Macular degeneration

Macular degeneration, which is atrophy or degeneration of the macular disk, accounts for about 12% of all cases of blindness in the United States and for about 17% of new cases of blindness. It’s one of the causes of severe irreversible loss of central vision in people older than age 50. It affects slightly more women than men.
Types of Macular Degenaration
Two types of age-related macular degeneration occur. The dry, or atrophic, form is characterized by atrophic pigment epithelial changes and is usually associated with a slow, progressive distortion of straight lines or edges and central visual loss. The wet, or exudative, form causes rapid onset of visual impairment. It’s characterized by subretinal neovascularization that causes leakage, hemorrhage, and fibrovascular scar formation, which produce significant loss of central vision.
Causes
Age-related macular degeneration results from the formation of drusen (clumps of epithelium) or subretinal neovascular membrane in the macular region. It may be hereditary. Cigarette smoking and lack of antioxidants, such as vitamins C and E, may also enhance occurrence.
Underlying pathologic changes occur primarily at the level of the retinal pigment epithelium, Bruch’s membrane, and choriocapillaris in the macular region. Drusen (bumps), which are common in elderly people, appear as yellow deposits beneath the pigment epithelium and may be prominent in the macula.
Signs and symptoms
The patient notices a change in central vision; for example, he may notice a blank spot in the center of the page when reading.
Diagnosis
The following tests are used to diagnose macular degeneration:

Fibromyalgia syndrome

fibromyalgiaA diffuse pain syndrome, fibromyalgia syndrome (FMS, previously called fibrositis) is one of the most common causes of chronic musculoskeletal pain; it’s observed in up to 15% of patients seen in a general rheumatology practice and 5% of general medicine clinic patients. Symptoms of FMS include diffuse musculoskeletal pain, daily fatigue, and sleep disturbances. Multiple tender points in specific areas on examination are the characteristic feature. Women are affected much more commonly than men, and although FMS can affect all age-groups, its peak incidence is between ages 20 and 60. It may occur as a primary disorder or in association with an underlying disease, such as systemic lupus erythematosus, rheumatoid arthritis, osteoarthritis, sleep apnea syndromes, and neck trauma.

Causes
The cause of FMS is unknown, but many theories exist regarding its pathophysiology. Although the pain is located primarily in muscle areas, no distinct abnormalities have been documented on microscopic evaluation of biopsies of tender points when compared to normal muscle. Other theories suggest decreased blood flow to muscle tissue (due to poor muscle aerobic conditioning versus other physiologic abnormalities); decreased blood flow in the thalamus and caudate nucleus, leading to a lowering of the pain threshold; endocrine dysfunction such as abnormal pituitary-adrenal axis responses; and abnormal levels of the neurotransmitter serotonin in brain centers, which affect pain and sleep. Abnormal functioning of other pain-processing pathways may also be involved. Considerable overlap of symptoms with other pain syndromes, such as chronic fatigue syndrome, raises the question of an association with an infection such as with parvovirus B19. Human immunodeficiency virus (HIV) infection and Lyme disease have also been associated with FMS.
It’s possible that the development of FMS is multifactorial and is influenced by stress (physical and mental), physical conditioning, and quality of sleep as well as by neuroendocrine, psychiatric and, possibly, hormonal factors (because of the female predominance).
Signs and symptoms
The primary symptom of FMS is diffuse, dull, aching pain that’s typically concentrated across the neck, shoulders, lower back, and proximal limbs. It can involve all four body quadrants— bilateral upper trunk and arms and bilateral lower trunk and legs. The pain is typically worse in the morning and sometimes accompanied by stiffness. It can vary from day to day and be exacerbated by stress, lack of sleep, weather changes, and inactivity.
The sleep disturbance associated with FMS may be another factor in symptom development. Many patients with this syndrome describe a habit of being a light sleeper and experiencing frequent arousal and fragmented sleep (possibly secondary to pain in those patients who have underlying illnesses, such as osteoarthritis and rheumatoid arthritis). Other patients may report feeling unrefreshed after a night’s sleep. Because of this nonrestorative sleep pattern, the patient can feel fatigued a half hour to several hours after awakening and remain so Continue reading “Fibromyalgia syndrome”

Personality disorders

Defined as individual traits that reflect chronic, inflexible, and maladaptive patterns of behavior, personality disorders cause social discomfort and impair social and occupational functioning. Although no statistics document the number of cases of personality disorder, these disorders are known to be widespread. Most patients with a personality disorder don’t receive treatment; when they do, they’re typically managed as outpatients.
According to the classification system of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition – Text Revision, personality disorders fall on Axis II. Knowing the features of personality disorders helps provide a more complete picture of the patient and a more accurate diagnosis. For example, many features characteristic of personality disorders are apparent during an episode of another mental disorder (such as a major depressive episode in a patient with compulsive personality features).
Personality disorders typically begin before or during adolescence and early adulthood and persist throughout adult life. The prognosis varies.
Causes
Only recently have personality disorders been categorized in detail, and research continues to identify their causes. Various theories attempt to explain the origin of personality disorders.
  • Biological theories hold that these disorders may stem from chromosomal and neuronal abnormalities or head trauma.
  • Social theories hold that the disorders reflect learned responses, having much to do with reinforcement, modeling, and aversive stimuli as contributing factors.
  • Psychodynamic theories hold that personality disorders reflect deficiencies in ego and superego development and are related to poor mother-child relationships that are characterized by unresponsiveness, overprotectiveness, or early separation.
Signs and symptoms
Each specific personality disorder produces characteristic signs and symptoms,

which may vary among patients and within the same patient at different times. In general, the history of the patient with a personality disorder will reveal long-standing difficulties in interpersonal relationships, ranging from dependency to withdrawal, and in occupational functioning, ranging from compulsive perfectionism to intentional sabotage.
The patient with a personality disorder may show any degree of self-confidence, ranging from no self-esteem to arrogance. Convinced that his behavior is normal, he avoids responsibility for its consequences, often resorting to projections and blame.
Treatment
Personality disorders are difficult to treat. Successful therapy requires a trusting relationship in which the therapist can use a direct approach. The type of therapy chosen depends on the patient’s symptoms.
Drug therapy is ineffective but may be used to relieve acute anxiety and depression. Family and group therapy usually are effective.
Hospital inpatient milieu therapy can be effective in crisis situations and possibly for long-term treatment for borderline personality disorders. Inpatient treatment is controversial, however, because most patients with personality disorders don’t comply with extended therapeutic regimens; for such patients, outpatient therapy may be more useful. Continue reading “Personality disorders”

Introduction to Atopic dermatitis

Atopic dermatitis is characterized by superficial skin inflammation and intense itching. Although atopic dermatitis may appear at any age, it typically begins during infancy or early childhood. It may then subside spontaneously, followed by exacerbations in late childhood, adolescence, or early adulthood. Atopic dermatitis affects less than 1% of the population.
Causes
Atopic dermatitis is a chronic, inherited skin disorder in which the immune system produces a hypersensitivity reaction to environmental allergens that are often difficult to identify.
Exacerbating factors of atopic dermatitis include irritants, infections (commonly caused by Staphylococcus aureus), and some allergens. Although no reliable link exists between atopic dermatitis and exposure to inhalant allergens (such as house dust and animal dander), exposure to food allergens (such as soybeans, fish, or nuts) may coincide with flare-ups of atopic dermatitis.
Signs and symptoms
Scratching the skin causes vasoconstriction and intensifies pruritus, resulting in erythematous and weeping lesions. Eventually, the lesions become scaly and lichenous. Usually, they’re located in areas of flexion and extension, such as the neck, antecubital fossa, popliteal folds, and the backs of the ears. Patients with atopic dermatitis are prone to unusually severe viral infections, bacterial and fungal skin infections, ocular complications, and allergic contact dermatitis.
Diagnosis
Typically, the patient has a history of atopy, such as allergic rhinitis asthma, or urticaria; family Continue reading “Introduction to Atopic dermatitis”

Trigeminal neuralgia

Also called tic douloureux, trigeminal neuralgia is a painful disorder of one or more branches of the fifth cranial (trigeminal) nerve that produces paroxysmal attacks of excruciating facial pain precipitated by stimulation of a trigger zone.
It occurs mostly in people over age 40, in women more often than men, and on the right side of the face more often than the left. Trigeminal neuralgia can subside spontaneously, with remissions lasting from several months to years.
Causes
Although the cause remains undetermined, trigeminal neuralgia may:
  • reflect an afferent reflex phenomenon located centrally in the brain stem or more peripherally in the sensory root of the trigeminal nerve
  • be related to compression of the nerve root by posterior fossa tumors, middle fossa tumors, or vascular lesions (subclinical aneurysm), although such lesions usually produce simultaneous loss of sensation
  • occasionally be a manifestation of multiple sclerosis or herpes zoster.
Whatever the cause, the pain of trigeminal neuralgia is probably produced by an interaction or short-circuiting of touch and pain fibers.
Signs and symptoms
Typically, the patient reports a searing or burning pain that occurs in lightning-like jabs and lasts from 1 to 15 minutes (usually 1 to 2 minutes) in an area innervated by one of the divisions of the trigeminal nerve, primarily the superior mandibular or maxillary division.
The pain rarely affects more than one division, and seldom the first division (ophthalmic) or both sides of the face. It affects the second (maxillary) and third (mandibular) divisions of the trigeminal nerve equally. (See Trigeminal nerve distribution and function.)
These attacks characteristically follow stimulation of a trigger zone, usually by a light touch to a hypersensitive area, such as the tip of the nose, the cheeks, or the gums. Although attacks can occur at any time, they may follow a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages.
The frequency of attacks varies greatly, from many times a day to several times a month or year. Between attacks, most patients are pain-free, although some have a constant, dull ache. No patient is Continue reading “Trigeminal neuralgia”

Legionnaires’ disease

Legionnaires' diseaseAn acute bronchopneumonia, legionnaires’ disease is produced by a fastidious, gram-negative bacillus. This disease may occur epidemically or sporadically, usually in late summer or early fall. Its severity ranges from a mild illness, with or without pneumonitis, to multilobar pneumonia, with a mortality as high as 15%. A milder, self-limiting form (Pontiac fever) subsides within a few days, but leaves the patient fatigued for several weeks; this form mimics legionnaires’ disease, but produces few or no respiratory symptoms, no pneumonia, and no fatalities.
Causes
The cause of legionnaires’ disease, Legionella pneumophila, is an aerobic, gram-negative bacillus that’s probably transmitted by an airborne route. With past epidemics, it has spread through cooling towers or evaporation condensers in air-conditioning systems. However, Legionella bacilli also flourish in soil and excavation sites. The disease doesn’t spread from person to person.
Legionnaires’ disease is more common in men than in women and is most likely to affect:
  • middle-aged to elderly people
  • immunocompromised people (particularly those receiving a corticosteroid, for example, after a transplant) or those with lymphoma or other disorders ssociated with delayed hypersensitivity
  • patients with a chronic underlying disease, such as diabetes, chronic renal failure, or chronic obstructive pulmonary disease
  • alcoholics
  • cigarette smokers (three to four times more likely to develop legionnaires’ disease than nonsmokers).
Signs and symptoms
Although signs and symptoms of legionnaires’ disease emerge in a predictable sequence, onset of the disease may be gradual or sudden.
After a 2- to 10-day incubation period, nonspecific, prodromal signs and symptoms appear, including diarrhea, anorexia, malaise, diffuse myalgia and generalized weakness, headache, recurrent chills, and an unremitting fever, which develops within 12 to 48 hours with a temperature as high as 105° F (40.6° C). A cough then develops that is initially nonproductive but eventually may produce grayish, nonpurulent and, occasionally, blood-streaked sputum.
Other characteristic signs and symptoms include nausea, vomiting, disorientation, mental Continue reading “Legionnaires’ disease”

Introduction to Breast cancer

Breast cancer is the most common cancer affecting women and is the number two killer (after lung cancer) of women ages 35 to 54. It occurs in men, though only rarely. (See Breast cancer in men.) The overall breast cancer death rate for American women has fallen. Lymph node involvement is the most valuable prognostic predictor. With adjuvant therapy, 70% to 75% of women with negative nodes will survive 10 years or more, compared with 20% to 25% of women with positive nodes.
Although breast cancer may develop anytime after puberty, it’s most common after age 50.
Causes
The cause of breast cancer is unknown, but its high incidence in women implicates estrogen. Certain predisposing factors are clear; women at high risk include those who:
  • have a family history of breast cancer
  • have long menses; began menses early or menopause late
  • have never been pregnant
  • were first pregnant after age 31
  • have had unilateral breast cancer
  • have had endometrial or ovarian cancer
  • have been exposed to low-level ionizing radiation.

Many other predisposing factors have been investigated, including estrogen therapy, antihypertensives, high-fat diet, obesity, and fibrocystic disease of the breasts.
Women at lower risk include those who:
  • were pregnant before age 20
  • have had multiple pregnancies
  • are Indian or Asian.
Pathophysiology
Breast cancer is more common in the left breast than in the right and more common in the upper outer quadrant. Growth rates vary. Theoretically, slow-growing breast cancer may take up to 8 years to become palpable at 1 cm in size. It spreads by way of the lymphatic system and the bloodstream, through the right side of the heart to the lungs and, eventually, to the other breast, the chest wall, liver, bone, and brain.
Many refer to the estimated growth rate of breast cancer as doubling time, or the time it takes the malignant cells to double in number. Survival time for breast cancer is based on tumor size and spread; the number of involved nodes is the single most important factor in predicting survival time.
Classified by histologic appearance and location of the lesion, breast cancer may be:
  • adenocarcinoma—arising from the epithelium
  • intraductal—developing within the ducts (includes Paget’s disease)
  • infiltrating—occurring in parenchymatous tissue of the breast
  • inflammatory (rare)—reflecting rapid tumor growth, in which the overlying skin becomes edematous, inflamed, and indurated
  • lobular carcinoma in situ—reflecting tumor growth involving lobes of glandular tissue
  • medullary or circumscribed—a large tumor with a rapid growth rate.
Signs and symptoms
Warning signals of breast cancer include:
  • a lump or mass in the breast (a hard, stony mass is usually malignant)
  • a change in symmetry or size of the breast
  • a change in breast skin (thickening, scaly skin around the nipple, dimpling, edema [peau d’orange], or ulceration)
  • a change in skin temperature (a warm, hot, or pink area; suspect cancer in a non-breast-feeding woman past childbearing age until proven otherwise) Continue reading “Introduction to Breast cancer”

Managing heat syndrome

Managing heat syndrome

Type and Predisposing Factors Signs and Symptoms Management
Heat cramps
  • Commonly affect young adults
  • Strenuous activity without training or acclimatization
  • Normal to high temperature or high humidity
  • Muscle twitching and spasms, weakness, severe muscle cramps
  • Nausea
  • Normal temperature or slight fever
  • Normal central nervous system findings
  • Diaphoresis
  • Hospitalization is usually unnecessary.
  • To replace fluid and electrolytes, give a balanced electrolyte drink.
  • Loosen patient’s clothing, and have him lie down in a cool place. Massage his muscles. If muscle cramps are severe, start an I.V. infusion with normal saline solution.
Heat exhaustion
  • Commonly affects young people
  • Physical activity without acclimatization
  • Decreased heat dissipation
  • High temperature and humidity
  • Muscle cramps (infrequent)
  • Nausea and vomiting
  • Decreased blood pressure
  • Thready, rapid pulse
  • Cool, pallid skin
  • Headache, mental con-fusion, syncope, giddiness
  • Oliguria, thirst
  • No fever
  • Sweating Continue reading “Managing heat syndrome”