Insulin-dependent and non-insulindependent diabetes have a varied pathological pattern and are caused by the interaction of several genetic and environmental factors.
Insulin-dependent diabetes mellitus (IDDM) (juvenile-onset diabetes, type 1 diabetes) describes subjects with a severe de?ciency or absence of insulin production. Insulin therapy is essential to prevent KETOSIS – a disturbance of the body’s acid/base balance and an accumulation of ketones in the tissues. The onset is most commonly during childhood, but can occur at any age. Symptoms are acute and weight loss is common.
Non-insulin-dependent diabetes mellitus (NIDDM) (maturity-onset diabetes, type 2 diabetes) may be further sub-divided into obese and non-obese groups. This type usually occurs after the age of 40 years with an insidious onset. Subjects are often overweight and weight loss is uncommon. Ketosis rarely develops. Insulin production is reduced but not absent.
A new hormone has been identi?ed linking obesity to type 2 diabetes. Called resistin – because of its resistance to insulin – it was ?rst found in mice but has since been identi?ed in humans. Researchers in the United States believe that the hormone may, in part, explain how obesity predisposes people to diabetes. Their hypothesis is that a protein in the body’s fat cells triggers insulin resistance around the body. Other research suggests that type 2 diabetes may now be occurring in obese children; this could indicate that children should be eating a more-balanced diet and taking more exercise.
Diabetes associated with other conditions (a) Due to pancreatic disease – for example, chronic pancreatitis (see PANCREAS, DISORDERS OF); (b) secondary to drugs – for example, GLUCOCORTICOIDS (see PANCREAS, DISORDERS OF); (c) excess hormone production
– for example, growth hormone (ACROMEGALY); (d) insulin receptor abnormalities; (e) genetic syndromes (see GENETIC DISORDERS).
Gestational diabetes Diabetes occurring in pregnancy and resolving afterwards.
Aetiology Insulin-dependent diabetes occurs as a result of autoimmune destruction of beta cells within the PANCREAS. Genetic in?uences are important and individuals with certain HLA tissue types (HLA DR3 and HLA DR4) are more at risk; however, the risks associated with the HLA genes are small. If one parent has IDDM, the risk of a child developing IDDM by the age of 25 years is 1·5–2·5 per cent, and the risk of a sibling of an IDDM subject developing diabetes is about 3 per cent.
Non-insulin-dependent diabetes has no HLA association, but the genetic in?uences are much stronger. The risks of developing diabetes vary with di?erent races. Obesity, decreased exercise and ageing increase the risks of disease development. The risk of a sibling of a NIDDM subject developing NIDDM up to the age of 80 years is 30–40 per cent.
Diet Many NIDDM diabetics may be treated with diet alone. For those subjects who are overweight, weight loss is important, although often unsuccessful. A diet high in complex carbohydrate, high in ?bre, low in fat and aiming towards ideal body weight is prescribed. Subjects taking insulin need to eat at regular intervals in relation to their insulin regime and missing meals may result in hypoglycaemia, a lowering of the amount of glucose in the blood, which if untreated can be fatal (see below).
Oral hypoglycaemics are used in the treatment of non-insulin-dependent diabetes in addition to diet, when diet alone fails to control blood-sugar levels. (a) SULPHONYLUREAS act mainly by increasing the production of insulin;
(b) BIGUANIDES, of which only metformin is available, may be used alone or in addition to sulphonylureas. Metformin’s main actions are to lower the production of glucose by the liver and improve its uptake in the peripheral tissues.
Complications The risks of complications increase with duration of disease.
Diabetic hypoglycaemia occurs when amounts of glucose in the blood become low. This may occur in subjects taking sulphonylureas or insulin. Symptoms usually develop when the glucose concentration falls below 2·5 mmol/l. They may, however, occur at higher concentrations in subjects with persistent hyperglycaemia – an excess of glucose – and at lower levels in subjects with persistent hypo-glycaemia. Symptoms include confusion, hunger and sweating, with coma developing if blood-sugar concentrations remain low. Re?ned sugar followed by complex carbohydrate will return the glucose concentration to normal. If the subject is unable to swallow, glucagon may be given intramuscularly or glucose intravenously, followed by oral carbohydrate, once the subject is able to swallow.
Although it has been shown that careful control of the patient’s metabolism prevents late complications in the small blood vessels, the risk of hypoglycaemia is increased and patients need to be well motivated to keep to their dietary and treatment regime. This regime is also very expensive. All risk factors for the patient’s cardiovascular system – not simply controlling hyperglycaemia – may need to be reduced if late complications to the cardiovascular system are to be avoided.
Diabetes is one of the world’s most serious health problems. Recent projections suggest that the disorder will affect nearly 240 million individuals worldwide by 2010 – double its prevalence in 1994. The incidence of insulin-dependent diabetes is rising in young children; they will be liable to develop late complications.
Although there are complications associated with diabetes, many subjects live normal lives and survive to an old age. People with diabetes or their relatives can obtain advice from Diabetes UK (www.diabetes.org.uk).
Increased risks are present of (a) heart disease, (b) peripheral vascular disease, and (c) cerebrovascular disease.
Diabetic eye disease (a) retinopathy, (b) cataract. Regular examination of the fundus enables any abnormalities developing to be detected and treatment given when appropriate to preserve eyesight.
Nephropathy Subjects with diabetes may develop kidney damage which can result in renal failure.
Neuropathy (a) Symmetrical sensory polyneuropathy; damage to the sensory nerves that commonly presents with tingling, numbness of pain in the feet or hands. (b) Asymmetrical motor diabetic neuropathy, presenting as progressive weakness and wasting of the proximal muscles of legs. (c) Mononeuropathy; individual motor or sensory nerves may be affected. (d) Autonomic neuropathy, which affects the autonomic nervous system, has many presentations including IMPOTENCE, diarrhoea or constipation and postural HYPOTENSION.
Skin lesions There are several skin disorders associated with diabetes, including: (a) necrobiosis lipoidica diabeticorum, characterised by one or more yellow atrophic lesions on the legs;
(b) ulcers, which most commonly occur on the feet due to peripheral vascular disease, neuropathy and infection. Foot care is very important.
Diabetic ketoacidosis occurs when there is insu?cient insulin present to prevent KETONE production. This may occur before the diagnosis of IDDM or when insu?cient insulin is being given. The presence of large amounts of ketones in the urine indicates excess ketone production and treatment should be sought immediately. Coma and death may result if the condition is left untreated.
Symptoms Thirst, POLYURIA, GLYCOSURIA, weight loss despite eating, and recurrent infections (e.g. BALANITIS and infections of the VULVA) are the main symptoms.
However, subjects with non-insulindependent diabetes may have the disease for several years without symptoms, and diagnosis is often made incidentally or when presenting with a complication of the disease.
Treatment of diabetes aims to prevent symptoms, restore carbohydrate metabolism to as near normal as possible, and to minimise complications. Concentration of glucose, fructosamine and glycated haemoglobin in the blood are used to give an indication of blood-glucose control.
Insulin-dependent diabetes requires insulin for treatment. Non-insulin-dependent diabetes may be treated with diet, oral HYPOGLYCAEMIC AGENTS or insulin.
Insulin All insulin is injected – mainly by syringe but sometimes by insulin pump – because it is inactivated by gastrointestinal enzymes. There are three main types of insulin preparation: (a) short action (approximately six hours), with rapid onset; (b) intermediate action (approximately 12 hours); (c) long action, with slow onset and lasting for up to 36 hours. Human, porcine and bovine preparations are available. Much of the insulin now used is prepared by genetic engineering techniques from micro-organisms. There are many regimens of insulin treatment involving di?erent combinations of insulin; regimens vary depending on the requirements of the patients, most of whom administer the insulin themselves. Carbohydrate intake, energy expenditure and the presence of infection are important determinants of insulin requirements on a day-to-day basis.
A new treatment for diabetes, pioneered in Canada and entering its preliminary clinical trials in the UK, is the transplantation of islet cells of Langerhans from a healthy person into a patient with the disorder. If the transplantation is successful, the transplanted cells start producing insulin, thus reducing or eliminating the requirement for regular insulin injections. If successful the trials would be a signi?cant advance in the treatment of diabetes.
Scientists in Israel have developed a drug, Dia Pep 277, which stops the body’s immune system from destroying pancratic ? cells as happens in insulin-dependent diabetes. The drug, given by injection, o?ers the possibility of preventing type 1 diabetes in healthy people at genetic risk of developing the disorder, and of checking its progression in affected individuals whose ? cells are already perishing. Trials of the drug are in progress.... diabetes mellitus
The speciality of anaesthesia broadly covers its provision for SURGERY, intensive therapy (intensive care), chronic pain management, acute pain management and obstetric analgesia. Anaesthetists in Britain are trained specialists with a medical degree, but in many countries some anaesthetists may be nurse practitioners working under the supervision of a medical anaesthetist.
The anaesthetist will assess the patient’s ?tness for anaesthesia, choose and perform the appropriate type of anaesthetic while monitoring and caring for the patient’s well-being, and, after the anaesthetic, supervise recovery and the provision of post-operative pain relief.
Anaesthesia may be broadly divided into general and local anaesthesia. Quite commonly the two are combined to allow continued relief of pain at the operation site after the patient awakens.
General anaesthesia is most often produced by using a combination of drugs to induce a state of reversible UNCONSCIOUSNESS. ‘Balanced’ anaesthesia uses a combination of drugs to provide unconsciousness, analgesia, and a greater or lesser degree of muscle relaxation.
A general anaesthetic comprises induction, maintenance and recovery. Historically, anaesthesia has been divided into four stages (see below), but these are only clearly seen during induction and maintenance of anaesthesia using inhalational agents alone.
(1) Onset of induction to unconsciousness
(2) Stage of excitement
(3) Surgical anaesthesia
(4) Overdosage
Induction involves the initial production of unconsciousness. Most often this is by INTRAVENOUS injection of a short-acting anaesthetic agent such as PROPOFOL, THIOPENTONE or ETOMIDATE, often accompanied by additional drugs such as ANALGESICS to smooth the process. Alternatively an inhalational technique may be used.
Maintenance of anaesthesia may be provided by continuous or intermittent use of intravenous drugs, but is commonly provided by administration of OXYGEN and NITROUS OXIDE or air containing a volatile anaesthetic agent. Anaesthetic machines are capable of providing a constant concentration of these, and have fail-safe mechanisms and monitors which guard against the patient’s receiving a gas mixture with inadequate oxygen (see HYPOXIC). The gases are adminstered to the patient via a breathing circuit either through a mask, a laryngeal mask or via ENDOTRACHEAL INTUBATION. In recent years, concerns about side-effects and pollution caused by volatile agents have led to increased popularity of total intravenous anaesthesia (TIVA).
For some types of surgery the patient is paralysed using muscle relaxants and then arti?cially ventilated by machine (see VENTILATOR). Patients are closely monitored during anaesthesia by the anaesthetist using a variety of devices. Minimal monitoring includes ELECTROCARDIOGRAM (ECG), blood pressure, PULSE OXIMETRY, inspired oxygen and end-tidal carbon-dioxide concentration – the amount of carbon dioxide breathed out when the lungs are at the ‘empty’ stage of the breathing cycle. Analgesic drugs (pain relievers) and local or regional anaesthetic blocks are often given to supplement general anaesthesia.
Volatile anaesthetics are either halogenated hydrocarbons (see HALOTHANE) or halogenated ethers (iso?urane, en?urane, des?urane and sevo?urane). The latter two are the most recently introduced agents, and produce the most rapid induction and recovery – though on a worldwide basis halothane, ether and chloroform are still widely used.
Despite several theories, the mode of action of these agents is not fully understood. Their e?cacy is related to how well they dissolve into the LIPID substances in nerve cells, and it is thought that they act at more than one site within brain cells – probably at the cell membrane. By whatever method, they reversibly depress the conduction of impulses within the CENTRAL NERVOUS SYSTEM and thereby produce unconsciousness.
At the end of surgery any muscle relaxant still in the patient’s body is reversed, the volatile agent is turned o? and the patient breathes oxygen or oxygen-enriched air. This is the reversal or recovery phase of anaesthesia. Once the anaesthetist is satis?ed with the degree of recovery, patients are transferred to a recovery area within the operating-theatre complex where they are cared for by specialist sta?, under the supervision of an anaesthetist, until they are ready to return to the ward. (See also ARTIFICIAL VENTILATION OF THE LUNGS.) Local anaesthetics are drugs which reversibly block the conduction of impulses in nerves. They therefore produce anaesthesia (and muscle relaxation) only in those areas of the body served by the nerve(s) affected by these drugs. Many drugs have some local anaesthetic action but the drugs used speci?cally for this purpose are all amide or ester derivatives of aromatic acids. Variations in the basic structure produce drugs with di?erent speeds of onset, duration of action and preferential SENSORY rather than MOTOR blockade (stopping the activity in the sensory or motor nerves respectively).
The use of local rather than general anaesthesia will depend on the type of surgery and in some cases the unsuitability of the patient for general anaesthesia. It is also used to supplement general anaesthesia, relieve pain in labour (see under PREGNANCY AND LABOUR) and in the treatment of pain in persons not undergoing surgery. Several commonly used techniques are listed below:
LOCAL INFILTRATION An area of anaesthetised skin or tissue is produced by injecting local anaesthetic around it. This technique is used for removing small super?cial lesions or anaesthetising surgical incisions.
NERVE BLOCKS Local anaesthetic is injected close to a nerve or nerve plexus, often using a peripheral nerve stimulator to identify the correct point. The anaesthetic di?uses into the nerve, blocking it and producing anaesthesia in the area supplied by it.
SPINAL ANAESTHESIA Small volumes of local anaesthetic are injected into the cerebrospinal ?uid through a small-bore needle which has been inserted through the tissues of the back and the dura mater (the outer membrane surrounding the spinal cord). A dense motor and sensory blockade is produced in the lower half of the body. How high up in the body it reaches is dependent on the volume and dose of anaesthetic, the patient’s position and individual variation. If the block is too high, then respiratory-muscle paralysis and therefore respiratory arrest may occur. HYPOTENSION (low blood pressure) may occur because of peripheral vasodilation caused by sympathetic-nerve blockade. Occasionally spinal anaesthesia is complicated by a headache, perhaps caused by continuing leakage of cerebrospinal ?uid from the dural puncture point.
EPIDURAL ANAESTHESIA Spinal nerves are blocked in the epidural space with local anaesthetic injected through a ?ne plastic tube (catheter) which is introduced into the space using a special needle (Tuohy needle). It can be used as a continuous technique either by intermittent injections, an infusion or by patient-controlled pump. This makes it ideal for surgery in the lower part of the body, the relief of pain in labour and for post-operative analgesia. Complications include hypotension, spinal headache (less than 1:100), poor e?cacy, nerve damage (1:12,000) and spinal-cord compression from CLOT or ABSCESS (extremely rare).... anaesthesia
Barrier methods These involve a physical barrier which prevents sperm (see SPERMATOZOON) from reaching the cervix (see CERVIX UTERI). Barrier methods reduce the risk of spreading sexually transmitted diseases, and the sheath is the best protection against HIV infection (see AIDS/HIV) for sexually active people. The e?ciency of barrier methods is improved if they are used in conjunction with a spermicidal foam or jelly, but care is needed to ensure that the preparation chosen does not damage the rubber barrier or cause an allergic reaction in the users. CONDOM OR SHEATH This is the most commonly used barrier contraceptive. It consists of a rubber sheath which is placed over the erect penis before intromission and removed after ejaculation. The failure rate, if properly used, is about 4 per cent. DIAPHRAGM OR CAP A rubber dome that is inserted into the vagina before intercourse and ?ts snugly over the cervix. It should be used with an appropriate spermicide and is removed six hours after intercourse. A woman must be measured to ensure that she is supplied with the correct size of diaphragm, and the ?t should be checked annually or after more than about 7 lbs. change in weight. The failure rate, if properly used, is about 2 per cent.
Non-barrier methods These do not provide a physical barrier between sperm and cervix and so do not protect against sexually transmitted diseases, including HIV. COITUS INTERRUPTUS This involves the man’s withdrawing his penis from the vagina before ejaculation. Because some sperm may leak before full ejaculation, the method is not very reliable. SAFE PERIOD This involves avoiding intercourse around the time when the woman ovulates and is at risk of pregnancy. The safe times can be predicted using temperature charts to identify the rise in temperature before ovulation, or by careful assessment of the quality of the cervical mucus. This method works best if the woman has regular menstrual cycles. If used carefully it can be very e?ective but requires a highly disciplined couple to succeed. It is approved by the Catholic church.
SPERMICIDAL GELS, CREAMS, PESSARIES, ETC.
These are supposed to prevent pregnancy by killing sperm before they reach the cervix, but they are unreliable and should be used only in conjunction with a barrier method.
INTRAUTERINE CONTRACEPTIVE DEVICE (COIL) This is a small metal or plastic shape, placed inside the uterus, which prevents pregnancy by disrupting implantation. Some people regard it as a form of abortion, so it is not acceptable to all religious groups. There is a risk of pelvic infection and eventual infertility in women who have used coils, and in many countries their use has declined substantially. Coils must be inserted by a specially trained health worker, but once in place they permit intercourse at any time with no prior planning. Increased pain and bleeding may be caused during menstruation. If severe, such symptoms may indicate that the coil is incorrectly sited, and that its position should be checked. HORMONAL METHODS Steroid hormones have dominated contraceptive developments during the past 40 years, with more than 200 million women worldwide taking or having taken ‘the pill’. In the past 20 years, new developments have included modifying existing methods and devising more e?ective ways of delivering the drugs, such as implants and hormone-releasing devices in the uterus. Established hormonal contraception includes the combined oestrogen and progesterone and progesterone-only contraceptive pills, as well as longer-acting depot preparations. They modify the woman’s hormonal environment and prevent pregnancy by disrupting various stages of the menstrual cycle, especially ovulation. The combined oestrogen and progesterone pills are very e?ective and are the most popular form of contraception. Biphasic and triphasic pills contain di?erent quantities of oestrogen and progesterone taken in two or three phases of the menstrual cycle. A wide range of preparations is available and the British National Formulary contains details of the commonly used varieties.
The main side-e?ect is an increased risk of cardiovascular disease. The lowest possible dose of oestrogen should be used, and many preparations are phasic, with the dose of oestrogen varying with the time of the cycle. The progesterone-only, or ‘mini’, pill does not contain any oestrogen and must be taken at the same time every day. It is not as e?ective as the combined pill, but failure rates of less than 1-per-100 woman years can be achieved. It has few serious side-effects, but may cause menstrual irregularities. It is suitable for use by mothers who are breast feeding.
Depot preparations include intramuscular injections, subcutaneous implants, and intravaginal rings. They are useful in cases where the woman cannot be relied on to take a pill regularly but needs e?ective contraception. Their main side-e?ect is their prolonged action, which means that users cannot suddenly decide that they would like to become pregnant. Skin patches containing a contraceptive that is absorbed through the skin have recently been launched.
HORMONAL CONTRACEPTION FOR MEN There is a growing demand by men worldwide for hormonal contraception. Development of a ‘male pill’, however, has been slow because of the potentially dangerous side-effects of using high doses of TESTOSTERONE (the male hormone) to suppress spermatogenesis. Progress in research to develop a suitable ANDROGEN-based combination product is promising, including the possibility of long-term STEROID implants. STERILISATION See also STERILISATION – Reproductive sterilisation. The operation is easier and safer to perform on men than on women. Although sterilisation can sometimes be reversed, this cannot be guaranteed and couples should be counselled in advance that the method is irreversible. There is a small but definite failure rate with sterilisation, and this should also be made clear before the operation is performed. POSTCOITAL CONTRACEPTION Also known as emergency contraception or the ‘morning after pill’, postcoital contraception can be e?ected by two di?erent hormonal methods. Levonorgesterol (a synthetic hormone similar to the natural female sex hormone PROGESTERONE) can be used alone, with one pill being taken within 72 hours of unprotected intercourse, but preferably as soon as possible, and a second one 12 hours after the ?rst. Alternatively, a combined preparation comprising ETHINYLESTRADIOL and levonorgesterol can be taken, also within 72 hours of unprotected intercourse. The single constituent pill has fewer side-effects than the combined version. Neither version should be taken by women with severe liver disease or acute PORPHYRIAS, but the ethinylestradiol/levonorgesterol combination is unsuitable for women with a history of THROMBOSIS.
In the UK the law allows women over the age of 16 to buy the morning-after pill ‘over the counter’ from a registered pharmacist.... contraception
Insulin is extracted mainly from pork pancreas and puri?ed by crystallisation; it may be made biosynthetically by recombinant DNA technology using Escherichia coli, or semisynthetically by enzymatic modi?cation of porcine insulin to produce human insulin. The latter is the form now generally used, although some patients ?nd it unsuitable and have to return to porcine insulin.
The hormone acts by enabling the muscles and other tissues requiring sugar for their activity to take up this substance from the blood. All insulin preparations are to a greater or lesser extent immunogenic in humans, but immunological resistance to insulin action is uncommon.
Previously available in three strengths, of 20, 40, and 80 units per millilitre (U/ml), these have now largely been replaced by a standard strength of 100 U/ml (U100). Numerous different insulin preparations are listed; these differ in their speed of onset and duration of action, and hence vary in their suitability for individual patients.
Insulin is inactivated by gastrointestinal enzymes and is therefore generally given by subcutaneous injection, usually into the upper arms, thighs, buttocks, or abdomen. Some insulins are also available in cartridge form, which may be administered by injection devices (‘pens’). The absorption may vary from di?erent sites and with strenuous activity. About 25 per cent of diabetics require insulin treatment: most children from the onset, and all patients presenting with ketoacidosis. Insulin is also often needed by those with a rapid onset of symptoms such as weight loss, weakness, and sometimes vomiting, often associated with ketonuria.
The aim of treatment is to maintain good control of blood glucose concentration, while avoiding severe HYPOGLYCAEMIA; this is usually achieved by a regimen of preprandial injections of short-acting insulin (often with a bedtime injection of long-acting insulin). Insulin may also be given by continuous subcutaneous infusion with an infusion pump. This technique has many disadvantages: patients must be well motivated and able to monitor their own blood glucose, with access to expert advice both day and night; it is therefore rarely used.
Hypoglycaemia is a potential hazard for many patients converting from porcine to human insulin, because human insulin may result in them being unaware of classical hypoglycaemic warning symptoms. Drivers must be particularly careful, and individuals may be forbidden to drive if they have frequent or severe hypoglycaemic attacks. For this reason, insurance companies should be warned, and diabetics should – after taking appropriate medical advice – either return to porcine insulin or consider stopping driving.... insulin
Injections may be intravenous (into a vein), intramuscular (into a muscle), intradermal (into the skin), intra-articular (into a joint), or subcutaneous (under the skin).... injection
It may be used before injections as an antiseptic.... surgical spirit
A depot injection is useful for patients who may not take their medication correctly.
It also prevents the necessity of giving a series of injections over a short period.
Hormonal contraceptives (see contraception, hormonal methods of), corticosteroid drugs, and antipsychotic drugs may be given by depot injection.
Side effects may arise due to the uneven release of the drug into the bloodstream.... depot injection
The blood serum of the animal, known now as anti-typhoid serum, is issued to laboratories for use when bacilli are found in the excretions of a patient who is possibly suffering from typhoid fever. The bacilli are exposed to the action of a drop of the serum; if the serum shows the power of agglutinating these bacteria, this forms evidence that the bacteria in question are typhoid bacilli. The reaction may also be carried out in the contrary manner: that is to say, the serum from the blood of a patient who may be suffering from typhoid fever, but in whom the diagnosis is still doubtful, is added to a drop of ?uid containing typhoid bacilli; if these are agglutinated into clumps by the patient’s serum, the patient is then known to be suffering from typhoid fever. If they do not agglutinate, the symptoms are due to some other condition. This reaction for typhoid fever is known as the Widal reaction. Comparable agglutination reactions, using an appropriate serum, are used in the diagnosis of a number of diseases, including glandular fever (when it is known as the Paul-Bunnell reaction), typhus fever (when it is known as the Weil-Felix reaction), undulant fever, and Weil’s disease. (For more information about these diseases, see under separate entries.)... agglutination
Alcohol depresses the central nervous system and disturbs both mental and physical functioning. Even small doses of alcohol will slow a person’s re?exes and concentration; potentially dangerous effects when, for example, driving or operating machinery. Drunkenness causes slurred speech, muddled thinking, amnesia (memory loss), drowsiness, erectile IMPOTENCE, poor coordination and dulled reactions – thereby making driving or operating machinery especially dangerous. Disinhibition may lead to extreme euphoria, irritability, misery or aggression, depending on the underlying mood at the start of drinking. Severe intoxication may lead to COMA and respiratory failure.
Persistent alcohol misuse leads to physical, mental, social and occupational problems, as well as to a risk of DEPENDENCE (see also ALCOHOL DEPENDENCE). Misuse may follow several patterns: regular but controlled heavy intake, ‘binge’ drinking, and dependence (alcoholism). The ?rst pattern usually leads to mainly physical problems such as gastritis, peptic ulcer, liver disease, heart disease and impotence. The second is most common among young men and usually leads to mainly social and occupational problems – getting into ?ghts, jeopardising personal relationships, overspending on alcohol at weekends, and missing days o? work because of hangovers. The third pattern – alcohol dependence – is the most serious, and can severely disrupt health and social stability.
Many researchers consider alcohol dependence to be an illness that runs in families, with a genetic component which is probably passed on as a vulnerable personality. But it is hard to disentangle genetic, environmental and social factors in such families. In the UK there are estimated to be around a million people suffering from alcohol dependence and a similar number who have di?culty controlling their consumption (together about 1:30 of the population).
Alcohol causes tolerance and both physical and psychological dependence (see DEPENDENCE for de?nitions). Dependent drinkers classically drink early in the morning to relieve overnight withdrawal symptoms. These symptoms include anxiety, restlessness, nausea and vomiting, and tremor. Sudden withdrawal from regular heavy drinking can lead to life-threatening delirium tremens (DTs), with severe tremor, hallucinations (often visual – seeing spiders and monsters, rather than the pink elephants of romantic myth), and CONVULSIONS. This must be treated urgently with sedative drugs, preferably by intravenous drip. Similar symptoms, plus severe INCOORDINATION and double-vision, can occur in WERNICKE’S ENCEPHALOPATHY, a serious neurological condition due to lack of the B vitamin thiamine (whose absorption from the stomach is markedly reduced by alcohol). If not treated urgently with injections of thiamine and other vitamins, this can lead to an irreversible form of brain damage called Korsako?’s psychosis, with severe amnesia. Finally, prolonged alcohol misuse can cause a form of dementia.
In addition to these severe neurological disorders, the wide range of life-threatening problems caused by heavy drinking includes HEPATITIS, liver CIRRHOSIS, pancreatitis (see PANCREAS, DISEASES OF), gastrointestinal haemorrhage, suicide and FETAL ALCOHOL SYNDROME; pregnant women should not drink alcohol as this syndrome may occur with more than a glass of wine or half-pint of beer a day. The social effects of alcohol misuse – such as marital breakdown, family violence and severe debt – can be equally devastating.
Treatment of alcohol-related problems is only moderately successful. First, many of the physical problems are treated in the short term by doctors who fail to spot, or never ask about, heavy drinking. Second, attempts at treating alcohol dependence by detoxi?cation or ‘drying out’ (substituting a tranquillising drug for alcohol and withdrawing it gradually over about a week) are not always followed-up by adequate support at home, so that drinking starts again. Home support by community alcohol teams comprising doctors, nurses, social workers and, when appropriate, probation o?cers is a recent development that may have better results. Many drinkers ?nd the voluntary organisation Alcoholics Anonymous (AA) and its related groups for relatives (Al-Anon) and teenagers (Alateen) helpful because total abstinence from alcohol is encouraged by intensive psychological and social support from fellow ex-drinkers.
Useful contacts are: Alcoholics Anonymous; Al-Anon Family Groups UK and Eire (including Alateen); Alcohol Concern; Alcohol Focus Scotland; and Alcohol and Substance Misuse.
1 standard drink =1 unit
=••• pint of beer
=1 measure of spirits
=1 glass of sherry or vermouth
=1 glass of wine
Limits within which alcohol is believed not to cause long-term health risks:... alcohol
There is little evidence that any one antihistamine is superior to another, and patients vary considerably in their response to them. The antihistamines di?er in their duration of action and in the incidence of side-effects such as drowsiness. Most are short-acting, but some (such as promethazine) work for up to 12 hours. They all cause sedation but promethazine, trimeprazine and dimenhydrinate tend to be more sedating while chlorpheniramine and cyclizine are less so, as are astemizole, oxatomide and terfenadine. Patients should be warned that their ability to drive or operate machinery may be impaired when taking these drugs, and that the effects of ALCOHOL may be increased.... antihistamine drugs
Nutritional Profile Energy value (calories per serving): Moderate Protein: High Fat: Low Saturated fat: Low Cholesterol: None Carbohydrates: High Fiber: Very high Sodium: Low Major vitamin contribution: Vitamin B6, folate Major mineral contribution: Iron, magnesium, zinc
About the Nutrients in This Food Beans are seeds, high in complex carbohydrates including starch and dietary fiber. They have indigestible sugars (stachyose and raffinose), plus insoluble cellulose and lignin in the seed covering and soluble gums and pectins in the bean. The proteins in beans are limited in the essential amino acids methionine and cystine.* All beans are a good source of the B vitamin folate, and iron. One-half cup canned kidney beans has 7.5 g dietary fiber, 65 mcg folate (15 percent of the R DA), and 1.6 mg iron (11 percent of the R DA for a woman, 20 percent of the R DA for a man). Raw beans contain antinutrient chemicals that inactivate enzymes required to digest proteins and carbohydrates. They also contain factors that inactivate vitamin A and also hemagglutinins, substances that make red blood cells clump together. Cooking beans disarms the enzyme inhibi- tors and the anti-vitamin A factors, but not the hemagglutinins. However, the amount of hemagglutinins in the beans is so small that it has no mea- surable effect in your body. * Soybeans are t he only beans t hat contain proteins considered “complete” because t hey contain sufficient amounts of all t he essent ial amino acids. The Folate Content of ½ Cup Cooked Dried Beans
| Bean | Folate (mcg) |
| Black beans | 129 |
| Chickpeas | 191 |
| Kidney beans canned | 65 |
| Navy beans | 128 |
| Pinto beans | 147 |
The Most Nutritious Way to Serve This Food Cooked, to destroy antinutrients. With grains. The proteins in grains are deficient in the essential amino acids lysine and isoleucine but contain sufficient tryptophan, methionine, and cystine; the proteins in beans are exactly the opposite. Together, these foods provide “complete” proteins. With an iron-rich food (meat) or with a vitamin C-rich food (tomatoes). Both enhance your body’s ability to use the iron in the beans. The meat makes your stomach more acid (acid favors iron absorption); the vitamin C may convert the ferric iron in beans into ferrous iron, which is more easily absorbed by the body.
Diets That May Restrict or Exclude This Food Low-calcium diet Low-fiber diet Low-purine (antigout) diet
Buying This Food Look for: Smooth-skinned, uniformly sized, evenly colored beans that are free of stones and debris. The good news about beans sold in plastic bags is that the transparent material gives you a chance to see the beans inside; the bad news is that pyridoxine and pyridoxal, the natural forms of vitamin B6, are very sensitive to light. Avoid: Beans sold in bulk. Some B vitamins, such as vitamin B6 (pyridoxine and pyridoxal), are very sensitive to light. In addition, open bins allow insects into the beans, indicated by tiny holes showing where the bug has burrowed into or through the bean. If you choose to buy in bulk, be sure to check for smooth skinned, uniformly sized, evenly colored beans free of holes, stones, and other debris.
Storing This Food Store beans in air- and moistureproof containers in a cool, dark cabinet where they are pro- tected from heat, light, and insects.
Preparing This Food Wash dried beans and pick them over carefully, discarding damaged or withered beans and any that float. (Only withered beans are light enough to float in water.) Cover the beans with water, bring them to a boil, and then set them aside to soak. When you are ready to use the beans, discard the water in which beans have been soaked. Some of the indigestible sugars in the beans that cause intestinal gas when you eat the beans will leach out into the water, making the beans less “gassy.”
What Happens When You Cook This Food When beans are cooked in liquid, their cells absorb water, swell, and eventually rupture, releasing the pectins and gums and nutrients inside. In addition, cooking destroys antinutri- ents in beans, making them more nutritious and safe to eat.
How Other Kinds of Processing Affect This Food Canning. The heat of canning destroys some of the B vitamins in the beans. Vitamin B is water-soluble. You can recover all the lost B vitamins simply by using the liquid in the can, but the liquid also contains the indigestible sugars that cause intestinal gas when you eat beans. Preprocessing. Preprocessed dried beans have already been soaked. They take less time to cook but are lower in B vitamins.
Medical Uses and/or Benefits Lower risk of some birth defects. As many as two of every 1,000 babies born in the United States each year may have cleft palate or a neural tube (spinal cord) defect due to their moth- ers’ not having gotten adequate amounts of folate during pregnancy. The current R DA for folate is 180 mcg for a woman and 200 mcg for a man, but the FDA now recommends 400 mcg for a woman who is or may become pregnant. Taking a folate supplement before becoming pregnant and continuing through the first two months of pregnancy reduces the risk of cleft palate; taking folate through the entire pregnancy reduces the risk of neural tube defects. Lower risk of heart attack. In the spring of 1998, an analysis of data from the records for more than 80,000 women enrolled in the long-run ning Nurses Health Study at Har vard School of Public Health/ Brigham and Woman’s Hospital in Boston demonstrated that a diet providing more than 400 mcg folate and 3 mg vitamin B6 a day from either food or supple- ments, more than t wice the current R DA for each, may reduce a woman’s risk of heart attack by almost 50 percent. A lthough men were not included in the analysis, the results are assumed to apply to them as well. NOT E : Beans are high in B6 as well as folate. Fruit, green leaf y vegetables, whole grains, meat, fish, poultr y, and shellfish are good sources of vitamin B6. To reduce the levels of serum cholesterol. The gums and pectins in dried beans and peas appear to lower blood levels of cholesterol. Currently there are two theories to explain how this may happen. The first theory is that the pectins in the beans form a gel in your stomach that sops up fats and keeps them from being absorbed by your body. The second is that bacteria in the gut feed on the bean fiber, producing short-chain fatty acids that inhibit the production of cholesterol in your liver. As a source of carbohydrates for people with diabetes. Beans are digested very slowly, produc- ing only a gradual rise in blood-sugar levels. As a result, the body needs less insulin to control blood sugar after eating beans than after eating some other high-carbohydrate foods (such as bread or potato). In studies at the University of Kentucky, a bean, whole-grain, vegetable, and fruit-rich diet developed at the University of Toronto enabled patients with type 1 dia- betes (who do not produce any insulin themselves) to cut their daily insulin intake by 38 percent. Patients with type 2 diabetes (who can produce some insulin) were able to reduce their insulin injections by 98 percent. This diet is in line with the nutritional guidelines of the American Diabetes Association, but people with diabetes should always consult with their doctors and/or dietitians before altering their diet. As a diet aid. Although beans are high in calories, they are also high in bulk (fiber); even a small serving can make you feel full. And, because they are insulin-sparing, they delay the rise in insulin levels that makes us feel hungry again soon after eating. Research at the University of Toronto suggests the insulin-sparing effect may last for several hours after you eat the beans, perhaps until after the next meal.
Adverse Effects Associated with This Food Intestinal gas. All legumes (beans and peas) contain raffinose and stachyose, complex sug- ars that human beings cannot digest. The sugars sit in the gut and are fermented by intestinal bacteria which then produce gas that distends the intestines and makes us uncomfortable. You can lessen this effect by covering the beans with water, bringing them to a boil for three to five minutes, and then setting them aside to soak for four to six hours so that the indigestible sugars leach out in the soaking water, which can be discarded. Alternatively, you may soak the beans for four hours in nine cups of water for every cup of beans, discard the soaking water, and add new water as your recipe directs. Then cook the beans; drain them before serving. Production of uric acid. Purines are the natural metabolic by-products of protein metabo- lism in the body. They eventually break down into uric acid, sharp cr ystals that may concentrate in joints, a condition known as gout. If uric acid cr ystals collect in the urine, the result may be kidney stones. Eating dried beans, which are rich in proteins, may raise the concentration of purines in your body. Although controlling the amount of purines in the diet does not significantly affect the course of gout (which is treated with allopurinol, a drug that prevents the formation of uric acid cr ystals), limiting these foods is still part of many gout regimens.
Food/Drug Interactions Monoamine oxidase (MAO) inhibitors. Monoamine oxidase inhibitors are drugs used to treat depression. They inactivate naturally occurring enzymes in your body that metabolize tyramine, a substance found in many fermented or aged foods. Tyramine constricts blood vessels and increases blood pressure. If you eat a food containing tyramine while you are taking an M AO inhibitor, you cannot effectively eliminate the tyramine from your body. The result may be a hypertensive crisis. Some nutrition guides list dried beans as a food to avoid while using M AO inhibitors.... beans
Habitat: Hedgerows.
Features ? Square, grey, hairy stem, up to two feet high. Leaves stalked, cordate-ovate, serrate, whitish down beneath. Flowers white, crimson dots, two-lipped, in short, dense spikes. Characteristic mint-like scent.Part used ? Herbs, leaves.Action: Carminative, tonic, diaphoretic, anti-spasmodic.
Especially used for flatulence and digestive pains in children, and for production of perspiration in both children and adults. For diaphoreticpurposes in adults, 2-tablespoonful doses of the 1 ounce to 1 pint infusion thrice daily, with a cupful at bedtime; proportionate doses in children's complaints.American physio-medical practice recommends blood-warm bowel injections of the infusion for babies with intestinal flatulence.... catnepUses Before the serious effects that result from its habitual use were realised, the drug was sometimes used by hunters, travellers and others to relieve exhaustion and breathlessness in climbing mountains and to dull hunger. Derivatives of cocaine are used as locally applied analgesics via sprays or injections in dentistry and for procedures in the ear, nose and throat. Because of its serious side-effects and the risk of addiction, cocaine is a strictly controlled Class A drug which can be prescribed only by a medical practitioner with a Home O?ce licence to do so.... cocaine
The dependence that most concerns modern society is one in which individuals become dependent on or addicted to certain substances such as alcohol, drugs, tobacco (nicotine), caffeine and solvents. This is often called substance abuse. Some people become addicted to certain foods or activities: examples of the latter include gambling, computer games and use of the Internet.
The 28th report of the World Health Organisation Expert Committee on Drug Dependence in 1993 de?ned drug dependence as: ‘A cluster of physiological, behavioural and cognitive phenomena of variable intensity, in which the use of a psychoactive drug (or drugs) takes on a high priority. The necessary descriptive characteristics are preoccupation with a desire to obtain and take the drug and persistent drug-seeking behaviour. Psychological dependence occurs when the substance abuser craves the drug’s desirable effects. Physical dependence occurs when the user has to continue taking the drug to avoid distressing withdrawal or abstinence symptoms. Thus, determinants and the problematic consequences of drug dependence may be biological, psychological or social and usually interact.’
Di?erent drugs cause di?erent rates of dependence: TOBACCO is the most common substance of addiction; HEROIN and COCAINE cause high rates of addiction; whereas ALCOHOL is much lower, and CANNABIS lower again. Smoking in the western world reached a peak after World War II with almost 80 per cent of the male population smoking. The reports on the link between smoking and cancer in the early 1960s resulted in a decline that has continued so that only around a quarter of the adult populations of the UK and USA smokes. Globally, tobacco consumption continues to grow, particularly in the developing world with multinational tobacco companies marketing their products aggressively.
Accurate ?gures for illegal drug-taking are hard to obtain, but probably approximately 4 per cent of the population is dependent on alcohol and 2 per cent on other drugs, both legal and illegal, at any one time in western countries.
How does dependence occur? More than 40 distinct theories or models of drug misuse have been put forward. One is that the individual consumes drugs to cope with personal problems or diffculties in relations with others. The other main model emphasises environmental in?uences such as drug availability, environmental pressures to consume drugs, and sociocultural in?uences such as peer pressure.
By contrast to these models of why people misuse drugs, models of compulsive drug use – where individuals have a compulsive addiction
– have been amenable to testing in the laboratory. Studies at cellular and nerve-receptor levels are attempting to identify mechanisms of tolerance and dependence for several substances. Classical behaviour theory is a key model for understanding drug dependence. This and current laboratory studies are being used to explain the reinforcing nature of dependent substances and are helping to provide an explanatory framework for dependence. Drug consumption is a learned form of behaviour. Numerous investigators have used conditioning theories to study why people misuse drugs. Laboratory studies are now locating the ‘reward pathways’ in the brain for opiates and stimulants where positive reinforcing mechanisms involve particular sectors of the brain. There is a consensus among experts in addiction that addictive behaviour is amenable to e?ective treatment, and that the extent to which an addict complies with treatment makes it possible to predict a positive outcome. But there is a long way to go before the mechanisms of drug addiction are properly understood or ways of treating it generally agreed.
Effects of drugs Cannabis, derived from the plant Cannabis sativa, is a widely used recreational drug. Its two main forms are marijuana, which comes from the dried leaves, and hashish which comes from the resin. Cannabis may be used in food and drink but is usually smoked in cigarettes to induce relaxation and a feeling of well-being. Heavy use can cause apathy and vagueness and may even cause psychosis. Whether or not cannabis leads people to using harder drugs is arguable, and a national debate is underway on whether its use should be legalised for medicinal use. Cannabis may alleviate the symptoms of some disorders – for example, MULTIPLE SCLEROSIS (MS) – and there are calls to allow the substance to be classi?ed as a prescribable drug.
About one in ten of Britain’s teenagers misuses volatile substances such as toluene at some time, but only about one in 40 does so regularly. These substances are given o? by certain glues, solvents, varnishes, and liquid fuels, all of which can be bought cheaply in shops, although their sale to children under 16 is illegal. They are often inhaled from plastic bags held over the nose and mouth. Central-nervous-system excitation, with euphoria and disinhibition, is followed by depression and lethargy. Unpleasant effects include facial rash, nausea and vomiting, tremor, dizziness, and clumsiness. Death from COMA and acute cardiac toxicity is a serious risk. Chronic heavy use can cause peripheral neuropathy and irreversible cerebellar damage. (See SOLVENT ABUSE (MISUSE).)
The hallucinogenic or psychedelic drugs include LYSERGIC ACID DIETHYLAMIDE (LSD) or acid, magic mushrooms, ecstasy (MDMA), and phencyclidine (PCP or ‘angel’ dust, mainly used in the USA). These drugs have no medicinal uses. Taken by mouth, they produce vivid ‘trips’, with heightened emotions and perceptions and sometimes with hallucinations. They are not physically addictive but can cause nightmarish bad trips during use and ?ashbacks (vivid reruns of trips) after use, and can probably trigger psychosis and even death, especially if drugs are mixed or taken with alcohol.
Stimulant drugs such as amphetamine and cocaine act like adrenaline and speed up the central nervous system, making the user feel con?dent, energetic, and powerful for several hours. They can also cause severe insomnia, anxiety, paranoia, psychosis, and even sudden death due to convulsions or tachycardia. Depression may occur on withdrawal of these drugs, and in some users this is su?ciently deterrent to cause psychological dependence. Amphetamine (‘speed’) is mainly synthesised illegally and may be eaten, sni?ed, or injected. Related drugs, such as dexamphetamine sulphate (Dexedrine), are prescribed pills that enter the black market. ECSTASY is another amphetamine derivative that has become a popular recreational drug; it may have fatal allergic effects. Cocaine and related drugs are used in medicine as local anaesthetics. Illegal supplies of cocaine (‘snow’ or ‘ice’) and its derivative, ‘crack’, come mainly from South America, where they are made from the plant Erythroxylon coca. Cocaine is usually sni?ed (‘snorted’) or rubbed into the gums; crack is burnt and inhaled.
Opiate drugs are derived from the opium poppy, Papaver somniferum. They are described as narcotic because they induce sleep. Their main medical use is as potent oral or injectable analgesics such as MORPHINE, DIAMORPHINE, PETHIDINE HYDROCHLORIDE, and CODEINE. The commonest illegal opiate is heroin, a powdered form of diamorphine that may be smoked, sni?ed, or injected to induce euphoria and drowsiness. Regular opiate misuse leads to tolerance (the need to take ever larger doses to achieve the same e?ect) and marked dependence. A less addictive oral opiate, METHADONE HYDROCHLORIDE, can be prescribed as a substitute that is easier to withdraw.
Some 75,000–150,000 Britons now misuse opiates and other drugs intravenously, and pose a huge public-health problem because injections with shared dirty needles can carry the blood-borne viruses that cause AIDS/HIV and HEPATITIS B. Many clinics now operate schemes to exchange old needles for clean ones, free of charge. Many addicts are often socially disruptive.
For help and advice see APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELF-HELP – National Dugs Helpline.
(See ALCOHOL and TOBACCO for detailed entries on those subjects.)... dependence
Arrhythmias An abnormal rate or rhythm of the heartbeat. The reason is a disturbance in the electrical impulses within the heart. Sometimes a person may have an occasional irregular heartbeat: this is called an ECTOPIC beat (or an extrasystole) and does not necessarily mean that an abnormality exists. There are two main types of arrhythmia: bradycardias, where the rate is slow – fewer than 60 beats a minute and sometimes so slow and unpredictable (heartblock) as to cause blackouts or heart failure; and tachycardia, where the rate is fast – more than 100 beats a minute. A common cause of arrhythmia is coronary artery disease, when vessels carrying blood to the heart are narrowed by fatty deposits (ATHEROMA), thus reducing the blood supply and damaging the heart tissue. This condition often causes myocardial infarction after which arrhythmias are quite common and may need correcting by DEFIBRILLATION (application of a short electric shock to the heart). Some tachycardias result from a defect in the electrical conduction system of the heart that is commonly congenital. Various drugs can be used to treat arrhythmias (see ANTIARRHYTHMIC DRUGS). If attacks constantly recur, the arrhythmia may be corrected by electrical removal of dead or diseased tissue that is the cause of the disorder. Heartblock is most e?ectively treated with an arti?cial CARDIAC PACEMAKER, a battery-activated control unit implanted in the chest.
Cardiomyopathy Any disease of the heart muscle that results in weakening of its contractions. The consequence is a fall in the e?ciency of the circulation of blood through the lungs and remainder of the body structures. The myopathy may be due to infection, disordered metabolism, nutritional excess or de?ciency, toxic agents, autoimmune processes, degeneration, or inheritance. Often, however, the cause is not identi?ed. Cardiomyopathies are less common than other types of heart diseases, and the incidence of di?erent types of myopathy (see below) is not known because patients or doctors are sometimes unaware of the presence of the condition.
The three recognised groups of cardiomyopathies are hypertrophic, dilated and restrictive.
•Hypertrophic myopathy, a familial condition, is characterised by great enlargement of the muscle of the heart ventricles. This reduces the muscle’s e?ciency, the ventricles fail to relax properly and do not ?ll suf?ciently during DIASTOLE.
In the dilated type of cardiomyopathy, both ventricles overdilate, impairing the e?ciency of contraction and causing congestion of the lungs.
In the restrictive variety, proper ?lling of the ventricles does not occur because the muscle walls are less elastic than normal. The result is raised pressure in the two atria (upper cavities) of the heart: these dilate and develop FIBRILLATION. Diagnosis can be di?cult and treatment is symptomatic, with a poor prognosis. In suitable patients, heart TRANSPLANTATION may be considered. Disorders of the heart muscle may also be
caused by poisoning – for example, heavy consumption of alcohol. Symptoms include tiredness, palpitations (quicker and sometimes irregular heartbeat), chest pain, di?culty in breathing, and swelling of the legs and hands due to accumulation of ?uid (OEDEMA). The heart is enlarged (as shown on chest X-ray) and ECHOCARDIOGRAPHY shows thickening of the heart muscle. A BIOPSY of heart muscle will show abnormalities in the cells of the heart muscle.
Where the cause of cardiomyopathy is unknown, as is the case with most patients, treatment is symptomatic using DIURETICS to control heart failure and drugs such as DIGOXIN to return the heart rhythm to normal. Patients should stop drinking alcohol. If, as often happens, the patient’s condition slowly deteriorates, heart transplantation should be considered.
Congenital heart disease accounts for 1–2 per cent of all cases of organic heart disease. It may be genetically determined and so inherited; present at birth for no obvious reason; or, in rare cases, related to RUBELLA in the mother. The most common forms are holes in the heart (atrial septal defect, ventricular septal defect – see SEPTAL DEFECT), a patent DUCTUS ARTERIOSUS, and COARCTATION OF THE AORTA. Many complex forms also exist and can be diagnosed in the womb by fetal echocardiography which can lead to elective termination of pregnancy. Surgery to correct many of these abnormalities is feasible, even for the most severe abnormalities, but may only be palliative giving rise to major diffculties of management as the children become older. Heart transplantation is now increasingly employed for the uncorrectable lesions.
Coronary artery disease Also known as ischaemic heart disease, this is a common cause of symptoms and death in the adult population. It may present for the ?rst time as sudden death, but more usually causes ANGINA PECTORIS, myocardial infarction (heart attack) or heart failure. It can also lead to a disturbance of heart rhythm. Factors associated with an increased risk of developing coronary artery disease include diabetes, cigarette smoking, high blood pressure, obesity, and a raised concentration of cholesterol in the blood. Older males are most affected.
Coronary thrombosis or acute myocardial infarction is the acute, dramatic manifestation of coronary-artery ischaemic heart disease – one of the major killing diseases of western civilisation. In 1999, ischaemic heart disease was responsible for about 115,000 deaths in England and Wales, compared with 153,000 deaths in 1988. In 1999 more than 55,600 people died of coronary thrombosis. The underlying cause is disease of the coronary arteries which carry the blood supply to the heart muscle (or myocardium). This results in narrowing of the arteries until ?nally they are unable to transport su?cient blood for the myocardium to function e?ciently. One of three things may happen. If the narrowing of the coronary arteries occurs gradually, then the individual concerned will develop either angina pectoris or signs of a failing heart: irregular rhythm, breathlessness, CYANOSIS and oedema.
If the narrowing occurs suddenly or leads to complete blockage (occlusion) of a major branch of one of the coronary arteries, then the victim collapses with acute pain and distress. This is the condition commonly referred to as a coronary thrombosis because it is usually due to the affected artery suddenly becoming completely blocked by THROMBOSIS. More correctly, it should be described as coronary occlusion, because the ?nal occluding factor need not necessarily be thrombosis.
Causes The precise cause is not known, but a wide range of factors play a part in inducing coronary artery disease. Heredity is an important factor. The condition is more common in men than in women; it is also more common in those in sedentary occupations than in those who lead a more physically active life, and more likely to occur in those with high blood pressure than in those with normal blood pressure (see HYPERTENSION). Obesity is a contributory factor. The disease is more common among smokers than non-smokers; it is also often associated with a high level of CHOLESTEROL in the blood, which in turn has been linked with an excessive consumption of animal, as opposed to vegetable, fats. In this connection the important factors seem to be the saturated fatty acids (low-density and very low-density lipoproteins [LDLs and VLDLs] – see CHOLESTEROL) of animal fats which would appear to be more likely to lead to a high level of cholesterol in the blood than the unsaturated fatty acids of vegetable fats. As more research on the subject is carried out, the arguments continue about the relative in?uence of the di?erent factors. (For advice on prevention of the disease, see APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELFHELP.)
Symptoms The presenting symptom is the sudden onset, often at rest, of acute, agonising pain in the front of the chest. This rapidly radiates all over the front of the chest and often down over the abdomen. The pain is frequently accompanied by nausea and vomiting, so that suspicion may be aroused of some acute abdominal condition such as biliary colic (see GALLBLADDER, DISEASES OF) or a perforated PEPTIC ULCER. The victim soon goes into SHOCK, with a pale, cold, sweating skin, rapid pulse and dif?culty in breathing. There is usually some rise in temperature.
Treatment is immediate relief of the pain by injections of diamorphine. Thrombolytic drugs should be given as soon as possible (‘rapid door to needle time’) and ARRHYTHMIA corrected. OXYGEN is essential and oral ASPIRIN is valuable. Treatment within the ?rst hour makes a great di?erence to recovery. Subsequent treatment includes the continued administration of drugs to relieve the pain; the administration of ANTIARRHYTHMIC DRUGS that may be necessary to deal with the heart failure that commonly develops, and the irregular action of the heart that quite often develops; and the continued administration of oxygen. Patients are usually admitted to coronary care units, where they receive constant supervision. Such units maintain an emergency, skilled, round-the-clock sta? of doctors and nurses, as well as all the necessary resuscitation facilities that may be required.
The outcome varies considerably. The ?rst (golden) hour is when the patient is at greatest risk of death: if he or she is treated, then there is a 50 per cent reduction in mortality compared with waiting until hospital admission. As each day passes the prognosis improves with a ?rst coronary thrombosis, provided that the patient does not have a high blood pressure and is not overweight. Following recovery, there should be a gradual return to work, care being taken to avoid any increase in weight, unnecessary stress and strain, and to observe moderation in all things. Smoking must stop. In uncomplicated cases patients get up and about as soon as possible, most being in hospital for a week to ten days and back at work in three months or sooner.
Valvular heart disease primarily affects the mitral and aortic valves which can become narrowed (stenosis) or leaking (incompetence). Pulmonary valve problems are usually congenital (stenosis) and the tricuspid valve is sometimes involved when rheumatic heart disease primarily affects the mitral or aortic valves. RHEUMATIC FEVER, usually in childhood, remains a common cause of chronic valvular heart disease causing stenosis, incompetence or both of the aortic and mitral valves, but each valve has other separate causes for malfunction.
Aortic valve disease is more common with increasing age. When the valve is narrowed, the heart hypertrophies and may later fail. Symptoms of angina or breathlessness are common and dizziness or blackouts (syncope) also occur. Replacing the valve is a very e?ective treatment, even with advancing age. Aortic stenosis may be caused by degeneration (senile calci?c), by the inheritance of two valvular leaflets instead of the usual three (bicuspid valve), or by rheumatic fever. Aortic incompetence again leads to hypertrophy, but dilatation is more common as blood leaks back into the ventricle. Breathlessness is the more common complaint. The causes are the same as stenosis but also include in?ammatory conditions such as SYPHILIS or ANKYLOSING SPONDYLITIS and other disorders of connective tissue. The valve may also leak if the aorta dilates, stretching the valve ring as with HYPERTENSION, aortic ANEURYSM and MARFAN’S SYNDROME – an inherited disorder of connective tissue that causes heart defects. Infection (endocarditis) can worsen acutely or chronically destroy the valve and sometimes lead to abnormal outgrowths on the valve (vegetations) which may break free and cause devastating damage such as a stroke or blocked circulation to the bowel or leg.
Mitral valve disease leading to stenosis is rheumatic in origin. Mitral incompetence may be rheumatic but in the absence of stenosis can be due to ISCHAEMIA, INFARCTION, in?ammation, infection and a congenital weakness (prolapse). The valve may also leak if stretched by a dilating ventricle (functional incompetence). Infection (endocarditis) may affect the valve in a similar way to aortic disease. Mitral symptoms are predominantly breathlessness which may lead to wheezing or waking at night breathless and needing to sit up or stand for relief. They are made worse when the heart rhythm changes (atrial ?brillation) which is frequent as the disease becomes more severe. This leads to a loss of e?ciency of up to 25 per cent and a predisposition to clot formation as blood stagnates rather than leaves the heart e?ciently. Mitral incompetence may remain mild and be of no trouble for many years, but infection must be guarded against (endocarditis prophylaxis).
Endocarditis is an infection of the heart which may acutely destroy a valve or may lead to chronic destruction. Bacteria settle usually on a mild lesion. Antibiotics taken at vulnerable times can prevent this (antibiotic prophylaxis) – for example, before tooth extraction. If established, lengthy intravenous antibiotic therapy is needed and surgery is often necessary. The mortality is 30 per cent but may be higher if the infection settles on a replaced valve (prosthetic endocarditis). Complications include heart failure, shock, embolisation (generation of small clots in the blood), and cerebral (mental) confusion.
PERICARDITIS is an in?ammation of the sac covering the outside of the heart. The sac becomes roughened and pain occurs as the heart and sac rub together. This is heard by stethoscope as a scratching noise (pericardial rub). Fever is often present and a virus the main cause. It may also occur with rheumatic fever, kidney failure, TUBERCULOSIS or from an adjacent lung problem such as PNEUMONIA or cancer. The in?ammation may cause ?uid to accumulate between the sac and the heart (e?usion) which may compress the heart causing a fall in blood pressure, a weak pulse and circulatory failure (tamponade). This can be relieved by aspirating the ?uid. The treatment is then directed at the underlying cause.... heart, diseases of
Cause Asthma runs in families, so that parents with asthma have a strong risk of having children with asthma, or with other atopic (see ATOPY) illnesses such as HAY FEVER or eczema (see DERMATITIS). There is therefore a great deal of interest in the genetic basis of the condition. Several GENES seem to be associated with the condition of atopy, in which subjects have a predisposition to form ANTIBODIES of the IgE class against allergens (see ALLERGEN) they encounter – especially inhaled allergens.
The allergic response in the lining of the airway leads to an in?ammatory reaction. Many cells are involved in this in?ammatory process, including lymphocytes, eosinophils, neutrophils and mast cells. The cells are attracted and controlled by a complex system of in?ammatory mediators. The in?amed airway-wall produced in this process is then sensitive to further allergic stimuli or to non-speci?c challenges such as dust, smoke or drying from the increased respiration during exercise. Recognition of this in?ammation has concentrated attention on anti-in?ammatory aspects of treatment.
Continued in?ammation with poor control of asthma can result in permanent damage to the airway-wall such that reversibility is reduced and airway-narrowing becomes permanent. Appropriate anti-in?ammatory therapy may help to prevent this damage.
Many allergens can be important triggers of asthma. House-dust mite, grass pollen and animal dander are the commonest problems. Occupational factors such as grain dusts, hard-metals fumes and chemicals in the plastic and paint industry are important in some adults. Viral infections are another common trigger, especially in young children.
The prevalence of asthma appears to be on the increase in most countries. Several factors have been linked to this increase; most important may be the vulnerability of the immature immune system (see IMMUNITY) in infants. High exposure to allergens such as house-dust mite early in life may prime the immune system, while reduced exposure to common viral infections may delay the maturation of the immune system. In addition, maternal smoking in pregnancy and infancy increases the risk.
Clinical course The major symptoms of asthma are breathlessness and cough. Occasionally cough may be the only symptom, especially in children, where night-time cough may be mistaken for recurrent infection and treated inappropriately with antibiotics.
The onset of asthma is usually in childhood, but it may begin at any age. In childhood, boys are affected more often than girls but by adulthood the sex incidence is equal. Children who have mild asthma are more likely to grow out of the condition as they go through their teenaged years, although symptoms may recur later.
The degree of airway-narrowing, and its change with time and treatment, can be monitored by measuring the peak expiratory ?ow with a simple monitor at home – a peak-?ow meter. The typical pattern shows the peak ?ow to be lowest in the early morning and this ‘morning dipping’ is often associated with disturbance of sleep.
Acute exacerbations of asthma may be provoked by infections or allergic stimuli. If they do not respond quickly and fully to medication, expert help should be sought urgently since oxygen and higher doses of drugs will be necessary to control the attack. In a severe attack the breathing rate and the pulse rate rise and the chest sounds wheezy. The peak-?ow rate of air into the lungs falls. Patients may be unable to talk in full sentences without catching their breath, and the reduced oxygen in the blood in very severe attacks may produce the blue colour of CYANOSIS in the lips and tongue. Such acute attacks can be very frightening for the patient and family.
Some cases of chronic asthma are included in the internationally agreed description CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) – a chronic, slowly progressive disorder characterised by obstruction of the air?ow persisting over several months.
Treatment The ?rst important consideration in the treatment of asthma is avoidance of precipitating factors. When this is a speci?c animal or occupational exposure, this may be possible; it is however more di?cult for house-dust mite or pollens. Exercise-induced asthma should be treated adequately rather than avoiding exercise.
Desensitisation injections using small quantities of speci?c allergens are used widely in some countries, but rarely in the UK as they are considered to have limited value since most asthma is precipitated by many stimuli and controlled adequately with simple treatment.
There are two groups of main drugs for the treatment of asthma. The ?rst are the bronchodilators which relax the smooth muscle in the wall of the airways, increase their diameter and relieve breathlessness. The most useful agents are the beta adrenergic agonists (see ADRENERGIC RECEPTORS) such as salbutamol and terbutaline. They are best given by inhalation into the airways since this reduces the general side-effects from oral use. These drugs are usually given to reverse airway-narrowing or to prevent its onset on exercise. However, longer-acting inhaled beta agonists such as salmeterol and formoterol or the theophyllines given in tablet form can be used regularly as prevention. The beta agonists can cause TREMOR and PALPITATION in some patients.
The second group of drugs are the antiin?ammatory agents that act to reduce in?ammation of the airway. The main agents in this group are the CORTICOSTEROIDS. They must be taken regularly, even when symptoms are absent. Given by inhalation they have few side-effects. In acute attacks, short courses of oral steroids are used; in very severe disease regular oral steroids may be needed. Other drugs have a role in suppressing in?ammation: sodium cromoglycate has been available for some years and is generally less e?ective than inhaled steroids. Newer agents directed at speci?c steps in the in?ammatory pathway, such as leukotriene receptor-antagonists, are alternative agents.
Treatment guidelines have been produced by various national and international bodies, such as the British Thoracic Society. Most have set out treatment in steps according to severity, with objectives for asthma control based on symptoms and peak ?ow. Patients should have a management plan that sets out their regular treatment and their appropriate response to changes in their condition.
Advice and support for research into asthma is provided by the National Asthma Campaign.
See www.brit-thoracic.org.uk
Prognosis Asthma is diagnosed in 15–20 per cent of all pre-school children in the developed world. Yet by the age of 15 it is estimated that fewer than 5 per cent still have symptoms. A study in 2003 reported on a follow-up of persons born in 1972–3 who developed asthma and still had problems at the age of nine. By the time these persons were aged 26, 27 per cent were still having problems; around half of that number had never been free from the illness and the other half had apparently lost it for a few years but it had returned.... asthma
Abnormal prion proteins accumulate in the brain and the spinal cord, damaging neurones (see NEURON(E)) and producing small cavities. Diagnosis can be made by tonsil (see TONSILS) biopsy, although work is under way to develop a diagnostic blood test. Abnormal prion proteins are unusually resistant to inactivation by chemicals, heat, X-RAYS or ULTRAVIOLET RAYS (UVR). They are resistant to cellular degradation and can convert normal prion proteins into abnormal forms. Human prion diseases, along with scrapie in sheep and BSE in cattle, belong to a group of disorders known as transmissible spongiform encephalopathies. Abnormal prion proteins can transfer from one animal species to another, and variant CJD has occurred as a result of consumption of meat from cattle infected with BSE.
From 1995 to 1999, a scienti?c study of tonsils and appendixes removed at operation suggested that the prevalence of prion carriage may be as high as 120 per million. It is not known what percentage of these might go on to develop disease.
One precaution is that, since 2003, all surgical instruments used in brain biopsies have had to be quarantined and disposable instruments are now used in tonsillectomy.
Measures have also been introduced to reduce the risk of transmission of CJD from transfusion of blood products.
In the past, CJD has also been acquired from intramuscular injections of human cadaveric pituitary-derived growth hormone and corneal transplantation.
The most common form of CJD remains the sporadic variety, although the eventual incidence of variant CJD may not be known for many years.... creutzfeldt-jakob disease (cjd)
Universal in?ammation of the skin may cause heart failure, particularly in elderly people with pre-existing heart disease. It may lead to HYPOTHERMIA due to excessive heat loss from the skin and protein de?ciency caused by the shedding of large quantities of skin scales containing keratin. Rarely, these complications can be fatal.
Treatment depends on the cause, but in eczematous erythroderma, oral CORTICOSTEROIDS (PREDNISOLONE) in full dosage may be needed.... erythroderma
Strategies are also being evaluated for treating cancer by boosting the patient’s own immunity to cancer cells. One approach is immunisation with cancer cells manipulated in vivo to increase a T-lymphocyte attack on antigens expressed by tumour cells. Another method is to manipulate the cytokine network into encouraging an immune attack on, or self-destruction (‘apoptosis’) of, malignant cells.
Immunotherapy is however a developing science, and its place in the routine treatment of immunological and malignant diseases is still evolving.... immunotherapy
Psychiatrists like to categorise mental illnesses because mental signs and symptoms do occur together in clusters or syndromes, each tending to respond to certain treatments. The idea that illnesses can be diagnosed simply by recognising their symptom patterns may not seem very scienti?c in these days of high technology. For most common mental illnesses, however, this is the only method of diagnosis; whatever is going wrong in the brain is usually too poorly understood and too subtle to show up in laboratory tests or computed tomography scans of the brain. And symptom-based definitions of mental illnesses are, generally, a lot more meaningful than the vague lay term ‘nervous breakdown’, which is used to cover an attack of anything from AGORAPHOBIA to total inability to function.
There is still a lot to learn about the workings of the brain, but psychiatry has developed plenty of practical knowledge about the probable causes of mental illness, ways of relieving symptoms, and ways of aiding recovery. Most experts now believe that mental illnesses generally arise from di?erent combinations of inherited risk and psychological STRESS, sometimes with additional environmental exposure – for example, viruses, drugs or ALCOHOL.
The range of common mental illnesses includes anxiety states, PHOBIA, DEPRESSION, alcohol and drug problems, the EATING DISORDERS anorexia and bulimia nervosa, MANIC DEPRESSION, SCHIZOPHRENIA, DEMENTIA, and a group of problems related to coping with life that psychiatrists call personality disorders.
Of these mental illnesses, dementia is the best understood. It is an irreversible and fatal form of mental deterioration (starting with forgetfulness and eventually leading to severe failure of all the brain’s functions), caused by rapid death of brain cells and consequent brain shrinkage. Schizophrenia is another serious mental illness which disrupts thought-processes, speech, emotions and perception (how the brain handles signals from the ?ve senses). Manic depression, in which prolonged ‘highs’ of extremely elevated mood and overexcitement alternate with abject misery, has similar effects on the mental processes. In both schizophrenia and manic depression the sufferer loses touch with reality, develops unshakeable but completely unrealistic ideas (delusions), and hallucinates (vividly experiences sensations that are not real, e.g. hears voices when there is nobody there). This triad of symptoms is called psychosis and it is what lay people, through fear and lack of understanding, sometimes call lunacy, madness or insanity.
The other mental illnesses mentioned above are sometimes called neuroses. But the term has become derogatory in ordinary lay language; indeed, many people assume that neuroses are mild disorders that only affect weak people who cannot ‘pull themselves together’, while psychoses are always severe. In reality, psychoses can be brief and reversible and neuroses can cause lifelong disability.
However de?ned and categorised, mental illness is a big public-health problem. In the UK, up to one in ?ve women and around one in seven men have had mental illness. About half a million people in Britain suffer from schizophrenia: it is three times commoner than cancer. And at any one time, up to a tenth of the adult population is ill with depression.
Treatment settings Most people with mental-health problems get the help they need from their own family doctor(s), without ever seeing a psychiatrist. General practictitioners in Britain treat nine out of ten recognised mental-health problems and see around 12 million adults with mental illness each year. Even for the one in ten of these patients referred to psychiatrists, general practitioners usually handle those problems that continue or recur.
Psychiatrists, psychiatric nurses, social workers, psychologists, counsellors and therapists often see patients at local doctors’ surgeries and will do home visits if necessary. Community mental-health centres – like general-practice health centres but catering solely for mental-health problems – o?er another short-cut to psychiatric help. The more traditional, and still more common, route to a psychiatrist for many people, however, is from the general practititioner to a hospital outpatient department.
Specialist psychiatric help In many ways, a visit to a psychiatrist is much like any trip to a hospital doctor – and, indeed, psychiatric clinics are often based in the outpatient departments of general hospitals. First appointments with psychiatrists can last an hour or more because the psychiatrist – and sometimes other members of the team such as nurses, doctors in training, and social workers – need to ask lots of questions and record the whole consultation in a set of con?dential case notes.
Psychiatric assessment usually includes an interview and an examination, and is sometimes backed up by a range of tests. The interview begins with the patient’s history – the personal story that explains how and, to some extent, why help is needed now. Mental-health problems almost invariably develop from a mixture of causes – emotional, social, physical and familial – and it helps psychiatrists to know what the people they see are normally like and what kind of lives they have led. These questions may seem unnecessarily intrusive, but they allow psychiatrists to understand patients’ problems and decide on the best way to help them.
The next stage in assessment is the mental-state examination. This is how psychiatrists examine minds, or at least their current state. Mental-state examination entails asking more questions and using careful observation to assess feelings, thoughts and mental symptoms, as well as the way the mind is working (for example, in terms of memory and concentration). During ?rst consultations psychiatrists usually make diagnoses and explain them. The boundary between a life problem that will clear up spontaneously and a mental illness that needs treatment is sometimes quite blurred; one consultation may be enough to put the problem in perspective and help to solve it.
Further assessment in the clinic may be needed, or some additional tests. Simple blood tests can be done in outpatient clinics but other investigations will mean referral to another department, usually on another day.
Further assessment and tests
PSYCHOLOGICAL TESTS Psychologists work in or alongside the psychiatric team, helping in both assessment and treatment. The range of psychological tests studies memory, intelligence, personality, perception and capability for abstract thinking. PHYSICAL TESTS Blood tests and brain scans may be useful to rule out a physical illness causing psychological symptoms. SOCIAL ASSESSMENT Many patients have social diffculties that can be teased out and helped by a psychiatric social worker. ‘Approved social workers’ have special training in the use of the Mental Health Act, the law that authorises compulsory admissions to psychiatric hospitals and compulsory psychiatric treatments. These social workers also know about all the mental-health services o?ered by local councils and voluntary organisations, and can refer clients to them. The role of some social workers has been widened greatly in recent years by the expansion of community care. OCCUPATIONAL THERAPY ASSESSMENT Mental-health problems causing practical disabilities – for instance, inability to work, cook or look after oneself – can be assessed and helped by occupational therapists.
Treatment The aims of psychiatric treatment are to help sufferers shake o?, or at least cope with, symptoms and to gain or regain an acceptable quality of life. A range of psychological and physical treatments is available.
COUNSELLING This is a widely used ‘talking cure’, particularly in general practice. Counsellors listen to their clients, help them to explore feelings, and help them to ?nd personal and practical solutions to their problems. Counsellors do not probe into clients’ pasts or analyse them. PSYCHOTHERAPY This is the best known ‘talking cure’. The term psychotherapy is a generalisation covering many di?erent concepts. They all started, however, with Sigmund Freud (see FREUDIAN THEORY), the father of modern psychotherapy. Freud was a doctor who discovered that, as well as the conscious thoughts that guide our feelings and actions, there are powerful psychological forces of which we are not usually aware. Applying his theories to his patients’ freely expressed thoughts, Freud was able to cure many illnesses, some of which had been presumed completely physical. This was the beginning of individual analytical psychotherapy, or PSYCHOANALYSIS. Although Freud’s principles underpin all subsequent theories about the psyche, many di?erent schools of thought have emerged and in?uenced psychotherapists (see ADLER; JUNGIAN ANALYSIS; PSYCHOTHERAPY). BEHAVIOUR THERAPY This springs from theories of human behaviour, many of which are based on studies of animals. The therapists, mostly psychologists, help people to look at problematic patterns of behaviour and thought, and to change them. Cognitive therapy is very e?ective, particularly in depression and eating disorders. PHYSICAL TREATMENTS The most widely used physical treatments in psychiatry are drugs. Tranquillising and anxiety-reducing BENZODIAZEPINES like diazepam, well known by its trade name of Valium, were prescribed widely in the 1960s and 70s because they seemed an e?ective and safe substitute for barbiturates. Benzodiazepines are, however, addictive and are now recommended only for short-term relief of anxiety that is severe, disabling, or unacceptably distressing. They are also used for short-term treatment of patients drying out from alcohol.
ANTIDEPRESSANT DRUGS like amitriptyline and ?uoxetine are given to lift depressed mood and to relieve the physical symptoms that sometimes occur in depression, such as insomnia and poor appetite. The side-effects of antidepressants are mostly relatively mild, when recommended doses are not exceeded – although one group, the monoamine oxidase inhibitors, can lead to sudden and dangerous high blood pressure if taken with certain foods.
Manic depression virtually always has to be treated with mood-stabilising drugs. Lithium carbonate is used in acute mania to lower mood and stop psychotic symptoms; it can also be used in severe depression. However lithium’s main use is to prevent relapse in manic depression. Long-term unwanted effects may include kidney and thyroid problems, and short-term problems in the nervous system and kidney may occur if the blood concentration of lithium is too high – therefore it must be monitored by regular blood tests. Carbamazepine, a treatment for EPILEPSY, has also been found to stabilise mood, and also necessitates blood tests.
Antipsychotic drugs, also called neuroleptics, and major tranquillisers are the only e?ective treatments for relieving serious mental illnesses with hallucinations and delusions. They are used mainly in schizophrenia and include the short-acting drugs chlorpromazine and clozapine as well as the long-lasting injections given once every few weeks like ?uphenazine decanoate. In the long term, however, some of the older antipsychotic drugs can cause a brain problem called TARDIVE DYSKINESIA that affects control of movement and is not always reversible. And the antipsychotic drugs’ short-term side-effects such as shaking and sti?ness sometimes have to be counteracted by other drugs called anticholinergic drugs such as procyclidine and benzhexol. Newer antipsychotic drugs such as clozapine do not cause tardive dyskinesia, but clozapine cannot be given as a long-lasting injection and its concentration in the body has to be monitored by regular blood tests to avoid toxicity. OTHER PHYSICAL TREATMENTS The other two physical treatments used in psychiatry are particularly controversial: electroconvulsive therapy (ECT) and psychosurgery. In ECT, which can be life-saving for patients who have severe life-threatening depression, a small electric current is passed through the brain to induce a ?t or seizure. Before the treatment the patient is anaesthetised and given a muscle-relaxing injection that reduces the magnitude of the ?t to a slight twitching or shaking. Scientists do not really understand how ECT works, but it does, for carefully selected patients. Psychosurgery – operating on the brain to alleviate psychiatric illness or di?cult personality traits – is extremely uncommon these days. Stereo-tactic surgery, in which small cuts are made in speci?c brain ?bres under X-ray guidance, has super-seded the more generalised lobotomies of old. The Mental Health Act 1983 ensures that psychosurgery is performed only when the patient has given fully informed consent and a second medical opinion has agreed that it is necessary. For all other psychiatric treatments (except another rare treatment, hormone implantation for reducing the sex drive of sex o?enders), either consent or a second opinion is needed – not both. TREATMENT IN HOSPITAL Psychiatric wards do not look like medical or surgical wards and sta? may not wear uniforms. Patients do not need to be in their beds during the day, so the beds are in separate dormitories. The main part of most wards is a living space with a day room, an activity and television room, quiet rooms, a dining room, and a kitchen. Ward life usually has a certain routine. The day often starts with a community meeting at which patients and nurses discuss issues that affect the whole ward. Patients may go to the occupational therapy department during the day, but there may also be some therapy groups on the ward, such as relaxation training. Patients’ symptoms and problems are assessed continuously during a stay in hospital. When patients seem well enough they are allowed home for trial periods; then discharge can be arranged. Patients are usually followed up in the outpatient clinic at least once.
TREATING PATIENTS WITH ACUTE PSYCHIATRIC ILLNESS Psychiatric emergencies – patients with acute psychiatric illness – may develop from psychological, physical, or practical crises. Any of these crises may need quick professional intervention. Relatives and friends often have to get this urgent help because the sufferer is not ?t enough to do it or, if psychotic, does not recognise the need. First, they should ring the person’s general practitioner. If the general practitioner is not available and help is needed very urgently, relatives or friends should phone the local social-services department and ask for the duty social worker (on 24-hour call). In a dire emergency, the police will know what to do.
Any disturbed adult who threatens his or her own or others’ health and safety and refuses psychiatric help may be moved and detained by law. The Mental Health Act of 1983 authorises emergency assessment and treatment of any person with apparent psychiatric problems that ful?l these criteria.
Although admission to hospital may be the best solution, there are other ways that psychiatric services can respond to emergencies. In some districts there are ‘crisis intervention’ teams of psychiatrists, nurses, and social workers who can visit patients urgently at home (at a GP’s request) and, sometimes, avert unnecessary admission. And research has shown that home treatment for a range of acute psychiatric problems can be e?ective.
LONG-TERM TREATMENT AND COMMUNITY CARE Long-term treatment is often provided by GPs with support and guidance from psychiatric teams. That is ?ne for people whose problems allow them to look after themselves, and for those with plenty of support from family and friends. But some people need much more intensive long-term treatment and many need help with running their daily lives.
Since the 1950s, successive governments have closed the old psychiatric hospitals and have tried to provide as much care as possible outside hospital – in ‘the community’. Community care is e?ective as long as everyone who needs inpatient care, or residential care, can have it. But demand exceeds supply. Research has shown that some homeless people have long-term mental illnesses and have somehow lost touch with psychiatric services. Many more have developed more general long-term health problems, particularly related to alcohol, without ever getting help.
The NHS and Community Care Act 1990, in force since 1993, established a new breed of professionals called care managers to assess people whose long-term illnesses and disabilities make them unable to cope completely independently with life. Care managers are given budgets by local councils to assess people’s needs and to arrange for them tailor-made packages of care, including services like home helps and day centres. But co-ordination between health and social services has sometimes failed – and resources are limited – and the government decided in 1997 to tighten up arrangements and pool community-care budgets.
Since 1992 psychiatrists have had to ensure that people with severe mental illnesses have full programmes of care set up before discharge from hospital, to be overseen by named key workers. And since 1996 psychiatrists have used a new power called Supervised Discharge to ensure that the most vulnerable patients cannot lose touch with mental-health services. There is not, however, any law that allows compulsory treatment in the community.
There is ample evidence that community care can work and that it need not cost more than hospital care. Critics argue, however, that even one tragedy resulting from inadequate care, perhaps a suicide or even a homicide, should reverse the march to community care. And, according to the National Schizophrenia Fellowship, many of the 10–15 homicides a year carried out by people with severe mental illnesses result from inadequate community care.
Further information can be obtained from the Mental Health Act Commission, and from MIND, the National Association for Mental Health. MIND also acts as a campaigning and advice organisation on all aspects of mental health.... mental illness
Frozen shoulder is caused by inflammation and thickening of the lining of the joint capsule. In some cases, it occurs following a minor injury to the shoulder or a stroke. The condition is more common in middle-aged people and those with diabetes mellitus.
Moderate symptoms of frozen shoulder can be eased by exercise, by taking analgesic drugs and nonsteroidal antiinflammatory drugs, and by applying ice-packs. In severe cases, injections of corticosteroid drugs into the joint may be used. Manipulation of the joint under a general anaesthetic can restore mobility, but this treatment carries the risk of increasing pain in the joint initially. Recovery is often slow but the shoulder is usually back to normal and pain free within 2 years.... frozen shoulder
Possible postoperative complications are fullness and discomfort after meals; regurgitation of bile, which may lead to gastritis, oesophagitis, and vomiting of bile; diarrhoea; and dumping syndrome. Other complications include malabsorption, which may lead to anaemia or osteoporosis. After total gastrectomy, patients cannot absorb vitamin B12 and are given it in the form of injections for the rest of their lives.... gastrectomy
Treatment may include counselling or sex therapy for psychological problems.
The drug sildenafil is used to treat both organic and psychological impotence, but side effects may occur.
Other treatments include self-administered injections into the penis and a surgical implant, which can produce a sustained erection.... impotence
A nerve may be blocked as it leaves the spinal cord. This occurs in epidural anaesthesia, used mainly in childbirth, and in spinal anaesthesia, used mainly for surgery of the lower abdomen and limbs. In a caudal block an anaesthetic is injected around nerves leaving the lowest part of the spinal cord. It produces anaesthesia in the buttock and genital areas, and is occasionally used in childbirth. A pudendal nerve block involves the injection of an anaesthetic into nerves passing under the pelvis into the floor of the vagina. This type of nerve block is sometimes used in a forceps delivery. (See also anaesthesia, local.)... nerve block
Treatment may include washing out the stomach (see lavage, gastric) or removing soiled clothing and washing contaminated skin.
Injections of atropine may be given, and oxygen therapy and/or artificial ventilation may be needed.
With rapid treatment, people may survive doses that would otherwise have been fatal.
Long term effects of organophosphates in sheep dips are thought to be responsible for debilitating illness with neural, muscular, and mental symptoms.... organophosphates
There is no cure for osteoarthritis. Symptoms can be relieved by nonsteroidal anti-inflammatory drugs, analgesics, injections of corticosteroid drugs into affected joints, and physiotherapy. In overweight people, weight loss often provides relief of symptoms. Surgery for severe osteoarthritis includes arthroplasty and arthrodesis.... osteoarthritis
There may also be nausea, vomiting, sweating, and blood in the urine.
Treatment is usually with bed rest, plenty of fluids, and injections of an analgesic drug, such as pethidine.... renal colic
Also called hay fever, it causes sneezing, a runny nose, and nasal congestion.
Antihistamine drugs and topical corticosteroid drugs are used to treat mild attacks.
The drug sodium cromoglicate, inhaled regularly throughout the pollen season, may help to prevent attacks.
Long-term relief of symptoms can sometimes follow desensitization to a pollen allergen by a course of injections (see hyposensitization).... rhinitis, allergic
Viral infections by any of hepatitis A, B, C, D, or E viruses and also CYTOMEGALOVIRUS (CMV), EPSTEIN BARR VIRUS, and HERPES SIMPLEX.
Autoimmune disorders such as autoimmune chronic hepatitis, toxins, alcohol and certain drugs – ISONIAZID, RIFAMPICIN, HALOTHANE and CHLORPROMAZINE.
WILSON’S DISEASE.
Acute viral hepatitis causes damage throughout the liver and in severe infections may destroy whole lobules (see below).
Chronic hepatitis is typi?ed by an invasion of the portal tract by white blood cells (mild hepatitis). If these mononuclear in?ammatory cells invade the body (parenchyma) of the liver tissue, ?brosis and then chronic disease or cirrhosis can develop. Cirrhosis may develop at any age and commonly results in prolonged ill health. It is an important cause of premature death, with excessive alcohol consumption commonly the triggering factor. Sometimes, cirrhosis may be asymptomatic, but common symptoms are weakness, tiredness, poor appetite, weight loss, nausea, vomiting, abdominal discomfort and production of abnormal amounts of wind. Initially, the liver may enlarge, but later it becomes hard and shrunken, though rarely causing pain. Skin pigmentation may occur along with jaundice, the result of failure to excrete the liver product BILIRUBIN. Routine liver-function tests on blood are used to help diagnose the disease and to monitor its progress. Spider telangiectasia (caused by damage to blood vessels – see TELANGIECTASIS) usually develop, and these are a signi?cant pointer to liver disease. ENDOCRINE changes occur, especially in men, who lose their typical hair distribution and suffer from atrophy of their testicles. Bruising and nosebleeds occur increasingly as the cirrhosis worsens, and portal hypertension (high pressure of venous blood circulation through the liver) develops due to abnormal vascular resistance. ASCITES and HEPATIC ENCEPHALOPATHY are indications of advanced cirrhosis.
Treatment of cirrhosis is to tackle the underlying cause, to maintain the patient’s nutrition (advising him or her to avoid alcohol), and to treat any complications. The disorder can also be treated by liver transplantation; indeed, 75 per cent of liver transplants are done for cirrhosis. The overall prognosis of cirrhosis, however, is not good, especially as many patients attend for medical care late in the course of the disease. Overall, only 25 per cent of patients live for ?ve years after diagnosis, though patients who have a liver transplant and survive for a year (80 per cent do) have a good prognosis.
Autoimmune hepatitis is a type that most commonly occurs in women between 20 and 40 years of age. The cause is unknown and it has been suggested that the disease has several immunological subtypes. Symptoms are similar to other viral hepatitis infections, with painful joints and AMENORRHOEA as additional symptoms. Jaundice and signs of chronic liver disease usually occur. Treatment with CORTICOSTEROIDS is life-saving in autoimmune hepatitis, and maintenance treatment may be needed for two years or more. Remissions and exacerbations are typical, and most patients eventually develop cirrhosis, with 50 per cent of victims dying of liver failure if not treated. This ?gure falls to 10 per cent in treated patients.
Viral hepatitis The ?ve hepatic viruses (A to E) all cause acute primary liver disease, though each belongs to a separate group of viruses.
•Hepatitis A virus (HAV) is an ENTEROVIRUS
which is very infectious, spreading by faecal contamination from patients suffering from (or incubating) the infection; victims excrete viruses into the faeces for around ?ve weeks during incubation and development of the disease. Overcrowding and poor sanitation help to spread hepatitis A, which fortunately usually causes only mild disease.
Hepatitis B (HBV) is caused by a hepadna virus, and humans are the only reservoir of infection, with blood the main agent for transferring it. Transfusions of infected blood or blood products, and injections using contaminated needles (common among habitual drug abusers), are common modes of transfer. Tattooing and ACUPUNCTURE may spread hepatitis B unless high standards of sterilisation are maintained. Sexual intercourse, particularly between male homosexuals, is a signi?cant infection route.
Hepatitis C (HCV) is a ?avivirus whose source of infection is usually via blood contacts. E?ective screening of blood donors and heat treatment of blood factors should prevent the spread of this infection, which becomes chronic in about 75 per cent of those infected, lasting for life. Although most carriers do not suffer an acute illness, they must practise life-long preventive measures.
Hepatitis D (HDV) cannot survive independently, needing HBV to replicate, so its sources and methods of spread are similar to the B virus. HDV can infect people at the same time as HBV, but it is capable of superinfecting those who are already chronic carriers of the B virus. Acute and chronic infection of HDV can occur, depending on individual circumstances, and parenteral drug abuse spreads the infection. The disease occurs worldwide, being endemic in Africa, South America and the Mediterranean littoral.
Hepatitis E virus (HEV) is excreted in the stools, spreading via the faeco-oral route. It causes large epidemics of water-borne hepatitis and ?ourishes wherever there is poor sanitation. It resembles acute HAV infection and the patient usually recovers. HEV does not cause chronic infection. The clinical characteristics of the ?ve hepatic
viruses are broadly similar. The initial symptoms last for up to two weeks (comprising temperature, headache and malaise), and JAUNDICE then develops, with anorexia, nausea, vomiting and diarrhoea common manifestations. Upper abdominal pain and a tender enlarged liver margin, accompanied by enlarged cervical lymph glands, are usual.
As well as blood tests to assess liver function, there are speci?c virological tests to identify the ?ve infective agents, and these are important contributions to diagnosis. However, there is no speci?c treatment of any of these infections. The more seriously ill patients may require hospital care, mainly to enable doctors to spot at an early stage those developing acute liver failure. If vomiting is a problem, intravenous ?uid and glucose can be given. Therapeutic drugs – especially sedatives and hypnotics – should be avoided, and alcohol must not be taken during the acute phase. Interferon is the only licensed drug for the treatment of chronic hepatitis B, but this is used with care.
Otherwise-?t patients under 40 with acute viral hepatitis have a mortality rate of around
0.5 per cent; for those over 60, this ?gure is around 3 per cent. Up to 95 per cent of adults with acute HBV infection recover fully but the rest may develop life-long chronic hepatitis, particularly those who are immunode?cient (see IMMUNODEFICIENCY).
Infection is best prevented by good living conditions. HVA and HVB can be prevented by active immunisation with vaccines. There is no vaccine available for viruses C, D and E, although HDV is e?ectively prevented by immunisation against HBV. At-risk groups who should be vaccinated against HBV include:
Parenteral drug abusers.
Close contacts of infected individuals such as regular sexual partners and infants of infected mothers.
Men who have sex with men.
Patients undergoing regular haemodialysis.
Selected health professionals, including laboratory sta? dealing with blood samples and products.... hepatitis
Sulphonylureas The main group of hypoglycaemic agents, these act on the beta cells to stimulate insulin release; consequently they are e?ective only when there is some residual pancreatic beta-cell activity (see INSULIN). They also act on peripheral tissues to increase sensitivity, although this is less important. All sulphonylureas may lead to HYPOGLYCAEMIA four hours or more after food, but this is relatively uncommon, and usually an indication of overdose.
There are several di?erent sulphonylureas; apart from some di?erences in their duration or action (and hence in their suitability for individual patients) there is little di?erence in their e?ectiveness. Only chlorpropamide has appreciably more side-effects – mainly because of its prolonged duration of action and consequent risk of hypoglycaemia. There is also the common and unpleasant chlorpropamide/ alcohol-?ush phenomenon when the patient takes alcohol. Selection of an individual sulphonylurea depends on the patient’s age and renal function, and often just on personal preference. Elderly patients are particularly prone to the risks of hypoglycaemia when long-acting drugs are used. In these patients chlorpropamide, and preferably glibenclamide, should be avoided and replaced by others such as gliclazide or tolbutamide.
These drugs may cause weight gain and are indicated only if poor control persists despite adequate attempts at dieting. They should not be used during breast feeding, and caution is necessary in the elderly and in those with renal or hepatic insu?ciency. They should also be avoided in porphyria (see PORPHYRIAS). During surgery and intercurrent illness (such as myocardial infarction, COMA, infection and trauma), insulin therapy should be temporarily substituted. Insulin is generally used during pregnancy and should be used in the presence of ketoacidosis.
Side-effects Chie?y gastrointestinal disturbances and headache; these are generally mild and infrequent. After drinking alcohol, chlorpropamide may cause facial ?ushing. It also may enhance the action of antidiuretic hormone (see VASOPRESSIN), very rarely causing HYPONATRAEMIA.
Sensitivity reactions are very rare, usually occurring in the ?rst six to eight weeks of therapy. They include transient rashes which rarely progress to erythema multiforme (see under ERYTHEMA) and exfoliate DERMATITIS, fever and jaundice; chlorpropamide may also occasionally result in photosensitivity. Rare blood disorders include THROMBOCYTOPENIA, AGRANULOCYTOSIS and aplastic ANAEMIA.
Biguanides Metformin, the only available member of this group, acts by reducing GLUCONEOGENESIS and by increasing peripheral utilisation of glucose. It can act only if there is some residual insulin activity, hence it is only of value in the treatment of non-insulin dependent (type 2) diabetics. It may be used alone or with a sulphonylurea, and is indicated when strict dieting and sulphonylurea treatment have failed to control the diabetes. It is particularly valuable in overweight patients, in whom it may be used ?rst. Metformin has several advantages: hypoglycaemia is not usually a problem; weight gain is uncommon; and plasma insulin levels are lowered. Gastrointestinal side-effects are initially common and persistent in some patients, especially when high doses are being taken. Lactic acidosis is a rarely seen hazard occurring in patients with renal impairment, in whom metformin should not be used.
Other antidiabetics Acarbose is an inhibitor of intestinal alpha glucosidases (enzymes that process GLUCOSIDES), delaying the digestion of starch and sucrose, and hence the increase in blood glucose concentrations after a meal containing carbohydrate. It has been introduced for the treatment of type 2 patients inadequately controlled by diet or diet with oral hypoglycaemics.
Guar gum, if taken in adequate doses, acts by delaying carbohydrate absorption, and therefore reducing the postprandial blood glucose levels. It is also used to relieve symptoms of the DUMPING SYNDROME.... hypoglycaemic agents
Injections of an analgesic drug and an antispasmodic drug may be given to relieve the colic.
Tests such as cholecystography or ultrasound scanning can confirm the presence of gallstones, in which case cholecystectomy (surgical removal of the gallbladder) is possible.... biliary colic
Symptoms These depend upon whether the anaemia is sudden in onset, as in severe haemorrhage, or gradual. In all cases, however, the striking sign is pallor, the depth of which depends upon the severity of the anaemia. The colour of the skin may be misleading, except in cases due to severe haemorrhage, as the skin of many Caucasian people is normally pale. The best guide is the colour of the internal lining of the eyelid. When the onset of the anaemia is sudden, the patient complains of weakness and giddiness, and loses consciousness if he or she tries to stand or sit up. The breathing is rapid and distressed, the pulse is rapid and the blood pressure is low. In chronic cases the tongue is often sore (GLOSSITIS), and the nails of the ?ngers may be brittle and concave instead of convex (koilonychia). In some cases, particularly in women, the Plummer-Vinson syndrome is present: this consists of di?culty in swallowing and may be accompanied by huskiness; in these cases glossitis is also present. There may be slight enlargement of the SPLEEN, and there is usually some diminution in gastric acidity.
CHANGES IN THE BLOOD The characteristic change is a diminution in both the haemoglobin and the red cell content of the blood. There is a relatively greater fall in the haemoglobin than in the red cell count. If the blood is examined under a microscope, the red cells are seen to be paler and smaller than normal. These small red cells are known as microcytes.
Treatment consists primarily of giving suf?cient iron by mouth to restore, and then maintain, a normal blood picture. The main iron preparation now used is ferrous sulphate, 200 mg, thrice daily after meals. When the blood picture has become normal, the dosage is gradually reduced. A preparation of iron is available which can be given intravenously, but this is only used in cases which do not respond to iron given by mouth, or in cases in which it is essential to obtain a quick response.
If, of course, there is haemorrhage, this must be arrested, and if the loss of blood has been severe it may be necessary to give a blood transfusion (see TRANSFUSION – Transfusion of blood). Care must be taken to ensure that the patient is having an adequate diet. If there is any underlying metabolic, oncological, toxic or infective condition, this, of course, must be adequately treated after appropriate investigations.
Megaloblastic hyperchromic anaemia There are various forms of anaemia of this type, such as those due to nutritional de?ciencies, but the most important is that known as pernicious anaemia.
PERNICIOUS ANAEMIA An autoimmune disease in which sensitised lymphocytes (see LYMPHOCYTE) destroy the PARIETAL cells of the stomach. These cells normally produce INTRINSIC FACTOR, the carrier protein for vitamin B12 (see APPENDIX 5: VITAMINS) that permits its absorption in the terminal part of the ILEUM. Lack of the factor prevents vitamin B12 absorption and this causes macrocytic (or megaloblastic) anaemia. The disorder can affect men and women, usually those over the age of 40; onset is insidious so it may be well advanced before medical advice is sought. The skin and MUCOSA become pale, the tongue is smooth and atrophic and is accompanied by CHEILOSIS. Peripheral NEUROPATHY is often present, resulting in PARAESTHESIA and numbness and sometimes ATAXIA. A rare complication is subacute combined degeneration of the SPINAL CORD.
In 1926 two Americans, G R Minot and W P Murphy, discovered that pernicious anaemia, a previously fatal condition, responded to treatment with liver which provides the absent intrinsic factor. Normal development requires a substance known as extrinsic factor, and this depends on the presence of intrinsic factor for its absorption from the gut. The disease is characterised in the blood by abnormally large red cells (macrocytes) which vary in shape and size, while the number of white cells (LEUCOCYTES) diminishes. A key diagnostic ?nd is the presence of cells in the BONE MARROW.
Treatment consists of injections of vitamin B12 in the form of hydroxocobalamin which must be continued for life.
Aplastic anaemia is a disease in which the red blood corpuscles are very greatly reduced, and in which no attempt appears to be made in the bone marrow towards their regeneration. It is more accurately called hypoplastic anaemia as the degree of impairment of bone-marrow function is rarely complete. The cause in many cases is not known, but in rather less than half the cases the condition is due to some toxic substance, such as benzol or certain drugs, or ionising radiations. The patient becomes very pale, with a tendency to haemorrhages under the skin and mucous membranes, and the temperature may at times be raised. The red blood corpuscles diminish steadily in numbers. Treatment consists primarily of regular blood transfusions. Although the disease is often fatal, the outlook has improved in recent years: around 25 per cent of patients recover when adequately treated, and others survive for several years. In severe cases promising results are being reported from the use of bone-marrow transplantation.
Haemolytic anaemia results from the excessive destruction, or HAEMOLYSIS, of the red blood cells. This may be the result of undue fragility of the red blood cells, when the condition is known as congenital haemolytic anaemia, or of acholuric JAUNDICE.
Sickle-cell anaemia A form of anaemia characteristically found in people of African descent, so-called because of the sickle shape of the red blood cells. It is caused by the presence of the abnormal HAEMOGLOBIN, haemoglobin S, due to AMINO ACID substitutions in their polypeptide chains, re?ecting a genetic mutation. Deoxygenation of haemoglobin S leads to sickling, which increases the blood viscosity and tends to obstruct ?ow, thereby increasing the sickling of other cells. THROMBOSIS and areas of tissue INFARCTION may follow, causing severe pain, swelling and tenderness. The resulting sickle cells are more fragile than normal red blood cells, and have a shorter life span, hence the anaemia. Advice is obtainable from the Sickle Cell Society.... inadequate intake of iron
Coccydynia may result from a blow to the base of the spine in a fall, from prolonged pressure due to poor posture when sitting, or the use of the lithotomy position during childbirth.
The pain usually eases in time.
Treatment may include heat, injections of a local anaesthetic, and manipulation.... coccydynia
It usually arises in alcoholics after withdrawal or abstinence from alcohol.
Early symptoms include restlessness, agitation, trembling, and sleeplessness.
The person may develop a rapid heartbeat, fever, and dilation of the pupils.
Sweating, confusion, hallucinations, and convulsions may also occur.
Treatment consists of rest, rehydration, and sedation.
Vitamin injections, particularly of thiamine (see vitamin B complex), may be given.... delirium tremens
Clinical features There are various types. The oligoarthritic type involves 1–4 joints (usually knee or ankle) which become hot, swollen and painful. One complication is an in?ammation of the eyes – UVEITIS. The condition often ‘burns out’, but may reappear at any time, even years later.
The polyarthritic type is more like RHEUMATOID ARTHRITIS in adults, and the child may have persistent symptoms leading to major joint deformity and crippling.
The systemic type, previously called Still’s disease, presents with a high fever and rash, enlarged liver, spleen and lymph nodes, and arthritis – although the latter may be mild. In some children the illness becomes recurrent; in others it dies down only to return as polyarthritis.
Complications These include uveitis, which can lead to loss of vision; a failure to thrive; osteoporosis (see under BONE, DISORDERS OF); joint deformity; and psychosocial diffculties.
Treatment This includes ANTIPYRETICS and ANALGESICS, including NON-STEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDS), intra-articular steroid injections, anti-tumour necrosis factor drugs and steroids.
Physiotherapy is vital, and children may need to wear splints or other orthotic devices to alleviate deformity and pain. Orthopaedic operative procedures may be necessary.... juvenile idiopathic arthritis (jia)
It is treated by regular injections of the missing enzyme.... gaucher’s disease
It is given either as regular injections or orally (see auranofin).
A common adverse effect is dermatitis.
Gold may damage the kidneys, liver, and bone marrow and may cause loss of appetite, nausea, and diarrhoea.... gold
(antibodies) to prevent or treat infectious diseases. Such preparations, also known as immune globulin or gammaglobulin, work by passing on antibodies obtained from the blood of people who have previously been exposed to these diseases. The main use of these injections is to prevent infectious diseases, such as chickenpox, in people exposed to infection who are not already immune or are at special risk (during cancer treatment, for example). They are also given regularly for immunodeficiency disorders. Side effects include rash, fever, and pain and tenderness at the injection site.... immunoglobulin injection
The chief object of perspiration is to maintain an even body temperature by regulating the heat lost from the body surface. Sweating is therefore increased by internally produced heat, such as muscular activity, or external heat. It is controlled by two types of nerves: vasomotor, which regulate the local blood ?ow, and secretory (part of the sympathetic nervous system) which directly in?uence secretion.
Eccrine sweat is a faintly acid, watery ?uid containing less than 2 per cent of solids. The eccrine sweat-glands in humans are situated in greatest numbers on the soles of the feet and palms of the hands, and with a magnifying glass their minute openings or pores can be seen in rows occupying the summit of each ridge in the skin. Perspiration is most abundant in these regions, although it also occurs all over the body.
Apocrine sweat-glands These start functioning at puberty and are found in the armpits, the eyelids, around the anus in association with the external genitalia, and in the areola and nipple of the breast. (The glands that produce wax in the ear are modi?ed apocrine glands.) The ?ow of apocrine sweat is evoked by emotional stimuli such as fear, anger, or sexual excitement.
Abnormalities of perspiration Decreased sweating may occur in the early stages of fever, in diabetes, and in some forms of glomerulonephritis (see KIDNEYS, DISEASES OF). Some people are unable to sweat copiously, and are prone to HEAT STROKE. EXCESSIVE SWEATING, OR HYPERIDROSIS, may be caused by fever, hyperthyroidism (see THYROID GLAND, DISEASES OF), obesity, diabetes mellitus, or an anxiety state. O?ensive perspiration, or bromidrosis, commonly occurs on the hands and feet or in the armpits, and is due to bacterial decomposition of skin secretions. A few people, however, sweat over their whole body surface. For most of those affected, it is the palmar and/or axillary hyperhidrosis that is the major problem.
Conventional treatment is with an ANTICHOLINERGIC drug. This blocks the action of ACETYLCHOLINE (a neurotransmitter secreted by nerve-cell endings) which relaxes some involuntary muscles and tightens others, controlling the action of sweat-glands. But patients often stop treatment because they get an uncomfortably dry mouth. Aluminium chloride hexahydrate is a topical treatment, but this can cause skin irritation and soreness. Such antiperspirants may help patients with moderate hyperhidrosis, but those severely affected may need either surgery or injections of BOTULINUM TOXIN to destroy the relevant sympathetic nerves to the zones of excessive sweating.... perspiration
Pathology There are three types of virus, infection spreading by the stools-contaminated hands-mouth route. Children are most susceptible.
One attack usually produces permanent immunity, and second attacks are rare. The virus typically affects the anterior horn cells of the spinal cord, especially those in the lumbar region; the grey matter of the brain stem and cortex may also be damaged.
Vaccination is given to infants at two, three and four months: a booster dose is given at around the age of ?ve. The vaccine contains all three types of polio virus. Two types of vaccine are available: inactivated polio virus (IPV) contains dead virus and is administered by injections; oral polio vaccine (OPV) contains live, harmless strains. The latter is used in the United Kingdom.
Symptoms The incubation period is around 7–14 days, the onset being marked by a mild fever and headache which improves after a few days. In around 85 per cent of infected children there is no further progression, but in some – after approximately one week – the symptoms recur, together with neck sti?ness and signs of meningeal irritation (see MENINGES). Weakness of individual muscle groups is common, and may progress – to a variable extent, depending on the distribution of the virus – to widespread PARALYSIS. Involvement of the diaphragm and intercostal muscles may lead to respiratory failure and rapid death unless arti?cial respiration is provided. Involvement of the cranial nerves and brain may lead to nystagmus (see under EYE, DISORDERS OF), hoarseness and di?culty in swallowing, and CONVULSIONS may occur in young children. The CEREBROSPINAL FLUID shows an early increase in lymphocytes, followed by a rise in protein concentration.
Treatment There is no e?ective drug treatment for the infection. Treatment involves early bed rest, followed by PHYSIOTHERAPY and orthopaedic measures as required. At the onset of respiratory diffculties a TRACHEOSTOMY and arti?cial ventilation should be started. (In the 1950s, when polio epidemics were occurring, respiratory diffculties were treated by placing patients in an ‘iron lung’ – a large, airtight, cylindrical container in which the air pressure was raised and lowered to simulate normal breathing.) In cases of severe paralysis with persistent wasting of the limbs, surgery may be necessary to minimise the resulting disability.... poliomyelitis
Acute pain is caused by internal or external injury or disease. It warns the individual that harm or damage is occurring and stimulates them to take avoiding or protective action. With e?ective treatment of disease or injury and/or the natural healing process, the pain resolves – although some acute pain syndromes may develop into chronic pain (see below). Stimuli which are su?ciently intense potentially to damage tissue will cause the stimulation of speci?c receptors known as NOCICEPTORS. Damage to tissues releases substances which stimulate the nociceptors. On the surface of the body there is a high density of nociceptors, and each area of the body is supplied by nerves from a particular spinal segment or level: this allows the brain to localise the source of the pain accurately. Pain from internal structures and organs is more di?cult to localise and is often felt in some more super?cial structure. For example, irritation of the DIAPHRAGM is often felt as pain in the shoulder, as the nerves from both structures enter the SPINAL CORD at the same level (often the structures have developed from the same parts of the embryo). This is known as referred pain.
The impulses from nociceptors travel along nerves to the spinal cord. Within this there is modulation of the pain ‘messages’ by other incoming sensory modalities, as well as descending input from the brain (Melzack and Walls’ gate-control theory). This involves morphine-like molecules (the ENDORPHINS and ENKEPHALINS) amongst many other pain-transmitting and pain-modulating substances. The modi?ed input then passes up the spinal cord through the thalamus to the cerebral cortex. Thus the amount of pain ‘felt’ may be altered by the emotional state of the individual and by other incoming sensations. Once pain is perceived, then ‘action’ is taken; this involves withdrawal of the area being damaged, vocalisation, AUTONOMIC NERVOUS SYSTEM response and examination of the painful area. Analysis of the event using memory will occur and appropriate action be taken to reduce pain and treat the damage.
Chronic pain may be de?ned in several ways: for example, pain resistant to one month’s treatment, or pain persisting one month beyond the usual course of an acute illness or injury. Some doctors may also arbitrarily choose the ?gure of six months. Chronic pain di?ers from acute pain: the physiological response is di?erent and pain may either be caused by stimuli which do not usually cause the perception of pain, or may arise within nerves or the central nervous system with no apparent external stimulation. It seldom has a physiological protective function in the way acute pain has. Also, chronic pain may be self-perpetuating: if individuals gain a psychological advantage from having pain, they may continue to do so (e.g. gaining attention from family or health professionals, etc.). The nervous system itself alters when pain is long-standing in such a way that it becomes more sensitive to painful inputs and tends to perpetuate the pain.
Treatment The treatment of pain depends upon its nature and cause. Acute pain is generally treated by curing the underlying complaint and prescribing ANALGESICS or using local anaesthetic techniques (see ANAESTHESIA – Local anaesthetics). Many hospitals now have acute pain teams for the management of postoperative and other types of acute pain; chronic pain is often treated in pain clinics. Those involved may include doctors (in Britain, usually anaesthetists), nurses, psychologists and psychiatrists, physiotherapists and complementary therapists. Patients are usually referred from other hospital specialists (although some may be referred by GPs). They will usually have been given a diagnosis and exhausted the medical and surgical treatment of their underlying condition.
All the usual analgesics may be employed, and opioids are often used in the terminal treatment of cancer pain.
ANTICONVULSANTS and ANTIDEPRESSANT DRUGS are also used because they alter the transmission of pain within the central nervous system and may actually treat the chronic pain syndrome.
Many local anaesthetic techniques are used. Myofascial pain – pain affecting muscles and connective tissues – is treated by the injection of local anaesthetic into tender spots, and nerves may be blocked either as a diagnostic procedure or by way of treatment. Epidural anaesthetic injections are also used in the same way, and all these treatments may be repeated at intervals over many months in an attempt to cure or at least reduce the pain. For intractable pain, nerves are sometimes destroyed using injections of alcohol or PHENOL or by applying CRYOTHERAPY or radiofrequency waves. Intractable or terminal pain may be treated by destroying nerves surgically, and, rarely, the pain pathways within the spinal cord are severed by cordotomy (though this is generally only used in terminal care).
ACUPUNCTURE and TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) are used for a variety of pain syndromes, particularly myofascial or musculoskeletal pain. It is thought that they work by increasing the release of endorphins and enkephalins (see above). It is possible to implant electrodes within the epidural space to stimulate directly the nerves as they traverse this space before passing into the spinal cord.
Physiotherapy is often used, particularly in the treatment of chronic backache, where pain may be reduced by improving posture and strengthening muscles with careful exercises. Relaxation techniques and psychotherapy are also used both to treat chronic pain and to help patients cope better with their disability.
Some types of chronic pain are caused by injury to sympathetic nerves or may be relieved by interrupting conduction in sympathetic nerves. This may be done in several ways. The nerves may be blocked using local anaesthetic or permanently destroyed using alcohol, phenol or by surgery.
Many of these techniques may be used in the management of cancer pain. Opioid drugs are often used by a variety of routes and methods, and management of these patients concentrates on the control of symptoms and on providing a good quality of life.... pain
Lassa fever is largely confined to West Africa.
The illness starts with fever, headache, muscular aches, and a sore throat.
Later, severe diarrhoea and vomiting develop.
In extreme cases, the disease can be fatal.
Treatment is injections of the drug ribavirin and serum containing antibodies to the virus.... lassa fever
Healthy people are inoculated with vaccine as a protection against a particular disease; this produces ANTIBODIES which will confer immunity against a subsequent attack of the disease. (See IMMUNISATION for programme of immunisation during childhood.)
Vaccines may be divided into two classes: stock vaccines, prepared from micro-organisms known to cause a particular disease and kept in readiness for use against that disease; and autogenous vaccines, prepared from microorganisms which are already in the patient’s body and to which the disease is due. Vaccines intended to protect against the onset of disease are of the former variety.
Autogenous vaccines are prepared by cultivating bacteria found in SPUTUM, URINE and FAECES, and in areas of in?ammation such as BOILS (FURUNCULOSIS). This type of vaccine was introduced by Wright about 1903.
Anthrax vaccine was introduced in 1882 for the protection of sheep and cattle against this disease. A safe and e?ective vaccine for use in human beings has now been evolved. (See ANTHRAX.)
BCG vaccine is used to provide protection against TUBERCULOSIS. (See also separate entry on BCG VACCINE.)
Cholera vaccine was introduced in India about 1894. Two injections are given at an interval of at least a week; this gives a varying degree of immunity for six months. (See CHOLERA.)
Diphtheria vaccine is available in several forms. It is usually given along with tetanus and pertussis vaccine (see below) in what is known as TRIPLE VACCINE. This is given in three doses: the ?rst at the age of two months; the second at three months; and the third at four months, with a booster dose at the age of ?ve years. (See DIPHTHERIA.)
Hay fever vaccine is a vaccine prepared from the pollen of various grasses. It is used in gradually increasing doses for prevention of HAY FEVER in those susceptible to this condition.
In?uenza vaccine A vaccine is now available for protection against INFLUENZA due to the in?uenza viruses A and B. Its use in Britain is customarily based on advice from the health departments according to the type of in?uenza expected in a particular year.
Measles, mumps and rubella (MMR) vaccines are given in combination early in the second year of life. A booster dose may prove necessary, as there is some interference between this vaccine and the most recent form of pertussis vaccine (see below) o?ered to children. Uptake has declined a little because of media reports suggesting a link with AUTISM – for which no reliable medical evidence (and much to the contrary) has been found by investigating epidemiologists. (See also separate entry for each disease, and for MMR VACCINE.)
Pertussis (whooping-cough) vaccine is prepared from Bordetella pertussis, and is usually given along with diphtheria and tetanus in what is known as triple vaccine. (See also WHOOPING-COUGH.)
Plague vaccine was introduced by Ha?kine, and appears to give useful protection, but the duration of protection is relatively short: from two to 20 months. Two injections are given at an interval of four weeks. A reinforcing dose should be given annually to anyone exposed to PLAGUE.
Poliomyelitis vaccine gives a high degree of protection against the disease. This is given in the form of attenuated Sabin vaccine which is taken by mouth – a few drops on a lump of sugar. Reinforcing doses of polio vaccine are recommended on school entry, on leaving school, and on travel abroad to countries where POLIOMYELITIS is ENDEMIC.
Rabies vaccine was introduced by Pasteur in 1885 for administration, during the long incubation period, to people bitten by a mad dog, in order to prevent the disease from developing. (See RABIES.)
Rubella vaccine, usually given with mumps and measles vaccine in one dose – called MMR VACCINE, see also above – now provides protection against RUBELLA (German measles). It also provides immunity for adolescent girls who have not had the disease in childhood and so ensures that they will not acquire the disease during any subsequent pregnancy – thus reducing the number of congenitally abnormal children whose abnormality is the result of their being infected with rubella via their mothers before they were born.
Smallpox vaccine was the ?rst introduced. As a result of the World Health Organisation’s successful smallpox eradication campaign – it declared the disease eradicated in 1980 – there is now no medical justi?cation for smallpox vaccination. Recently, however, there has been increased interest in the subject because of the potential threat from bioterrorism. (See also VACCINATION.)
Tetanus vaccine is given in two forms: (1) In the so-called triple vaccine, combined with diphtheria and pertussis (whooping-cough) vaccine for the routine immunisation of children (see above). (2) By itself to adults who have not been immunised in childhood and who are particularly exposed to the risk of TETANUS, such as soldiers and agricultural workers.
Typhoid vaccine was introduced by Wright and Semple for the protection of troops in the South African War and in India. TAB vaccine, containing Salmonella typhi (the causative organism of typhoid fever – see ENTERIC FEVER) and Salmonella paratyphi A and B (the organisms of paratyphoid fever – see ENTERIC FEVER) has now been replaced by typhoid monovalent vaccine, containing only S. typhi. The change has been made because the monovalent vaccine is less likely to produce painful arms and general malaise, and there is no evidence that the TAB vaccine gave any protection against paratyphoid fever. Two doses are given at an interval of 4–6 weeks, and give protection for 1–3 years.... vaccine
Habitat: Kashmir at 1,200-2,400 m.
English: Pale Wood Violet, Wood Violet.Unani: Banafashaa (related species).Action: Plant—pectoral, bechic; used in chest troubles. Stem, leaf and flower—applied to foul sores and wounds.
Habitat: Native to Europe; grown as an ornamental.
English: Heartsease, Wild Pansy.Unani: Banafashaa (related species).Action: Herb—anti-inflammatory, antiallergic, expectorant, diuretic, antirheumatic, alterative. Used for bronchitis, rheumatism, chronic skin disorders and for preventing capillary haemorrhage when under corticosteroid therapy. Root— antidysenteric; used as a substitute for Cephaelis ipecacuanha.
Key application: Externally in mild seborrheic skin diseases and milk scall in children. (German Commission E.) The British Herbal Pharmacopoeia recognizes the herb as an expectorant and dermatological agent.The herb contains rutin, violin and salicylic acid. The flower contains rutin, quercetin, violanthin (6,8-digly- coside of apigenin), violaxanthin, p- hydroxycinnamic acid and delphini- din. A flavone C-glycoside-saponarin has also been obtained from flowers. Flowers, in addition, contain 15-cis- violaxanthin.The herb exhibits anticoagulant property and diminishes the aggregation of platelets. It can be used as a preventive measure against thrombosis.Habitat: Temperate Himalayas from Kashmir to Nepal between 1,200 and 2,700 m (a semiparasitic plant).
English: European Mistletoe.Ayurvedic: Bandaaka, Suvarna- bandaaka. Vrikshaadani (substitute).Unani: Kishmish Kaabuli.Action: Vasodilator, cardiac depressant, tranquiliser, stimulates the vagus nerve which slows the pulse, anti-inflammatory, diuretic, immune enhancer, antineoplas- tic. Used for hypertension and tachycardia, as a nervine tonic.
The extract of leafy twigs is anti- inflammatory exerting an action upon capillary permeability and oedema. It stimulates granulation and the neoformation of connective tissue.Key application: For treating degenerative inflammation of the joints by stimulating cuti- visceral reflexes following local inflammation brought about by intradermal injections; as palliative therapy for malignant tumour through non-specific stimulation. (German Commission E.)Mistletoe contains glycoproteins; flavonoids, usually quercetin-derived (dependent on host tree to some extent); polypeptides; phenylcarboxylic acids; polysaccharides (including viscid acid); alkaloids; lignans.Cardiotonic activity is due to the lig- nans. The polysaccharides stimulate the immune response. Antineoplas- tic activity is claimed to be responsible for prolongation of survival time in cancer patients. Polypeptides (visco- toxins) inhibit tumours and stimulate immune resistance. (For uses of lectin from Mistletoe in cancer, see Eur J cancer, 2001, Jan, 37(1), 23-31; Eur J Cancer 2001, 37 (15), 19101920.) (For application in hepatitis, see Fitoterapia, 70, 2001.)... viola sylvestrisMost experiments are carried out on specially bred mice and rats. Fewer than 1 per cent are done on cats, dogs, non-human primates, farm animals, frogs, ?sh and birds. Control on experiments has recently been strengthened.
The great majority of animal experiments are done without anaesthesia because feeding experiments, taking blood, or giving injections does not require anaesthetics in animals any more than in humans. Universities in Britain are responsible for fewer than one-?fth of animal experiments; commercial concerns and government institutions are responsible for most of the rest. Tests on cosmetics account for under 1 per cent of all animal work, but are necessary because such materials are often applied with great frequency – and for a long time – to the skin of adults and infants.
The use of tissue cultures and computer models instead of live animals are methods of research and investigation that are being increasingly used. There is, however, a limit to the extent to which infection, cancer, or drugs can be investigated on cultures of tissue cells. Computerised or mathematical modelling of experiments is probably the most promising line of development.... vivisection
Symptoms. Skin of yellow tinge, failing eyesight, swollen ankles, feeble heart action, numbness of feet and legs, dyspepsia, tingling in limbs, diarrhoea, red beefy sore tongue, patches of bleeding under skin, unsteadiness and depression.
Treatment. Hospitalisation. Intramuscular injections of Vitamin B12. Herbs known to contain the vitamin – Comfrey, Iceland Moss. Segments of fresh Comfrey root and Garlic passed through a blender produce a puree – good results reported.
Alternatives:– Teas: Milk Thistle, Hops, Wormwood, Betony, White Horehound, Motherwort, Parsley, Nettles, Centuary.
Formula. Combine Centuary 2; Hyssop 1; White Horehound 1; Red Clover flower 1; Liquorice quarter. 1-2 teaspoons to each cup boiling water, infuse 15 minutes. 1 cup thrice daily.
Decoction. Combine Yellow Dock 1; Peruvian bark quarter; Blue Flag root quarter; Sarsaparilla 1; Bogbean half. 1 teaspoon to each cup of water, or 4oz (30 grams) to 1 pint (half litre) water. Simmer gently 10-15 minutes in covered vessel. Dose: Half-1 cup, thrice daily.
Decoction. Combine Yellow Dock 1; Peruvian bark quarter; Blue Flag root quarter; Sarsaparilla 1; Bogbean half. 1 teaspoon to each cup of water, or 4oz (30 grams) to 1 pint (one-half litre) water. Simmer gently 10-15 minutes in covered vessel. Dose: Half-1 cup, thrice daily.
Tablets/capsules. Echinacea, Dandelion, Kelp.
Powders. Formula. Equal parts: Gentian, Balm of Gilead, Yellow Dock. Dose: 500mg (two 00 capsules or one-third teaspoon), thrice daily before meals.
Liquid Extracts. Combine, Echinacea 2; Gentian 1; Dandelion 1; Ginger quarter. Dose: 15-30 drops in water thrice daily.
Gentian decoction. 1 teaspoon dried root to each cup cold water.
Diet. Dandelion coffee. Calves’ liver. Absorption of nutritious food may be poor through stomach’s inability to produce sufficient acid to break down food into its elements. Indicated: 2-3 teaspoons Cider vinegar in water between meals. Contraindicated – vegetarian diet.
Supplements. Vitamin B12, (in absence of injections). Iron – Floradix. Desiccated liver. Vitamin C 1g thrice daily at meals. Folic acid. 400mcg thrice daily. ... anaemia: pernicious
Symptoms: bleeding, with alteration of bowel habit. Common in diverticular disease where large polyps may be undetected. Early detection by flexible sigmoidoscopy at hospital is essential to accurate diagnosis. Sudden episodes of unexplained diarrhoea and constipation.
The term refers to cancers of the ascending colon, caecum, transverse colon, hepatic flexure, descending colon, splenic flexure, sigmoid colon and rectum. The large bowel tumours are almost wholly adeno-carcinoma.
Common causes: ulcerative colitis, Crohn’s disease, necrotic changes in polyps. The colon is at risk from cancer on a diet high in protein, fat and alcohol and which is low in fibre. An exception is the average diet in Finland where a high fat intake is present with a low incidence of cancer. Strong evidence advanced, includes the heavy consumption of yoghurt (acidophylus lacto bacillus) by the population.
A study of 8006 Japanese men living in Hawaii revealed the close relationship between cancer of the rectum and alcohol consumption. A family history of pernicious anaemia predisposes.
A 19-year prospective study of middle-aged men employed by a Chicago electric company reveals a strong correlation between colorectal cancer and Vitamin D and calcium deficiency. Results “support the suggestion that Vitamin D and calcium may reduce the risk of colorectal cancer”. (Lancet, 1985, Feb 9, i, 307)
Patients with ulcerative colitis of more than 10 years standing carry the increased risk of developing colorectal cancer. There is evidence that malignancy in the bowel may be reduced by saponins. Alternatives of possible value. Inoperable lesions may respond to: Bayberry, Goldenseal, Echinacea, Wild Yam, Stone root, Black root, Mistletoe, Clivers, Marshmallow root, Violet leaves, Chickweed, Red Clover, Thuja.
Tea. Equal parts: Red Clover, Gotu Kola, Violet leaves. 2-3 teaspoons to each cup boiling water; infuse 15 minutes. Freely, as tolerated.
Tablets/capsules. Echinacea, Goldenseal, Wild Yam.
Formula. Echinacea 2; Bayberry 1; Wild Yam 1; Stone root 1; Goldenseal half; Liquorice quarter. Mix. Dose: Powders: 500mg (two 00 capsules or one-third teaspoon). Liquid extracts: 1 teaspoon. Tinctures: 2 teaspoons. Thrice daily and at bedtime.
Mistletoe: Injections of fresh plant (Iscador). (Dr Rudolph Steiner Institute, Switzerland)
Violet leaves: Daily irrigations of strong infusion.
Chickweed: Bathe rectum with strong infusion. Follow with Chickweed ointment.
Chinese Herbalism. (1) Tea – Pan-chih-lien (Scutellaria barbarta), 2 liang. (2) Tea. Feng-wei ts’ao (Pteris multifida) 1 liang, and po-chi (water chestnut) 2 liang. (3) Concoction of suitable amount of ts’ang-erh ts’ao, for bathing affected area. (Barefoot Doctor’s Manual)
Diagnosis. Exploration of proctosigmoidoscope to confirm.
Diet. Special emphasis on yoghurt which is conducive to bowel health; orally and by enema. A vegan uncooked raw food diet has been shown to reduce the body’s production of toxins linked with colon cancer. A switch from conventional Western cooked diet to an uncooked vegan diet reduced harmful enzymes produced by gut bacteria. (Journal of Nutrition)
A substance has been found in fish oil believed to prevent cancer of the colon. Mackerel, herring and sardines are among fish with this ingredient. Bowel cancer and additives. See: CROHN’S DISEASE (Note).
Preventive care. All 55-year-olds with this predisposing condition should be screened by sigmoidoscopy. Regular faecal occult blood tests advised.
Regular exercise helps prevent development of bowel cancer. (Nottingham University researchers) Treatment by general medical practitioner or oncologist. ... cancer-colorectal
Etiology. The more severe form, in younger patients, needs insulin treatment, without which ketosis and diabetic coma are possible. The milder form in older patients can be managed with diet and hypoglycaemic agents. Now considered due to auto-immune attack on Islet of Langerhams cells in pancreas which secrete insulin. “The Pill” often raises blood sugar. Lack of trace minerals (chromium and zinc). Zinc is a component of insulin and Chromium produces enzymes to stimulate metabolism of sugars. Diabetes can cause heart attack, stroke, hardening of arteries, blindness. It is the leading cause of kidney failure and gangrene.
Symptoms. Great thirst. Urine of high specific gravity. Weakness, emaciation, skin ulcers, loss of tactile sensation in the fingertips (Vitamin B6). In men there may be inflammation of the glans penis and in women, itching of the vulvae. Boils are common. In spite of large appetite there may by severe weight loss. Magnesium deficiency.
Diabetics are subject to glaucoma and detachment of the retina. There is a high incidence of cataract of the eye. While surgery may be necessary, effective supportive herbal treatment can do much. Regular visits to the Hospital Specialist help detect in time future eye, kidney and circulation damage.
High fibre, low fat, high carbohydrate. To help control blood sugar a diabetic must avoid sweets.
Exercise lowers blood sugar.
Agents used with some success: Alfalfa, Damiana leaves, Fenugreek seeds, Aloe Vera juice, Dandelion, Fringe Tree, Guar gum, Garlic (anti-diabetic action shown by Dr Madaus, West Germany, 1967), Bilberry berries, Goat’s Rue (dried aerial parts reduce blood sugar BHP (1983), Olive leaves, onions, Nettles, Pipsissewa, White Horehound, Sweet Sumach, Jambul seeds rapidly reduce sugar in the urine. Karela. Gurmar, (Gymnema sylvestre) leaves are chewed in India to reduce sugar in the urine (mild cases). Balsam pear. Bitter melon (Momordica charastia).
Hypoglycaemic herbs can be effective where the pancreas still functions. Type 1 diabetes, suffered by children whose insulin-producing cells have been destroyed and who produce no insulin at all will always require administered insulin. Maturity-onset diabetes (Type 11) occurs in middle life, insulin- production being insufficient. This form is usually associated with obesity for which herbs are helpful.
Diabetics are specially prone to infections; a course of Echinacea at the onset of winter is beneficial. Coronary artery disease is common in diabetics (especially women) who may develop atherosclerosis at an early age. High blood pressure places undue strain upon kidneys which may excrete too much protein (Yarrow, Lime flowers, Hawthorn). Lack of sensation in the feet exposes the subject to unconscious bruising and injury from which septic ulceration may arise (Chamomile foot baths).
Alternatives. Liver herbs work positively on the pancreas. Diabetic cases should receive treatment for the liver also, Dandelion and Fringe Tree being a reliable combination. Dr John Fearn, California (Ellingwood) used Fringe Tree for all his cases of sugar in the urine: 10 drops, Liquid Extract, 4-5 times daily.
Tea. Equal parts: Peppermint leaves, Dandelion leaves, Goat’s Rue leaves. 1-2 teaspoons to each cup boiling water infuse 5-15 minutes. Cup 2-3 times daily.
Teas from any one of the following: Bilberry berries or leaves, Nettles, White Horehound, Alfalfa, Olive leaves.
Decoction. Fenugreek seeds. 2 teaspoons to each large cup water simmered gently 5 minutes. One cup daily, consuming the seeds.
Powders. Equal parts: Sweet Sumach, Jambul seeds, Dandelion. Dose: 750mg (three 00 capsules or half a teaspoon) thrice daily.
Tinctures. Formula. Equal parts: Jambul, Fringe Tree, Goat’s Rue. Dose: 1 teaspoon thrice daily and at bedtime.
Tablets. Dr Alfred Vogel: tablet containing: Bilberry, Kidney Bean, Tormentil, English Walnut leaves, Alfalfa leaves, Cuckoo flowers.
Karela (Momordica Charantia) Hypoglycaemic action gave good results in clinical trials. Daily dose: 50/60ml fresh juice.
Evening Primrose. See entry.
Guar Gum. 5g unit dose sachets (Guarina) containing dispersible granules. This gum has shown beneficial effects for insulin-dependants.
Hypoglycaemics (second degree). Allspice, Bugleweed, Burdock, Ginseng, Lily of the Valley, Wormwood, Nettles.
Diabetic gangrene. Tinctures: equal parts, Echinacea, Thuja. Internally and externally. Internal dose: 30- 60 drops.
Diabetic neuralgia. Cayenne pepper (Capsicum). Frequently successful.
American traditional. It is claimed that 500mg Bayleaf, Cinnamon, Cloves and Turmeric halve the need for insulin in diabetics.
Diet. Dietary treatment has changed over the past few years. Patients are now advised by the British Diabetic Association to eat food rich in complex carbohydrates (starches) and high in fibre as in wholemeal bread, oats and wholegrain breakfast cereals, wholewheat pasta, brown rice, beans and lentils, vegetables and fruit. Fat intake should be carefully watched (lean meat); skimmed milk, polyunsaturated or low-fat cheeses and salad dressings. Certain foods are known to encourage the pancreas to produce more insulin: banana, barley, cabbage, lettuce, oats, olive, papaya, turnip, sweet potato.
Coffee intake should be limited to prevent hypoglycaemic symptoms.
Barley. A study has shown that the use of barley flour as a substitute for wheat in bread helps to control diabetes, in Iraq. (Naismith D, et al, ‘Therapeutic Value of Barley in Management of Diabetes’: Annals Nutr Metab, 35, 61-64 1991)
Supplementation. Vitamins A, B-complex, C, D, E, F. Vitamin B6. Brewer’s yeast. Minerals: Chromium 50mcg; Manganese 15mg; Magnesium 300mg; Zinc 25mg; to normalise glucose metabolism.
Note: Over 400 traditional plant medicines have been documented for diabetes, but few have been evaluated for efficacy. In the undeveloped countries they are chiefly used for non-insulin dependent diabetes. (Diabetes Care, 1989, Sept 12, p553)
Insulin dependents. Whether adults or children, insulin dependents should under no circumstances discontinue insulin injections.
Treatment by or in liaison with general medical practitioner.
Information. British Diabetic Association, 10 Queen Anne Street, London W1M 0BD, UK. Send SAE. ... diabetes, mellitus
Etiology. May be hereditary. Excess alcohol, meat or starchy foods without adequate fresh vegetables and fruit. Alcohol increases synthesis of urates and inhibits secretion. High beer intake. There is a link between gout and the good life.
Symptoms. Joints hot, painful, inflamed, shiny and swollen. Temperature rises in acute cases. Urine strong-smelling, but little passed. Urate deposits (tophi) present a ready diagnostic sign on elbows or lobes of ears. Swollen big toe common. Joints normal between attacks.
Autumn Crocus (Colchicum) is the oldest and still one of the most effective plant medicines for relief and appears to act by inhibiting prostaglandin activity.
The symptoms of pseudo-gout are similar, focus of pain mostly in the knee. Instead of uric acid, pyrophosphoric acid crystals are laid down and calcium salts deposited in cartilages. For this, Colchicum is of little value, though reportedly good results follow use of White Willow.
Influenza vaccination injections may trigger acute gout in some patients.
Alternatives. Autumn Crocus (Colchicum), Black Cohosh, Boldo, Burdock root, Celery seeds, Gravel root, Guaiacum, Meadowsweet, Sarsaparilla, Valerian, White Willow, Wild Lettuce, Yarrow, Devil’s Claw.
Alternatives for acute conditions:– Tea. Equal parts: Boldo, Celery seeds, Meadowsweet. Mix. 1-2 teaspoons to each cup boiling water; infuse 15 minutes. 1 cup every 2 hours.
Decoction. Black Cohosh 1; Gravel root 1; White Willow 2. Mix. 1-2 teaspoons in 2 cupfuls water gently simmered 20 minutes. Half a cup every 2 hours.
Tablets/capsules. Boldo, Black Cohosh, Celery, Garlic, White Willow, Devil’s Claw, Prickly Ash. Colchicine USP, one 0.5mg tablet every 2 hours.
Powders. Formula. Black Cohosh 1; White Willow 3. Guaiacum quarter. Dose: 500mg (two 00 capsules or one-third teaspoon) every 2 hours.
Tinctures. Formula. White Willow 2; Celery 1; Black Cohosh quarter; Guaiacum quarter; Liquorice quarter. Dose: 1-2 teaspoons every 2 hours in water.
Cider vinegar. Traditional. (Vermont, USA)
Colchicum. Extract Colchici Liquid, dose: 2-5 drops. Tincture Colchici; 5-15 drops. In water as prescribed by a practitioner.
Topical. Cider vinegar as a lotion. Warm potato poultice for pain. Lotion: 1 part Oil of Sassafras to 20 parts Safflower seed oil. Slippery Elm poultice: mix well 2-3 teaspoons powdered Slippery Elm into 1 pint (500ml) equal parts Cider vinegar and water. Epsom salts bath. Comfrey ointment. Chamomile soaks. Aromatherapy. Wipe affected parts with any one diluted oil: Sage, Burdock, Bryony, Rosemary, St John’s Wort.
Diet. Low protein, fat, salt. Nettle tea. Plenty of water. No tea, coffee or alcohol. Reject: purine foods – organ meats, kidney, liver, brain, sweet-bread, red meat, meat extracts. Accept: bananas for potassium – 3 daily, and oily fish. For gout, a vegetarian diet has much to commend it.
Supplements. Daily. Bromelain 200mg. Folic acid 30mg. Vitamin C 3g. Vitamin E 200iu. Iron – Floradix. Magnesium.
General. Reduce acidity. Gout is a rewarding condition for the phytotherapist. Rest affected parts. Good responses with Guaiacum. For kidney involvement add Wild Carrot. For prevention, an older generation of physicians advised quarter to half a teaspoon Glauber Salts in breakfast tea, or cup of Nettle tea. Cradle affected joint against pressure from shoes or bedclothes. ... gout
Symptoms. Feeble appetite, irritable bowel, oedema, nervous irritability.
Alternatives. Teas. Alfalfa, Nettles, Oats, Betony, Red Clover. Irish Moss.
Tablets/capsules. Echinacea, Kelp, Slippery Elm, Seaweed and Sarsaparilla.
Formula. Echinacea 2; Gentian 1; Ginger 1. Dose – Powders: 500mg (two 00 capsules or one-third teaspoon). Liquid Extracts: one 5ml teaspoon. Tinctures: two 5ml teaspoons. Thrice daily before meals. Diet. High protein. Sugar-free. Salt-free. Slippery Elm gruel.
Supplementation. All vitamins. Intramuscular injections of B12. Chromium, Copper, Iron, Magnesium, Selenium. ... kwashiorkor
Poor housing and passive smoking suspected. Its association with non-germ meningitis, and inflammatory drugs is well recognised. Also caused by injury or concussion.
Commence by cleansing bowel with Chamomile enema.
Cerebrospinal relaxants indicated: Passion flower (cerebral), Black Cohosh (meningeal), Ladyslipper (spinal meningeal). (A.W. & L.R. Priest)
If patient is cold, give Cayenne pepper in honey to promote brisk circulation.
Aconite and Gelsemium. “For irritation of the meninges of the brain and spinal cord Aconite is indispensible. Combined with Gelsemium for restlessness it is an exceptional remedy. Tincture Aconite (5-15 drops) with Gelsemium (3-10 drops) hourly. Also used in combination with other agents as may be dictated by the course of the disease. (W.W. Martin MD., Kirksville, Mo., USA)
Crawley root. Decoction: 1 teaspoon to half a pint water, simmer 20 minutes. Dose: 1 teaspoon or more 3-4 times daily for children over 6 months. A powerful diaphoretic and sedative. (Dr Baker, Adrian, Michigan, USA)
Lobelia and Echinacea. Equal parts, Liquid Extract 30 drops in water every 3 hours. (Dr Finlay Ellingwood)
Lobelia, alone. Hypodermic injections of Lobelia in five cases of epidemic spinal meningitis, with complete recovery in every case. Dose: 10 drops hourly until symptoms abate, then twice daily. (Dr A.E. Collyer, Ellingwood Therapeutist)
Ecclectic School. Echinacea commended.
Before the Doctor comes. As onset is rapid, often less than 5 hours, an anti-inflammatory is justified. Teas or decoctions from any of the following: Catmint (Catnep), Prickly Ash berries, Pleurisy root, Boneset, Wild Cherry bark, Bugleweed (Virginian), Ladyslipper. When temperature abates and patient feels better: Chamomile tea or cold Gentian decoction with pinch Cayenne.
Hydrotherapy. Hot baths make patient feel worse. Sponge down with cold water.
Protective throat spray: equal parts, Tincture Myrrh and Tincture Goldenseal.
Protective gargle: 10-20 drops Tincture Myrrh and Goldenseal to glass of water.
Garlic. Dr Yan Cai, Department of Neurology, Ren Ji Hospital (affiliated to Shanghai Second Medical University), China, referred to the extensive use of Garlic in Chinese folk medicine and his hospital’s experience with Garlic products – diallyl trisulphide in particular – to treat viral infections including crypotococcal meningitis for which disease results were impressive.
Garlic appears to be a reliable preventative.
Diet. Fast as long as temperature is elevated; with fruit juices, red beet juice, carrot juice or herb teas. Note. GPs and other practitioners may help stop meningitis claiming lives by giving massive doses of Echinacea before they are admitted to hospital.
Note: The infection is often difficult to diagnose. At the end of each year (November and December) when the peak in cases approaches, every feverish patient with headache should be suspected, especially where accompanied by stiff neck.
The above entry is of historic interest only; more effective orthodox treatment being available. ... meningitis
Iron deficiency may also be caused or worsened by lack of iron in, or its poor absorption from, the diet.
The symptoms are those of the underlying cause, along with a sore mouth or tongue, and those common to all forms of anaemia, such as fatigue and breathlessness. The diagnosis is made from blood tests and tests to look for an underlying cause. Treatment is given for the cause, along with a course of iron tablets or, very rarely, injections.... anaemia, iron-deficiency
Recombinant parathyroid hormone (Preotact) is given by subcutaneous injection to treat postmenopausal osteoporosis.... parathyroid hormone
Vitamin B12 is found only in foods of animal origin, such as meat and dairy products. It is absorbed from the small intestine after first combining with intrinsic factor, a chemical produced by the stomach lining. The most common cause of vitamin B12 deficiency is failure of the stomach lining to produce intrinsic factor, usually due to an autoimmune disorder; this is called pernicious anaemia. Total gastrectomy (removal of the stomach) prevents production of intrinsic factor, and removal of part of the small intestine prevents B12 absorption, as does the intestinal disorder Crohn’s disease. In a minority of cases, vitamin B12 deficiency is due to a vegan diet.
Folic acid is found mainly in green vegetables and liver. The usual cause of deficiency is a poor diet. Deficiency can also be caused by anything that interferes with the absorption of folic acid from the small intestine (for example Crohn’s disease or coeliac disease). Folic acid requirements are greater than normal in pregnancy.
Many people with mild megaloblastic anaemia have no symptoms. Others may experience tiredness, headaches, a sore mouth and tongue, and mild jaundice. If B12 deficiency continues for a long time, additional symptoms due to nerve damage, including numbness and tingling in the feet, may develop.
Megaloblastic anaemia is diagnosed by blood tests and a bone marrow biopsy. Megaloblastic anaemia due to poor diet can be remedied with a short course of vitamin B12 injections or folic acid tablets and the introduction of a normal diet. A lifelong course of vitamin B12 injections or folic acid tablets is required if the underlying cause of malabsorption is untreatable.... anaemia, megaloblastic
Local anaesthetics applied topically before injections or blood tests include sprays and skin creams and ointments.
These are often used for children.
For minor surgical procedures, such as stitching of small wounds, local anaesthesia is usually produced by direct injection into the area to be treated.
To anaesthetize a large area, or when local injection would not penetrate deeply enough into body tissues, a nerve block may be used.
Nerves can also be blocked where they branch off from the spinal cord, as in epidural anaesthesia, which is widely used in childbirth, and spinal anaesthesia, which is used for surgery on the lower limbs and abdomen.
Serious reactions to local anaesthetics are uncommon.
Repeated use of topical preparations may cause allergic rashes.... anaesthesia, local
The most common cause is a sudden allergic reaction to a food. Less commonly, it results from allergy to a drug (such as penicillin), a reaction to an insect bite or sting, or from infection, emotional stress, or exposure to animals, moulds, pollens, or cold conditions. There is also a hereditary form of the disease.
Angioedema may cause sudden difficulty in breathing, swallowing, and speaking, accompanied by swelling of the lips, face, and neck, depending on the area of the body affected. Angioedema that affects the throat and the larynx is potentially life-threatening because the swelling can block the airway, causing asphyxia.
Severe cases are treated with injections of adrenaline (epinephrine) and may require intubation (passage of a breathing tube via the mouth into the windpipe) or tracheostomy (surgical creation of a hole in the windpipe) to prevent suffocation. Corticosteroid drugs may also be given. In less severe cases, antihistamine drugs may relieve symptoms.... angioedema
Hard plastic lenses give good vision, are long-lasting and durable, inexpensive, and easy to maintain. However, they are sometimes difficult to tolerate and may fall out. Hard gas-permeable lenses are more comfortable because they allow oxygen to pass through to the eye, but are less durable. Soft lenses are the most comfortable because of their high water content. Disposable soft lenses are for single-use only; extended wear lenses are worn for up to a month.
Other types of lenses include rigid, scleral lenses that cover the whole of the front of the eye and are used to disguise disfigurement due to injury or disease; bifocal contact lenses; and interruptus; hormonal methods, including the use of oral contraceptives, implants, and injections (see contraceptives, injectable); intrauterine devices (see IUDs); postcoital methods (see contraception, emergency); or sterilization of the male (see vasectomy) or female (see sterilization, female).
contraception, barrier methods of
The use of a device and/or a chemical to stop sperm reaching an ovum, preventing fertilization and pregnancy. Barrier methods also help prevent the sexual transmission of diseases such as AIDS, genital herpes (see herpes, genital), and viral hepatitis (see hepatitis, viral).
toric contact lenses with an uneven sur- face curvature to correct astigmatism.
Hard plastic contact lenses may cause abrasion of the cornea if they are worn for too long. Soft lens wearers sometimes develop sensitivity of the eyes and lids. Other problems that may occur with any type of contact lens include infections and redness of the eye.... contact lenses
Side effects are uncommon when corticosteroids are given as a cream or by inhaler, but tablets taken in high doses for long periods may cause oedema, hypertension, diabetes mellitus, peptic ulcer, Cushing’s syndrome, inhibited growth in children, and, in rare cases, cataract or psychosis. High doses also impair the body’s immune system. Long-term treatment suppresses production of corticosteroid hormones by the adrenal glands, and sudden withdrawal may lead to adrenal failure.... corticosteroid drugs
Protection against pertussis and tetanus gradually wanes. In adults, pertussis is mild but can be transmitted to children. Since tetanus is serious at any age, boosters are recommended at the time of any dirty, penetrating injury if there has not been a vaccination in the past 10 years.
Reactions to the diphtheria and tetanus parts of the vaccine are rare.
The pertussis vaccine often causes slight fever and irritability for a day or so.
More serious reactions are extremely rare and include seizures and an allergic reaction, which may lead to sudden breathing difficulty and shock.
Permanent damage from the vaccine is even rarer.
Doctors are now agreed that for most children, the benefits of outweigh the minimal risk from the vaccine.
The pertussis element of the vaccine should not be given to children who have reacted severely to a preceding dose of the vaccine, or who have a progressing brain abnormality.... dpt vaccination
Dystonia may be resolved with anticholinergic drugs or with benzodiazepine drugs.
In some cases, biofeedback training may help.
Injections of botulinum toxin into the affected muscles are effective in treating some types of dystonia.... dystonia
Pain and inflammation may be relieved by analgesic drugs, nonsteroidal anti-inflammatory drugs, and injections of corticosteroid drugs.
Swelling usually reduces with rest, firm bandaging, icepacks, and keeping the affected joint raised.
In some cases, the fluid is drawn out with a needle and syringe.... effusion, joint
Other hormonal contraceptives include injections and implants (see contraception). See also postcoital contraception.... oral contraceptive
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