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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.

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

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

Neurofibromatosis


Cleveland Clinic
Published on Oct 12, 2018
Cleveland Clinic’s Neurofibromatosis program offers comprehensive management and treatment of all forms of this complex disorder including NF1, NF2, segmental neurofibromatosis and schwannomatosis.

Neurofibromatosis is a genetic disorder that causes tumors to form on nerve tissue. These tumors can develop anywhere in your nervous system, including your brain, spinal cord and nerves. Neurofibromatosis is usually diagnosed in childhood or early adulthood.

The tumors are usually noncancerous (benign), but sometimes can become cancerous (malignant). Symptoms are often mild. However, complications of neurofibromatosis can include hearing loss, learning impairment, heart and blood vessel (cardiovascular) problems, loss of vision, and severe pain.

Neurofibromatosis treatment focuses on encouraging healthy growth and development in children affected with the disorder and early management of complications. When neurofibromatosis causes large tumors or tumors that press on a nerve, surgery can reduce symptoms. Some people may benefit from other therapies, such as stereotactic radiosurgery or medications to control pain.

Symptoms

There are three types of neurofibromatosis, each with different signs and symptoms.

Neurofibromatosis 1

Neurofibromatosis 1 (NF1) usually appears in childhood. Signs are often noticeable at birth or shortly afterward, and almost always by age 10. Signs and symptoms are often mild to moderate, but can vary in severity.

Signs and symptoms include:

  • Flat, light brown spots on the skin (cafe au lait spots). These harmless spots are common in many people. Having more than six cafe au lait spots is a strong indication of NF1. They are usually present at birth or appear during the first years of life. After early childhood, new spots stop appearing.
  • Freckling in the armpits or groin area. Freckling usually appears by ages 3 to 5. Freckles are smaller than cafe au lait spots and tend to occur in clusters in skin folds.
  • Tiny bumps on the iris of the eye (Lisch nodules). These harmless nodules can’t easily be seen and don’t affect vision.
  • Soft, pea-sized bumps on or under the skin (neurofibromas). These benign tumors usually develop in or under the skin, but can also grow inside the body. Sometimes, a growth will involve multiple nerves (plexiform neurofibroma). Plexiform neurofibromas, when located on the face, can cause disfigurement. Neurofibromas may increase with age.
  • Bone deformities. Abnormal bone growth and a deficiency in bone mineral density can cause bone deformities such as a curved spine (scoliosis) or bowed lower leg.
  • Tumor on the optic nerve (optic glioma). These tumors usually appear by age 3, rarely in late childhood and adolescence, and almost never in adults.
  • Learning disabilities. Impaired thinking skills are common in children with NF1 but are usually mild. Often there is a specific learning disability, such as a problem with reading or mathematics. Attention-deficit/hyperactivity disorder (ADHD) also is common.
  • Larger than average head size. Children with NF1 tend to have a larger than average head size due to increased brain volume.
  • Short stature. Children with NF1 often are below average in height.

Neurofibromatosis 2

Neurofibromatosis 2 (NF2) is much less common than NF1. Signs and symptoms of NF2 usually result from the development of benign, slow-growing tumors in both ears (acoustic neuromas), which can cause hearing loss. Also known as vestibular schwannomas, these tumors grow on the nerve that carries sound and balance information from the inner ear to the brain.

Signs and symptoms generally appear in the late teen and early adult years, and can vary in severity. Signs and symptoms can include:

  • Gradual hearing loss
  • Ringing in the ears
  • Poor balance
  • Headaches

Sometimes NF2 can lead to the growth of schwannomas in other nerves of the body, including the cranial, spinal, visual (optic) and peripheral nerves. Signs and symptoms of these schwannomas can include:

  • Numbness and weakness in the arms or legs
  • Pain
  • Balance difficulties
  • Facial drop
  • Vision problems or the development of cataracts

Schwannomatosis

This rare type of neurofibromatosis usually affects people after age 20. On average, symptoms appear between ages 25 and 30. Schwannomatosis causes tumors to develop on the cranial, spinal and peripheral nerves — but rarely on the nerve that carries sound and balance information from the inner ear to the brain. Because tumors don’t usually grow on both hearing nerves, schwannomatosis doesn’t cause the hearing loss experienced by people with NF2.

Symptoms of schwannomatosis include:

  • Chronic pain, which can occur anywhere in your body and can be disabling
  • Numbness or weakness in various parts of your body
  • Loss of muscle

When to see a doctor

See your doctor if you or your child develops signs or symptoms of neurofibromatosis. The tumors associated with neurofibromatosis are often benign and slow growing. So although it’s important to obtain a timely diagnosis, the situation isn’t an emergency.

Causes

Neurofibromatosis is caused by genetic defects (mutations) that either are passed on by a parent or occur spontaneously at conception. The specific genes involved depend on the type of neurofibromatosis:

  • NF1. The NF1 gene is located on chromosome 17. This gene produces a protein called neurofibromin that helps regulate cell growth. The mutated gene causes a loss of neurofibromin, which allows cells to grow uncontrolled.
  • NF2. The NF2 gene is located on chromosome 22, and produces a protein called merlin (also called schwannomin), which suppresses tumors. The mutated gene causes a loss of merlin, leading to uncontrolled cell growth.
  • Schwannomatosis. So far, two genes are known to cause schwannomatosis. Mutations of the genes SMARCB1 and LZTR1, which suppress tumors, are associated with this type of neurofibromatosis.

Risk factors

The biggest risk factor for neurofibromatosis is a family history of the disorder. About half of people with NF1 and NF2 inherited the disease from the affected parent. People with NF1 and NF2 that don’t have affected relatives likely have a new gene mutation.

NF1 and NF2 are both autosomal dominant disorders, which means that any child of a parent with the disorder has a 50 percent chance of inheriting the genetic mutation.

The inheritance pattern for schwannomatosis is less clear. Researchers currently estimate that the risk of inheriting schwannomatosis from an affected parent is about 15 percent.

Complications

Complications of neurofibromatosis vary, even within the same family. Generally, complications result from tumor growth distorting nerve tissue or pressing on internal organs.

NF1 complications

Complications of NF1 include:

  • Neurological problems. Learning and thinking difficulties are the most common neurological problems associated with NF1. Uncommon complications include epilepsy and the buildup of excess fluid in the brain.
  • Concerns with appearance. Visible signs of neurofibromatosis — such as extensive cafe au lait spots, many neurofibromas in the facial area or large neurofibromas — can cause anxiety and emotional distress, even if they’re not medically serious.
  • Skeletal problems. Some children have abnormally formed bones, which can result in bowing of the legs and fractures that sometimes don’t heal. NF1 can cause curvature of the spine (scoliosis) that may need bracing or surgery. NF1 is also associated with decreased bone mineral density, which increases the risk of weak bones (osteoporosis).
  • Vision problems. Sometimes a tumor develops in children on the optic nerve (optic glioma), which can affect vision.
  • Problems during times of hormonal change. Hormonal changes associated with puberty or pregnancy might cause an increase in neurofibromas. Most women with NF1 have healthy pregnancies but will likely need monitoring by an obstetrician familiar with the disorder.
  • Cardiovascular problems. People with NF1 have an increased risk of high blood pressure and may develop blood vessel abnormalities.
  • Breathing problems. Rarely, plexiform neurofibromas can put pressure on the airway.
  • Cancer. An estimated 3 to 5 percent of people with NF1 develop cancerous tumors. These usually arise from neurofibromas under the skin or from plexiform neurofibromas. People with NF1 also have a higher risk of other forms of cancer, such as breast cancer, leukemia, colorectal cancer, brain tumors and some types of soft tissue cancer. Women with NF1 should start screening for breast cancer at an earlier age than the general population.
  • Benign adrenal gland tumor (pheochromocytoma). This noncancerous tumor secretes hormones that raise your blood pressure. Surgery is usually needed to remove the pheochromocytoma.

NF2 complications

Complications of NF2 include:

  • Partial or total deafness
  • Facial nerve damage
  • Vision problems
  • Small benign skin tumors (skin schwannomas)
  • Weakness or numbness in the extremities
  • Multiple benign brain tumors or spinal tumors (meningiomas) requiring frequent surgeries

Schwannomatosis complications

The pain caused by schwannomatosis can be debilitating and may require surgical treatment or management by a pain specialist.

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

Neurofibromatosis NF1

What is neurofibromatosis type 1? 

— Neurofibromatosis type 1, also called NF1, is a genetic disorder that causes brown blotches and abnormal growths on the skin and along nerves. It is usually passed on in families, but children can sometimes get it even if their parents do not have it.

What are the signs and symptoms of NF1? 

— The signs and symptoms include:

●Abnormal growths or tumors (called “neurofibromas”) that form on the skin and along nerves

●Blotches of light to medium brown skin that look like giant freckles (called “café-au-lait spots”)

●Freckling of the skin in the armpits and in the crease where the legs meet the body

●Spots on the colored part of the eye that look like tiny freckles

●Problems with the way bones form, which can cause:

•Bumps along the arms or legs that look like joints but aren’t

•Deformed body parts (including the face)

•A curved spine or backbone (called “scoliosis”)

•Bones that break easily

•Short height for age

NF1 can also cause tumors to form inside the brain, around the nerves that connect the brain to the eye, and in other parts of the body. Some of these tumors can become cancer.

Should I take my child to see a doctor or nurse? 

— Yes. If your child develops any of the signs or symptoms listed above, take him or her to see the doctor or nurse.

Will my child need tests? 

— Maybe. If the doctor or nurse suspects your child has NF1, he or she will do an exam and ask you questions. Doctors can diagnose NF1 based on the results of the exam.

There is a blood test to check for the genetic problem that causes NF1. But doctors can diagnose NF1 without that test, so it is not always needed. If your child does have the genetic test, keep in mind that a child can have the genetic problem that causes NF1 but have only mild symptoms.

How is NF1 treated? 

— The most important part of treatment involves checking for changes that could mean NF1 is causing problems. Children with NF1 must see the doctor at least once a year and have certain tests. If NF1 starts causing certain problems, those problems must be treated. For example, if a skin growth gets too big or starts causing pain, surgery can be done to remove the growth.

What if my child wants to have children? 

— There is a chance your child would have children with the same problem. When your child grows up, he or she should talk to a doctor to find out what the risks might be.

What will my child’s life be like? 

— Your child will need medical care throughout his or her life. It’s best if he or she is treated by a team of experts who have experience with NF1. As your child ages, he or she will probably develop more neurofibromas and other health problems caused by NF1. Many of these problems can be dealt with, but some are very serious.

Esclerosis Multiple

¿Qué es la esclerosis múltiple? — La esclerosis múltiple es una enfermedad que causa problemas de visión, adormecimiento y hormigueo, y debilidad muscular, entre otros. Se produce cuando el sistema del organismo para luchar contra las infecciones ataca y daña las células nerviosas y sus conexiones en el cerebro y la médula espinal. El proceso en el que el sistema del organismo para luchar contra las infecciones, llamado “sistema inmunitario”, ataca las células del propio organismo se llama “respuesta autoinmune”.

Muchas personas usan las siglas “EM” para referirse a la esclerosis múltiple.

¿Cuales son los síntomas de la esclerosis múltiple? — El padecimiento puede causar muchos síntomas, pero no todas las personas con esclerosis múltiple tienen todos los síntomas. Además, los síntomas de la esclerosis múltiple también pueden ser causados por otros problemas. En general, los síntomas de la esclerosis múltiple pueden incluir:

●Adormecimiento, hormigueo y sensación de cosquilleo

●Debilidad o espasmos musculares, que pueden hacer que se le caigan cosas o se caiga

●Problemas de visión, dolor en los ojos y movimientos extraños de los ojos

●Sentirse mareado o perder el equilibrio, lo que puede hacer que se caiga

●Problemas para caminar o hablar

●Problemas para controlar esfínteres

●Problemas sexuales

●Sensibilidad al calor, lo que empeora los síntomas

●Problemas para pensar con claridad

La mayoría de las personas con esclerosis múltiple tienen solo unos pocos de estos síntomas, pero las personas con esclerosis múltiple grave pueden tener todos estos síntomas o la mayoría.

¿Existen distintas formas de esclerosis múltiple? — Sí. Los médicos dan distintos nombres a la esclerosis múltiple según cómo avanza. La enfermedad puede ser:

Con recaídas y remisiones – Esto significa que los síntomas de la esclerosis múltiple van y vienen. La agudización de los síntomas se llama “ataque”. Estos ataques pueden durar de días a semanas y por lo general mejoran lentamente. Entre ataques, las personas a menudo se sienten bastante bien, pero algunas personas tienen problemas duraderos incluso después de que un ataque mejora. La esclerosis múltiple con recaídas y remisiones es el tipo más frecuente.

Secundaria progresiva – Esto significa que los síntomas van y vienen al principio, pero después comienzan a empeorar constantemente. Esto les sucede a muchas personas que al principio tienen la enfermedad con recaídas y remisiones.

Primaria progresiva – Esto significa que los síntomas empeoran en forma constante desde el inicio.

Progresiva con recaídas – Esto significa que los síntomas empeoran constantemente, y además también tiene ataques que van y vienen.

¿Existe una prueba para detectar la esclerosis múltiple? — Sí y no. Si su médico sospecha que usted tiene esclerosis múltiple, puede indicar que se realice una resonancia magnética nuclear del cerebro y en algunos casos de la médula espinal. La resonancia magnética nuclear es un estudio de imagen que crea imágenes del interior del cuerpo. Esta prueba puede mostrar si sus nervios están dañados. Incluso si esto es así, es posible que esta prueba no pueda mostrar de inmediato si usted tiene esclerosis múltiple. En muchos casos, los médicos pueden diagnosticar la esclerosis múltiple solo después de ver cambios en los síntomas y las pruebas con el paso del tiempo.

¿Debo consultar a un médico o enfermero? — Consulte a su médico o enfermero de inmediato si tiene alguno de los síntomas mencionados anteriormente y no sabe cuál es la causa.

¿Cómo se trata la esclerosis múltiple? — Depende del tipo de esclerosis múltiple que tenga. Existen distintas medicinas para lo siguiente:

●Tratar los ataques – Si tiene un ataque de esclerosis múltiple, su médico puede darle medicinas llamadas esteroides. No son los mismos esteroides que toman los atletas para aumentar la masa muscular. Estos esteroides reducen la respuesta autoinmune del cuerpo para poder reducir la duración del ataque.

●Prevenir los ataques – Existen varias medicinas para las personas que tienen ataques de esclerosis múltiple (esclerosis múltiple con recaídas y remisiones). Se llaman “medicinas que modifican la enfermedad”, y reducen las probabilidades de que los síntomas de la esclerosis múltiple se agudicen, pero no curan la enfermedad Muchas de estas medicinas vienen en inyecciones. Muchas personas aprenden a ponerse ellas mismas las inyecciones. Algunas medicinas más nuevas para la esclerosis múltiple vienen en forma de píldoras o cápsulas que se pueden tragar. Otras medicinas se aplican mediante una inyección en una vena. Hable con su médico sobre el tipo de medicina más adecuado para usted.

●Retrasar el avance de la esclerosis múltiple progresiva – Una medicina llamada ocrelizumab puede servir para algunas personas con esclerosis múltiple progresiva primaria. No cura la enfermedad, pero podría retrasar su avance. También podría servirles a algunas personas que padecen esclerosis multiple con recaídas y remisiones.

¿Hay algo que pueda hacer por mi cuenta para sentirme mejor? — Es importante informarle a su médico o enfermero todos sus síntomas, incluso aunque no crea que estén relacionados con la esclerosis múltiple. Por ejemplo, si se siente deprimido, tiene pérdidas de orina, o problemas sexuales, dígaselo a su médico o enfermero. De esa forma, le puede ofrecer tratamientos para esos síntomas específicos.

¿Qué sucede si quiero quedar embarazada? — Consulte a su médico antes de comenzar a buscar un embarazo. Ciertas medicinas para la esclerosis múltiple no se deben usar durante el embarazo, porque no son seguras para el bebé. Otras medicinas para la esclerosis múltiple podrían ser aptas para tomar durante el embarazo, si es necesario hacerlo. Algunos médicos recomiendan dejar las medicinas para la esclerosis múltiple justo antes del embarazo y durante este, siempre que sea posible. Si tiene un ataque de esclerosis múltiple mientras está embarazada, es seguro tomar esteroides para manejar los síntomas.

¿Cómo será mi vida? — Si le diagnosticaron esclerosis múltiple recientemente, trate de mantener una actitud positiva. En la mayoría de las personas, la enfermedad avanza muy lentamente. En promedio, la esclerosis múltiple tarda muchos años en causar discapacidad grave. Además, las medicinas usadas para tratar la esclerosis múltiple con frecuencia son muy buenas para prevenir los ataques. Algunas personas con esclerosis múltiple con recaídas y remisiones pueden pasar muchos meses e incluso años sin ataques. A pesar de esto, es imposible decir en cuánto tiempo empeorarán los síntomas de una persona.

Multiple Sclerosis

What is multiple sclerosis? — Multiple sclerosis is a disease that causes vision problems, numbness and tingling, muscle weakness, and other problems. It happens when the body’s infection-fighting system attacks and damages nerve cells and their connections in the brain and spinal cord. When the body’s infection-fighting system, called the “immune system,” attacks the body’s own cells, it is called an “autoimmune response.”

Many people refer to multiple sclerosis as “MS.”

What are the symptoms of MS? — The condition can cause many symptoms, but not everyone with MS has all of them. Plus, the symptoms of MS can also be caused by problems other than MS. In general, MS symptoms can include:

●Numbness, tingling, and feeling “pins and needles”

●Muscle weakness or spasms, which can cause you to drop things or fall

●Vision problems, eye pain, and odd eye movements

●Feeling dizzy or off-balance, which can cause you to fall

●Trouble walking or speaking

●Problems controlling your bowels or bladder

●Sex problems

●Sensitivity to heat, which makes symptoms worse

●Trouble thinking clearly

Most people with MS have only a few of these symptoms. But people with severe MS can have most or all of them.

Are there different forms of MS? — Yes. Doctors give different names to MS, depending on how it progresses. The disease can be:

Relapsing-remitting – This means the symptoms of MS come and go. When the symptoms flare up, it is called an “attack” or “relapse.” These attacks can last for days to weeks and usually get better slowly. In between attacks, people often feel pretty normal. But some people have problems that last even after an attack gets better. Relapsing-remitting is the most common type of MS.

Secondary progressive – This means the symptoms come and go at first but then begin to steadily get worse. This happens to many people who start out with relapsing-remitting disease.

Primary progressive – This means the symptoms steadily get worse from the beginning.

Progressive relapsing – This means the symptoms steadily get worse, and on top of that there are also attacks that come and go.

Is there a test for MS? — Yes and no. If your doctor suspects you have MS, he or she can order an MRI of your brain and sometimes your spinal cord. An MRI is an imaging test that creates pictures of the inside of your body. This test can show whether your nerves are damaged. Even so, this test might not be able to show right away if you have MS. In many cases, doctors can diagnose MS only after seeing how symptoms and test results change over time.

In some cases, your doctor might order additional tests to see if you have MS. These might include:

●A lumbar puncture (sometimes called a “spinal tap”) – During this procedure, a doctor puts a thin needle into your lower back and removes a small amount of spinal fluid. He or she then checks the fluid for signs of MS.

●A test called “evoked potentials” or “evoked responses” – This is a way for the doctor to look at the electrical signals in your brain and spinal cord. It involves sticking small “electrodes” to your skin. The doctor can then measure the nerve signals in your brain while you look at lights, listen to sounds, or feel a mild electrical current.

●Optical coherence tomography – This test uses a special light to look at the inside of your eyes for signs of MS.

In other cases, you may need blood tests to check for diseases that can be similar to MS.

Should I see a doctor or nurse? — See your doctor or nurse right away if you have any of the symptoms listed above and you do not know what is causing them.

How is MS treated? — It depends on what type of MS you have. There are different medicines for:

●Treating attacks – If you have an MS attack, your doctor can give you medicines called steroids. These are different than the steroids athletes take to build up muscle. They reduce the body’s autoimmune response, so they can shorten the length of an attack.

●Preventing attacks – There are several different medicines for people who have MS attacks (relapsing-remitting MS). These medicines are called “disease-modifying therapy.” They reduce the chances that MS symptoms will flare up. But they do not cure the disease. Some of these medicines come in shots. Many people learn to give themselves the shots. Some newer medicines for MS come as pills or capsules that you can swallow. Other medicines are given through a thin tube that goes into a vein, called an “IV.” There are different schedules for the IV medicines, but most involve doses only every few weeks or months.

Some of these medicines might also reduce the chances that MS attacks will turn into progressive MS. Talk to your doctor about which kind of medicine is best for you.

●Slowing down progressive MS – A medicine called ocrelizumab can help some people with primary progressive MS. This medicine is a type of disease-modifying therapy and is also used in people with relapsing-remitting MS. It doesn’t cure the disease, but it might slow it down. This medicine might also help some people with relapsing-remitting MS.

Doctors can also treat symptoms of MS. So it’s important to tell your doctor or nurse about all your symptoms, even if you do not think they have anything to do with MS. For example, if you feel depressed, leak urine, or have sex problems, tell your doctor or nurse. That way, he or she can offer you treatments to deal with those specific symptoms.

What if I want to get pregnant? — Talk to your doctor before you start trying to get pregnant. Certain MS medicines should not be used during pregnancy, because they are not safe for a baby. Other MS medicines might be OK to use during pregnancy, if necessary. Some doctors recommend going off MS medicines right before and during pregnancy when possible. If you have an MS attack while you are pregnant, you can still safely take steroids to deal with symptoms.

What will my life be like? — If you were recently diagnosed with MS, try to stay positive. In most people, the disease progresses very slowly. On average, it takes many years before MS causes serious disability. Plus, the medicines used to treat MS are often very good at preventing attacks. Some people with relapsing-remitting MS can go many months or even years between attacks. Even so, it’s impossible to say how fast symptoms will get worse for any one person.

Narcolepsia

¿Qué es la narcolepsia? — La narcolepsia es una enfermedad cerebral que provoca sueño casi todo el tiempo. Las personas con narcolepsia a veces se quedan dormidas de repente, incluso cuando no lo esperan. Hasta pueden quedarse dormidas en medio de una actividad, como comer, hablar o conducir.

Por lo general, la narcolepsia se desarrolla durante la adolescencia o los primeros años de la adultez. Algunas personas comienzan a sufrirla antes de estas etapas y otras después. Una vez que empieza, el trastorno puede dificultar el trabajo, el estudio u otras actividades normales.

¿Cuáles son los síntomas de la narcolepsia? — Los síntomas pueden ser, entre otros:

●Somnolencia durante el día

●Dormirse de repente, con frecuencia en momentos inoportunos – Esto es lo que algunas personas llaman “ataques de sueño”.

●Caerse, cojear o sentirse débil de repente, en especial al emocionarse, enojarse o reírse – El término médico para esto es “cataplexia”.

●No poder moverse o hablar inmediatamente después de despertarse o justo antes de dormirse

●Ver, sentir o escuchar cosas que no son reales en los instantes antes de dormirse o justo después de despertarse – Esto puede causar temor y parecer muy real.

Algunas personas que padecen narcolepsia también tienen dificultades con la depresión o la ansiedad. Algunos de los síntomas de la depresión son sentirse triste la mayor parte del tiempo o perder interés en cosas que antes se disfrutaban. Uno de los síntomas de la ansiedad es sentirse preocupado la mayor parte del tiempo.

¿Debo consultar a un médico o enfermero? — Sí. Si tiene síntomas de narcolepsia, consulte a su médico o enfermero. Los síntomas pueden ser peligrosos si aparecen al conducir o hacer algo que podría provocar una caída o lesión.

También debe hablar con su médico o enfermero si piensa que podría tener depresión o ansiedad. Existen tratamientos que pueden ayudar.

¿Es necesario que me realice pruebas? — Sí. Si su médico o enfermero sospecha que tiene narcolepsia, es posible que le pida que se realice un “estudio del sueño”. Para el estudio, debe ir a un laboratorio del sueño, donde lo conectan a diferentes máquinas que supervisan su frecuencia cardíaca, su respiración, su actividad cerebral y otras funciones del organismo mientras duerme por la noche. Varias horas después de terminar el estudio del sueño, se hace otra prueba en la que se baja la intensidad de las luces y le dan un momento a solas para que trate de tomar varias siestas.

Las personas con narcolepsia tienen patrones de sueño anormales en las siestas y por la noche. Estos patrones anormales se pueden detectar durante los estudios.

¿Cómo se trata la narcolepsia? — La narcolepsia se suele tratar con cambios de comportamiento. Las personas con el trastorno deben:

●Evitar medicinas que provoquen somnolencia, como algunas medicinas para la alergia

●Tomar siestas antes de eventos importantes y en horarios programados del día

●Mantener un cronograma de sueño regular

●Asegurarse de dormir lo suficiente por la noche

Las personas que sufren mucha somnolencia incluso después de aplicar estas medidas pueden recibir medicinas que las ayuden a mantenerse despiertas. Las medicinas pueden ayudar, pero aun con tratamiento, los pacientes pueden sentirse somnolientos. Es por eso que incluso las personas que reciben tratamiento deben tener cuidado con las actividades que hacen. Por ejemplo, conducir puede ser peligroso para las personas con narcolepsia.

Las medicinas que se usan para ayudar a los pacientes a mantenerse despiertos a veces pueden causar presión arterial alta, pérdida del apetito y otros problemas. Si su médico le receta una de estas medicinas, asegúrese de conocer los riesgos.

Las personas que tienen debilidad muscular o cojean cuando tienen emociones fuertes también pueden tomar medicinas para aliviar este problema.

¿Hay algo que pueda hacer por mi cuenta para sobrellevar la narcolepsia? — Si tiene narcolepsia, considere consultar a un terapeuta y trate de buscar apoyo en el trabajo o la escuela. Este padecimiento puede producirle tristeza, frustración y vergüenza. Además, otras personas que no entienden la enfermedad a veces pueden tratarlo de haragán o acusarlo de evitar sus deberes. Todo esto puede ser difícil de sobrellevar, por lo que puede ser útil contar con alguien con quien hablar.

Narcolepsy

What is narcolepsy? — Narcolepsy is a brain disorder that makes you feel sleepy most of the time. People with narcolepsy sometimes fall asleep all of a sudden, even when they don’t expect to. They can even fall asleep while they are in the middle of activities, such as eating, talking, or driving.

People usually develop narcolepsy during their teens or early 20s. Some people get it earlier and others later. Once it starts, the disorder can make it hard to work, do schoolwork, or do other normal activities.

What are the symptoms of narcolepsy? — The symptoms can include:

●Feeling sleepy during the day

●Falling asleep all of a sudden, often at inappropriate times – Some people call these “sleep attacks.”

●Suddenly falling down, going limp, or feeling weak, especially when excited, angry, or laughing – The medical term for this is “cataplexy.”

●Being unable to move or speak in the few moments right after waking or just before falling asleep

●Seeing, feeling, or hearing things that are not really there in the few moments before falling asleep or right after waking up – This can be scary and feel very real.

Some people with narcolepsy also have problems with depression or anxiety. Symptoms of depression include feeling sad most of the time, or losing interest in things you used to like to do. Symptoms of anxiety include feeling worried most of the time.

Should I see a doctor or nurse? — Yes, if you have symptoms of narcolepsy, see your doctor or nurse. The symptoms can be dangerous if they happen while you are driving or doing something that could lead to a fall or injury.

You should also talk to your doctor or nurse if you think you might have depression or anxiety. There are treatments that can help.

Will I need tests? — Yes. If your doctor or nurse suspects you have narcolepsy, he or she might send you for a “sleep study.” For the study, you go to a sleep lab where you are hooked up to different machines that monitor your heart rate, breathing, brain activity, and other body functions while you sleep at night. Several hours after the sleep study is done, another test is done in which the lights are dimmed and you are given privacy and asked to try napping several times.

People with narcolepsy have abnormal sleep patterns during naps and at night. These abnormal patterns can be detected during the studies.

How is narcolepsy treated? — Narcolepsy is usually treated with behavior changes. People with the disorder should:

●Avoid medicines that can make people sleepy, such as some allergy medicines

●Take naps just before important events and at scheduled times during the day

●Keep a regular sleep schedule

●Make sure they get enough sleep at night

People who are still very sleepy even if they make these changes can be treated with medicines to help them stay awake. These medicines can help, but even with treatment, people can still feel sleepy. That’s why even people who are being treated have to be careful about the activities they do. Driving, for example, can be dangerous for people with narcolepsy.

The medicines used to help people stay awake can sometimes cause high blood pressure, decreased appetite, and other problems. If your doctor prescribes one of these medicines, make sure you understand the risks.

People who have muscle weakness or go limp when they feel strong emotions can get medicines to help with that problem, too.

Is there anything I can do on my own to deal with narcolepsy? — If you have narcolepsy, think about seeing a counselor and try to find support at work or school. This condition can make you feel sad, frustrated, and embarrassed. Plus, other people who do not understand the condition can sometimes treat you like you are lazy or accuse you of avoiding things. All of this can be hard to deal with, so it can help to have someone to talk to.