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How to prevent another stroke?

Dr. Carlo Oller

— If you had an ischemic stroke – a stroke caused by a blocked artery in the brain – medicines and lifestyle changes can help to lower the chances of having another stroke. If you had a transient ischemic attack or “TIA,” these same things can help prevent a full-blown stroke.

Medicines and lifestyle changes work together to give the most benefit. It’s very important that you take all the medicines your doctor prescribes. It’s just as important to make the lifestyle changes your doctor recommends.

Medicines — If you had a stroke or TIA, your doctor or nurse will prescribe medicines to lower your risk of having another stroke. Some of these medicines work by “lowering your risk factors.” That means that they help lower blood pressure, blood sugar and cholesterol. Other medicines help by keeping blood clots from forming. (Blood clots cause many strokes.)

Medicines that are especially important in preventing strokes include:

●Medicines to lower blood pressure

●Medicines called statins, which lower cholesterol

●Medicines to prevent blood clots, such aspirin or blood thinners

●Medicines that help to keep your blood sugar as close to normal as possible (if you have diabetes)

Whatever medicines your doctor prescribes, make sure you take them every day as directed. If you cannot afford your medicines or if they cause side effects, talk to your doctor or nurse. There are often ways to deal with these problems.

Lifestyle changes 

— Lifestyle changes can do a lot to lower your risk of stroke. That’s partly because the right lifestyle choices can help control risk factors such as blood pressure, blood sugar, and cholesterol. Besides, the lifestyle changes that help lower your risk of stroke can also help prevent lots of other health problems.

Here are the most important lifestyle changes:

●Stop smoking, if you smoke

●Get regular exercise (if your doctor says it’s safe) for at least 30 minutes a day on most days of the week

●Lose weight, if you are overweight

●Eat a “Mediterranean” diet rich in fruits, vegetables, and low-fat dairy products, and low in meats, sweets, and refined grains (such as white bread or white rice)

●Eat less salt (sodium)

●Limit the amount of alcohol you drink

•If you are a woman, do not drink more than 1 drink a day

•If you are a man, do not drink more than 1 to 2 drinks a day

Help with quitting smoking — If you smoke, ask your doctor or nurse about how to quit. There are strategies and medicines that can improve your chances of success. Studies show that people are most successful at quitting if they take medicines to help them quit and work with a counselor. You might also have a better chance at success if you combine nicotine replacement with one of the prescription medicines that help people quit.

You can also get help from a free phone line (1-800-QUIT-NOW) or online at www.smokefree.gov.

  • Dr. Carlo Oller (emergency physician with www.DrER.tv) has put together more than 1800 FREE patient education videos which can be found at www.patienteducation.video
  • Please contact Dr. Carlo Oller at carlooller@gmail.com if you would like to use his videos in your own website, or educational materials. Or if you would like some more information or education on a title NOT available at this time.

Stroke

— Stroke is the term doctors use when a part of the brain is damaged because of a problem with blood flow. Strokes can happen when:

●An artery going to the brain gets clogged or closes off, and part of the brain goes without blood for too long

●An artery breaks open and starts bleeding into or around the brain

How do strokes affect people? 

— The effects of a stroke depend on a lot of things, including:

●Which part and how much of the brain is affected

●How quickly the stroke is treated

Some people who have a stroke have no lasting effects. Others lose important brain functions. For example, some people become partly paralyzed or unable to speak. Stroke is one of the leading causes of death and disability in the world.

How can you tell if someone is having a stroke? — There is an easy way to remember the signs of a stroke. Just think of the word “FAST”. Each letter in the word stands for one of the things you should watch for:

Face – Does the person’s face look uneven or droop on one side?

Arm – Does the person have weakness or numbness in one or both arms? Does one arm drift down if the person tries to hold both arms out?

Speech – Is the person having trouble speaking? Does his or her speech sound strange?

Time – If you notice any of these stroke signs, call for an ambulance (in the US and Canada, dial 9-1-1). You need to act FAST. The sooner treatment begins, the better the chances of recovery.

How are strokes treated?

 — The right treatment depends on what kind of stroke you are having. You need to get to the hospital very quickly to figure this out.

People whose strokes are caused by clogged arteries can:

●Get treatments that help reopen clogged arteries. These treatments can help you recover from the stroke.

●Get medicines that prevent new blood clots. These medicines also help prevent future strokes.

People whose strokes are caused by bleeding can:

●Have treatments that might reduce the damage caused by bleeding in or around the brain

●Stop taking medicines that increase bleeding, or take a lower dose

●Have surgery to repair the artery or stop the bleeding (this is not always possible to do)

Can strokes be prevented? 

— Many strokes can be prevented, though not all. You can greatly lower your chance of having a stroke by:

●Taking your medicines exactly as directed. Medicines that are especially important in preventing strokes include:

•Blood pressure medicines

•Medicines called statins, which lower cholesterol

•Medicines to prevent blood clots, such aspirin or blood thinners

•Medicines that help to keep your blood sugar as close to normal as possible (if you have diabetes)

●Making lifestyle changes:

•Stop smoking, if you smoke

•Get regular exercise (if your doctor says it’s safe) for at least 30 minutes a day on most days of the week

•Lose weight, if you are overweight

•Eat a diet rich in fruits, vegetables, and low-fat dairy products, and low in meats, sweets, and refined grains (such as white bread or white rice)

•Eat less salt (sodium)

•Limit the amount of alcohol you drink

-If you are a woman, do not drink more than 1 drink a day

-If you are a man, do not drink more than 2 drinks a day

Another way to prevent strokes is to have surgery to reopen clogged arteries in the neck. This surgery is appropriate for only a small group of people.

What is a “TIA”? 

— A TIA is like a stroke, but it does not damage the brain. TIAs happen when an artery in the brain gets clogged or closes off and then reopens on its own. This can happen if a blood clot forms and then moves away or dissolves. TIA stands for “transient ischemic attack.”

Even though TIAs do not cause lasting symptoms, they are serious. If you have a TIA, you are at high risk of having a stroke. It’s important that you see a doctor and take steps to prevent that from happening. Do not ignore the symptoms of a stroke even if they go away!

How to prevent strokes? (lick here for more information)

  • Dr. Carlo Oller (emergency physician with www.DrER.tv) has put together more than 1800 FREE patient education videos which can be found at www.patienteducation.video
  • Please contact Dr. Carlo Oller at carlooller@gmail.com if you would like to use his videos in your own website, or educational materials. Or if you would like some more information or education on a title NOT available at this time.

Tuberculosis

Tuberculosis (TB) is a disease caused by the bacteria Mycobacterium tuberculosis. It most commonly affects the lungs, although it can affect other parts of the body. Medications are available to treat TB and must be taken as prescribed by your provider. Depending on the medication(s) prescribed, the duration can be from four months to nine months or more.

Worldwide, TB remains a leading cause of death. In the United States, TB is on the decline. In 2016, more than 9200 new TB cases were reported in the United States, with cases reported from every state. This is the lowest number of national cases since TB became a reportable disease in the 1950s.

TB can be fatal if not recognized and treated. It also can spread from person to person to infect others. However, TB is treatable and preventable. Identifying and treating those who are infected but who have not yet become ill with active TB can prevent the disease and thus eliminate the spread of TB in the community.

HOW DOES TUBERCULOSIS OCCUR? 

— The tuberculosis (TB) bacteria are spread through the air from a person who is ill with active TB that involves the lungs or airways. In these infectious individuals, bacteria are contained in small airborne droplets created by coughing or sneezing. Anyone who inhales these droplets is called a “contact.” A contact can be someone who spends a lot of time with the person who has infectious TB, such as a family member, friend, or coworker.

The contact person does not usually develop active TB immediately. In some cases, the person’s immune system is able to remove the bacteria and he/she does not develop the disease. In other cases, the person develops an immune response that controls the bacteria by containing it inside the body. This causes the bacteria to become “latent” (dormant, or asleep). The person does not develop active TB or become ill at this time but is said to have latent TB infection (LTBI). Up to one-third of the world’s population is infected with LTBI.

Latent TB — During this latent stage of TB, also called TB infection, the person is well and cannot spread the infection to others. If the person is treated at this stage, active TB can usually be prevented. Treatment is recommended for TB-infected individuals who are at increased risk for the development of active TB.

Active TB — Active TB may develop if latent infection is not fully treated. This is called reactivation TB, and it occurs in 5 to 10 percent of people with latent infection at a later time in their lives.

Reactivation TB may occur if the individual’s immune system becomes weakened and is no longer able to contain the latent bacteria. The bacteria then become active; they overwhelm the immune process and make the person sick with TB. This also is called TB disease.

The greatest risk for developing reactivation TB disease is within the first two years following the initial infection as a contact to a person with infectious TB. Reactivation can also occur more readily in people with HIV, diabetes mellitus, malnutrition, or those who take medications that weaken the immune system, such as medications for rheumatoid arthritis, steroids, or cancer chemotherapy. It can also occur with aging and weakening of the immune system. Reactivation may also occur for other unknown reasons.

HOW IS LATENT TUBERCULOSIS DIAGNOSED? 

— Latent tuberculosis (TB) infection (LTBI) can be diagnosed with a skin test or with a blood test, followed by a clinical evaluation and imaging (usually a chest X-ray) to make sure the tuberculosis is not active and causing disease. These tests recognize the immune system’s prior exposure and sensitization to the TB bacteria and result in a positive test after TB infection has occurred.

Skin testing — The TB skin test is known as the tuberculin skin test (sometimes also called a purified protein derivative test [PPD]) and is one method of detecting TB infection. In a person who is newly infected, the skin test usually becomes positive within 4 to 10 weeks after exposure to the person who is ill with TB.

TB skin tests are performed by injecting a small amount of PPD solution just beneath the surface of the skin, usually on the forearm. This solution contains an inactivated portion of the TB bacteria. Most individuals previously infected with TB develop a skin reaction (red or swollen) at this site.

Some reasons for skin testing — Tuberculin skin tests generally are performed for persons who are at risk of having TB infection:

●If the person is a healthcare or laboratory worker who may be a new employee to a healthcare facility or have contact with patients infected with TB.

●If the person knows he or she was exposed to someone with active TB. If the first test is negative, a second test usually will be performed 8 to 10 weeks later.

●If the person requires a medication that may weaken the immune system, such as steroids or medications for rheumatoid arthritis.

●If the person has HIV infection.

Interpreting the results — The skin test must be examined 48 to 72 hours after the PPD solution is injected under the skin. The skin is examined to determine if there is swelling (a reaction) at the injection site. The area may also be reddened, but redness should not be measured.

A trained healthcare provider (not the patient or a family member) interprets the test as positive or negative based on the size of the reaction and criteria for what size of reaction is considered positive in certain patient groups. Anyone who has a reaction larger than 15 mm is considered to have a positive test, and some people with a reaction that is 5 mm (eg, HIV, close contact to an active TB case) or 10 mm (eg, recent immigrant from a region with a high rate of TB) are considered to have a positive test if they are at higher risk for developing TB.

What does a positive TB skin test mean? 

— The TB skin test indicates that TB bacteria are in the body. It cannot determine if a person has active TB disease or LTBI; this requires further testing, usually a chest X-ray and a clinical examination. People who have active infectious TB usually have symptoms, such as a cough (usually persisting for several weeks), fevers, night sweats, and/or unexplained weight loss.

Skin testing after a positive test in the past 

— Anyone who has demonstrated a positive reaction to the TB skin test in the past usually will have a positive reaction in the future. Even after taking medication to treat TB, the reaction to the skin test will remain positive. Therefore, anyone who has a positive skin test does not need to have skin testing again. Repeat testing can rarely cause a large and painful skin reaction at the injection site and should be avoided.

BCG vaccine — A TB vaccine called Bacillus Calmette-Guérin (BCG) is given in many countries to prevent infection with TB. It usually is given to infants, although it may be given again at other times. BCG offers protection against TB in young children but typically does not offer continuing protection. BCG is not routinely used to prevent TB in the United States.

This vaccine may or may not cause a positive skin test. In the United States, a positive reaction to a TB skin test is interpreted as positive, regardless of prior BCG vaccination. Previous BCG vaccination should NOT stop a person from obtaining a TB skin test unless the person had a positive TB skin test reaction in the past.

Two-step skin testing — In some people, the TB skin test is falsely negative because the immune system’s response to TB has weakened over time. This may occur in people who were exposed to TB many years before. If a first skin test is negative, a second skin test may be done one to two weeks later. Performing the first test may “boost” the immune system, allowing it to react on the repeat test if the person was previously exposed to TB.

If the person has two negative tests, this is considered a true negative. If the second test is positive, further testing will be done to determine if the person has active TB disease or LTBI.

Two-step testing establishes a baseline in people who will need skin testing at regular intervals in the future (eg, healthcare workers, employees and residents of institutions such as prisons or nursing homes).

Blood tests for TB — Blood tests, known as interferon-gamma release assays (IGRAs), are available as another option for testing to identify TB infection. The blood test may be offered instead of, or in addition to, the TB skin test. Blood tests may simplify TB testing because they do not require the person to make a return trip to read the test reaction. In addition, blood test results for TB infection are not affected by prior immunization with BCG vaccine or by prior infection with harmless bacteria from the environment that might affect the TB skin test.

Further testing — If the TB skin test or blood test is positive, a healthcare provider will ask some specific questions, perform a physical examination, and obtain a chest X-ray to determine if person has active TB, either currently or in the past. In some cases, the person will be referred to a TB specialist for this evaluation.

If these tests indicate that the person has active TB rather than LTBI, the treatment regimen is different than that of someone with LTBI.

TREATMENT OF LATENT TUBERCULOSIS

Treatment approach — Latent tuberculosis (TB) infection (LTBI) is treated with one or more medications to kill the latent bacteria. Treating LTBI greatly reduces the risk of the infection progressing to active TB later in life (ie, it is given to prevent reactivation TB disease). Prior to starting treatment, it’s important to review all current medications with your health care provider in order to avoid any possible medication interactions.

While undergoing treatment, it is important to avoid drinking alcohol and taking acetaminophen (Tylenol). Both of these substances can make the liver work harder, potentially increasing the risk of liver injury from the medications.

There are several different regimens available for treating LTBI:

●Rifampin daily for four months

●Isoniazid plus rifampin daily for three months

●Isoniazid plus rifapentine weekly for three months

●Isoniazid daily for six or nine months

The best regimen depends on potential medication interactions, concerns about side effects, and how likely the person is to take all of the medication. It’s important to finish the entire course of treatment.

If there are concerns that a person may not be able to reliably take their medication on schedule and/or report any side effects, the health care provider might suggest “directly observed therapy”. In other cases, the person can take his or her medication at home without direct observation.

Monitoring during treatment — People who are being treated for LTBI must be monitored by a healthcare provider at least once per month to monitor for any signs of medication toxicity, such as liver injury. Minority women in the postpartum period may be at higher risk for side effects. Signs of liver injury may include unexplained tiredness, loss of appetite, nausea, vomiting, dark-colored urine, jaundice (yellowing of the skin or the white portion of the eye), fatigue, abdominal pain, or, rarely, unexplained bruises. Anyone who experiences one or more of these problems while taking any of these medications should stop their medication immediately and notify their healthcare provider.

In certain special cases, monthly monitoring may also include blood tests to monitor the function of the liver or blood counts.

ACTIVE TUBERCULOSIS — Active tuberculosis (TB) disease occurs when the TB bacteria become “active”; they overwhelm the immune system and cause a person to become ill. This usually occurs in the lung, although TB can affect any part of the body, including the lymph nodes, brain, kidneys, or bones.

If there is evidence on a chest X-ray or other signs that active pulmonary (lungs) TB is present, sputum cultures will be performed to culture (grow) the bacteria in the laboratory. This usually involves coughing up a “deep” specimen of phlegm from the chest. The phlegm is then sent to a laboratory and cultured to determine if TB bacteria are present. Other tests, such as a bronchoscopy or biopsy, may also be needed. A tissue biopsy may be performed to obtain specimens for culture if TB is suspected in other organs (such as lymph nodes or kidney).

While waiting for the results of the culture (some laboratory results are positive within a day or two, but it may take as long as two months for the bacteria to grow in the laboratory), treatment with several (usually four) TB drugs may be recommended. It is important to use more than one medicine and to take the medicines exactly as prescribed to reduce the risk of the bacteria becoming resistant to one (or more) of the medicines.

Infection caused by a strain of TB that has become resistant to standard TB drugs is more difficult to treat and may require four to six medications and a longer duration of treatment.

TUBERCULOSIS AND PUBLIC HEALTH — Tuberculosis (TB) is a disease that can easily be spread through the air by anyone with active disease. As a result, laws in the United States require that anyone with active TB be reported to the health department. Health department staff will work with the patient’s healthcare provider and the patient to make sure that a safe and effective treatment regimen is completed.

Directly observed therapy (DOT) is a program used by public health departments to ensure that a patient safely takes his or her medication exactly as prescribed. Since there is daily interaction with a healthcare worker where symptoms and signs of an adverse reaction to the medication can be reviewed, DOT also minimizes the risk of serious side effects. With this program, a health worker watches a person swallow the TB medication every day. DOT may help to improve cure rates.

The health department can also help to identify people who have been in contact with a person with active TB. Contacts are advised to have TB testing and treatment if necessary.

Public health programs for TB are essential for several reasons:

●To reduce the number of new cases of TB (by identifying and treating people with LTBI in order to prevent disease from developing) and therefore

●To limit spread of the disease in the community (by monitoring and assuring safe, complete treatment of people with active TB).

  • Dr. Carlo Oller (emergency physician with www.DrER.tv) has put together more than 1800 FREE patient education videos which can be found at www.patienteducation.video
  • Please contact Dr. Carlo Oller at carlooller@gmail.com if you would like to use his videos in your own website, or educational materials. Or if you would like some more information or education on a title NOT available at this time.

Psoriasis

PSORIASIS OVERVIEW 

— Psoriasis is a chronic skin disorder that causes areas of thickened, inflamed, red skin, often covered with silvery scales. Children and adolescents can develop psoriasis, but it occurs primarily in adults. Women and men are equally affected. Psoriasis is not an infection, and it is not contagious.

The severity of psoriasis is determined by how much of the body’s surface is covered and how much it affects a person’s quality of life. Psoriasis is not curable, although many treatments are available to reduce the symptoms and appearance of the disease.

PSORIASIS CAUSES 

— Researchers have not identified the exact cause of psoriasis. However, the disease develops due to a combination of immune, genetic, and environmental factors.

Immune system 

— The immune system plays an important role in the skin changes that occur in psoriasis. Understanding the normal process of skin development is helpful for understanding why skin changes occur in people with psoriasis.

The skin is made up of several layers. The top layer is the epidermis, a layer of cells that divide and eventually die, covering the surface of the skin with a layer of dead cells called the stratum corneum. The middle layer is the dermis; this is the layer where collagen and blood vessels are found. The inner layer is the subcutaneous layer, a layer of fat underneath the skin. Every day, as cells in the epidermis die and become part of the stratum corneum, dead cells at the top of the stratum corneum also are shed. This balance prevents the dead skin layer from becoming too thick.

In skin affected by psoriasis, immune cells enter the skin through blood vessels and cause the epidermis to grow very rapidly and to stop shedding properly. This causes thickening of the skin as well as the scaly build-up composed of dead skin cells that is seen on areas affected by psoriasis. Dilated blood vessels in the dermis that feed the rapidly growing epidermis cause the red color of the skin.

Genetics 

— Genetic factors play a role in determining whether someone develops psoriasis. About 40 percent of people with psoriasis or psoriatic arthritis (a type of arthritis closely related to psoriasis) have family members with the disorder. Several genes have been identified that make people more susceptible to psoriasis, but there is no genetic test that can definitely tell whether an individual will develop the disease.

Environment and behavior 

— Certain environmental and behavioral factors seem to be linked to psoriasis. Bacterial and viral infections, alcohol consumption, and certain medications (including beta blockers, lithium, and antimalarial drugs) may affect a person’s risk of developing psoriasis or worsen symptoms. Smoking appears to increase the risk and severity of psoriasis, particularly for psoriasis of the palms and soles.

PSORIASIS SYMPTOMS 

— Symptoms of psoriasis include:

●Areas of skin that are dry or red, usually covered with silvery-white scales, and sometimes with raised edges

●Rashes on the scalp, genitals, or in the skin folds

●Itching and skin pain

●Joint pain, swelling, or stiffness

●Nail abnormalities, such as pitted, discolored, or crumbly nails

TYPES OF PSORIASIS 

— There are several common types of psoriasis:

Plaque psoriasis — Plaque psoriasis is the most common form of psoriasis. Plaque psoriasis tends to affect young and middle aged adults, but can occur at any age. The individual skin plaques are usually between 0.4 and 4 inches (1 to 10 cm) wide but may be larger. Some of the most common areas for plaques are the scalp, elbows, knees, and back. The severity of plaque psoriasis varies widely. Plaque psoriasis may occur in just a few small areas or may cover a large portion of the body.

Guttate psoriasis — This type of psoriasis is sometimes linked to a recent streptococcal infection, usually pharyngitis (eg, strep throat). It often affects children or young adults with no past history of psoriasis, and causes a sudden eruption of small scaly papules on the trunk of the body (picture 2).

Pustular psoriasis — Pustular psoriasis can be a severe, and occasionally life-threatening, form of psoriasis. It develops quickly, with multiple small pustules that may join into larger areas (picture 3). Symptoms can include fever and abnormal blood levels of white blood cells and calcium. Pustular psoriasis can also cause pus-filled blisters on the palms of the hands and soles of the feet. These blisters can crack, causing painful breaks in the skin, and can be disabling.

Inverse psoriasis — This type of psoriasis affects less visible body areas, such as the groin, armpits, buttocks, genitals, and the area under the breasts. Sometimes this is mistakenly diagnosed as a fungal or bacterial infection.

Nail psoriasis — Some people with psoriasis develop nail problems, including tiny pits over the surface of the nails. The pits look as if someone has taken a pin and pricked the nail several times (picture 5). In addition, nails may develop a tan-brown color (also known as “oil spots”) or may separate from the nail bed (also known as “onycholysis”) (picture 6). In more severe cases, people have thick, crumbling nails.

Treatment of nail psoriasis is difficult and may include injections of steroids into the nail bed or oral medications such as methotrexate, cyclosporine, or immunomodulatory drugs.

Psoriatic arthritis — Up to one-third of people with psoriasis also have psoriatic arthritis, a condition that causes joint pain and swelling. Skin signs usually develop first, although about 15 percent of patients develop arthritis (joint swelling and stiffness) before symptoms of psoriasis. People with psoriatic arthritis often have severe nail problems.

Other associated conditions — There is a higher than normal frequency of depression in people with psoriasis. Psoriasis also has been associated with obesity and an increased risk of heart disease.

PSORIASIS DISEASE COURSE — Psoriasis is usually a lifelong condition and is not currently curable, although the severity of the disease can improve or worsen over time and can be controlled with treatment.

In people with certain forms of the disease, itching or pain and stiffness is severe and disabling. Some people with visible psoriasis lesions have feelings of embarrassment about their appearance. Stress, anxiety, loneliness, and low self-esteem can occur as a result.

People with psoriasis have higher rates of depression compared with those without the condition. People who have depression often benefit from working with a psychologist, clinical social worker, or other therapist to discuss their illness and identify possible ways to cope. A number of organizations, such as the National Psoriasis Foundation (www.psoriasis.org), are available to provide support to people with psoriasis and their families.

PSORIASIS DIAGNOSIS 

— Psoriasis can be diagnosed by examining the skin. Occasionally, a skin biopsy or scraping may be taken to rule out other disorders. There is no blood test that can definitively diagnose psoriasis.

PSORIASIS TREATMENT 

— Psoriasis is not curable but many treatments are available that can reduce the bothersome symptoms and appearance of the disease. Treatment depends upon the severity of the disease, the cost and convenience of the treatment, and a person’s response to the treatment. A combination of therapies is often recommended.

Referral to a dermatologist (a doctor who specializes in skin conditions) may be needed if the diagnosis of psoriasis is uncertain, if the initial treatment does not improve symptoms, or if the disease is widespread or severe. People with psoriatic arthritis may need to see a rheumatologist (a doctor who specializes in joint conditions).

Medicines applied to the skin — Many medications are available that can be rubbed onto the skin to treat psoriasis. Because psoriasis cannot be cured, continued use of medication is required to maintain improvement. For the best results, patients must use treatments as directed.

Emollients — Keeping skin soft and moist can minimize itching and tenderness. Over-the-counter moisturizers such as petroleum jelly or thick creams may be recommended; these should be applied immediately after bathing or showering.

Topical corticosteroids — Corticosteroids (sometimes called “steroids” but distinct from body building steroids) are applied to the skin to help to reduce inflammation. This is often done twice per day at the beginning of treatment. As a patient’s psoriasis improves, a doctor may recommend decreasing the frequency of treatment.

These cortisone-type creams and ointments are available in a variety of strengths (potencies); the least potent are available without a prescription (eg, hydrocortisone 1% cream) and are usually only effective in sensitive skin areas like the face and body folds. More potent formulations require a prescription. Other forms, such as solutions, gels, shampoo, lotion, foam, and spray, are available. Some people with psoriasis prefer these forms of medication over creams or ointments.

Side effects can include thinning of the skin and stretch marks (particularly when applied to normal skin). These effects are most likely to occur when topical corticosteroids are used for long periods of time. It is important to use these medications properly to reduce the risk for these side effects. A patient who notices these effects should contact his or her doctor.

Calcipotriene or calcitriol — Calcipotriene (sample brand names: Dovonex, Sorilux) and calcitriol (sample brand name: Vectical) are related to vitamin D and work by slowing the growth of skin cells in the epidermis. These medicines can be used instead of or in addition to topical corticosteroids. They are usually applied twice a day when used alone. The side effects are usually minimal, with skin irritation being the most common problem. These drugs do not cause thinning of the skin.

Other preparations (Taclonex, Enstilar) combine calcipotriene with a corticosteroid (betamethasone) in a once daily treatment. Although effective, combination products can be expensive.

Tar — Tar is a substance distilled from coal that has been used to treat psoriasis for many years. It is not completely clear how tar works, although it appears to inhibit the inflammation that leads to psoriasis. Tar preparations are available in shampoos, creams, oils, and lotions without a prescription, and are usually applied to the skin or scalp once or twice a day. Tar products do not cause serious side effects, although they can stain skin, hair, and clothing. Tar products are often used along with corticosteroids or with ultraviolet light treatments.

Tazarotene — Tazarotene (sample brand name: Tazorac) is a skin treatment derived from vitamin A that is available in a cream or gel. It is usually applied once per day, in the evening. It may also be applied for 20 minutes and then washed off if skin irritation develops. Improvement should be seen within two months of treatment.

Calcineurin inhibitors — Topical calcineurin inhibitors, including tacrolimus (brand name: Protopic) and pimecrolimus (Elidel) creams, can be used to treat psoriasis, especially on the face and skin folds, such as in the armpits or under the breasts.

Anthralin — Anthralin is a treatment for psoriasis that has been used for psoriasis since the early 20th century. It is now used less commonly than many other medications because the treatment can cause temporary red-brown stains on skin and permanent stains on clothing. Because anthralin can be irritating, it is usually applied to the skin for only 10 to 60 minutes per day. Anthralin may be less effective than topical corticosteroid, topical calcipotriene, and topical calcitriol therapy.

Ultraviolet light — Exposure to ultraviolet light is another way to treat psoriasis. During the summer months, people with psoriasis often notice that their symptoms improve. Ultraviolet light treatment (from a dermatologist) may be recommended to treat psoriasis. However, it is important to discuss the potential risks and benefits of ultraviolet light therapy before beginning treatment.

Before receiving ultraviolet light therapy, you may be asked to bathe and gently scrub areas affected by psoriasis, and then apply mineral oil to these areas; the oil allows the light to penetrate the skin more easily.

Although ultraviolet light therapy is effective for treating psoriasis, office treatment can be inconvenient and expensive, despite insurance coverage. Some dermatologists may recommend brief sun exposure or home light treatment (or use of a tanning bed if other options are not feasible) as alternatives to office treatment. Sometimes, an oral medication may be prescribed to sensitize the skin to the light treatment; when this is done, care must be taken to prevent severe burns from occurring.

Risks — Long-term ultraviolet light therapy may increase the risk for skin cancer. Ultraviolet light therapy is not recommended for people with a history of melanoma or other skin cancers.

Some clinicians also use lasers to treat psoriasis. The laser allows higher doses of ultraviolet B (UVB) radiation to be directed to the lesions while sparing normal skin; as a result, skin may heal with fewer treatments than with traditional ultraviolet light therapy. Laser treatment is most suitable for people who have small areas of psoriasis.

Oral medications

Methotrexate — Methotrexate treats psoriasis by suppressing the immune response that triggers the disease. This drug is often used to treat moderate to severe psoriasis and/or psoriatic arthritis. It is usually taken once per week, and it may be taken in oral (pill) form or as an injection.

Methotrexate can be used for long-term treatment of psoriasis, although it is important to have your liver monitored during treatment; methotrexate can affect liver function in some people. Patients should avoid drinking alcohol while on methotrexate because alcohol also hurts the liver. Improvement in psoriasis may not be seen until three months of methotrexate treatment are completed.

While taking methotrexate, many providers recommend taking folic acid 1 mg daily or leucovorin (also known as folinic acid) 5 mg weekly to reduce the risk of certain methotrexate side effects, such as upset stomach and a sore mouth.

Severe side effects can occur with methotrexate – including damage to the lungs, liver and bone marrow, and even death – so careful monitoring is essential. Serious interactions may occur with certain medications, particularly sulfa-type antibiotics. Methotrexate is not safe to take during pregnancy.

Retinoids — Retinoids are derived from vitamin A. An oral form called acitretin (brand name: Soriatane) may be recommended to people with severe forms of psoriasis. Improvement may be noticeable within one month, although the full effect of retinoids may take up to three to six months.

Side effects of retinoids include cracking and drying of the lips and skin, nosebleeds, trouble seeing in the dark, hair loss, joint pain, and depression. Acitretin may cause increased levels of triglycerides and liver enzymes in the blood; blood testing is usually recommended to monitor for these changes. Acitretin can cause severe birth defects and is only slowly removed from the body, so women should not get pregnant while taking acitretin or within three years after stopping the medication. Thus, for practical reasons, this medication is typically not prescribed to women who could get pregnant.

Apremilast — Apremilast (brand name: Otezla) is a newer oral medication for psoriasis and psoriatic arthritis that works by reducing inflammation. Apremilast is usually taken twice daily. People with severe kidney problems typically take apremilast only once daily.

Improvement in psoriasis may begin within the first few weeks of apremilast treatment. The most common side effects of apremilast are diarrhea, nausea, upper respiratory tract infection, and headache. In addition, people taking apremilast should contact their health care providers if they notice the emergence or worsening of depression, suicidal thoughts, or other mood changes while taking this medication.

Other drugs — Several medications that suppress the immune system can be used to treat severe psoriasis for a short period of time. These include cyclosporine, hydroxyurea, and azathioprine.

Injectable medications — Several injectable medications, known as “biologics,” target the overactive immune system and may be beneficial in the treatment of psoriasis. Medications include etanercept (Enbrel), infliximab (sample brand name: Remicade), adalimumab (brand name: Humira), ustekinumab (brand name: Stelara), secukinumab (brand name: Cosentyx), ixekizumab (brand name: Taltz), brodalumab (brand name: Siliq), guselkumab (brand name: Tremfya), tildrakizumab (brand name: Ilumya), and certolizumab pegol (brand name: Cimzia).

Biologics can be highly effective for the treatment of psoriasis, with improvement in skin symptoms that usually begins within a few weeks of starting treatment. Because of their cost and potential side effects, biologics are generally reserved for people with moderate to severe psoriasis that has not responded to other treatments.

Like methotrexate and cyclosporine, biologics affect the immune system and should not be used in people with serious infections. Screening for tuberculosis (TB) is necessary before starting therapy since the risk of developing active TB infection is increased. If there is evidence of prior infection with tuberculosis, treatment to prevent reactivation of the infection is recommended. Testing for hepatitis B is also recommended.

Dietary changes — The role of dietary interventions in treating psoriasis has been unclear. Experts recommend that people with psoriasis who are overweight or obese reduce the number of calories they consume in order to try to lose weight. They also recommend a gluten-free diet for people with psoriasis who have been diagnosed with celiac disease or confirmed to have gluten sensitivity based on blood tests. Beyond this, there is no specific approach that has been proven to improve psoriasis symptoms; however, eating a nutritious, balanced diet (high in fruits, vegetables, and whole grains; and low in unhealthy fats and added sugar) has many other health benefits.

  • Dr. Carlo Oller (emergency physician with www.DrER.tv) has put together more than 1800 FREE patient education videos which can be found at www.patienteducation.video
  • Please contact Dr. Carlo Oller at carlooller@gmail.com if you would like to use his videos in your own website, or educational materials. Or if you would like some more information or education on a title NOT available at this time.

Hiatal Hernia

Mr Ahmed R. Ahmed discusses hiatal hernias (often called hiatus hernias), what causes them, and how they can be treated. 

Any time an internal body part pushes into an area where it doesn’t belong, it’s called a hernia.

The hiatus is an opening in the diaphragm — the muscular wall separating the chest cavity from the abdomen. Normally, the esophagus (food pipe) goes through the hiatus and attaches to the stomach. In a hiatal hernia (also called hiatus hernia) the stomach bulges up into the chest through that opening.

There are two main types of hiatal hernias: sliding and paraesophageal (next to the esophagus).

In a sliding hiatal hernia, the stomach and the section of the esophagus that joins the stomach slide up into the chest through the hiatus. This is the more common type of hernia.

The paraesophageal hernia is less common, but is more cause for concern. The esophagus and stomach stay in their normal locations, but part of the stomach squeezes through the hiatus, landing it next to the esophagus. Although you can have this type of hernia without any symptoms, the danger is that the stomach can become “strangled,” or have its blood supply shut off.

Many people with hiatal hernia have no symptoms, but others may have heartburn related to gastroesophageal reflux disease, or GERD. Although there appears to be a link, one condition does not seem to cause the other, because many people have a hiatal hernia without having GERD, and others have GERD without having a hiatal hernia.

People with heartburn may experience chest pain that can easily be confused with the pain of a heart attack. That’s why it’s so important to undergo testing and get properly diagnosed.

What Causes a Hiatal Hernia?

Most of the time, the cause is not known. A person may be born with a larger hiatal opening. Increased pressure in the abdomen such as from pregnancy, obesity, coughing, or straining during bowel movements may also play a role.

Who Is at Risk for Hiatal Hernia?

Hiatal hernias occur more often in women, people who are overweight, and people older than 50.

How Is a Hiatal Hernia Diagnosed?

A hiatal hernia can be diagnosed with a specialized X-ray (using a barium swallow) that allows a doctor to see the esophagus or with endoscopy.

How Are Hiatal Hernias Treated?

Most people do not experience any symptoms of their hiatal hernia so no treatment is necessary. However, the paraesophageal hernia (when part of the stomach squeezes through the hiatus) can sometimes cause the stomach to be strangled, so surgery is sometimes recommended. Other symptoms that may occur along with the hernia such as chest pain should be properly evaluated. Symptoms of GERD, such as heartburn, should be treated.

When Is Hiatal Hernia Surgery Necessary?

If the hiatal hernia is in danger of becoming constricted or strangulated (so that the blood supply is cut off), surgery may be needed to reduce the hernia, meaning put it back where it belongs.

Hiatal hernia surgery can often be performed as a laparoscopic, or “minimally invasive,” procedure. During this type of surgery, a few small (5 to 10 millimeter) incisions are made in the abdomen. The laparoscope that allows the surgeon to see inside the abdomen and surgical instruments are inserted through these incisions. The surgeon is guided by the laparoscope, which transmits a picture of the internal organs to a monitor. The advantages of laparoscopic surgery include smaller incisions, less risk of infection, less pain and scarring, and a more rapid recovery.

Many patients are able to walk around the day after hernia surgery. Generally, there are no dietary restrictions and the patient can resume his or her regular activities within a week. Complete recovery will take two to three weeks, and hard labor and heavy lifting should be avoided for at least three months after surgery. Unfortunately, there is no guarantee, even with surgery, that the hernia will not return.

When Should I Call the Doctor About a Hiatal Hernia?

If you have been diagnosed with a hiatal hernia and you develop severe pain in the chest or abdomen, become nauseated, are vomiting, or are unable to have a bowel movement or pass gas, you may have a strangulated hernia or an obstruction, which are medical emergencies. Call your doctor immediately.

Hernia

What is a hernia? 

— A hernia is an area in a layer of tissue that is weak or torn. Often when there is a hernia, other tissues that are normally held in by the damaged layer bulge or stick out through the weak or torn spot.

Hernias can happen in different parts of the body. When they happen where the thigh and body meet (called the groin), they are called inguinal or femoral hernias. Inguinal hernias are a bit higher on the groin than femoral hernias. Either type of hernia can balloon out and form a sac. In some cases, the sac holds a loop of intestine or a piece of fat that is normally tucked inside the belly.

Groin hernias are more common in men than in women.

What are the symptoms of a groin hernia? 

— Groin hernias do not always cause symptoms. But when symptoms do occur, they can include:

●A heavy or tugging feeling in the groin area

●Dull pain that gets worse when straining, lifting, coughing, or otherwise using the muscles near the groin

●A bulge or lump at the groin

Hernias can be very painful and even dangerous if the tissue in the hernia becomes trapped and unable to slide back into the belly. When this happens, the tissue does not get enough blood, so it can get damaged or die. This is more likely with femoral hernias than with inguinal hernias.

Should I see a doctor or nurse? 

— Yes. See a doctor or nurse if you:

●Feel or see a bulge in your groin

●Feel a pulling sensation or pain in your groin even if you have no bulge

In most cases, doctors can diagnose a hernia just by doing an exam. During the exam, the doctor will ask you to cough while pressing on the bulge. This can be uncomfortable, but it is necessary to find the source of the problem.

Most of the time, the contents of the hernia can be “reduced,” or gently pushed back into the belly. Still, there are times when the hernia gets trapped and can’t be pushed back in. If that happens, the tissue that is trapped can get damaged.

If you develop pain around the bulge or feel sick, call your doctor or surgeon right away.

How are hernias treated?

 — Not all hernias need treatment right away. But many do need to be repaired with surgery. Femoral hernias, in particular, usually need repair. They are more likely than inguinal hernias to cause tissue damage.

Surgeons can repair groin hernias in 1 of 2 ways. The best surgery for you will depend on your preferences and your surgeon’s experience. It will also depend on the type and size of your hernia, whether this is the first time it is getting repaired, and your overall health.

The 2 types of surgery are:

Open surgery – During an open surgery, the surgeon makes one incision near the hernia. Then he or she gently pushes the bulging tissue back into place. Next, the surgeon sews the weak tissue layer back together, so that nothing can bulge through. In most cases, surgeons will also patch the area with a piece of mesh. Mesh takes the strain off the tissue wall. That way the hernia is not likely to happen again.

Laparoscopic surgery – During laparoscopic surgery, the surgeon makes several small incisions. Then he or she inserts long thin tools into the area near the hernia. One of the tools has a camera (called a “laparoscope”) on the end, which sends pictures to a TV screen. The surgeon can look at the picture on the screen to guide his or her movements. Then he or she uses the long tools to repair the hernia with mesh.

If your hernia has reduced the blood supply to a loop of intestine, your doctor might need to remove that piece of intestine and sew the 2 ends back together.

Varicose Veins

https://youtu.be/89xuyftWmyU – Varicose Vein Video by Nucleus Medical


La Jolla Vein Care specializes in vein conditions and offers a variety of treatment options. This educational video provides information on vein problems as well as a different treatment options available.

Vein disease happens when the veins in the legs do not work the right way. Normally, the veins in the legs carry blood from the legs back to the heart. The veins have valves inside them to help keep blood moving in only one direction (toward the heart). The valves open to let blood flow to the heart, and close to keep it from flowing back down the leg. Vein disease can happen when the valves are damaged or do not work well. This causes blood to collect in the legs. Blood is especially likely to collect in the legs when a person sits or stands for a long time without walking.

What conditions can cause vein disease? 

— Vein disease can be caused by:

●A blood clot in a leg vein

●Leg injury

●Being pregnant, especially more than once – This causes a change in hormone levels that can weaken vein walls.

●Weight gain

Vein disease can also run in families.

What are the symptoms of vein disease? 

— People with vein disease can have symptoms that include:

●Leg pain, or the leg feeling tired or heavy, especially at the end of the day.

●Swollen veins – “Spider veins” are small leg veins that are swollen. “Varicose veins” are larger leg veins that are swollen and twisted.

●Swelling in the lower legs or ankles

– People can have swelling at the end of the day or all the time.

●Skin color changes – The skin can turn red or red-brown. Skin color changes often happen first around the ankle.

●Open sores, also called “venous ulcers” – These are usually at the ankle and can be painful and ooze.

Is there a test for vein disease? 

— Yes. Your doctor or nurse will do an exam to look at your legs. He or she might also do a test called an ultrasound. An ultrasound can check how well the valves in the legs work. It can also see if any of the veins in the legs are blocked.

What can I do to reduce my symptoms? 

— To reduce swelling, you can:

●Walk around, and try not to sit or stand in one place for a long time

●Raise your legs up 3 or 4 times a day, for 30 minutes each time

●Do exercises to point your toes and feet down and up a few times each day

To treat dry or itchy skin, you can:

●Wash your legs each day with a gentle cleanser. Do not use regular soap, which can make skin more dry.

●Use an unscented moisturizing cream or ointment while your skin is still damp. Petroleum jelly works well. Ask your doctor or nurse before using any other type of cream or ointment, because some can cause a rash.

If your skin problems are severe, your doctor or nurse might suggest special ointment, medicine, or bandages.

How is vein disease treated? 

— Doctors can use different treatments to treat symptoms and reduce swelling. These can include:

●Special socks, bandages, or devices:

•”Compression stockings” are special socks that fit tightly over the ankle and leg. If your doctor or nurse recommends that you wear them, he or she will tell you which type to wear and how to put them on (figure 2 and table 1).

•”Compression bandages” are layers of bandages that wrap around a person’s leg.

•A “compression pump” is a device that fits around the leg and squeezes the leg every few minutes.

●Special coverings that are put on an open sore to help it heal

●Medicines – Doctors can use different types of medicines to treat different symptoms. For example, people who cannot use compression stockings or bandages might be able to try medicines that help the veins work better. People with a skin infection might need antibiotics. People with itchy skin might need a prescription cream or ointment.

●Procedures – Doctors can do procedures if other treatments do not work. A doctor can remove or destroy damaged veins so they can no longer fill with blood.

  • Dr. Carlo Oller (emergency physician with www.DrER.tv) has put together more than 1800 FREE patient education videos which can be found at www.patienteducation.video
  • Please contact Dr. Carlo Oller at carlooller@gmail.com if you would like to use his videos in your own website, or educational materials. Or if you would like some more information or education on a title NOT available at this time.

Hyperemesis Gravidum

video explains HG causes, symptoms, and treatment

What is hyperemesis gravidarum? 

— Hyperemesis gravidarum is a condition that causes frequent vomiting (throwing up) in pregnant women. It is like morning sickness, except the symptoms are much more severe.

Morning sickness is the nausea and vomiting that many women have during pregnancy. Even though it is called “morning” sickness, symptoms can happen any time of day.

What are the symptoms of hyperemesis gravidarum? 

— Women with hyperemesis gravidarum vomit every day, often many times a day. Women can lose weight and get dehydrated because they are vomiting so much.

Symptoms of dehydration include:

●Urinating less often than usual

●Having dark yellow urine

●Feeling dizzy when standing up

●Weight loss

Symptoms of hyperemesis gravidarum usually start during the first 2 to 3 months of pregnancy. Most women feel better by the middle of their pregnancy. But some women feel sick until late in the pregnancy.

How can I find out if I have hyperemesis gravidarum? 

— Your doctor or nurse should be able to tell if you have hyperemesis gravidarum by learning about your symptoms and doing an exam.

Are there tests I should have? 

— Maybe. Your doctor or nurse might do tests to see if the vomiting is hurting your body and to make sure another condition isn’t causing your symptoms. These tests can include:

●Blood tests

●Urine tests

●An ultrasound to check your baby

Is there anything I can do on my own to feel better? 

— Yes. To feel better, you can try the following:

●Eat as soon as you feel hungry, or even before you feel hungry.

●Snack often and eat small meals. The best foods to eat are high in protein or carbohydrates, and low in fat. These include crackers, bread, pretzels, nuts, and low-fat yogurt.

●Avoid foods that are spicy, greasy, or acidic (such as oranges).

●Drink cold, clear beverages, such as sports drinks and ginger ale. Avoid coffee. Also, try to drink between meals, rather than with a meal.

●Suck on popsicles or ginger-flavored lollipops.

●Brush your teeth right after you eat.

●Avoid lying down right after you eat.

●Take your vitamins at bedtime with a snack, not in the morning

●Avoid things in your environment that upset your stomach, such as stuffy rooms, strong smells, hot places, or loud noises.

●Have someone make your meals for you.

●Wear “acupressure” bands on your wrists. These are special bands that can help with morning or motion sickness.

Should I see a doctor or nurse? 

— If you are pregnant, see your doctor or nurse right away if you have any of the symptoms listed above.

How is hyperemesis gravidarum treated? 

— Treatment depends on how severe your symptoms are. If you are dehydrated or have lost a lot of weight, you will probably need to be treated in the hospital with:

●Fluids that go into your vein through a tube called an “IV”

●Medicines to help stop your nausea and vomiting

If this treatment doesn’t work, your doctor can feed you through a tube that goes in your nose and down into your stomach or through a vein.

Can hyperemesis gravidarum be prevented? 

— Doctors strongly recommend that all women who might get pregnant or who are pregnant take vitamins. The vitamin should contain at least 400 micrograms of folic acid. Taking vitamins before pregnancy and in early pregnancy might help prevent nausea and vomiting.

Will my baby be healthy? 

— Babies born to women with hyperemesis gravidarum for the entire pregnancy are a little more likely to be smaller than average. But otherwise, the condition doesn’t seem to cause problems. Taking medicines for nausea and vomiting during the pregnancy should not affect the baby either.

  • Dr. Carlo Oller (emergency physician with www.DrER.tv) has put together more than 1800 FREE patient education videos which can be found at www.patienteducation.video
  • Please contact Dr. Carlo Oller at carlooller@gmail.com if you would like to use his videos in your own website, or educational materials. Or if you would like some more information or education on a title NOT available at this time.

Peritoneal Dialysis


DaVita Kidney Care
Published on May 29, 2012

What is peritoneal dialysis? 

— Peritoneal dialysis is a treatment for kidney failure. Normally, the kidneys work to filter the blood and remove waste and excess salt and water. Kidney failure, also called “end-stage renal disease,” is when the kidneys stop working completely.

Peritoneal dialysis is a procedure that involves piping a special fluid into the belly. This fluid collects waste and excess salt and water from the blood. Then the used fluid drains out of the belly.

Where will I do peritoneal dialysis? 

— You will do peritoneal dialysis at your home. You will need to do it every day.

When will I start peritoneal dialysis? 

— You and your doctor will decide the right time for you to start. It will depend partly on how well your kidneys work, and on your symptoms and overall health. Your doctor will do blood tests to check how well your kidneys are working.

Before you start peritoneal dialysis, you need surgery to create a way for the fluid to get in and out of your belly. The doctor will put a thin tube (called a “catheter”) in your belly. One end of the tube stays in your belly. The other end stays outside your body. It takes about 2 weeks for your body to heal with the tube in it before you can start dialysis.

You will also need to learn how to do peritoneal dialysis. A nurse will teach you or a family member (if he or she will do it) how to set up and use the equipment.

What happens during peritoneal dialysis? 

— During peritoneal dialysis, you will hook up your belly tube to the dialysis tubing. You will pipe clean fluid into your belly. The fluid will stay there for a certain amount of time. When the fluid is in your belly, it’s called a “dwell.” During a dwell, your belly might feel full or bloated, but it shouldn’t hurt.

After the dwell, you will drain the used fluid out of your belly and throw it away. Then you will refill your belly with clean fluid. Each time you drain the used fluid and refill your belly with clean fluid, it’s called an “exchange.” It’s important to follow all your doctor’s instructions about each exchange and dwell.

How often will I do peritoneal dialysis and how long does it take? 

— Your schedule depends on the type of peritoneal dialysis you do. There are 2 types of peritoneal dialysis:

●Continuous ambulatory peritoneal dialysis (CAPD) – CAPD is done all day and night. People do the exchanges themselves. People usually do 3 to 5 exchanges during the day and do a dwell overnight. Each daytime exchange takes about 30 to 40 minutes.

●Continuous cycling peritoneal dialysis (CCPD) – For CCPD, a machine does the exchanges. CCPD is usually done overnight.

Most people can choose the type of peritoneal dialysis they have. Talk with your doctor about which type of peritoneal dialysis is best for you.

What problems can happen with peritoneal dialysis? — Problems that can happen with peritoneal dialysis include:

●An infection of the skin around the tube – An infection can cause the skin to become red, painful, or hard. Pus might also drain from the area. Treatment usually includes antibiotic medicines or creams.

●An infection inside the belly (called “peritonitis”) – Peritonitis can cause belly pain, fever, nausea, or diarrhea. It can also cause the used fluid to look cloudy. Treatment usually includes antibiotics that go into the belly with the dialysis fluid.

●A hernia – A hernia is when a belly muscle becomes weak. It causes an area of the belly to bulge out. It usually doesn’t hurt. A hernia is treated with surgery.

Call your doctor or nurse if:

●The skin around your tube gets red, painful, or hard, or pus drains from it.

●You have belly pain, fever, or the used dialysis fluid looks cloudy.

●A part of your belly bulges out.

Is there anything else I should do? — Yes, you will need to:

●Weigh yourself every day – You need to use your weight to figure out each day’s dialysis treatment.

●Take care of the skin around your tube – Every 1 to 2 days, wash the area carefully, pat it dry, and put an antibiotic cream on it. Keep the area covered with gauze and tape. Tell your doctor or nurse if you injure the area or if the tube moves out of place.

●Follow a special diet – You might need to limit the amount of fluids you drink and eat. You might also need to avoid foods with a lot of sodium, potassium, and phosphorous. These are minerals that can build up in your body if you have kidney problems.

This educational content was put together by Dr. Carlo Oller (Emergency Physician) as part of a project to accumulate quality patient education about different conditions under one website for free. You can find this, and many other educational content at www.patienteducation.video

Hemodialysis

Published by
Emory Department of Medicine

What is hemodialysis? 

— Hemodialysis is a treatment for kidney failure. Normally, the kidneys work to filter the blood and remove waste and excess salt and water. Kidney failure, also called “end-stage renal disease,” is when the kidneys stop working completely.

With hemodialysis, a machine takes over the job of the kidneys. The machine pumps blood out of the body, filters it, and returns it to the body. People have hemodialysis at least 3 times a week.

When do I prepare for hemodialysis? 

— You will need to start preparing a few months before you begin hemodialysis treatment.

How do I prepare for hemodialysis? 

— You prepare for hemodialysis by talking with your doctor, making certain choices, and having surgery.

Before you start hemodialysis, you will need to choose where you have it. Most people can choose between having hemodialysis at a dialysis center (in a hospital or clinic) or at home. If you plan to have hemodialysis at home, you will need to get your home ready. You will need a dialysis machine and supplies. You might need to make changes to your home’s plumbing or electricity.

You also need to prepare your body for hemodialysis by having surgery ahead of time. Your doctor will create an “access,” which is a way for the blood to leave and return to your body during hemodialysis. An access is usually created under the skin in the lower part of the arm. An access needs time to heal before it can be used.

There are 3 different types of access:

●AV fistula – Most people get this type of access. To make this access, a doctor does surgery to connect an artery directly to a vein. An AV fistula needs to heal for 2 to 4 months or more before it can be used for dialysis.

●AV graft – To make this access, a doctor uses a rubber tube to connect an artery to a vein. An AV graft needs to heal for 2 weeks before it can be used for dialysis.

●Central venous catheter – To make this access, a doctor puts a tube in a large vein (usually in the neck). This access is usually used only short-term or if people don’t have any other access. It doesn’t work as well as an AV fistula or AV graft.

How do I take care of my access? 

— That depends on the type of access you have. If you have a central venous catheter, the dialysis nurse will cover the catheter site with a clean dressing and waterproof bandage each time you have dialysis. You should keep the dressing and bandage in place until the next dialysis session.

If you have an AV fistula or graft, here is what you should do:

●Wash it with soap and warm water every day and before each dialysis treatment.

●Check it every day to make sure that it’s working normally and blood is flowing through it. When your access is working normally, you should be able to feel a vibration (called a “thrill”) over the area.

●Be careful with the arm that has the fistula or graft. It’s important that you not get an injury on that arm.

●Do not scratch or pick at your access.

●Do not wear tight clothes or jewelry on the arm with the access.

●Do not sleep on the arm with the access.

●Do not let anyone take blood from or measure blood pressure in the arm with the access.

Problems can sometimes happen with an AV fistula or graft access. Call your doctor or nurse if:

●You don’t feel a vibration – This could mean that your access has stopped working or closed up.

●Your access is red or warm – This could mean that your access is infected.

●Your access bleeds a lot after hemodialysis.

This educational content was put together by Dr. Carlo Oller (Emergency Physician) as part of a project to accumulate quality patient education about different conditions under one website for free. You can find this, and many other educational content at www.patienteducation.video

Chronic Kidney Disease

What is chronic kidney disease? 

— Chronic kidney disease (CKD) is when the kidneys stop working as well as they should. When they are working normally, the kidneys filter the blood and remove waste and excess salt and water (figure 1).

In people with CKD, the kidneys slowly lose the ability to filter the blood. In time, the kidneys can stop working completely. That is why it is so important to keep CKD from getting worse.

What are the symptoms of CKD? 

— At first, CKD causes no symptoms. As the disease gets worse, it can:

●Make your feet, ankles, or legs swell (doctors call this “edema”)

●Give you high blood pressure

●Make you very tired

●Damage your bones

Is there anything I can do to keep my kidneys from getting worse if I have CKD? — Yes, you can protect your kidneys by:

●Taking blood pressure and other medicines every day, if your doctor or nurse prescribes them to you

●Keeping your blood sugar in a healthy range, if you have diabetes

●Changing your diet, if your doctor or nurse says you should

●Quitting smoking, if you smoke

●Losing weight, if you are overweight

●Avoiding medicines known as “nonsteroidal antiinflammatory drugs,” or NSAIDs. These medicines include ibuprofen (sample brand names: Advil, Motrin) and naproxen (sample brand name: Aleve). Check with your doctor, nurse, or kidney specialist before starting any new medicines – even over-the-counter ones.

What are the treatments for CKD?

 — People in the early stages of CKD can take medicines to keep the disease from getting worse. For example, many people with CKD should take medicines known as “ACE inhibitors” or “angiotensin receptor blockers.” If your doctor or nurse prescribes these medicines, it is very important that you take them every day as directed. If they cause side effects or cost too much, speak to your doctor or nurse about it. He or she might have solutions to offer.

What happens if my kidneys stop working completely? 

— If your kidneys stop working completely, you can choose between 3 different treatments to take over the job of your kidneys. Your choices are described below.

●You can have kidney transplant surgery. That way, the new kidney can do the job of your own kidneys. If you have a kidney transplant, you will need to take medicines for the rest of your life to keep your body from reacting badly to the new kidney. (You only need one kidney to live.)

●You can have your blood filtered by a machine. This treatment is called “hemodialysis,” but many people call it just “dialysis.” If you choose this approach, you will need to be hooked up to the machine at least 3 times a week for a few hours for the rest of your life. Before you start, you will also need to have surgery to prepare a blood vessel for attachment to the machine.

●You can learn to use a special fluid that has to be piped in and out of your belly every day. This treatment is called “peritoneal dialysis.” If you choose this type of dialysis, you will need surgery to have a tube implanted in your belly. Then you will have to learn how to pipe the fluid in and out through that tube.

How do I choose between the different treatment options? 

— You and your doctor will need to work together to find a treatment that’s right for you. Kidney transplant surgery is usually the best option for most people. But often there are no kidneys available for transplant.

Ask your doctor to explain all of your options and how they might work for you. Then talk openly with him or her about how you feel about all of the options. You might even decide that you do not want any treatment. That is your choice.

This educational content was put together by Dr. Carlo Oller (Emergency Physician) as part of a project to accumulate quality patient education about different conditions under one website for free. You can find this, and many other educational content at www.patienteducation.video

Granulomoatosis with Polyangiitis

What is granulomatosis with polyangiitis? 

— Granulomatosis with polyangiitis is a rare disease that causes pain and swelling of blood vessels and other tissues. It can affect organs or structures anywhere in the body. In most cases, granulomatosis with polyangiitis affects the nose, mouth, ears, lungs, and kidneys.

What are the symptoms of granulomatosis with polyangiitis? 

— The symptoms include:

●Runny nose – The discharge from the nose can include pus or blood and does not go away.

●Small sores in the nose or mouth

●Sinus infections – The sinuses are hollow areas in the bones of the face.

●Ear problems, including fluid leaking from the ear, ear pain, ear infections, and hearing loss

●Inflammation and break down of “cartilage” – Cartilage is the tough, elastic tissue found in the ears, the windpipe, and the spaces between bones.

●A hoarse voice

●Cough

●Wheezing and breathing problems

●Chest pain

●Blood in the urine

●Red or purple spots on the skin, most often on the lower legs

Is there a test for granulomatosis with polyangiitis? 

— Yes. Your doctor or nurse will ask about your symptoms and do an exam. Other tests include:

●Blood tests

●Urine tests

●A X-ray or CT scan (a special type of X-ray) of the chest

●A biopsy – This is a test that involves taking a small sample of tissue. A doctor examines the sample in a lab. The tissue is usually taken from the skin or the kidney. Sometimes, the sample is taken from inside the nose or the lungs.

How is granulomatosis with polyangiitis treated? — The treatment happens in two parts, one after the other. It involves medicines that suppress the body’s infection-fighting system, called the “immune system.”

The first part of treatment is called “induction.” You will need to take strong medicines that are given as pills or through a thin tube that goes into a vein, called an “IV.” You will need to see your doctor at least once a month during this part of treatment. That’s because the medicines can have serious side effects. This part lasts until your symptoms get better, which usually takes about 6 months.

The second part of treatment is called “maintenance.” For this part, your doctor will switch you to a lower dose of the medicines you are taking. Or you might take different medicines that have less serious side effects. The maintenance part lasts at least one year.

This educational content was put together by Dr. Carlo Oller (Emergency Physician) as part of a project to accumulate quality patient education about different conditions under one website for free. You can find this, and many other educational content at www.patienteducation.video

Tremor

What is tremor? 

— Tremor is the medical term for trembling or shaking. A person with tremor has a body part that shakes, and the person cannot control the shaking. Most often this shaking affects the hands or the head, but other body parts can be affected, too. The tremor can be a problem on its own, or it can be caused by another health problem.

There are several different types of tremor. They fall into several main groups:

●Rest tremors

– Rest tremors happen while you are sitting or lying down and relaxed. People who have a rest tremor can usually stop the tremor by making a point of moving the part of their body that shakes.

●Action tremors

– Action tremors happen when you are moving your muscles on purpose. There are a few different kinds of action tremors, including:

•Kinetic tremors

– These happen when you move on purpose, such as writing or drinking from a cup. Sometimes, the tremor gets worse gradually as you get closer to what you trying to do or reach. This is called “intention” tremor.

•Postural tremors

– These happen when you try to hold a body part still in a position other than its resting position. For example, your legs might shake when you are standing up, or your arms might shake if you hold them out in front of you.

•Isometric tremors

– These happen when you move a muscle against something that is still. For example, they might happen when you push against a wall or make a fist with your hand.

●Functional tremor

– Functional tremor can combine features of rest and action tremors. Unlike other kinds of tremor, functional tremor has no known medical cause. This kind of tremor usually gets less severe if you are distracted while your doctor examines you, for example, if he or she asks you to do something else with another part of your body. Other types of tremor tend to get worse with distraction.

What are the most common causes of rest tremor? 

— The most common cause of rest tremor is Parkinson disease. If that is the cause of your tremor, your doctor or nurse will probably focus on treating your Parkinson disease. This will hopefully help reduce your tremor.

Other problems that can cause rest tremors include diseases that damage parts of the brain, and a rare condition called Wilson disease, which causes copper to build up in the body.

What are the most common causes of action tremor? 

— The most common cause is something called a “physiologic” tremor. Everyone, even people who are healthy, has a little bit of shaking of the hands. This is what doctors refer to as “physiologic tremor.” It is normal, and you don’t usually notice it, because it is very mild. But in some cases this “physiologic” or normal tremor can become exaggerated. This can happen:

●If you take certain medicines, such as those used to treat depression, or asthma and other breathing problems

●If you drink coffee, smoke cigarettes, or use “stimulants” (including caffeine and certain medicines)

●If you are anxious, excited, or afraid

●If your muscles are very tired, for example because you just worked out

●As the effects of alcohol or other drugs are wearing off

●If you have an overactive thyroid gland

●If you have a fever

If your tremor is caused by 1 of the problems listed above, the tremor should go away as soon as the problem goes away. Of course, if your tremor is caused by a medicine, you might not be able to stop taking it. But it might be possible to switch medicines or to lower the dose.

What is essential tremor? 

— Essential tremor is a nervous system problem that causes action tremor. It is different from physiologic tremor in that it is not related to medicines, substances, or physical conditions such as fever. Essential tremor can be passed on in families.

People who have essential tremor usually shake when they try to hold their arms out straight. They also tend to shake when they move their hands with a goal in mind. For instance, their hands might shake when they try to write, drink from a glass, or touch their nose with their finger.

Essential tremor sometimes even affects the head. This makes it look as though the person is nodding their head “yes-yes” or shaking their head “no-no.”

Is there a test to find out the cause of tremor? 

— No, there is no test. But your doctor or nurse can learn about a lot about your tremor just by asking you questions and watching you move. Your doctor or nurse might send you for a brain scan or blood tests to make sure your tremor is not caused by something serious. But it’s likely that he or she will be able to tell what’s wrong just by doing an exam.

How is tremor treated? 

— If a tremor is caused by another medical problem, treating that problem – if it can be treated – sometimes helps reduce the tremor, too. For example, people whose tremor is caused by high thyroid hormone levels often stop shaking when their hormone levels go back to normal.

Even when no other medical problems are involved, there are treatments that can help. There are a few medicines that can reduce a person’s tremor. If the medicines are not effective enough and the tremor is severe, it is even possible to have a device implanted in the brain that can help control tremor.

This educational content was put together by Dr. Carlo Oller (Emergency Physician) as part of a project to accumulate quality patient education about different conditions under one website for free. You can find this, and many other educational content at www.patienteducation.video

Last updated 3/3/19

Peyronie’s Disease


Landon Trost, M.D., provides a general background of Peyronie’s disease. Topics include: common symptoms at presentation, how often the condition occurs, populations of men where this is more common, age of onset, average curvatures, typical directions of curvature, and associated psychological conditions.

Landon Trost, M.D., Assistant Professor of Urology and current Head of Andrology and Male Infertility, Mayo Clinic, Rochester, Minnesota discusses Peyronies Disease therapies. He defines the therapeutic objectives and how curvature is often a primary end-point of therapy.

PEYRONIE’S DISEASE 

— Up to 7 percent of men can experience an abnormal curvature of their penis when it is erect. This is known as Peyronie’s disease. The most common cause of Peyronie’s disease is penile trauma that occurs during sexual intercourse. The penis develops a scar, and this scar then causes the penis to bend when it is erect. Significant penile curvatures can result in pain, poor erections, and an inability to engage in sexual intercourse. If the penis bends more than 60 degrees, couples usually are unable to have intercourse. Many men are extremely distressed by this curvature of their penis.

Treatments 

— There is currently only one US Food and Drug Administration (FDA)-approved treatment, known as collagenase (brand name: Xiaflex) injections. These injections are placed directly into the penile plaque, and they help remove the scar tissue. Studies have found that patients typically experience a 30 to 40 percent improvement in penile curvature after completing this type of therapy.

Tonsil Stones (Tonsilloliths)

What Causes Tonsil Stones?

Your tonsils are filled with nooks and crannies where bacteria and other materials, including dead cells and mucous, can become trapped. When this happens, the debris can become concentrated in white formations that occur in the pockets.

Tonsil stones, or tonsilloliths, are formed when this trapped debris hardens, or calcifies. This tends to happen most often in people who have chronic inflammation in their tonsils or repeated bouts of tonsillitis.

While many people have small tonsilloliths that develop in their tonsils, it is quite rare to have a large and solidified tonsil stone.

What Are the Symptoms of Tonsil Stones?

Many small tonsil stones do not cause any noticeable symptoms. Even when they are large, some tonsil stones are only discovered incidentally on X-rays or CT scans. Some larger tonsilloliths, however, may have multiple symptoms:

  • Bad breath . One of the prime indicators of a tonsil stone is exceedingly bad breath, or halitosis, that accompanies a tonsil infection. One study of patients with a form of chronic tonsillitis used a special test to see if volatile sulfur compounds were contained in the subjects’ breath. The presence of these foul-smelling compounds provides evidence of bad breath. The researchers found that 75% of the people who had abnormally high concentrations of these compounds also had tonsil stones. Other researchers have suggested that tonsil stones be considered in situations when the cause of bad breath is in question.
  • Sore throat . When a tonsil stone and tonsillitis occur together, it can be difficult to determine whether the pain in your throat is caused by your infection or the tonsil stone. The presence of a tonsil stone itself, though, may cause you to feel pain or discomfort in the area where it is lodged.
  • White debris. Some tonsil stones are visible in the back of the throat as a lump of solid white material. This is not always the case. Often they are hidden in the folds of the tonsils. In these instances, they may only be detectable with the help of non-invasive scanning techniques, such as CT scans or magnetic resonance imaging.
  • Difficulty swallowing. Depending on the location or size of the tonsil stone, it may be difficult or painful to swallow foods or liquids.
  • Ear pain . Tonsil stones can develop anywhere in the tonsil. Because of shared nerve pathways, they may cause a person to feel pain in the ear, even though the stone itself is not touching the ear.
  • Tonsil swelling. When collected debris hardens and a tonsil stone forms, inflammation from infection (if present) and the tonsil stone itself may cause a tonsil to swell or become larger.

How Are Tonsil Stones Treated?

The appropriate treatment for a tonsil stone depends on the size of the tonsillolith and its potential to cause discomfort or harm. Options include:

  • No treatment. Many tonsil stones, especially ones that have no symptoms, require no special treatment.
  • At-home removal. Some people choose to dislodge tonsil stones at home with the use of picks or swabs.
  • Salt water gargles. Gargling with warm, salty water may help ease the discomfort of tonsillitis, which often accompanies tonsil stones.
  • Antibiotics. Various antibiotics can be used to treat tonsil stones. While they may be helpful for some people, they cannot correct the basic problem that is causing tonsilloliths. Also, antibiotics can have side effects.
  • Surgical removal. When tonsil stones are exceedingly large and symptomatic, it may be necessary for a surgeon to remove them. In certain instances, a doctor will be able to perform this relatively simple procedure using a local numbing agent. Then the patient will not need general anesthesia.

Can Tonsil Stones Be Prevented?

Since tonsil stones are more common in people who have chronic tonsillitis, the only surefire way to prevent them is with surgical removal of the tonsils. This procedure, known as a tonsillectomy, removes the tissues of the tonsils entirely, thereby eliminating the possibility of tonsillolith formation.

Unlike tonsil stone extraction, tonsillectomies are typically performed under general anesthesia. Patients who undergo the surgery have difficulty swallowing and a sore throat for at least a few days after the procedure.

  • Dr. Carlo Oller (emergency physician with www.DrER.tv) has put together more than 1800 patient education videos which can be found at www.patienteducation.video
  • If you are looking for FREE medical education please visit this website. Please contact Dr. Carlo Oller at carlooller@gmail.com if you would like to use his videos in your own website, or educational materials. Or if you would like some more information or education on a title NOT available at this time.

Last updated 3/2/19

Last updatedL 3/2/19