ can be found in the blood of some people with lupus, but they are also seen in people without any known illness. &upus anticoagulant #&%'$ and anticardiolipin antibody #%'%$ are the two known antiphospholipid antibodies that are associated with recurrent pregnancy loss. What is the antiphospholipid antibody syndrome? 3ifferent physicians may use slightly different definitions to diagnose the antiphospholipid antibody syndrome. %n general you need to have a positive blood test for either the lupus anticoagulant or the anticardiolipin antibody, on two separate occasions, at least eight weeks apart. %n addition to the blood tests you must also have one the following criteria+ A history of thrombosis (clots within the blood vessels), thrombocytopenia (low platelet count) or recurrent pregnancy loss. Several other manifestations may be seen, but not always, in patients with the antiphospholipid antibody syndrome which include skin, heart and nervous system abnormalities.

What is the association between antiphospholipid antibodies and pregnancy loss? %mong women with recurrent pregnancy losses antiphospholipid antibodies have reported to be present in (()*++). &upus anticoagulant #&%'$ and,or medium to high anticardiolipin antibodies #%'%$ have been associated with first, second, and third trimester pregnancy losses. The association is even higher when the antiphospholipid antibody tests are persistently positive. %lthough it is unknown e actly how the antiphospholipid antibody syndrome adversely affects pregnancy, one theory is that it may cause blood clots. These blood clots, which can be microscopic, may occur in the blood vessels of the placenta. The placenta provides nourishment to the baby and any interruption in this process can be harmful to the pregnancy. The antiphospholipid syndrome may increase the risk of miscarriage, poor fetal growth, preeclampsia #high blood pressure during pregnancy$, and stillbirth. "t has yet to be proven but many researchers think the antiphospholipid antibody syndrome may e ist in a state of remission or e acerbation similar to other diseases such as lupus or rheumatoid arthritis. This means you could have periods of times when the antibodies are not active. Who should be tested for antiphospholipid antibody syndrome -omen who have had a history of recurrent pregnancy losses should be tested for antiphospholipid antibodies in addition to other routine tests. % history of une plained poor fetal growth and or the early onset of severe preeclampsia #to emia, also known as high blood pressure in pregnancy$ or an une plained placental abruption are indications for testing. % history of thrombosis #clots in the blood vessels$, stroke, heart attack, thrombocytopenia #low platelet count$, presence of other autoimmune disorders such as lupus, an abnormal ./0&, or 1TT blood tests would suggest the need for testing. What is the treatment for the antiphospholipid syndrome in pregnancy? The drug of choice for treatment is 2eparin, which is an in3ection to prevent blood from clotting. "t is used in combination with 4baby4 #low dose$ aspirin. "n certain cases 1rednisone and baby aspirin are used to treat the antiphospholipid antibody syndrome. %ll medications have side effects and the choice of therapy should be made after the risks and benefits of the treatments have been discussed between the physician and the patient. These pregnancies should be monitored closely by ultrasound every month to check on fetal growth and by antenatal testing #non*stress tests and biophysical profiles$ weekly, beginning at 5+ weeks gestation. %lthough there are a few reports of successful pregnancies without treatment, the ma3ority of researchers have reported a 67)*68) success rate with treatment.

St.

Catherine's Monastery

'ocated at the foot of $ount $oses, St. 5atherine"s $onastery, was constructed by order of the (mperor 9ustinian between :6; and :<:. %s built around what is thought to be $oses" =urning =ush, which has a chapel built atop it. %t is a spectacular natural setting for priceless works of art, including Arab mosaics, >reek and ,ussian icons, )estern oil paintings, paintings on wa*, fine sacerdotal ornaments, marbles, enamels, chalices, reli0uaries, including one donated by 5?ar Ale*ander %% in the -@th century, and another by (mpress 5atherine of ,ussia in the -;th century. =ut of perhaps even greater significance is that it is the second largest collection of illuminated manuscripts (!he 4atican

has the largest). !he collection consists of some .,:AA volumes in >reek, 5optic, Arabic, Armenian, Bebrew, Slavic, Syriac, >eorgian and other languages. Around the year -8:A, the fourth century 5ode* Sinaiticus, which is now in the =ritish $useum in 'ondon, was discovered here. !he $onastery even has a small -Ath or --th century mos0ue which was probably built to appease the %slamic authorities of the time. !here is also a small chapel (the 5hapel of St. !riphone, also known as the Skull Bouse) which houses the skulls of deceased monks.

The Fatimid Mos ue! which lies within the walls o" St# Catherine$s Monastery St. 5atherine"s has a rich history indeed. So rich that it is a sparkling e*ample of an undiscovered 9ewell of travel. %t has been called the oldest working 5hristian monastery, though St. Anthony"s predates it, and the smallest diocese in the world. !he $onastery was originally ordered built by (mpress Belen, the mother of 5onstantine the >reat, but was actually built by (mperor 9ustinian to house the bones of St. 5atherine of Ale*andria. St. 5atherine, whose body was reportedly carried away by angels, was discovered five hundred years later at the top of the peak that now bears her name. Ber relics are stored in a marble reli0uary in the =asilica. )e have additional pictures of this church, and of its interior. St. 5atherine"s is also a formidable fortification, with granite walls CA to 6AA feet tall, surrounded by gardens and cypresses. Prior to probably the twentieth century, the only entrance to St. 5atherine"s was a small door .A feet high, where provisions and people were lifted with a system of pulleys, and where food was often lowered to nomads. %t has withstood numerous attacks over its -C hundred year e*istence thus protecting a rich store of art, and today, while it is one of the oldest monasteries in the world, its original, preserved state is unmatched.

!hough established and patroni?ed most of its history by the ,ussian 1rthodo* 5hurch, it is now under the auspices of the >reek 1rthodo* 5hurch. $ost of its monks are also of >reek origin.

C%IFFT&P M&'AST()I(S &F M(T(&)A! *)((C(

%n the northwest corner of !hessaly, the wide bed of the Pinios ,iver emerges from the mighty canyons of the (astern Pindus $ountains that plummet abruptly onto the !hassalian plain. Bere, in the shadow of the mountains and &ust beyond the town of 2alambaka, massive gray colored pinnacles rise towards the sky. %t is a strange but breathtaking landscape that has been sculpted by wind and water over thousands of years. !hese smooth, vertical rocks have become a favorite destination for rock climbers who are, perhaps, the only ones today who can truly appreciate the feat of the @th century hermits who first climbed them to settle in the caves and fissures of the rocks. 1n Sundays, they clambered down from their cells to celebrate mass in 3oupiani and as their numbers increased, the !heotokos of 3oupiani was established as the first semi organi?ed community during the --th century. =y the -Cth century, the =y?antine (mpire was already on the wane and the monastic communities of the Athos peninsula were increasingly besieged by !urkish pirates. After an encounter with brigands, three monks, >regory, $oses and Athanasius, left the $onastery of %viron on the western coast of the peninsula to search for a new home. !hey had heard of DmiraclesE taking place in the land of the great rock forest and on arriving there, settled on top of the rock called Stylos or the Pillar where they built a hesychasterion or wooden hut. 'ater, Athanasius assembled a

small community and constructed a few cells and a chapel in a cave on the nearby Platys Lithos or the Broad Rock. !he Serbian (mperor, Symeon /ros provided them with an endowment that allowed them to build the 5hurch of the !ransfiguration around -.:< and to e*pand the monastery with more cells and cloisters. Bis son, 9ohn /ros, retired here as the $onk %oasaph about -.;. adding to the already si?able endowment en&oyed by the >rand $eteoron, also known as the $onastery of the !ransfiguration. %oasaph assumed authority upon the death of Athanasius in -.8. and he further e*panded the monastery and the 5hurch. $eaning Dsuspended in airE the name $eteora soon came to encompass the entire rock community of 6C monasteries. !here were no steps and the main access to the monasteries was by means of a net that was hitched over a hook and hoisted up by rope and a hand cranked windlass to winch towers overhanging the chasm. $onks descended in the nets or on retractable wooden ladders up to CAm long to the fertile valleys below to grow grapes, corn and potatoes. (ach community developed its own resources and by the end of the -Cth century, the >rand $eteoron emerged as the dominant community. %ts wealth included landed estates, flocks of sheep, and herds of cattle. After %oasaph died in -C66, $eteora gradually plunged into a period of disorder and decline. /nscrupulous men e*propriated the income of the monasteries, 4lach s0uatters settled in Boly !rinity and 2allistratos and a s0uint eyed monk named !heodore lived with two women dressed as monks in the $onastery of the Pantocrator. !he rock community en&oyed a brief revival of monasticism in the -<th 5entury under the reign of Suileman the $agnificent who rela*ed earlier prohibitions on the building and restoration of 5hristian churches but lapsed once again into decline. =y the -8th century, $eteora had become a refuge center for >reeks escaping the increasingly harsh administration and ta*ation of the 1ttoman overlords as well as a hideout of the klephts, rebel warriors who harassed the !urks and participated in the fight for independence in the -@th century. !he >erman and %talian occupation during )orld )ar %% saw further looting and destruction of the monasteries. !oday, only si* monasteries survive as museums. !hey are sparsely occupied by a few monks and nuns but they offer a rare glimpse of 1rthodo* monastic life.

=est !imes to >o+ !he $onasteries of $eteora may be visited year round but the weather
is wet and cool from 3ecember to $arch. 5rowds and high season rates are guaranteed from 9uly -st to 1ctober -:th . $ay and 9une are the best months for comfortable weather, low season rates and the opportunity to leisurely e*plore the area.

>etting !here+ =uses to 2alambaka are available from %oannina, !rikala, !hessaloniki and
Athens. %t is also possible to take the train from !hessaloniki or Athens with a switch at 'arissa. %f you are traveling from Athens, take a morning train so that you can en&oy the spectacular scenery as you pass through the mountains between 'ivadia and 'amia.

5lothingF>ear+ Appropriate clothing is re0uired to visit the monasteries. Sleeveless clothing

and shorts are prohibited. Skirts and shawls are available at the entrance for those who are deemed to be unacceptably dressed (including guys wearing shorts and tanktops).

>eneral %nformation+ A visit to the $onasteries of $eteora is highly recommended. (ach

monastery charges a small admission fee. !he nearby towns of 2alambaka and 2astraki have become very touristy with accompanying higher rates than the outlying areas. )e suggest combining a trip to $eteora with another destination such as Gagoria or the Balkidiki peninsula. %f you do not plan to travel to other areas in northern >reece or if your time is limited, the most efficient way to visit $eteora is to take a bus tour from Athens. #ou can usually negotiate a good deal with any of the several travel agencies to be found around Syntagma S0uare. !he >reek National !ourist 1rgani?ation produces a brochure entitled H>reece+ !hessalia $eteoraH which lists several A, = and 5 class hotels in 2alambaka as well as their telephone numbers. /nlisted are many 3 and ( class hotels, domatia and campsites. A listing can be obtained from the local !ourist Police located near the bus station (Bat?ipetrou -A, 2alambaka !el+ 66-A@). Botel rooms in the A,= and 5 classes cost about I:A I-AA per night for a double in the high season and about a third less in the low season. !he village of 2astraki is closer to the monasteries and convenient for those who want to visit by foot but there are more options for food and lodging in 2alambaka.

Planning !ips+
Plan to spend a full day at $eteora. #ou will delight in the play of light on the rocks and their changing moods. 1n sunny mornings, the red roof tiles of the monasteries glisten in sharp contrast to the weather stained grayness of the rocks while the late afternoon sun bathes the landscape with a golden glow. At nighttime, the rocks are dramatically illuminated by spotlights while autumnal mists shroud them in an ethereal mysteriousness that must have appealed to the hermits and monks who sought refuge from the things of the world. (*plore the paths between the rock towers but be careful because they are not all intact and some scrambling over uneven ground is re0uired. Ac0uaint yourself with >reek 1rthodo*y. %t will enhance your appreciation of the 5hurches and $onasteries of $eteora and their valuable displays of =y?antine art. !here are volunteers at the 5hurch of the !ransfiguration who will e*plain the rich tradition of =y?antine iconography. ,emember to carry bottled water, especially if you are visiting the monasteries by foot. !here are refreshment vendors along the road by the monasteries but their prices are e*cessive.

,elated =ooks+
Greece: A Lonely Planet Travel Survival Kit by 3avid )illett, ,osemary Ball, Paul Bellander and 2erry 2enihan provides e*cellent general travel information on >reece. !hey also provide food and lodging recommendations for small villages like 2astraki. Roumeli: Travels in Northern Greece by Patrick 'eigh Jermor is one of the best travel books written about Northern >reece. H!he $onasteries of the AirH is a chapter that should be read before visiting $eteora but it is likely that you will want to read the book in its entirety. Monasteries of Greece by 5hris Bellier is a lavish Hcoffee tableH book with a chapter on $eteora. %t features beautiful photographs with an interesting te*t. %t also has a wonderful chapter on $t. Athos, the preeminent monastic community that is closed to women and allows only restricted visitation by non 1rthodo* men.