Trigger finger or stenosing tenosynovitis is a condition that involves one of the fingers or thumbs becoming stuck in a bent position and then rapidly straightened like the trigger of a gun. This condition is caused by a narrowing of the sheath that surrounds the tendons in the finger, and is common in people who perform repetitive gripping actions but can occur in anyone. Trigger finger causes stiffness, pain and may eventually lead to an inability to completely straighten the finger. When you try to straighten your finger, it will lock or catch before popping out straight.
It is one of the most common causes of hand pain in adults. The reported prevalence is roughly 2 percent in the general population, and is more common among women than men in the fifth or sixth decade of life. It can occur in one or many fingers in each hand and can be bilateral. The prevalence of trigger finger is also higher among patients with diabetes mellitus, rheumatoid arthritis, or conditions that cause systemic deposition of protein such as amyloidosis. Trigger finger is occasionally observed in children.
Trigger Finger risk factors
Risk factors may be more likely to develop trigger finger if you have any of the following conditions:
Diabetes: A long-term condition that is caused by too much glucose in the blood
Rheumatoid arthritis: A long-term condition caused by a problem with your immune system (the body’s defence system), resulting in pain and stiffness in your joints
Gout: A short-term condition that causes inflammation (swelling) in one or more of your joints
Amyloidosis: A condition where abnormal protein called amyloid builds up in organs, such as your liver
Underactive thyroid: Your body does not produce enough of certain hormones
Mucopolysaccharide storage disorders: A group of rare disorders that cause progressive physical and sometimes mental disability
Carpal tunnel syndrome: Acondition that affects the nerves in your wrist, causing pain and tingling
Dupuytren’s contracture: A condition that causes one or more fingers to bend into the palm of your hand
De Quervain’s disease: A condition that affects the tendons in your thumb, causing pain in your wrist
Causes of Trigger Finger
Trigger finger is caused by inflammation of the tenosynovium. The tenosynovium is the substance that lines the protective sheath around the tendon in the finger. This substance enables the tendon toglide smoothly within the sheath when the finger is bent or straightened.
When inflammation is present, the tendon is unable to glide smoothly within its sheath causing “catching” of the finger in a bent position and then suddenly releasing the finger straight. Causes of trigger finger can include the following:
Repetitive Motion: Individuals who perform heavy, repetitive hand and wrist movements with prolonged gripping at work or play are believed to be at high risk for developing trigger finger.
Medical Conditions: Conditions associated with developing trigger finger include hypothyroidism, rheumatoid arthritis, diabetes, and certain infections such as TB.
Gender: Trigger finger is more common in females than males.
The most common symptom of trigger finger is stiffness in the joints of the finger, especially in the morning. Other symptoms may include:
Popping or clicking is felt when moving the finger
Tenderness, sometimes accompanied by a lump in the palm of the hand at the base of the affected finger
Finger is locked in a bent position and is unable to straighten
Trigger thumb, stuck in a flexed position
Symptoms are usually worse in the morning and after periods of inactivity. Maintaining mobility and activity in the fingers will keep them from becoming too stiff. In some cases, more than one finger may be affected.
In children with the congenital form of the condition, there is often no pain related with the bent finger position and there is generally no history of trauma or continuing use of the joint. In about one fourth of all congenital cases, the condition befalls in both hands.
Your doctor will start with a physical exam of your hand and fingers. The finger may be swollen, stiff, and painful. You might have a bump over the joint in the palm of your hand. Or it could be locked in a bent position. There are no X-rays or lab tests to diagnose trigger finger.
Treatment of Trigger Finger
Initial treatment for a trigger finger is usually nonsurgical.
Rest: Resting your hand and avoiding activities that make it worse may be enough to resolve the problem.
Splinting: Wearing a splint at night to keep the affected finger or thumb in a straight position while you sleep may be helpful.
Trigger Finger Splint
Exercises: Gentle stretching exercises can help decrease stiffness and improve range of motion in the involved digit.
Medications: Over-the-counter medications, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), can help relieve pain and inflammation.
Steroid injections: Corticosteroid, or cortisone, is an anti-inflammatory agent that can be injected into the tendon sheath at the base of the trigger finger. A steroid injection may resolve the triggering over a period of one day to several weeks. If symptoms do not improve with time, a second injection may be given. If two injections do not help the problem, surgery may be considered.
Steroid injections are less likely to be effective in patients with diabetes, but may still help avoid surgery. They can cause a short-term rise in blood sugar, so glucose levels in diabetic patients should be monitored after injection.
If your finger does not get better with nonsurgical treatment, you may wish to consider surgery. Surgery is elective. The decision for surgery is based on how much pain or loss of function you have in your finger. If, however, your finger or thumb is stuck in a flexed or bent position, your doctor may recommend surgery to prevent permanent stiffness.
Surgical procedure: The surgical procedure for trigger finger is called “tenolysis” or “trigger finger release.” The goal of the procedure is to release the A1 pulley that is blocking tendon movement so the flexor tendon can glide more easily through the tendon sheath.
During trigger release surgery, the A1 pulley is cut (dotted blue line)
Complications are rare with trigger finger release surgery. However, as with any surgery, complications could occur and include:
Pain or stiffness in your finger
A tender scar
Bowstringing – where the tendon is in the wrong position
Complex regional pain syndrome (CRPS) – pain and swelling in your hand that usually resolves after a few months.
Prevention of Trigger Finger
Avoiding overuse is the main component of preventing trigger finger.
If you have diabetes, rheumatoid arthritis, or any reason to believe you are more prone to getting trigger finger consider practicing the exercises from above.
If you feel a slight onset of trigger finger resting your hand will be the most effective way to avoid further issues.
Adenosine deaminase (ADA) deficiency is an inherited disorder that damages the immune system and causes severe combined immunodeficiency (SCID). People with SCID lack virtually all immune protection from bacteria, viruses, and fungi. They are prone to repeat and persistent infections that can be very serious or life-threatening. These infections are often caused by “opportunistic” organisms that ordinarily do not cause illness in people with a normal immune system.
Pathophysiology of ADA Deficiency
Due to the lack of enzyme adenosine deaminase, there is an onset of ADA deficiency. This gradually results in an accumulation of deoxyadenosine, which, in turn, leads to:
A buildup of dATP in all cells, which inhibits ribonucleotide reductase and prevents DNA synthesis, so cells are unable to divide. Since developing T cells and B cells are some of the most mitotically active cells, they are highly susceptible to this condition.
An increase in S-adenosylhomocysteine since the enzyme adenosine deaminase is important in the purine salvage pathway; both substances are toxic to immature lymphocytes, which thus fail to mature.
Because T cells undergo proliferation and development in the thymus, affected individuals typically have a small, underdeveloped thymus. As a result, the immune system is severely compromised or completely lacking.
What are the Causes and Risk factors of ADA Deficiency?
The major cause of ADA deficiency is by mutations in the ADA gene. This gene provides instructions for producing the enzyme adenosine deaminase. This enzyme is found throughout the body but is most active in specialized white blood cells called lymphocytes. These cells protect the body against potentially harmful invaders, such as bacteria and viruses, by making immune proteins called antibodies or by directly attacking infected cells. Lymphocytes are produced in specialized lymphoid tissues including the thymus, which is a gland located behind the breastbone, and lymph nodes, which are found throughout the body. Lymphocytes in the blood and in lymphoid tissues make up the immune system.
The function of the adenosine deaminase enzyme is to eliminate a molecule called deoxyadenosine, which is generated when DNA is broken down. Adenosine deaminase converts deoxyadenosine, which can be toxic to lymphocytes, to another molecule called deoxyinosine that is not harmful. Mutations in the ADA gene reduce or eliminate the activity of adenosine deaminase and allow the buildup of deoxyadenosine to levels that are toxic to lymphocytes.
Immature lymphocytes in the thymus are particularly vulnerable to a toxic buildup of deoxyadenosine. These cells die before they can mature to help fight infection. The number of lymphocytes in other lymphoid tissues is also greatly reduced. The loss of infection-fighting cells results in the signs and symptoms of SCID.
Clinical Manifestations of ADA Deficiency
Symptoms usually appear in the first months of life. If your baby has this disease, he may have a lot of infections in different parts of his body, including:
It’s common for babies to get infections. Pay special attention if your child has them often and they are:
Children with ADA-SCID often have diarrhea and widespread skin rashes. They may also grow slowly and have delayed progress in other development areas like motor and social skills.
If the disease doesn’t appear until later in childhood or adulthood, the symptoms may be mild at first. The first symptoms may be an ear or upper-respiratory infections that keep coming back.
Complications after ADA Deficiency
Getting a Diagnosis and Test
There may also be clues in chest X-rays, including the absence of a thymic shadow, lung abnormalities, and signs of pneumonia, and in infants with ADA-SCID, the presence of skeletal abnormalities may aid in the diagnosis. Unusually persistent, severe, or opportunistic infections are the most common presentation, particularly viruses, fungi, or bacteria, and indicate a possible SCID diagnosis
Diagnosis of ADA-deficiency is established by biochemical and molecular genetic testing.
Biochemical testing demonstrates absent or greatly reduced ADA activity (< 1% of normal) and marked the elevation of the metabolite dATP or total dAdo nucleotides (the sum of dAMP, dADP and dATP) in erythrocytes. Reduced activity of SAH hydrolase in erythrocytes (< 5% of normal) is also characteristic. If a patient with suspected ADA- deficiency has had a recent blood transfusion, analysis of ADA activity can be measured in the parents, with reduced activity seen in heterozygous carriers, or can be performed on nonerythroid cells such as leukocytes. Fibroblasts can also be used, but fibroblast cultures are usually not readily available and this may delay diagnosis.
Molecular genetic testing relies on the identification of biallelic pathogenic mutations in the ADA gene, located on chromosome 20q12-q13.11 and in which over 70 causative mutations have been identified. Diagnosis of ADA-deficiency is established by biochemical and molecular genetic testing.
Treatment and Medications for ADA Deficiency
Treatment of ADA deficiency is possible through 3 main routes:
Bone marrow or stem cell transplants from a haploidentical donor is available for a minority of patients.
Enzyme therapy can directly add missing ADA. This can occur through a transfusion of irradiated red blood cells. Patients on this regime experienced equally depressed antibody responses as untreated ADA deficient patients. Direct enzyme injections are a better method of introducing ADA to the patient.
Somatic gene therapy can create functional ADA + T cells. The latest treatment for ADA deficiency is gene therapy. Gene therapy provides victims with their own T cells into which a normal copy of the human ADA gene has been inserted. ADA deficiency is the first disease to be treated with human gene therapy.
Injection of intravenous medications to boost immunity
Prognosis of ADA Deficiency
The long-term outlook (prognosis) for people with adenosine deaminase deficiency (ADA deficiency) varies depending on the severity of the condition, the timing of the diagnosis, and the response to treatment. Early screening of SCID during birth could be easy to diagnose and treat the ADA deficiency which may also reduce the duration of outcomes.
For babies diagnosed early and treated with a bone marrow transplant/stem cell transplant, the long-term outlook is generally good. At this time, it isn’t clear if these children will still develop developmental or behavioral problems later in life. Long term outlook can be seen in ADA deficiency patient if they have been treated with gene therapy. However, enzyme replacement therapy generally gives better results but it may lose effectiveness over many years.
Sarcoidosis is a disease that results from a specific type of inflammation of tissues of the body. It can appear in almost any body organ, but it starts most often in the lungs or lymph nodes. The cause of sarcoidosis is unknown. The disease can appear suddenly and disappear.
Or it can develop gradually and go on to produce symptoms that come and go, sometimes for a lifetime.
As sarcoidosis progresses, microscopic lumps of a specific form of inflammation, called granulomas, appear in the affected tissues. In the majority of cases, these granulomas clear up, either with or without treatment. In the few cases where the granulomas do not heal and disappear, the tissues tend to remain inflamed and become scarred (fibrotic).
Types of Sarcoidosis
Sarcoidosis can affect almost any part of the body, and depending on where it occurs, patients can experience very different symptoms and require different treatment methods. Additionally, a patient may experience more than one type of sarcoidosis at once. Some of the common types are discussed here.
Pulmonary sarcoidosis refers to sarcoidosis affecting the lungs. This is the most common form since the majority of sarcoidosis patients experience some level of lung involvement.
Ocular sarcoidosis refers to sarcoidosis affecting the eyes or the surrounding structures. It occurs in about 50 percent of sarcoidosis patients. The symptoms can vary depending on which parts of the eye are affected, with the most common complication being uveitis.
When granulomas develop in and around the nervous system, the disease is referred to as neurosarcoidosis. Depending on the nerves affected, it can have a wide variety of symptoms. Neurosarcoidosis most commonly affects hormone-producing regions of the brain, the hypothalamus, and the pituitary gland. This can disrupt many systems, such as menstrual cycles in female patients.
Neurosarcoidosis can also affect the peripheral nerves and lead to problems with motor function, such as muscle weakness or numbness. Granulomas around the optic nerve can lead to vision loss.
When sarcoidosis affects the heart, the condition is referred to as cardiac sarcoidosis. While cardiac sarcoidosis occurs in a third of sarcoidosis patients, only around 5 percent will experience symptoms. These include irregular heartbeat, or arrhythmia, as the granulomas disrupt the electrical signals that trigger the contraction of the heart muscle.
Musculoskeletal sarcoidosis refers to sarcoidosis affecting the bones, muscles, or joints. Sarcoidosis can cause inflammation in the bones, but this normally does not cause symptoms. Some sarcoidosis medications, such as prednisone, can also cause the bones to become more fragile and prone to breaking (osteoporosis).
Sarcoidosis can cause several skin complications, occurring in about 20-35 percent of patients. Examples include:
Erythema nodosum, or acute painful red lumps on the lower legs or arms
Lupus pernio, associated with chronic, painful blue lesions or discoloration on the face, ears, fingers, or toes
Lesions, on the extremities, face, scalp, back, and buttocks, which can vary in severity from relatively painless lumps and rashes to more severe plaques where multiple lesions have occurred together in the same location.
Sarcoidosis can lead to kidney stone formation, kidney damage, or kidney failure. This can be due to sarcoidosis causing changes in calcium metabolism, resulting in too much calcium in the blood (hypercalcemia). Inflammation, caused by granulomas in the kidneys, can cause scarring and permanent kidney damage.
Liver involvement, called hepatic sarcoidosis, is common. However, this rarely affects organ function. In rare cases, it can cause cirrhosis (liver disease), or portal hypertension (high blood pressure in the liver).
Sarcoidosis of the spleen and bone marrow
Sarcoidosis of the spleen and bone marrow can result in cytopenia — or low blood cell counts. Bone marrow is involved in the production of blood cells, so when sarcoidosis affects the bone marrow, this can lead to abnormalities such as anemia, or low red blood cells. The spleen is involved in filtering out blood cells, and if is not functioning correctly, too many, or the wrong type of blood cells, can be removed.
How Sarcoidosis is progressed?
The unknown antigen triggers a cell-mediated immune response that is characterized by the accumulation of T cells and macrophages, the release of cytokines and chemokines, and organization of responding cells into granulomas. Clusters of disease in families and communities suggest a genetic predisposition, shared exposures, or, less likely, person-to-person transmission.
The inflammatory process leads to the formation of non-caseating granulomas, the pathologic hallmark of sarcoidosis. Granulomas are collections of mononuclear cells and macrophages that differentiate into epithelioid and multinucleated giant cells and are surrounded by lymphocytes, plasma cells, fibroblasts, and collagen. Granulomas occur most commonly in the lungs and lymph nodes but can involve any organ and cause significant dysfunction. Granulomas in the lungs are distributed along lymphatics, with most occurring in peribronchiolar, subpleural, and perilobular regions.
Hypercalcemia may occur because of increased conversion of vitamin D to the activated form by activated macrophages. Hypercalciuria may be present, even in patients with normal serum calcium levels. Nephrolithiasis and nephrocalcinosis may occur, sometimes leading to chronic kidney disease.
What are the Symptoms of Sarcoidosis?
Many people with sarcoidosis think they have the flu or a respiratory infection before they’re diagnosed. Sarcoidosis can affect many different organs, but it most commonly affects your lungs.
Common symptoms of sarcoidosis include:
Shortness of breath
Wheezing or abnormal breathing
Sarcoidosis also can cause the following:
Skin rashes or raised bumps on the skin
Joint pain or stiffness
Eye irritation, dryness of the eyes and sometimes blurry vision
Fast heart rate or lightheadedness
Increased levels of calcium in the bloodstream
Abnormal liver function
Causes of sarcoidosis
The body’s immune system normally fights off infections by releasing white blood cells into the blood to isolate and destroy the germs. This results in inflammation (swelling and redness) of the body tissues in that area. The immune system responds like this to anything in the blood it doesn’t recognize and dies down when the infection has been cleared.
It’s thought that sarcoidosis happens because the immune system has gone into “overdrive”, where the body starts to attack its own tissues and organs. The resulting inflammation then causes granulomas to develop in the organs.
There are many similar conditions, such as rheumatoid arthritis and lupus that are caused by the body attacking its own tissues. These are collectively known as autoimmune conditions.
It’s not known why the immune system behaves like this.
It’s possible that some environmental factor triggers the condition in people who are already genetically susceptible to it.
Sarcoidosis can occasionally occur in more than one family member, but there’s no evidence that the condition is inherited. The condition isn’t infectious, so it can’t be passed from person to person.
Risk factors for Sarcoidosis
You may have an increased risk for sarcoidosis because of your age, your family history, and genetics, or your race. Some risk factors, such as occupation, can be changed. Most risk factors, such as age, family history and genetics, race and ethnicity, and sex, cannot be changed.
Age: You can be diagnosed with sarcoidosis at any age, but sarcoidosis is most commonly diagnosed in people age 55 and older.
Environment or occupation: Your risk for sarcoidosis may be higher if you have repeated exposure to environmental substances that cause inflammation, such as insecticides or mold, or if you work in health care or as a firefighter. Working in these occupations may expose you to substances that trigger the formation of granulomas.
Family history and genetics: You have a higher risk of sarcoidosis if you have a close relative with sarcoidosis.
Other medical conditions: Sarcoidosis sometimes occurs after lymphoma, a type of blood cancer.
Race or ethnicity: People of any race can get sarcoidosis, but it is more common in people of African or Scandinavian descent.
Sex: Both men and women can develop sarcoidosis, but it is more common in women.
Complications during Sarcoidosis
If sarcoidosis is untreated or if the treatment does not work, inflammation can continue and scarring may develop. Sarcoidosis can cause serious and life-threatening damage to the organs it affects, including:
Blood and bone marrow problems, including lower-than-usual numbers of red or white blood cells
Endocrine conditions, including hypercalcemia external link, diabetes insipidus, and amenorrhea
Heart complications, including arrhythmia, heart failure, sudden cardiac arrest, cardiomyopathy
Kidney conditions, such as kidney stones or kidney failure
Lung diseases, such as pulmonary hypertension and pulmonary fibrosis
Problems with the nervous system, including brain tumors, meningitis, hydrocephalus, psychiatric problems, and nerve pain
How is Sarcoidosis Diagnosed?
There is no single way to diagnose sarcoidosis since all the symptoms and laboratory results can occur in other diseases. For this reason, your doctor will carefully review your medical history and examine you to determine if you have sarcoidosis. The main tools your doctor will use to diagnose sarcoidosis include:
Chest X-rays to look for cloudiness (pulmonary infiltrates) or swollen lymph nodes (lymphadenopathy).
HRCT scan (high-resolution CT) to provide an even more detailed look at the lungs and lymph nodes than provided by a chest X-ray. CT findings in more advanced stages (II to IV) include
Thickening of the bronchovascular bundles and bronchial walls
Beading of the interlobular septa
Parenchymal nodules, cysts, or cavities
Pulmonary function (breathing) tests to measure how well the lungs are working.
Bronchoscopy to inspect the bronchial tubes and to extract a biopsy (a small tissue sample) to look for granulomas and to obtain material to rule out infection. Bronchoscopy involves passing a small tube (bronchoscope) down the trachea (windpipe) and into the bronchial tubes (airways) of the lungs.
Mediastinoscopy is rarely needed if a bronchoscopy does not make a diagnosis. This procedure is done in a hospital where an anesthesia doctor puts you completely to sleep. A lung surgeon makes a small incision above your breastbone, a camera is used to look down into your chest, and lymph nodes may be removed and sent to a lab for testing.
Skin biopsy is a procedure done in a dermatologist’s office if you have skin rashes or bumps. The doctor numbs the skin near your rash with a needle and numbing medication. They then take a small sample of your skin and send it to the lab for testing.
Blood tests to check your lung and kidney functions, as well as ACE level, which is an enzyme that is sometimes a marker for active sarcoidosis.
The treatment and medications that cure Sarcoidosis
There’s no cure for sarcoidosis, but in many cases, it goes away on its own. You may not even need treatment if you have no symptoms or only mild symptoms of the condition. The severity and extent of your condition will determine whether and what type of treatment is needed.
If your symptoms are severe or organ function is threatened, you will likely be treated with medications. These may include:
These powerful anti-inflammatory drugs are usually the first line treatment for sarcoidosis. In some cases, corticosteroids can be applied directly to an affected area – via a cream to a skin lesion or drops to the eyes.
Medications that suppress the immune system. Medications such as methotrexate (Trexall) and azathioprine (Azasan, Imuran) reduce inflammation by suppressing the immune system.
Hydroxychloroquine (Plaquenil) may be helpful for skin lesions and elevated blood-calcium levels.
Tumor necrosis factor-alpha (TNF-alpha) inhibitors. These medications are commonly used to treat the inflammation associated with rheumatoid arthritis. They can also be helpful in treating sarcoidosis that hasn’t responded to other treatments.
An organ transplant may be considered if this disease has severely damaged your lungs, heart or liver.
Looking after yourself
If you currently smoke, the most important thing you can do to look after your health is to quit.
Getting regular exercise and enough sleep is very important.
It’s also important to eat well and maintain a healthy weight. Avoid sugar and processed foods where possible. Drink plenty of fluid to keep hydrated. Foods and fluids contain essential nutrients to help control your symptoms and keep you feeling as strong as possible.
If you have sarcoidosis, you might have a tendency to develop high levels of calcium in your urine or blood. Don’t take any calcium or vitamin D supplements unless they’re specifically recommended for you by your doctor. You should be able to get all the calcium and vitamin D you need from a balanced diet.
Is it possible to prevent sarcoidosis?
The cause of sarcoidosis still remains unknown, so there is at present no known way to prevent or cure this disease. However, doctors have had a great deal of experience in the management of the illness. It should be noted that most people with sarcoidosis lead normal lives.
If you have sarcoidosis, you can help yourself by following sensible health measures. You should not smoke. You should also avoid exposure to other substances such as dust and chemicals that can harm your lungs.
If you have any symptoms of sarcoidosis, see your doctor regularly so that the illness can be watched and, if necessary, treated. Regular checkups with the doctor are important even if there are no symptoms present. Eye examinations by an eye specialist can detect early eye inflammation from sarcoidosis.
Psychosis can be a symptom of serious mental illness like bipolar disorder or schizophrenia. In a psychotic episode, a person loses touch with reality as other people see it. They might hear voices, see or feel things that aren’t there, feel paranoid or believe things that don’t rationally make sense. These symptoms are there for most of the time for several weeks. Although it can be scary, psychosis is treatable. Some people have one episode of psychosis and never have another one, while others might need ongoing treatment.
A number of disorders can display psychotic symptoms, including:
Schizophrenia- A serious mental health disorder affecting the way someone feels, thinks, and acts. Individuals find it difficult to distinguish between what is real and what is imaginary
Schizoaffective disorder- A condition similar to schizophrenia that includes periods of mood disturbances
Brief psychotic disorder- Psychotic symptoms last at least 1 day but no longer than 1 month. Often occurring in response to a stressful life event. Once symptoms have gone, they may never return
Delusional disorder- The individual has a strong belief in something irrational and often bizarre with no factual basis. Symptoms last for 1 month or longer
Bipolar psychosis- Individuals have the symptoms of bipolar disorder (intense highs and lows in the mood) and also experience episodes of psychosis. The psychosis more commonly occurs during manic phases
Psychotic depression- Also known as a major depressive disorder with psychotic features
Postpartum (also called postnatal) psychosis- A severe form of postnatal depression
Substance-induced psychosis- Including alcohol, certain illegal drugs, and some prescription drugs, including steroids and stimulants
These are the primary causes of psychotic symptoms, but psychosis can also be secondary to other disorders and diseases, including:
Brain tumor or cyst
Dementia – Alzheimer’s disease, for example
Neurological illness – such as Parkinson’s disease and Huntington’s disease
HIV and other infections that can affect the brain
Some types of epilepsy
Phases of Psychosis
The typical course of psychotic episodes can be thought of as having three phases: Prodrome Phase, Acute Phase, and Recovery Phase.
The first phase- Prodrome Phase
Psychotic episodes rarely occur out of the blue. Almost always, a psychotic episode is preceded by gradual non-specific changes in the person’s thoughts, perceptions, behaviors, and functioning. The first phase is referred to as the prodrome (or prodromal) phase. During this period the person starts to experience changes in themselves, but have not yet started experiencing clear-cut psychotic symptoms.
Types of changes in feelings, thoughts, perceptions, and behaviors include:
Difficulty screening out distracting information and sensations.
Difficulty focusing or understanding what they are hearing
Changes in perceptual experiences – visual experiences may become brighter or sounds louder
Finding harder to keep track of what they are thinking and what others are saying.
Desire or need to be alone
Unexplained difficulty at/skipping school or work
Prodrome symptoms vary from person to person and some people may not experience any of the changes. This phase can last from several months to a year or more.
The second phase- Acute Phase
This is the stage when characteristic psychotic symptoms – such as hallucinations, delusions and very odd or disorganized speech or behaviors – emerge and are most noticeable. The experiences are often very distressing for the person. It is during this phase when appropriate treatment for psychosis needs to be started as soon as possible.
Third phase- Recovery
Within a few weeks or months of starting treatment, most people begin to recover. Many of the symptoms get less intense or disappear, and people are generally better able to cope with daily life. Some of the symptoms that emerged in the Acute Phase may linger in the Recovery Phase, but with appropriate treatments, the vast majority of people successfully recover from their first episode of psychosis.
It’s not currently possible to precisely identify who is likely to develop psychosis. However, research has shown that genetics may play a role.
People are more likely to develop a psychotic disorder if they have a close family member, such as a parent or sibling, who has a psychotic disorder.
Children born with the genetic mutation known as 22q11.2 deletion syndrome are at risk for developing a psychotic disorder, especially schizophrenia.
Medical problems that can cause psychosis to include:
Alcohol and certain illegal drugs, both during use and during withdrawal
Brain diseases, such as Parkinson disease, Huntington disease
Brain tumors or cysts
Dementia (including Alzheimer disease)
HIV and other infections that affect the brain
Some prescription drugs, such as steroids and stimulants
Some types of epilepsy
Psychosis may also be found in:
Most people with schizophrenia
Some people with bipolar disorder (manic-depressive) or severe depression
Some personality disorders
Symptoms and Signs of psychosis
The classic signs and symptoms of psychosis are:
Hallucinations – hearing, seeing, or feeling things that do not exist
Delusions – false beliefs, especially based on fear or suspicion of things that are not real
Disorganization – in thought, speech, or behavior
Disordered thinking – jumping between unrelated topics, making strange connections between thoughts
Catatonia – unresponsiveness
Depending on the cause, psychosis can come on quickly or slowly. The same is the case in schizophrenia, although symptoms may have a slow onset and begin with milder psychosis, some people may experience a rapid transition back to psychosis if they stop taking their medication.
The milder, initial symptoms of psychosis might include:
Feelings of suspicion
Hallucinations can affect any of the senses (sight, sound, smell, taste, and touch) in the person with psychosis, but in about two-thirds of patients with schizophrenia, hallucinations are auditory – hearing things and believing them to be real when they do not exist.
The following auditory hallucinations are common:
Hearing several voices talking, often negatively, about the patient
A voice giving a commentary on what the patient is doing
A voice repeating what the patient is thinking
Bizarre delusions during psychosis
Examples of psychotic delusions include the paranoid type – more likely to be associated with schizophrenia – and delusions of grandeur.
Paranoid delusions – these may cause the person with psychosis to be unduly suspicious of individuals or organizations, believing them to be plotting to cause them harm.
Delusions of grandeur – clearly false but strongly held belief in having a special power or authority – for instance, they may believe that they are a world leader.
Complications of Psychosis
Someone experiencing a psychotic episode may self-harm. Suicidal thoughts and an increased risk of suicide are also common.
Self-harming behavior is a relatively common complication in people with psychosis. A study found 1 in 10 people with psychosis also had a history of self-harm.
The risk of self-harm is thought to be highest in people who are experiencing their first episode of psychosis but aren’t receiving treatment.
If you think a friend or relative is self-harming, lookout for signs of unexplained cuts, bruises or cigarette burns, usually on the wrists, arms, thighs, and chest. People who self-harm may keep themselves covered up at all times, even in hot weather.
A person who’s self-harming may feel deep shame and guilt, or they may feel confused and worried about their own behavior. It’s important to approach them with care and understanding.
They may not want to discuss their self-harming behavior with you, but you could suggest they speak to their GP or a counselor on a support helpline.
People with psychosis also have an increased risk of suicide. It’s estimated 1 in 5 people with psychosis will attempt suicide at some point in their life, and 1 in 25 people with psychosis will kill themselves.
Using antipsychotics on a medium- to long-term basis can cause a number of complications. Some of the more common complications are discussed below.
Weight gain is a complication of many commonly used antipsychotics. There are two main reasons why weight gain is thought to occur.
Lead to an increase in appetite
Make you less active
Metabolic syndrome is a term describing a number of related conditions linked to weight gain, such as:
High blood sugar (hyperglycemia)
High blood pressure (hypertension)
These health conditions can also increase your risk of developing type 2 diabetes, heart disease and, most seriously, heart attack or stroke.
Tardive dyskinesia (TD)
Tardive dyskinesia (TD) is another common complication of long-term antipsychotic use.
TD is a movement disorder where a person experiences involuntary movements, such as twitching, tics, grimaces, tremors, and spasms. It usually starts in the face and mouth before spreading to the rest of the body.
In some cases, stop taking an antipsychotic will provide relief from TD symptoms, but in other cases, it makes the symptoms worse.
Diagnosis and Examination of Psychosis
You should visit your GP if you’re experiencing symptoms of psychosis.
It’s important to speak to your GP as soon as possible because earlier treatment can be more effective.
There’s no test to positively diagnose psychosis. However, your GP will ask about your symptoms and possible causes.
For example, they may ask you:
Whether you’re taking any medication
Whether you’ve been taking illegal substances
How your moods have been – for example, whether you’ve been depressed
How you’ve been functioning day-to-day – for example, whether you’re still working
Whether you have a family history of mental health conditions, such as schizophrenia
About the details of your hallucinations, such as whether you’ve heard voices
About the details of your delusions, such as whether you feel people are controlling you
About any other symptoms you have
Treatment and Medication for Psychosis
It’s important to get treated early, after the first episode of psychosis. That will help keep the symptoms from affecting your relationships, work, or school. It may also help you avoid more problems down the road.
You doctor may recommend coordinated specialty care (CSC). This is a team approach to treating schizophrenia when the first symptoms appear. It combines medicine and therapy with social services and work and education support. The family is involved as much as possible.
What your doctor recommends will depend on the cause of your psychosis.
Your doctor will prescribe antipsychotic drugs — in pills, liquids, or shots — to ease your symptoms. They’ll also suggest you avoid using drugs and alcohol.
You might need to get treated in a hospital if you’re at risk of harming yourself or others, or if you can’t control your behavior or do your daily activities. The doctor will check your symptoms, look for causes, and suggest the best treatment for you.
Some clinics and programs offer help just for young people.
Counseling, along with medicines, can also help manage psychosis.
Cognitive-behavioral therapy (CBT) can help you recognize when you have psychotic episodes. It also helps you figure out whether what you see and hear is real or imagined. This kind of therapy also stresses the importance of antipsychotic medications and sticking with your treatment.
Supportive psychotherapy helps you learn to live with and manage psychosis. It also teaches healthy ways of thinking.
Cognitive enhancement therapy (CET) uses computer exercises and group work to help you think and understand better.
Family psychoeducation and support involves your loved ones. It helps you bond and improves the way you solve problems together.
Coordinated specialty care (CSC) creates a team approach in treating psychosis when it’s first diagnosed. CSC combines medication and psychotherapy with social services and work and education support.
When you are living with a mental health condition, learning about managing your mental health and finding the support you need will help you reach your recovery goals. You can do many things to improve your ability to manage symptoms and cope with psychosis.
Get help early. Reach out for help to locate the best treatment possible. If you’re a teenager or young adult, the most effective treatment for early or first-episode psychosis is Coordinated Specialty Care (CSC). These programs are available in a growing number of areas. CSC focuses on you and your unique needs using a team-based approach that works.
Manage stress. Stress is a natural reaction for most people when they experience psychosis. The first episode of psychosis, when you’re learning about the initial evaluation, diagnosis and treatment choices, can be a stressful, overwhelming and confusing time. Managing or reducing stress can greatly improve your symptoms and well-being. Here are some tips for reducing stress:
Learn about psychosis. Ask questions and learn about what you’re experiencing. The more you know about psychosis, the less worried or anxious you may be.
Adjust your expectations. Know your limits, at home, work or school. Don’t take on more than you can handle and take time to yourself if you’re feeling overwhelmed.
Find balance. Don’t push yourself too hard. If you’ve recently experienced an episode of psychosis, you may need to adjust your schedule or lifestyle. Working or going to school part-time keeps you engaged in your own life but allows time for you to focus on recovery and take time for yourself.
Make time for fun. Make time for hobbies, recreation, and regular exercise.
Avoid alcohol and drugs. Substance abuse affects the benefits of medication and worsens symptoms. If you have a substance abuse problem, seek help.
Maintain connections. Having friends and family involved in your treatment plan can go a long way toward recovery. People experiencing psychosis often have a difficult time in social situations, so surround yourself with people who understand.
How to prevent Psychosis?
Preventing psychosis involves getting good treatment and the following factors
Controlling triggers for psychosis
Certain things like stress or use of street drugs can increase the risk of psychosis – these are triggers for psychosis. Some of the more common triggers for psychosis include:
Problems with family or friends
Problems at work or school
Drug or alcohol use
Once you know what your triggers are, you can start to plan to control these. You might want to try to limit your use of street drugs. Or you might problem-solve with your EPI Clinician about difficulties you are having getting along with friends or family.
Recognizing early warning signs of psychosis
Many people experience changes in behavior, thoughts or feelings before symptoms of psychosis appear. These are often called “early warning signs” – signals that something is not right.
Common early warning signs:
Sleeping too much or too little
Finding it difficult to concentrate
Feeling more sensitive to sounds, lights or colors
Missing work or school
Feeling high or “excited”
Talking more or less than usual
Not enjoying hobbies
Becoming easily annoyed at others
Not showering or taking care of yourself
Feeling suspicious of other people
Not wanting to go out or spend time with family or friends
Knowing what early warning signs you had before developing psychosis will help you know what to look for. The same changes may signal any future relapses.
Preventing psychosis from coming back
There are many different things you can include in your relapse prevention plan.
Contact people who can support you
EPI Clinician or Psychiatrist
Identify ways you can cope
Reducing your responsibilities
Engaging in calming or enjoyable activities
Medication strategies (pre-arranged with your Psychiatrist)
Hypertensive heart disease is characterized by a firmly continuous high blood pressure in which the force of blood against the artery walls is too high. Continuous hypertension causes structural and functional abnormalities of the heart. This can also cause damage to the ventricular and arterial myocardium as well as the epicardium and intramural coronary arteries. As a result, other heart diseases can occur like myocardial ischemia, arterial fibrillation, and congestive heart failure.
Epidemiology of Hypertensive Heart Disease
Hypertension or high blood pressure affects at least 4 billion people worldwide. Hypertensive heart disease is only one of several diseases attributable to high blood pressure. Other diseases caused by high blood pressure include ischemic heart disease, stroke, peripheral arterial disease, aneurysms, and kidney disease.
Hypertension increases the risk of heart failure by two or three-folds and probably accounts for about 25% of all cases of heart failure. In addition, hypertension precedes heart failure in 90% of cases, and the majority of heart failure in the elderly may be attributable to hypertension.
Hypertensive heart disease was estimated to be responsible for 1.0 million deaths worldwide in 2004 (or approximately 1.7% of all deaths globally) and was ranked 13th in the leading global causes of death for all ages.
Types of Hypertensive Heart Disease
Coronary Heart Disease (CHD):
Coronary heart disease (CHD) in general, the heart problems caused due to high blood pressure are related to the heart’s arteries and muscles. It is called coronary artery disease. It can put you at risk for a heart attack from a blood clot that gets stuck in one of the narrowed arteries and cuts off blood flow to your heart.
Left Ventricular Hypertrophy (LVH):
High blood pressure makes pumping of blood to heart difficult. Like other muscles in your body, regular hard work causes your heart muscles to thicken and grow and this alters the way, the heart functions. The main pumping functions in the chamber of the heart happen usually by changing, the left ventricle. This condition is known as left ventricular hypertrophy (LVH).
CHD can cause LVH and they are directly proportional to each other. When you have CHD, your heart must work harder. If LVH enlarges your heart, it compacts the coronary arteries.
Risk factors of Hypertensive Heart Disease
Some of the risk factors that are
Male sex; it is said that eostrogen produced in women confers a beneficial effect on them. However, he is lost after menopause or in DM.
Positive family history
What causes Hypertensive Heart Disease?
High blood pressure means the pressure inside the blood vessels (called arteries) is too high. As the heart pumps against this pressure, it must work harder. Over time, this causes the heart muscle to thicken.
Because there are often no symptoms with high blood pressure, people can have a problem without knowing it. Symptoms most often do not occur until after many years of poor blood pressure control, when damage to the heart has occurred.
Without treatment of high blood pressure, symptoms of heart failure may develop. Sometimes, the muscle can be so thick that it does not get enough oxygen. This can cause angina (chest pain).
High blood pressure also leads to thickening of the blood vessel walls. When combined with cholesterol deposits in the blood vessels, the risk of heart attack and stroke increases.
Hypertensive heart disease is the leading cause of illness and death from high blood pressure.
How do we know if Hypertensive Heart Disease arise?
There are a few symptoms of hypertensive heart disease such as :
Leg or ankle swelling
Pain in the neck, shoulder, back, and arm
Loss of appetite
Tightness or pressure in the chest
Bloating and abdominal pain
Both CHD and LVH can lead to:
Heart failure: your heart is unable to pump enough blood to the rest of your body
Arrhythmia: your heart beats abnormally
Ischemic heart disease: your heart doesn’t get enough oxygen
Heart attack: blood flow to the heart is interrupted and the heart muscle dies from lack of oxygen
Sudden cardiac arrest: your heart suddenly stops working, you stop breathing, and you lose consciousness
Stroke and sudden death
Diagnosis and test
To begin with, the treating physician will take a detailed history to include family history and social history. The physician will then conduct a physical examination to check the blood pressure and if found chronically hypertensive then the following tests will be conducted:
Electrocardiogram: This test shows the heartbeat in the form of electrical impulses. This test can show whether there is any abnormality in the rhythm of the heart and whether the heart is functioning normally.
Echocardiogram: This test makes use of ultrasound waves to look at the functioning of the heart. This test can accurately identify any abnormality of the functioning of the heart.
Chest X-ray: This can reveal whether there is any enlargement of the heart or not which can rule in or rule out cardiomegaly as a cause of the heart murmur. Apart from these tests a CT scan or an MRI will also be obtained which can accurately detect the presence of a cardiac problem.
Coronary Angiography: This test checks the blood flow to and from the heart examines. Any abnormality in flow of blood in the heart can be confirmed through this test.
Treadmill Stress Test: This test is conducted to find out the exercise tolerance of the patient and how much distance the patient can cover on the treadmill before the patient starts having symptoms. This is quite helpful in confirming the diagnosis and formulating a treatment plan.
Treatment and medications
Treatment of heart disease of involves a mix of lifestyle changes and medications. It all depends on what sort of condition the victim is in and the individual problems that are occurring. Some of the medications prescribed are:
Angiotensin-converting enzyme (ACE) inhibitors
Calcium channel blockers
Angiotensin II receptor antagonists
If the symptoms of heart disease are bad enough, the doctor may want to do corrective surgery. This could be surgeries such as a coronary bypass, repair of the heart valves, or surgeries to repair damaged or malformed blood vessels.
Diagnosing high blood pressure early can help prevent heart disease, stroke, eye problems, and chronic kidney disease.
All adults over the age of 18 should have their blood pressure checked every year. More frequent measurement may be needed for those with a history of high blood pressure readings or those with risk factors for high blood pressure.
Guidelines can change as new information becomes available, Therefore, your health care provider may recommend more frequent screenings based on your blood pressure levels and other health conditions.
If your blood pressure is high, you need to lower it and keep it under control.
Do not stop or change high blood pressure medicines without talking to your provider.
Acoustic Neuroma is also known as vestibular schwannoma. An acoustic neuroma is a benign tumor that develops when the specialized (Schwann) cells surrounding the vestibular division of the auditory nerve, grow at an abnormal rate in the internal auditory canal. The tumor if left untreated, can grow into the auditory canal and all the way through to the brain.
Acoustic neuromas generally grow slowly, so symptoms develop gradually. The main ones – dizziness, hearing loss and ringing in the ears (tinnitus) – are due to the effects of the tumor pressing on the auditory nerve. If the tumor grows large enough, it also may press on the nearby facial nerve and cause facial paralysis or tingling. Although the tumors are not cancerous, they can become life-threatening if they grow so large that they press on brain structures that control vital body functions.
People with a hereditary disease called neurofibromatosis have a higher risk of developing acoustic neuromas and can develop tumors on both sides of the head.
Types of Acoustic Neuroma
There are two main types of acoustic neuroma:
A tumor affects only one ear. This variant is by far the more common, accounting for 95% of all instances of acoustic neuroma. It is also known as the ‘sporadic’ type and the causes behind its appearance are not well understood.
Tumors arise on both sides affecting both ears. Acoustic neuroma of this kind accounts for only 5% of reported cases, is clearly linked with a rare genetic disorder known as neurofibromatosis type II (NF2).
Pathophysiology of acoustic neuroma
As the acoustic neuroma grows, it compresses the hearing and balance nerves, usually causing unilateral (one-sided) hearing loss, tinnitus (ringing in the ear), and dizziness or loss of balance. As it grows, it can also interfere with the facial sensation nerve (the trigeminal nerve), causing facial numbness.
It can also exert pressure on nerves controlling the muscles of the face, causing facial weakness or paralysis on the side of the tumor.
Vital life-sustaining functions can be threatened when large tumors cause severe pressure on the brainstem and cerebellum.
What causes acoustic neuroma?
The cause of acoustic neuromas is largely unknown. No environmental factor (such as cell phones or diet) has been scientifically proven to cause these tumors. Acoustic neuromas can be sporadic or caused by an inherited condition called neurofibromatosis type 2 (NF-2). Sporadic tumors occur 95% of the time, while 5% of acoustic neuromas occur with NF-2.
Neurofibromatosis is a rare disease that occurs in two forms. Type 1 causes tumors to grow on nerves throughout the body, especially the skin. Type 2 can cause acoustic neuromas on both the left and right sides, creating the possibility of complete deafness if the tumors grow unchecked. The presence of bilateral acoustic tumors affects the choice of treatment, as hearing preservation is a prime objective.
Who is at risk?
The only known risk factor for acoustic neuroma is having a parent with the genetic disorder neurofibromatosis 2 (NF2). Most of these tumors appear spontaneously. They occur in people with no family history of the disease.
Scientists still don’t understand why some people get these tumors. Some risk factors might include:
A parathyroid neuroma, which is a benign tumor of the thyroid
Exposure to low levels of radiation during childhood
How to find if you have acoustic neuroma?
Signs and symptoms of acoustic neuroma are often subtle and may take many years to develop. They usually arise from the tumor’s effects on the hearing and balance nerves. Pressure from the tumor on adjacent nerves controlling facial muscles and sensation (facial and trigeminal nerves), nearby blood vessels, or brain structures may also cause problems.
As the tumor grows, it may be more likely to cause more noticeable or severe signs and symptoms.
Common signs and symptoms of acoustic neuroma include:
Hearing loss, usually gradual – although in some cases sudden – and occurring on only one side or more pronounced on one side
Ringing (tinnitus) in the affected ear
Unsteadiness, loss of balance
Facial numbness and very rarely, weakness or loss of muscle movement
In rare cases, an acoustic neuroma may grow large enough to compress the brainstem and become life-threatening.
Complications of acoustic neuroma
Several complications can arise, including:
Hearing loss: This may persist even after treatment.
Dizziness and loss of balance: If this occurs, it can make daily activities difficult to do.
Facial palsy: If surgery, or rarely, the tumor itself, affects the facial nerve, which is close to the acoustic nerve, the face may droop on one side, and swallowing and speaking clearly may be difficult. This is facial palsy, also known as Bell’s palsy.
Hydrocephalus: If a large tumor presses against the brainstem, this can affect the flow of fluid between the spinal cord and the brain. If fluid accumulates in the head, it can lead to hydrocephalus.
How is acoustic neuroma (vestibular schwannoma) diagnosed?
Because symptoms of these tumors resemble other middle and inner ear conditions, they may be difficult to diagnose. Preliminary diagnostic procedures include ear examination and hearing test. Computerized tomography (CT) and magnetic resonance imaging (MRI) scans help to determine the location and size of the tumor. Early diagnosis offers the best opportunity for successful treatment.
A hearing test (audiometry): A test of hearing function, which measures how well the patient hears sounds and speech, is usually the first test performed to diagnose acoustic neuroma. The patient listens to sounds and speech while wearing earphones attached to a machine that records responses and measures hearing function. The audiogram may show increased “pure tone average” (PTA), increased “speech reception threshold” (SRT) and decreased “speech discrimination” (SD).
Brainstem auditory evoked response (BAER): This test is performed in some patients to provide information on brain wave activity as a response to clicks or tones. The patient listens to these sounds while wearing electrodes on the scalp and earlobes and earphones. The electrodes pick up and record the brain’s response to these sounds.
Scans of the head: If other tests show that the patient may have an acoustic neuroma, magnetic resonance imaging (MRI) is used to confirm the diagnosis. MRI uses magnetic fields and radio waves, rather than x-rays, and computers to create detailed pictures of the brain. It shows visual “slices” of the brain that can be combined to create a three-dimensional picture of the tumor. A contrast dye is injected into the patient. If an acoustic neuroma is present, the tumor will soak up more dye than normal brain tissue and appear clearly on the scan. The MRI commonly shows a densely “enhancing” (bright) tumor in the internal auditory canal.
Acoustic Neuroma Treatments
There are three main courses of treatment for acoustic neuroma:
Observation is also called watchful waiting. Because acoustic neuromas are not cancerous and grow slowly, immediate treatment may not be necessary. Often doctors monitor the tumor with periodic MRI scans and will suggest other treatment if the tumor grows a lot or causes serious symptoms.
Surgery for acoustic neuromas may involve removing all or part of the tumor.
There are three main surgical approaches for removing an acoustic neuroma:
Translabyrinthine, which involves making an incision behind the ear and removing the bone behind the ear and some of the middle ear. This procedure is used for tumors larger than 3 centimeters. The upside of this approach is that it allows the surgeon to see an important cranial nerve (the facial nerve) clearly before removing the tumor. The downside of this technique is that it results in permanent hearing loss.
Retrosigmoid/sub-occipital, which involves exposing the back of the tumor by opening the skull near the back of the head. This approach can be used for removing tumors of any size and offers the possibility of preserving hearing.
Middle fossa, which involves removing a small piece of bone above the ear canal to access and remove small tumors confined to the internal auditory canal, the narrow passageway from the brain to the middle and inner ear. Using this approach may enable surgeons to preserve a patient’s hearing.
Radiation therapy is recommended in some cases for acoustic neuromas. State-of-the-art delivery techniques make it possible to send high doses of radiation to the tumor while limiting expose and damage to surrounding tissue.
Radiation therapy for this condition is usually delivered in one of two ways:
Single fraction stereotactic radiosurgery (SRS), in which many hundreds of small beams of radiation are aimed at the tumor in a single session.
Multi-session fractionated stereotactic radiotherapy (FRS), which delivers smaller doses of radiation daily, generally over several weeks. Early studies suggest multi-session therapy may preserve hearing better than SRS.
Both of these are outpatient procedures, which means they don’t require a hospital stay. They work by causing tumor cells to die. The tumor’s growth may slow or stop or it may even shrink, but radiation doesn’t completely remove the tumor.
Early diagnosis of a vestibular schwannoma is key to preventing its serious consequences.
Peripheral Neuropathy also called peripheral neuropathy refers to any condition that affects the normal activity of the nerves of the peripheral nervous system. The peripheral nervous system is the network of nerves that connects the central nervous system the brain and spinal cord to the rest of the body.
The peripheral nervous system is made up of 3 types of nerves, each with an important role to play in keeping your body healthy and functioning properly.
Sensory nerves carry messages from your senses through your spinal cord to your brain. For example, they tell your brain you are touching something hot.
Motor nerves travel in the opposite direction. They carry messages from the brain to your muscles. They tell your muscles to move you away from the hot surface.
Autonomic nerves are responsible for controlling body functions that occur outside our control, such as breathing, digestion, heart rate, and blood pressure.
Neuropathy results when nerve cells, or neurons, are damaged or destroyed. This distorts the way the neurons communicate with each other and with the brain. Neuropathy can affect 1 nerve or nerve type, or a combination of nerves.
Types of peripheral neuropathy
Classified on the basis of the onset of the disease there is:
Acute peripheral neuropathy which is a sudden or rapid onset of neuropathy.
Chronic peripheral neuropathy develops more gradually and persists for a longer time.
Classified on the basis of the number of nerves that are involved there is:
Mononeuropathy when only one nerve or nerve group is damaged.
Polyneuropathy when all the nerves are damaged. This is the most common type of neuropathy. It starts by affecting the longest nerves and so usually the feet are first affected. It then starts spreading to the shorter nerves and gradually affecting the arms.
Peripheral Neuropathy Risk factors
Thirty percent to 40 percent of patients treated with chemotherapy develop some degree of peripheral neuropathy. Doctors cannot predict who will develop peripheral neuropathy, but some things make you more likely to develop it:
Having had chemotherapy, radiation, or surgery before
Needing a high dose or long course of treatment
Taking more than 1 drug that can cause neuropathy
Having a history of alcohol abuse
Being a diabetic
Having HIV or AIDS
Having severe malnutrition
Having multiple myeloma, lymphoma, or lung or breast cancer
Having nerve damage from previous injury or illness
In the United States, the most common cause of peripheral neuropathy is diabetes. According to the American Diabetes Association, 60 to 70 percent of people with diabetes will develop neuropathy within their lifetime.
Causes of peripheral neuropathy
Other causes of peripheral neuropathy include:
Certain medications including some chemotherapy drugs.
Heredity: Some people have a family history of peripheral neuropathy.
Advanced age: Peripheral neuropathy is more common as people age.
Arthritis: Certain type of arthritis, especially involving the back, can cause peripheral neuropathy.
Alcoholism: According to the US National Library of Medicine, up to half of all long-term heavy alcohol users develop peripheral neuropathy.
Neurological disorders: Certain neurological disorders, including spina bifida and fibromyalgia, are associated with peripheral neuropathy.
Injury: Acute injury to the peripheral nerves may also cause peripheral neuropathy.
Symptoms of peripheral neuropathy
The symptoms of peripheral neuropathy will depend on the nerve involved and the level of damage sustained. One of the most common symptoms are as follows:
Numbness, tingling, pins, and needles,
Abnormally sensitive skin,
Electric shock pain,
Loss of balance
Neuropathy will generally worsen over time and it can lead to further complications and more pronounced symptoms.
Complications of peripheral neuropathy can include:
Burns and skin trauma: You might not feel temperature changes or pain in parts of your body that are numb.
Infection: Your feet and other areas lacking sensation can become injured without your knowing. Check these areas regularly and treat minor injuries before they become infected, especially if you have diabetes.
Falls: Weakness and loss of sensation may be associated with a lack of balance and falling.
Diagnosis and test
The physician will review the medical history of the patient, including signs & symptoms, lifestyle, drinking habits, exposures to toxins and a family history of the nervous system (neurological) disorder.
Neurological examination: Your specialist may check ligament reflexes, muscle quality and tone, your capacity to feel certain sensations, and stance and coordination.
Blood tests: These can recognize vitamin insufficiencies, diabetes, unusual resistant capacity and different signs of conditions that can cause (Peripheral) fringe neuropathy.
Imaging tests: CT or MRI outputs can search for herniated plates, tumors or different variations or abnormalities.
Nerve function tests: Electromyography records the electrical activity in muscles to recognize nerve harm. A test sends electrical signs to a nerve, and an anode set along the nerve’s pathway records the nerve’s reaction to the signs (nerve conductions studies).
Other nerve function tests: These might incorporate an autonomic reflex screen that records how the autonomic nerve filaments (fibers) function, a sweat test, and sensory tests that record how you feel touch, vibration, cooling, and warmth.
Nerve biopsy: This involves removing a small portion of a nerve, generally a sensory nerve, to look for abnormalities.
Skin biopsy: Removes a small portion of skin to look for a devaluation nerve endings
Treatment and medications
The treatment for peripheral neuropathy depends on its cause. The first step in treatment is, therefore, to look for the cause.
Vitamin deficiencies can be corrected.
Diabetes can be controlled, although control may not reverse the neuropathy. The goal with diabetes is early detection and adequate treatment to prevent the occurrence of neuropathy.
Neuropathies that are associated with immune diseases can improve with treatment of the autoimmune disease.
Neuropathy caused by nerve entrapment can be treated by physical therapy, injections, or surgery.
Prompt treatment with sympathetic injections can minimize the chance of shingles progressing to postherpetic neuralgia.
If a specific treatment isn’t available, the pain of the neuropathy can usually be controlled with medications.
In some cases, over-the-counter pain relievers can help. Other times, prescription medicines are needed. Some of these medicines are:
Mexiletine, a medicine developed to correct irregular heart rhythms
Antiseizure medicines, such as gabapentin, phenytoin, and carbamazepine
Some classes of antidepressants including tricyclics such as amitriptyline
Lidocaine injections and patches may help with pain in other cases. And in extreme cases, surgery can be used to destroy nerves or fix injuries that are causing neuropathic pain and symptoms.
Physical therapy can treat weakness and muscle loss. It can also treat problems with balance. Some people may need splints or braces to help them walk.
Other types of help
If your symptoms are mild, you may not need any additional help in managing them. However, if you have more troublesome symptoms, support is available to help you cope with them.
A physiotherapist can offer treatment and advice if you’re having problems with:
If you’re finding it hard to do daily tasks because of peripheral neuropathy, you can ask to be referred to an occupational therapist. They can assess your needs and recommend appropriate aids and equipment to help you. There are organizations that provide equipment for people who need help with daily tasks
Prevention and management
Take care of your hands and feet. Wear well-fitting protective shoes and keep hands and feet warm.
Be careful when getting into the bath or shower and check the temperature of the water first.
Do regular, gentle exercise to keep your muscles toned and to improve circulation.
Low resistant bed clothing such as silk sheets can be more comfortable.
Eat a well-balanced diet.
Avoid falls by reducing the risks in your own home.
Ask for a referral to an occupational therapist to look at possible assistive devices and assess any risks around your home.
Adopt good posture and avoid sitting with legs crossed for long periods of time.
Transcutaneous electrical nerve stimulation (TENS) machines can sometimes help reduce your level of pain by delivering tiny electrical impulses to specific nerve pathways.
Complementary therapies such as acupuncture, reflexology and gently massage as well as relaxation techniques may all help to relieve some of your symptoms.
Concussion is a brain injury caused by a force transmitted to the head from direct or indirect contact with the head, face, neck, or body. This can cause either a collision between the brain and skull or a strain on the neural tissue and vasculature. When there is trauma to the brain in this way, waves of cellular and molecular changes occur. In our brain, we have axons that are very thin, delicate strands connecting different thought processes and chemicals. When you take a blow to the head these axons are damaged and prevent vital processes from working correctly.
Types of Concussion
Concussions are graded as mild (grade 1), moderate (grade 2), or severe (grade 3), depending on such factors as loss of consciousness, amnesia, and loss of equilibrium.
In a grade 1 concussion, symptoms last for less than 15 minutes. There is no loss of consciousness.
With a grade 2 concussion, there is no loss of consciousness but symptoms last longer than 15 minutes.
In a grade 3 concussion, the person loses consciousness, sometimes just for a few seconds.
A number of different factors associated with a higher risk of experiencing a concussion have been outlined in the literature. These are outlined below.
A higher rate of concussion has been recorded for males in all sports. However, it appears likely that this is a result of the larger number of males participating in the sports investigated. In an evidence-based guideline update by Giza et al in 2013, it was suggested that the association of certain sex with higher rates of concussion varies across different sports, with a higher rate of concussion for females in both soccer and basketball. Other studies have suggested that the higher incidence of concussion noted in females may be a result of greater reporting of concussive symptoms by female athletes and as a result of their smaller head size and neck strength relative to their male counterparts.
Type of Sport
As stated above, the risk of concussion associated with sports varies across different sports. Australian rugby and American football are associated with the highest incidence of concussion, while a lower risk is associated with sports such as baseball, softball, volleyball and gymnastics. Several high quality studies have associated soccer with the greatest concussion risk for female athletes.
The athlete’s playing position can also be associated with higher/lower concussion risk. In American football greater risk has been associated among linebackers, offensive linemen, and defensive backs compared to receivers. Currently there is insufficient evidence to associate player position with greater/lesser concussion risk in other sports.
Several factors specific to the individual athlete have been associated with greater concussion risk, including a body mass index greater than 27 kg/m2. The training time of fewer than 3 hours also weekly likely increases the risk of concussion. Currently, in the literature, there is insufficient evidence to determine links between age and competition level and risk of concussion.
Causes of Concussion
The brain floats in cerebral fluid, which protects it from jolts and bumps. A violent jolt or a severe blow to the head can cause the brain to bump hard against the skull. This can result in the tearing of nerve fibers and the rupturing of blood vessels under the skull, leading to a build-up of blood.
Concussions are most commonly caused by:
Horseback riding accident
Signs and Symptoms
Concussion signs are what someone could observe about you to determine if you have a concussion. Signs of a concussion range from obvious to much more nuanced, but even one sign of a concussion after a hit to the head should be reported to a medical professional.
Common concussion signs include:
Loss of consciousness
Problems with balance
The glazed look in the eyes
Delayed response to questions
Forgetting an instruction, confusion about an assignment or position, or confusion of the game, score, or opponent
The symptoms are what someone who is concussed will tell you that they are experiencing. Concussion symptoms typically fall into four major categories:
Somatic (Physical) Symptoms
Sensitivity to light
Sensitivity to noise
Difficulties with attention
Loss of focus
Difficulty completing mental tasks
Sleeping more than usual
Sleeping less than usual
Having trouble falling asleep
It may take a few days for concussion symptoms to appear after the initial injury.
Side effects of a concussion cause changes in how the brain functions, such as reduced reaction time. This can increase your chance of getting another concussion if you return to play before seeking treatment.
Repeated concussions can cause problems such as lasting cognitive issues.
No athlete should return to the game until all symptoms are gone and a doctor has cleared him or her to play.
Diagnosis and test
Diagnosing a concussion can be tricky. Although any degree of head trauma can cause one, the most common concussions that result from mild head injuries do not involve identifiable bleeding or bruising in the brain.
This means that using a brain scan technique such as magnetic resonance imaging (MRI) or computed tomographies (CT), which are done to diagnose a severe traumatic brain injury (TBI), isn’t a viable way to diagnose a concussion.
Since brain scans can identify bruising or bleeding in the brain, but not the cellular damage thought to cause concussion symptoms, doctors must rely on a careful assessment of symptoms and neuropsychological function.
Sometimes this is done on-site, immediately after an injury, when an athlete experiences a blow or jolt to the head and a decision must be made quickly about whether he or she can safely get back into the game.
The main treatment is rest. Your doctor may tell you to take time off from work or school. Over time, the symptoms will go away as your brain heals.
Symptoms typically last about 6 to 10 days, depending on how severe the concussion is. Most people get better within a week. People with symptoms that last more than one week should see their doctor.
General advice for treating a concussion includes the following:
Get plenty of sleep at night and rest during the day.
Avoid visual and sensory stimuli, including video games and loud music.
Eat well-balanced meals.
Ease into normal activities slowly, not all at once.
Ask your doctor’s opinion about when to return to work or school.
Make sure to let employers or teachers know that you had a concussion.
Avoid strenuous physical or mental tasks.
Avoid activities that could lead to another concussion, such as sports, certain amusement park rides, or (for children) playground activities.
Get your doctor’s permission before driving, operating machinery, or riding a bike (since a concussion can slow one’s reflexes).
If necessary, ask your employer if it is possible to return to work gradually (for example, starting with half-days at first). Students may need to spend fewer hours at school, have frequent rest periods, or more time to complete tests.
Take only those drugs approved by your doctor.
Do not drink alcohol without your doctor’s okay. Alcohol and other drugs may slow recovery and increase the chance of further injury.
For some people, an airplane flight shortly after a concussion can make symptoms worse.
Avoid tiring activities such as heavy cleaning, exercising, working on the computer, or playing video games.
See your doctor again for testing before you resume your routines, including driving, sports, and play.
Reduce your chances of getting a concussion:
Wear a seat belt every time you drive or ride in a car or other motor vehicle.
Never drive when you are under the influence of drugs or alcohol.
Make your home safer to prevent falls.
Wear a helmet for any activity that can cause a fall or impact to the head or neck. Examples include bike riding, football, baseball, hockey, ATV riding, skateboarding, skiing, snowboarding, inline skating, and horseback riding. Helmets help protect your skull from injury. But brain damage can occur even when a helmet is worn.
Reduce your child’s chances of getting a concussion:
Use child car seats and booster seats correctly.
Teach your child bicycle safety.
Teach your child how to be safe around streets and cars.
Keep your child safe from falls.
Teach your child playground safety.
Help your child prevent injury from sports and other activities.
Hirsutism is excessive hair growth in certain areas of a woman’s face and body, such as the mustache and beard area, that creates a “male pattern” of hair. Women normally can have fine, pale, faintly visible hair in these areas, but heavy hair growth in a male pattern with coarse or colored hair is not expected.
Normal patterns of hair growth and hair distribution vary widely, determined mostly by racial background. For example, whites as a group have more facial and non-scalp hair growth than do blacks or Asians, and white women of Mediterranean heritage normally have more hair growth than do women from Nordic countries.
Hirsutism in women means that hair follicles are being over-stimulated by testosterone or other androgen hormones. Androgens are the dominant sex hormones in men. Women normally have low levels of androgens. Hirsutism can be caused by abnormally high levels of androgens or abnormal stimulation of hair follicles even when androgen levels are normal.
Pathophysiology of hirsutism
Hormones and the intrinsic characteristics of the hair follicle determine the quality of hair growth. Vellus hairs are fine, lightly pigmented hairs that cover most of the body before puberty. Pubertal androgens promote the conversion of these vellus hairs to coarser, pigmented terminal hairs. The level and duration of exposure to androgens, the local 5-alpha-reductase activity, and the intrinsic sensitivity of the hair follicle to androgen action determine the extent of conversion from vellus to terminal hair. However, some terminal hair growth is androgen-independent (eg, scalp, eyebrows, lashes).
The development of terminal hair or reversion back to a vellus pattern may not be immediately evident because of the characteristics of the hair cycle. This cycle has 2 phases that include active hair growth (anagen phase) and a resting period (telogen phase), which follows the anagen phase. During the resting period, the hair shaft separates from the dermal papillae at the follicle base, and no further growth takes place. Eventually, growth restarts and the new hair shaft formed by the reactivated papillae pushes the old hair out. The cycle may take months to years to complete, and this causes a delay in hair growth response to changes in the androgen milieu.
Dihydrotestosterone is the androgen that acts on the hair follicle to produce terminal hair. This hormone is derived from both the bloodstream and local conversion of a precursor, testosterone. The local production of dihydrotestosterone is determined by 5-alpha-reductase activity in the skin. Differences in the activity of this enzyme may explain why women with the same plasma levels of testosterone can have different degrees of hirsutism.
What causes hirsutism?
In many cases, the exact cause of hirsutism is not known. However, there are several conditions that are known to cause hirsutism. These conditions include:
The natural production of male hormones (androgens). Women naturally produce androgen, however, if a woman’s androgen levels are higher than normal, or if her hair follicles are more sensitive to androgens, she may develop hirsutism.
Polycystic ovarian syndrome (PCOS) is a common hormonal condition that causes a woman to produce too many androgens. Women with PCOS may also have acne, irregular or absent menstrual periods, diabetes, weight gain, and/or problems with fertility.
The hormonal changes of menopause may lead to increased facial hair (mustache and whiskers).
Other more serious conditions. Hirsutism that occurs suddenly along with other male characteristics, such as a deeper voice, acne or increased muscle mass, may be caused by a more serious condition, such as disorders of the adrenal glands or ovaries.
Medications. The following medications can cause hirsutism:
Minoxidil (Loniten®, Rogaine®)
Several factors can influence your likelihood of developing hirsutism, including:
Family history. Several conditions that cause hirsutism, including congenital adrenal hyperplasia and polycystic ovary syndrome, run in families.
Women of Mediterranean, Middle Eastern and South Asian ancestry are more likely to have more body hair with no identifiable cause than are other women.
Being obese causes increased androgen production, which can worsen hirsutism.
Hirsutism is stiff or dark body hair, appearing on the body where women don’t commonly have hair – primarily the face, chest, lower abdomen, inner thighs and back. People have widely varying opinions on what’s considered excessive.
When high androgen levels cause hirsutism, other signs might develop over time, a process called virilization. Signs of virilization might include:
Decreased breast size
Increased muscle mass
Enlargement of the clitoris
Hirsutism may have a detrimental impact on a woman’s body image.
Facial hirsutism may cause considerable emotional distress and social embarrassment to women; hirsutism exceeding culturally normal levels can be very distressing.
Hirsutism is commonly associated with lower quality of life and symptoms of anxiety and depression
Diagnosis and test
A physician will look at the medical history with a special focus on the menstrual cycle. If the individual has a regular pattern of menstrual periods, the hirsutism is likely to have a genetic or inherited cause.
If menstruation has always been irregular, the cause could be polycystic ovary syndrome (PCOS).
If both the hirsutism and menstrual irregularity have onset recently, and if the woman is missing periods, the healthcare professional may carry out tests for a condition that could be more serious, such as a tumor of the ovaries, adrenal glands, or pituitary gland.
By measuring levels of testosterone and DHEA in the blood, a doctor can check for signs of PCOS, ovarian tumors, adrenal gland tumors, or tumors that can stimulate the adrenal glands.
In cases of mild hirsutism, in which no other symptoms suggesting overproduction of androgen hormones, further testing may not be necessary.
If more testing is necessary, several blood tests are available to test for deficiencies in the adrenal gland hormones. This can cause overgrowth of the adrenal glands.
Blood tests include tests for hormones like:
TSH (thyroid-stimulating hormone)
Testosterone (to determine if higher androgen levels is the cause)
The following might also help to identify tumors or physical irregularities that could have led to hirsutism:
MRI scans of the brain
CT scan of the adrenal glands
An ultrasound of the ovaries
If you have more facial or body hair than you want, there are a number of ways you can remove it.
Weight loss. If you’re overweight and drop pounds, your body should make fewer male hormones, so you should grow less hair on your face or body.
Shaving. You can remove unwanted hair easily with a razor or electric shaver. You may need to shave daily to avoid stubble growth. Some people get razor burn from shaving too often, but a soothing cream may help.
Tweezing or threading. There are different ways to pluck hair out at the root. You can use tweezers. Or you can hire someone to “thread” — use a long, tight strand to loop around and remove each unwanted hair. These methods can cause pain and redness.
Waxing. A quick way to remove lots of unwanted hair by the root is with melted wax. Often you get this done in a salon. Wax is applied to the skin, then removed quickly. It can cause pain and redness.
Creams. Some creams have strong chemicals called depilatories. You apply the cream, let it sit for a while, and when you wipe it off, the hair goes with it. They can irritate sensitive skin, so test a small spot before you use one on a large area.
Electrolysis. You can remove hair for good with electrolysis, a pricey service that zaps hair at the root with an electric current. After you repeat the process a few times, hair should stop growing in treated areas.
Laser Hair Removal. The heat from lasers can remove hair, but you need to repeat the process a few times, and it sometimes grows back. The treatment targets hair at the root, so it’s painful and could damage or scar your skin.
Medication. Doctors can prescribe drugs that change the way your body grows hair. When you stop using the medication, hair will grow back, though.
Birth control pills make the body produce fewer male hormones. With regular use, you should have less hair on your face or body.
Anti-androgen blockers help your body make and use fewer male hormones, so you should grow less hair over time.
Vaniqa (eflornithine) is a face cream that slows hair growth where you apply it.
Hirsutism can be prevented with measures such as losing weight if you are overweight, as this can reduce androgen production. Also, if you have polycystic ovary syndrome, controlling obesity may reduce hirsutism.
In some cases, hirsutism may be prevented by not taking a medicine that can cause excess hair growth.
Reduce your calorie intake, especially during the evening. Distribute your calorie intake into 5-6 small meals with the breakfast being the heaviest. This will keep your weight under control and reduce the chances of obesity and hirsutism.
Eat foods with a low glycemic index which do not increase blood glucose levels sharply such as non-starchy vegetables, legumes and fruits. Include enough amounts of protein in your diet. Keep control on your daily intake of fats, but don’t eliminate all fats especially essential fatty acids.
Glycyrrhizin from licorice has been found to reduce plasma testosterone levels and may be useful in hirsutism patients. However, excess use does have its side effects.
Increase your intake of vitamin B, especially B2, B3, B5 and B6. The trace minerals chromium and magnesium reduce glucose resistance and will be useful.