ibs

Ulcerative Colitis

Ulcerative colitis is a condition in which the lining of the large intestine (colon) and rectum become inflamed. It is a form of inflammatory bowel disease (IBD). Crohn disease is a related condition.

Causes

The cause of ulcerative colitis is unknown. People with this condition have problems with their immune system. However, it is not clear if immune problems cause this illness. Stress and certain foods can trigger symptoms, but they do not cause ulcerative colitis.

Ulcerative colitis may affect any age group. There are peaks at ages 15 to 30 and then again at ages 50 to 70.

The disease begins in the rectal area. It may stay in the rectum or spread to higher areas of the large intestine. However, the disease does not skip areas. It may involve the entire large intestine over time.

Risk factors include a family history of ulcerative colitis or other autoimmune diseases, or Jewish ancestry.

Symptoms

The symptoms can be more or less severe. They may start slowly or suddenly. Half of people only have mild symptoms. Others have more severe attacks that occur more often. Many factors can lead to attacks.

Symptoms may include:

  • Pain in the abdomen (belly area) and cramping
  • A gurgling or splashing sound heard over the intestine
  • Blood and possibly pus in the stools
  • Diarrhea, from only a few episodes to very often
  • Feeling that you need to pass stools, even though your bowels are already empty. It may involve straining, pain, and cramping (tenesmus).
  • Weight loss
  • Children’s growth may slow.

Other symptoms that may occur with ulcerative colitis include the following:

  • Joint pain and swelling
  • Mouth sores (ulcers)
  • Nausea and vomiting
  • Skin lumps or ulcers

Exams and Tests

Colonoscopy with biopsy is most often used to diagnose ulcerative colitis. Colonoscopy is also used to screen people with ulcerative colitis for colon cancer.

Other tests that may be done to help diagnose this condition include:

  • Barium enema
  • Complete blood count (CBC)
  • C-reactive protein (CRP)
  • Erythrocyte sedimentation rate (ESR)
  • Stool calprotectin or lactoferrin
  • Antibody tests by blood

Sometimes, tests of the small intestine are needed to differentiate between ulcerative colitis and Crohn disease, including:

  • CT scan
  • MRI
  • Upper endoscopy or capsule study
  • MR enterography

Treatment

The goals of treatment are to:

  • Control the acute attacks
  • Prevent repeated attacks
  • Help the colon heal

During a severe episode, you may need to be treated in the hospital. Your doctor may prescribe corticosteroids. You may be given nutrients through a vein (IV line).

Diet And Nutrition

Certain types of foods may worsen diarrhea and gas symptoms. This problem may be more severe during times of active disease. Diet suggestions include:

  • Eat small amounts of food throughout the day.
  • Drink plenty of water (drink small amounts throughout the day).
  • Avoid high-fiber foods (bran, beans, nuts, seeds, and popcorn).
  • Avoid fatty, greasy or fried foods and sauces (butter, margarine, and heavy cream).
  • Limit milk products if you are lactose intolerant. Dairy products are a good source of protein and calcium.

Stress

You may feel worried, embarrassed, or even sad or depressed about having a bowel accident. Other stressful events in your life, such as moving, or losing a job or a loved one can cause worsening of digestive problems.

Ask your health care provider for tips about how to manage your stress.

Medicines

Medicines that may be used to decrease the number of attacks include:

  • 5-aminosalicylates such as mesalamine or sulfasalazine, which can help control moderate symptoms. Some forms of the drug are taken by mouth. Others must be inserted into the rectum.
  • Medicines to quiet the immune system.
  • Corticosteroids such as prednisone. They may be taken by mouth during a flare-up or inserted into the rectum.
  • Immunomodulators, medicines taken by mouth that affect the immune system, such as azathioprine and 6-MP.
  • Biologic therapy, if you do not respond to other drugs.
  • Acetaminophen (Tylenol) may help relieve mild pain. Avoid drugs such as aspirin, ibuprofen (Advil, Motrin), or naproxen (Aleve, Naprosyn). These can make your symptoms worse.

Surgery

Surgery to remove the colon will cure ulcerative colitis and removes the threat of colon cancer. You may need surgery if you have:

  • Colitis that does not respond to complete medical therapy
  • Changes in the lining of the colon that suggests an increased risk for cancer
  • Severe problems, such as rupture of the colon, severe bleeding, or toxic megacolon

Most of the time, the entire colon, including the rectum, is removed. After surgery, you may have:

  • An opening in your belly called the stoma (ileostomy). Stool will drain out through this opening.
  • A procedure that connects the small intestine to the anus to gain more normal bowel function.

Support Groups

Social support can often help with the stress of dealing with illness, and support group members may also have useful tips for finding the best treatment and coping with the condition.

The Crohn’s and Colitis Foundation of America (CCFA) has information and links to support groups.

Outlook (Prognosis)

Symptoms are mild in about one half of people with ulcerative colitis. More severe symptoms are less likely to respond well to medicines.

Cure is only possible through complete removal of the large intestine.

The risk for colon cancer increases in each decade after ulcerative colitis is diagnosed.

Possible Complications

You have a higher risk for small bowel and colon cancer if you have ulcerative colitis. At some point, your provider will recommend tests to screen for colon cancer.

More severe episodes that recur may cause the walls of the intestines to become thickened, leading to:

  • Colon narrowing or blockage (more common in Crohn disease)
  • Episodes of severe bleeding
  • Severe infections
  • Sudden widening (dilation) of the large intestine within one to a few days (toxic megacolon)
  • Tears or holes (perforation) in the colon
  • Anemia, low blood count

Problems absorbing nutrients may lead to:

  • Thinning of the bones (osteoporosis)
  • Problems maintaining a healthy weight
  • Slow growth and development in children
  • Anemia or low blood count

Less common problems that may occur include:

  • Type of arthritis that affects the bones and joints at the base of the spine, where it connects with the pelvis (ankylosing spondylitis)
  • Liver disease
  • Tender, red bumps (nodules) under the skin, which may turn into skin ulcers
  • Sores or swelling in the eye

When to Contact a Medical Professional

Contact your provider if:

  • You develop ongoing abdominal pain, new or increased bleeding, fever that does not go away, or other symptoms of ulcerative colitis
  • You have ulcerative colitis and your symptoms worsen or do not improve with treatment
  • You develop new symptoms

Prevention

There is no known prevention for this condition.

References

Chan NC, Weitz JI. Venous thromboembolism. In: Hoffman R, Benz EJ, Silberstein LE, et al, eds. Hematology: Basic Principles and Practice. 8th ed. Philadelphia, PA: Elsevier; 2023:chap 140.

Kabrhel C. Pulmonary embolism and deep vein thrombosis. In: Walls RM, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10th ed. Philadelphia, PA: Elsevier; 2023:chap 74.

Lockhart ME, Umphrey HR, Weber TM, Robbin ML. Peripheral vessels. In: Rumack CM, Levine D, eds. Diagnostic Ultrasound. 5th ed. Philadelphia, PA: Elsevier; 2018:chap 27.

Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert panel report. Chest. 2021;160(6):e545-e608. PMID: 34352278 pubmed.ncbi.nlm.nih.gov/34352278/

Chronic Venous Thrombotic Disease

Chronic Venous Thrombotic Disease—also known as deep vein thrombosis (DVT)—is a condition that occurs when a blood clot forms in a vein deep inside a part of the body.

DVT mainly affects the large veins in the lower leg and thigh, but can occur in other deep veins, such as in the arms and pelvis. DVT most often affects only one side of the body.

Causes

DVT is most common in adults over age 60. But it can occur at any age. When a clot breaks off and moves through the bloodstream, it is called an embolism. An embolism can get stuck in the blood vessels in the brain, lungs, heart, or another area, leading to severe damage.

Blood clots may form when something slows or changes the flow of blood in the veins.

Risk factors include:

  • A pacemaker catheter that has been passed through a vein in the groin
  • Bed rest or sitting in one position for too long, such as plane travel
  • Family history of blood clots
  • Fractures in the pelvis or legs
  • Giving birth within the last 6 months
  • Pregnancy
  • Obesity
  • Recent surgery (most commonly hip, knee, or female pelvic surgery)
  • Too many blood cells being made by the bone marrow, causing the blood to be thicker than normal (polycythemia vera)
  • Having an indwelling (long-term) catheter in a blood vessel
  • Age greater than 60

Blood is more likely to clot in someone who has certain problems or disorders, such as:

  • Cancer
  • Certain autoimmune disorders, such as lupus
  • Cigarette smoking
  • Conditions that make it more likely to develop blood clots
  • Taking estrogens or birth control pills (this risk is even higher with smoking)

Sitting for long periods when traveling can increase the risk for DVT. This is most likely when you also have one or more of the risk factors listed above.

Symptoms

DVT mainly affects the large veins in the lower leg and thigh, most often on one side of the body. The clot can block blood flow and cause:

  • Redness of the skin
  • Skin that feels warm to the touch
  • Swelling (edema) of a leg or arm
  • Pain or tenderness in a leg or arm

Exams and Tests

Your health care provider will perform a physical exam. The exam may show a red, swollen, or tender leg.

Tests that are often done to diagnose a DVT are:

Blood tests may be done to check if you have an increased chance of blood clotting, including:

Treatment

Your provider will give you medicine to thin your blood (called an anticoagulant). This will keep more clots from forming or old ones from getting bigger.

Heparin is often the first medicine you will receive.

  • If heparin is given through a vein (IV), you must stay in the hospital. However, most people can be treated without staying in the hospital.
  • Low molecular weight heparin can be given by injection under your skin once or twice a day. You may not need to stay in the hospital as long, or at all, if you are prescribed this type of heparin.

One type of blood-thinning medicine called warfarin (Coumadin or Jantoven) may be started along with heparin. Warfarin is taken by mouth. It takes several days to fully work.

Another class of blood thinners are called direct oral anticoagulants (DOAC), including:

  • Rivaroxaban (Xarelto)
  • Apixaban (Eliquis)
  • Dabigatran (Pradaxa)
  • Edoxaban (Savaysa)

These medicines work in a similar way to heparin and can be used right away in place of heparin. Your provider will decide which medicine is right for you.

You will most likely take a blood thinner for at least 3 months. Some people take it longer, or even for the rest of their lives, depending on their risk for another clot.

When you are taking a blood thinning medicine, you are more likely to bleed, even from activities you have always done. If you are taking a blood thinner at home:

  • Take the medicine just the way your provider prescribed it.
  • Ask your provider what to do if you miss a dose.
  • Ask your provider if you need to take an oral medicine on an empty stomach.
  • Get blood tests as advised by your provider to make sure you are taking the right dose. These tests are usually needed with people who are taking warfarin.
  • Find out how to watch for problems caused by the medicine.

In rare cases, you may need a procedure instead of or in addition to anticoagulants. These may involve:

  • Placing a filter in the body’s largest vein to prevent blood clots from traveling to the lungs
  • Removing a large blood clot from the vein or injecting clot-busting medicines

Follow any other instructions you are given to treat your DVT.

Outlook (Prognosis)

DVT often goes away without a problem, but the condition can return. The symptoms can appear right away or you may not develop them for one or more years afterward. Wearing compression stockings during and after the DVT may help prevent this problem.

Possible Complications

Complications of DVT may include:

  • Pulmonary embolism (which may be fatal)
  • Constant pain and swelling (post-phlebitic or post-thrombotic syndrome)
  • Varicose veins
  • Non-healing skin ulcers (less common)
  • Changes in skin color

When to Contact a Medical Professional

Contact your provider if you have symptoms of DVT.

Go to the emergency room or call the local emergency number (such as 911) if you have DVT and you develop:

Prevention

To prevent DVT:

  • Move your legs often during long plane trips, car trips, and other situations in which you are sitting or lying down for long periods.
  • Take blood-thinning medicines your provider prescribes.
  • DO NOT smoke. Smoking increases the risk for blood clots. Talk to your provider if you need help quitting.
  • DO NOT smoke. Smoking increases the risk for blood clots. Talk to your provider if you need help quitting.

References

Chan NC, Weitz JI. Venous thromboembolism. In: Hoffman R, Benz EJ, Silberstein LE, et al, eds. Hematology: Basic Principles and Practice. 8th ed. Philadelphia, PA: Elsevier; 2023:chap 140.

Kabrhel C. Pulmonary embolism and deep vein thrombosis. In: Walls RM, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10th ed. Philadelphia, PA: Elsevier; 2023:chap 74.

Lockhart ME, Umphrey HR, Weber TM, Robbin ML. Peripheral vessels. In: Rumack CM, Levine D, eds. Diagnostic Ultrasound. 5th ed. Philadelphia, PA: Elsevier; 2018:chap 27.

Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert panel report. Chest. 2021;160(6):e545-e608. PMID: 34352278 pubmed.ncbi.nlm.nih.gov/34352278/

sleep apnea

Sleep Apnea

People with sleep apnea stop breathing for short periods of time while they are asleep. They usually do not wake up completely when this happens, but in the morning, they feel exhausted and continue to feel sleepy during the day.

There are two types of sleep apnea. Obstructive sleep apnea is the most common. It happens when your throat muscles relax, blocking your airway. The other type, central sleep apnea, is caused when your brain does not send the right signals to the muscles that control your breathing. Some people have a combination of the two types, called complex sleep apnea.

Sleep apnea is a potentially serious condition and should be treated.

Signs and Symptoms

Symptoms of sleep apnea include:

  • Loud, irregular snoring, then quiet periods of at least 10 seconds when breathing stops. These episodes can happen up to 100 times each hour
  • Daytime sleepiness and always feeling tired
  • Morning headaches, sore throat, dry mouth, or cough
  • Feeling depressed, moody, or irritable
  • Not being able to concentrate or remember things
  • Possible impotence or high blood pressure

What Causes It?

Sleep apnea is caused by:

  • A blocked upper airway (obstructive apnea)
  • Your brain not signaling your lungs to breathe while you sleep (central apnea)
  • A combination of obstructive and central apnea

Sleep apnea is also linked to:

  • Being overweight
  • Having large tonsils and adenoids
  • High blood pressure
  • Diabetes
  • Smoking
  • Alcohol use, especially before bed
  • Drugs, such as sleeping pills or heart medications
  • Excess sitting and lack of activity

The typical person with sleep apnea is an overweight, middle-aged man with allergies. But apnea can happen at any age, and in women as well. It can also be inherited.

What to Expect at Your Doctor’s Office

People with sleep apnea often go to the doctor because they feel tired all the time or because their partner complains about their snoring. Your doctor will check your weight and blood pressure and ask about allergies. You may get a device to check your oxygen levels while you sleep.

Your doctor may also refer you to a sleep clinic for overnight testing. Your doctor may request X-rays, computed tomography scans (CTs), or magnetic resonance imaging scans (MRIs) to see what may be blocking your airway.

Treatment Options

Treatment depends on:

  • What is blocking your airway
  • How severe your sleep apnea is
  • Other conditions or medical problems you may have

The most effective treatment is continuous positive airway pressure (CPAP). CPAP treatment includes using a machine and mask to blow air through your airway to keep it open. Studies show CPAP also reduces arterial stiffness.

Wearing dental appliances may help by pushing the lower jaw forward, keeping the tongue from blocking the airway, or a combination of both. These may be uncomfortable until you get used to them.

In severe cases, surgery may be needed. But most often, sleep apnea can be managed with CPAP and lifestyle changes.

Lifestyle changes that may help obstructive apnea include:

  • Losing weight. This may cause your sleep apnea to go away entirely
  • Limiting your use of alcohol, antihistamines, or tranquilizers
  • Getting treatment for allergies, colds, or sinus problems
  • Gargling with salt water (without swallowing) to shrink your tonsils
  • Developing regular sleep habits and making sure you get enough sleep at night
  • Sleeping on your side rather than your back, or with your body elevated from the waist up. You can use foam wedges to raise your upper body. DO NOT use soft pillows, which tend to make apnea worse by pushing the chin toward the chest
  • Using an air humidifier at night
  • Not smoking and not exposing yourself to other irritants, such as dust or perfumes
  • Raising the head of your bed by placing bricks under the headboard
  • Studies show regular exercise is associated with a lower risk of sleep apnea. Exercise also reduces sleepiness and improves quality of life among people who have the disorder

Drug Therapies

There is no drug that completely treats sleep apnea. Some of the drugs used in combination with CPAP include medications used to treat central apnea and medications used to treat obstructive apnea.

Central apnea may be treated with medicines including acetazolamide and clomipramine (Anafranil). Side effects of clomipramine may include impotence.

Obstructive apnea may be treated with modafinil (Provigil), which is sometimes prescribed in combination with CPAP to treat excessive daytime sleepiness.

Complementary and Alternative Therapies

Sleep apnea is a potentially dangerous condition that needs to be evaluated and treated with conventional medicine. Complementary and alternative therapies (CAM) may be helpful when used in addition to medical treatment. You should coordinate CAM therapies with your medical doctor. Alternative therapies may help treat sleep apnea caused by allergies. Homeopathy and nutrition are most likely to have a positive effect. While some manufacturers promote supplements for weight loss, none of these products have been proven to work as well as eating less and exercising more.

Nutrition and Supplements

  • Try eliminating mucus-producing foods (such as bananas) for 2 weeks, then reintroducing them to see if you notice any difference in sleepiness or other symptoms.
  • To lose weight, eat lots of fresh fruits and vegetables, along with whole grains and low-fat dairy. Limit the amount of saturated fat (found in meats, butter, and processed foods) you consume and use healthier fats like olive oil instead.
  • Chromium or chromium picolonate is a popular supplement among bodybuilders, and those trying to lose weight and build more lean muscle mass. However, results from scientific studies have been mixed, and its effects are small compared to those of exercise and a well-balanced diet. Chromium may improve blood sugar, which is also a risk factor for heart disease, especially in people with diabetes and glucose intolerance. However, you should not take chromium to lower blood sugar without your doctor’s supervision. People with psychiatric disorders should be closely monitored by their doctors when using chromium supplements. People with a history of liver disease should avoid chromium supplements. In addition, large doses of chromium may cause kidney damage.
  • Regular exercisewill also help you lose weight. If you are not used to exercising, start slowly and build up to about 30 minutes of exercise a day, at least 5 days a week. An ideal exercise program includes aerobic activity (walking, swimming, biking), strength training (lifting weights), and flexibility (stretching). If you are obese, or have other medical problems, talk to your doctor before starting a new exercise program.

Homeopathy

Few studies have examined the effectiveness of specific homeopathic remedies, though it may be helpful as a supportive therapy. Professional homeopaths, however, may recommend one or more of the following treatments for sleep apnea based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person’s constitutional type, includes your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

  • Arsenicum album. For respiratory disorders that worsen at night and are accompanied by fear, agitation, restlessness, weakness, and exhaustion.
  • Lachesis. For conditions that get worse while trying to sleep. This remedy is most appropriate for those who are intense, talkative, jealous, and may feel depressed (particularly in the morning). It may also help people who are frightened of going to sleep.
  • Opium. This remedy may be prescribed for individuals with sleep apnea and narcolepsy (inability to control falling asleep during the daytime). This remedy is appropriate for individuals who may be somewhat confused due to their sleep disorders.
  • Sambucus. For difficulty breathing at night. This remedy is most appropriate for individuals who may have nasal obstruction or asthma and actually jump up out of bed with a feeling of suffocation.
  • Spongia. For respiratory symptoms that are worsened by cold air and lying down. This remedy is appropriate for individuals who often feel a tightness in the chest area.
  • Sulphur. For chronic conditions accompanied by sleep disturbances and nightmares, especially if the individual also has skin rashes that become worse with heat. This remedy is most appropriate for individuals who prefer cold temperatures and strongly dislike any kind of restriction.

Acupuncture

Some evidence suggests that a type of acupuncture called auriculotherapy acupoint pressure may help treat sleep apnea.

Following Up

Sleep apnea is a serious condition that can cause fatal heart problems. So it is crucial to stick with your treatment plan. If you are using a mask and ventilator equipment, be sure to take care of them. If they are uncomfortable, talk to your doctor so they can be adjusted. If you have sleep apnea, you may have an increased risk of peptic ulcer bleeding. Talk to your doctor.

Keep in contact with your doctor or sleep clinic to make sure your treatment is working.

Special Considerations

If you are pregnant, you may have nasal congestion that makes you snore in a way that people with apnea do. However, this is not the same as sleep apnea. If you have apnea and become pregnant, be sure to continue your treatment so that your condition will not affect your baby.

People who have had a stroke and who have obstructive sleep apnea have a higher risk of early death.

References

Abad VC, Guilleminault C. Treatment options for obstructive sleep apnea. Curr Treat Options Neurol. 2009;11(5):358-367.

Ackel-D’Elia C, da Silva AC, Silva RS, et al. Effects of exercise training associated with continuous positive airway pressure treatment in patients with obstructive sleep apnea syndrome. Sleep Breath. 2012;16(3):723-735.

Asha’ari ZA, Hasmoni MH, Ab R, Yusof RA, Ahmad RA. The association between sleep apnea and young adults with hypertension. Laryngoscope. 2012;122(10):2337-2342.

Awad K, Malhorta A, Barnet J, Quan S, Peppard P. Exercise is associated with a reduced incidence of sleep-disordered breathing. The Amer J of Med. 2012;125(5):485-490.

Bope ET, Kellerman RD, eds. Conn’s Current Therapy 2016. 1st ed. Philadelphia, PA: Elsevier; 2013.

Buchner NJ, Quack I, Stegbauer J, Woznowski M, Kaufmann A, Rump LC. Treatment of sleep apnea reduces arterial stiffness. Sleep Breath. 2012;16(1):123-133.

Buman MP, Kline CE, Youngstedt SD, Phillips B, Tulio de Mello M, Hirshkowitz M. Sitting and television viewing: novel risk factors for sleep disturbance and apnea risk? results from the 2013 National Sleep Foundation Sleep in America Poll. Chest. 2015;147(3):728-734.

Chasens ER. Obstructive sleep apnea, daytime sleepiness, and type 2 diabetes. Diabetes Educ. 2007;33(3):475-482.

Dahlqvist J, Dahlqvist A, Marklund M, Berggren D, Stenlund H, Franklin KA. Physical findings in the upper airways related to obstructive sleep apnea in men and women. Acta Otolaryngol. 2007;127(6):623-630.

Dieltjens M, Vanderveken O, Heyning PH, Braem MJ. Current opinions and clinical practice in the titration of oral appliances in the treatment of sleep-disordered breathing. Sleep Med Rev. 2012;16(2):177-185.

Ehrhardt J, Schwab M, Finn S, et al. Sleep apnea and asymptomatic carotid stenosis: a complex interaction. Chest. 2015;147(4):1029-1036.

Faccenda JF, Mackay TW, Boon NA, et al. Randomized placebo-controlled trial of continuous positive airway pressure on blood pressure in the sleep apnea-hypopnea syndrome. Am J Respir Crit Care Med. 2001;163(2):344-348.

Flemons WW. Clinical practice: obstructive sleep apnea. N Engl J Med. 2002;347(7):498-504.

Freire AO, Sugai GC, Togeiro SM, Mello LE, Tufik S. Immediate effect of acupuncture on the sleep pattern of patients with obstructive sleep apnoea. Acupunct Med. 2010;28(3):115-119.

Grotz W, Buchner N, Wessendorf T, et al. Sleep apnea — treatment improves hypertension. Med Klin. 2006;101(11)880-885.

Hein H. The sleep apnoea syndromes: alternative therapies. Pneumologie. 2004;58(5):325-329.

Ioachimescu OC, Collop NA. Sleep-Disordered Breathing. Neurol Clin. 2012;30(4):1095-1136.

Sahlin C, Sandberg O, Gustafson Y, et al. Obstructive sleep apnea is a risk factor for death in patients with stroke: a 10-year follow-up. Arch Intern Med. 2008;168(3):297-301.

Sengul YS, Ozalevli S, Oztura I, Itil O, Baklan B. The effect of exercise on obstructive sleep apnea: a randomized and controlled trial. Sleep Breath. 2011;15(1):49-56.

Shah NA, Yaggi HK, Concato J, Mohsenin V. Obstructive sleep apnea as a risk factor for coronary events or cardiovascular death. Sleep Breath. 2010;14(2):131-136.

Shiao TH, Liu CJ, Luo JC, et al. Sleep apnea and risk of peptic ulcer bleeding: a nationwide population-based study. Am J Med. 2013;126(3):249-255, 255.e1.

Swanson CM, Shea SA, Stone KL, et al. Obstructive sleep apnea and metabolic bone disease: insights into the relationship between bone and sleep. J Bone Miner Res. 2015;30(2):199-211.

Valentino RM, Foldvary-Schaefer N. Modafinil in the treatment of excessive daytime sleepiness. Cleve Clin J Med. 2007;74(8):561-566, 568-571. Review

Veasey SC, Guilleminault C, Strohl KP, Sanders MH, Ballard RD, Magalang UJ. Medical therapy for obstructive sleep apnea: a review by the Medical Therapy for Obstructive Sleep Apnea Task Force of the Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 2006;29(8):1036-1044.

Villa MP, Brasili L, Ferretti A, et al. Oropharyngeal exercises to reduce symptoms of OSA after AT. Sleep Breath. 2015;19(1):281-289.

Vozoris NT. Sleep apnea-plus: prevalence, risk factors, and association with cardiovascular diseases using United States population-level data. Sleep Med. 2012;13(6):637-644.

Wang XH, Yuan YD, Wang BF. Clinical observation of effect of auricular acupoint pressing in treating sleep apnea syndrome. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2003;23(10):747-749.

Weaver TE, Mancini C, Maislin G, et al. Continuous positive airway pressure treatment of sleepy patients with milder obstructive sleep apnea: results of the CPAP Apnea Trial North America Program (CATNAP) randomized clinical trial. Am J Respir Crit Care Med. 2012;186(7):677-683.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a disease that leads to inflammation of the joints and surrounding tissues. It is a long-term disease. It can also affect other organs.

Causes

  1. The cause of RA is not known. It is an autoimmune disease. This means the immune system of the body mistakenly attacks healthy tissue.
  2. RA can occur at any age, but is more common in middle age. Women get RA more often than men.
  3. Infection, genes, and hormone changes may be linked to the disease. Smoking may also be linked to RA.
  4. It is less common than osteoarthritis (OA) which is a condition that occurs in many people due to wear and tear on the joints as they age.

Symptoms

Most of the time, RA affects joints on both sides of the body equally. Fingers, wrists, knees, feet, elbows, ankles, hips and shoulders are the most commonly affected.

The disease often begins slowly. Early symptoms may include:

  • Minor joint pain
  • Stiffness
  • Fatigue

Joint symptoms may include:

  • Morning stiffness, which lasts more than 1 hour, is common.
  • Joints may feel warm, tender, and stiff when not used for an hour.
  • Joint pain is often felt in the same joint on both sides of the body.
  • Joints are often swollen.
  • Over time, joints may lose their range of motion and may become deformed.

Other symptoms include:

The diagnosis of RA is made when:

  • You have pain and swelling in 3 or more joints.
  • Arthritis has been present for longer than 6 weeks.
  • You have a positive test for rheumatoid factor or anti-CCP antibody.
  • You have elevated ESR or CRP.
  • Other types of arthritis have been ruled out.

Sometimes the diagnosis of RA is made even without all of the conditions shown above if the arthritis is otherwise typical for RA.

Exams and Tests

There is no test that can determine for sure whether you have RA. Most people with RA will have some abnormal test results. However, some people will have normal results for all tests.

Two lab tests that are positive in most people and often help in the diagnosis are:

These tests are positive in most patients with RA. The anti-CCP antibody test is more specific for RA.

Other tests that may be done include:

Treatment

RA most often requires long-term treatment by an expert in arthritis called a rheumatologist. Treatment includes:

  • Medicines
  • Physical therapy
  • Exercise
  • Education to help you understand the nature of RA, your treatment options, and the need for regular follow-up.
  • Surgery, if required

Early treatment for RA with medicines called disease-modifying antirheumatic drugs (DMARDs) should be used in all patients. This will slow joint destruction and prevent deformities. The activity of the RA should be checked at regular visits to make sure the disease is under control. The goal of treatment is to stop the progression of the RA.

Medicines

Anti-inflammatory medicines: These include aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen and celecoxib.

  • These medicines work very well to reduce joint swelling and inflammation, but they can have long-term side effects. Therefore, they should be taken only for a short time and in low doses when possible.
  • Since they do not prevent joint damage if used alone, DMARDs should be used as well.

Disease modifying antirheumatic drugs (DMARDs): These are often the medicines that are tried first in people with RA. They are prescribed along with rest, strengthening exercise, and anti-inflammatory drugs.

  • Methotrexate is the most commonly used DMARD for rheumatoid arthritis. Leflunomide and hydroxychloroquine may also be used.
  • Sulfasalazine is a drug that is often combined with methotrexate and hydroxychloroquine (triple therapy).
  • It may be weeks or months before you see any benefit from these drugs.
  • These drugs may have serious side effects, so you will need frequent blood tests and other monitoring when taking them.
  • Antimalarial medicines — This group of medicines includes hydroxychloroquine (Plaquenil). They are most often used along with methotrexate. It may be weeks or months before you see any benefit from these drugs.

Corticosteroids — These medicines work very well to reduce joint swelling and inflammation, but they can have long-term side effects and do not prevent joint damage if used alone. Therefore, they should be taken only for a short time and in low doses when possible.

Biologic DMARD agents — These medicines are designed to affect parts of the immune system that play a role in the disease process of RA.

  • They may be given when other medicines, usually methotrexate, have not worked. Biologic drugs are often added to methotrexate. However, because they are very expensive, insurance approval is generally required.
  • Most of them are given either under the skin or into a vein. There are now many different types of biologic agents.

Biologic and synthetic agents can be very helpful in treating RA. However, people taking these medicines must be watched closely because of uncommon, but serious adverse reactions:

  • Infections from bacteria, viruses, and fungi
  • Skin cancer, but not melanoma
  • Skin reactions
  • Allergic reactions
  • Worsened heart failure
  • Damage to nerves
  • Low white blood cell count

Surgery

Surgery may be needed to correct severely damaged joints. Surgery may include:

Physical Therapy

Range-of-motion exercises and exercise programs prescribed by a physical therapist can delay the loss of joint function and help keep muscles strong.

Sometimes, therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint movement.

Other therapies that may help ease joint pain include:

  • Joint protection techniques
  • Heat and cold treatments
  • Splints or orthotic devices to support and align joints
  • Frequent rest periods between activities, as well as 8 to 10 hours of sleep per night

Nutrition

Some people with RA may have intolerance or allergies to certain foods. A balanced nutritious diet is recommended. It may be helpful to eat foods rich in fish oils (omega-3 fatty acids). Smoking cigarettes should be stopped. Excessive alcohol should also be avoided.

Support Groups

More information and support for people with Rheumatoid arthritis and their families can be found by taking part in an arthritis support group.

Some people may benefit from taking part in an arthritis support group.

Outlook (Prognosis)

Whether your RA progresses or not depends on the severity of your symptoms and your response to treatment. It is important to start the treatment as soon as possible. Regular follow up visits with a rheumatologist are needed to adjust the treatment.

Permanent joint damage may occur without proper treatment. Early treatment with a three-medicine DMARD combination known as “triple therapy,” or with the biologic or targeted synthetic medicines can prevent joint pain and damage.

Possible Complications

If not well treated, RA can affect nearly every part of the body. Complications may include:

  • Damage to the lung tissue.
  • Increased risk of hardening of the arteries, leading to cardiovascular disease.
  • Spinal injury when the neck bones become damaged.
  • Inflammation of the blood vessels (rheumatoid vasculitis), which can lead to skin, nerve, heart, and brain problems.
  • Swelling and inflammation of the outer lining of the heart (pericarditis) and of the heart muscle (myocarditis), which can lead to congestive heart failure.

However, these complications can be avoided with proper treatment. The treatments for RA can also cause serious side effects. Talk to your provider about the possible side effects of treatment and what to do if they occur.

When to Contact a Medical Professional

Contact your provider if you think you have symptoms of rheumatoid arthritis.

Prevention

There is no known prevention. Smoking appears to worsen RA, so it is important to avoid tobacco. Proper early treatment can help prevent further joint damage.

References

Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2021;73(7):924-939. PMID: 34101387 pubmed.ncbi.nlm.nih.gov/34101387/.

McInnes I, O’Dell JR. Rheumatoid arthritis. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 248.

Mori S, Urata Y, Yoshitama T, Ueki Y. Tofacitinib versus tocilizumab in the treatment of biological-naïve or previous biological-failure patients with methotrexate-refractory active rheumatoid arthritis. RMD Open. 2021;7(2):e001601. PMID: 33958440 pubmed.ncbi.nlm.nih.gov/33958440/.

O’Dell JR. Treatment of rheumatoid arthritis. In: Firestein GS, Budd RC, Gabriel SE, Koretzky GA, McInnes IB, O’Dell JR, eds. Firestein & Kelley’s Textbook of Rheumatology. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 77.

blood vessels, veins and arteries, circulatory system

Pulmonary Hypertension with COPD

Pulmonary hypertension is most commonly associated with chronic obstructive lung disease (COPD) but may also be associated with some types of heart disease, auto-immune diseases, and other, rarer, conditions.

What causes Pulmonary Hypertension with COPD?

Pulmonary Hypertension is classified into 5 groups, depending on the cause.

Group 1: Pulmonary arterial hypertension (PAH)

Causes include:

  • Unknown cause (idiopathic pulmonary arterial hypertension)
  • Changes in a gene passed down through families (heritable pulmonary arterial hypertension)
  • Use of certain drugs or illegal substances
  • Heart problems present at birth (congenital heart disease)
  • Other conditions such as HIV infection, chronic liver disease (cirrhosis) and connective tissue disorders (scleroderma, lupus, others)

Group 2: Pulmonary hypertension caused by left-sided heart disease

Causes include:

  • Left-sided heart valve disease such as mitral valve or aortic valve disease
  • Failure of the lower left heart chamber (left ventricle)

Group 3: Pulmonary hypertension caused by lung disease

Causes include:

  • Chronic obstructive pulmonary disease (COPD)
  • Scarring of the tissue between the lung’s air sacs (pulmonary fibrosis)
  • Obstructive sleep apnea
  • Long-term exposure to high altitudes in people who may be at higher risk of pulmonary hypertension

Group 4: Pulmonary hypertension caused by chronic blood clots

Causes include:

  • Chronic blood clots in the lungs (pulmonary emboli)
  • Other clotting disorders

Group 5: Pulmonary hypertension triggered by other health conditions

Causes include:

  • Blood disorders, including polycythemia vera and essential thrombocythemia
  • Inflammatory disorders such as sarcoidosis and vasculitis
  • Metabolic disorders, including glycogen storage disease
  • Kidney disease
  • Tumors pressing against pulmonary arteries

What to do if you think you have Pulmonary Hypertension?

Discussing your medical history and symptoms with a healthcare professional can help you in getting a clear diagnosis. The condition is diagnosed primarily with an echocardiogram (an ultrasound of the heart).

Early warning signs that can indicate the need for assessment by doctors include:

  • shortness of breath
  • tiredness
  • feeling faint or dizzy
  • chest pain (angina)
  • a racing heartbeat (palpitations)
  • swelling (oedema) in the legs, ankles, feet or tummy (abdomen)

The symptoms often get worse during exercise, which can limit your ability to take part in physical activities.

Who is most at risk for developing Pulmonary Hypertension?

  • Pulmonary hypertension happens at all ages, including children, and its incidence increases with age
  • Pulmonary hypertension is more common among women, non-Hispanic black people, and people aged 75 or older

What does having Pulmonary Hypertension feel like?

Most commonly, the condition causes shortness of breath with activity as one of the first symptoms.

What to do if you experience complications of Pulmonary Hypertension?

If you experience the following, call 911 or visit the emergency room:

  • Chest pain
  • Loss of consciousness
  • Coughing up blood
  • Worsening shortness of breath
  • Unusual shortness of breath
  • Dizziness
  • Rapid heart rate
  • Headache
  • Blue lips, fingernails, or earlobes

Lifestyle Changes

Making healthy lifestyle changes can help prevent your Pulmonary Hypertension from getting worse. Consider quitting smoking, reducing the salt in your diet, and eating a healthy diet overall.

For more information, visit https://phassociation.org/

human cardiovascular system, showing the heart with arteries

Pulmonary Hypertension (non-COPD)

Pulmonary hypertension is high blood pressure in the arteries of the lungs. It makes the right side of the heart work harder than normal.

Causes

The right side of the heart pumps blood through the lungs, where it picks up oxygen. Blood returns to the left side of the heart, where it is pumped to the rest of the body.

When the small arteries (blood vessels) of the lungs become narrowed, they cannot carry as much blood. When this happens, pressure builds up. This is called pulmonary hypertension.

The heart needs to work harder to force the blood through the vessels against this pressure. Over time, this causes the right side of the heart to become larger. This condition is called right-sided heart failure, or cor pulmonale.

Pulmonary hypertension may be caused by:

In rare cases, the cause of pulmonary hypertension is unknown. In this case, the condition is called idiopathic pulmonary arterial hypertension (IPAH). Idiopathic means the cause of a disease is not known. IPAH affects more women than men.

If pulmonary hypertension is caused by a known medicine or medical condition, it is called secondary pulmonary hypertension.

Symptoms

Shortness of breath or lightheadedness during activity is often the first symptom. Fast heart rate (palpitations) may be present. Over time, symptoms occur with lighter activity or even while at rest.

Other symptoms include:

  • Ankle and leg swelling
  • Bluish color of the lips or skin (cyanosis)
  • Chest pain or pressure, most often in the front of the chest
  • Dizziness or fainting spells
  • Fatigue
  • Increased abdominal size
  • Weakness

People with pulmonary hypertension often have symptoms that come and go. They report good days and bad days.

Exams and Tests

Your health care provider will perform a physical exam and ask about your symptoms. The exam may find:

  • Abnormal heart sounds
  • Feeling of a pulse over the breastbone
  • Heart murmuron the right side of the heart
  • Larger-than-normal veins in the neck
  • Leg swelling
  • Liver and spleen swelling
  • Normal breath sounds if pulmonary hypertension is idiopathic or due to congenital heart disease
  • Abnormal breath sounds if pulmonary hypertension is from other lung disease

In the early stages of the disease, the exam may be normal or almost normal. The condition may take several months to diagnose. Asthma and other diseases may cause similar symptoms and must be ruled out.

Tests that may be ordered include:

Treatment

There is no cure for pulmonary hypertension. The goal of treatment is to control symptoms and prevent more lung damage. It is important to treat medical disorders that cause pulmonary hypertension, such as obstructive sleep apnea, lung conditions, and heart valve problems.

Many treatment options for pulmonary arterial hypertension are available. If you are prescribed medicines, they may be taken by mouth (oral), received through the vein (intravenous, or IV), or breathed in (inhaled).

Your provider will decide which medicine is best for you. You will be closely monitored during treatment to watch for side effects and to see how well you are responding to the medicine. DO NOT stop taking your medicines without talking to your provider.

Other treatments may include:

  • Blood thinners to reduce the risk of blood clots, especially for some forms of pulmonary hypertension
  • Oxygen therapy at home
  • Lung transplant, or in some cases, heart-lung transplant, if medicines do not work

Other important tips to follow:

  • Avoid pregnancy.
  • Avoid heavy physical activities and lifting.
  • Avoid traveling to high altitudes.
  • Get a yearly flu vaccine, as well as other vaccines such as the pneumonia vaccine, and the COVID vaccine.
  • Stop smoking.

Outlook (Prognosis)

How well you do depends on what caused the condition. Medicines for IPAH may help slow the disease.

As the illness gets worse, you will need to make changes in your home to help you get around the house.

For patients with severe disease, lung transplant, or in some cases, heart-lung transplant can be considered.

When to Contact a Medical Professional

Contact your provider if:

  • You begin to develop shortness of breath when you are active
  • Shortness of breath gets worse
  • You develop chest pain
  • You develop other symptoms
  • You feel lightheaded or dizzy
  • You have persistent palpitations

References

Lammi MR, Mathai SC. Pulmonary hypertension: general approach. In: Broaddus VC, Ernst JD, King TE, et al, eds. Murray and Nadel’s Textbook of Respiratory Medicine. 7th ed. Philadelphia, PA: Elsevier; 2022:chap 83.

Maron BA. Pulmonary hypertension. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier; 2022:chap 88.

Polymyalgia Rheumatica

Polymyalgia rheumatica (PMR) is an inflammatory disorder. It involves pain and stiffness in the shoulders and often the hips.

Causes

Polymyalgia rheumatica most often occurs in people over 50 years old. The cause is unknown.

PMR may occur before or with giant cell arteritis (GCA; also called temporal arteritis). This is a condition in which blood vessels that supply blood to the head and eye become inflamed.

PMR can sometimes be hard to tell apart from rheumatoid arthritis (RA) in an older person. This occurs when tests for rheumatoid factor and anti-CCP antibody are negative.

Symptoms

The most common symptom is pain and stiffness in both shoulder regions and the neck. The pain and stiffness are worse in the morning. This pain most often progresses to the hip regions.

Fatigue is also present. People with this condition find it increasingly hard to get out of bed and to move around.

Other symptoms include:

Exams and Tests

Lab tests alone can’t diagnose PMR. Most people with this condition have high markers of inflammation, such as the sedimentation rate (ESR) and C-reactive protein (CRP).

Other test results for this condition include:

  • Abnormal levels of proteins in the blood
  • Abnormal level of white blood cells
  • Anemia (low blood count)

These tests may also be used to monitor your condition.

However, imaging tests such as x-rays of the shoulder or hips are not often helpful. These tests may reveal joint damage that is not related to recent symptoms. In difficult cases, ultrasound or MRI of the shoulder may be done. These imaging tests often show bursitis or low levels of joint inflammation.

Treatment

Without treatment, PMR does not get better. However, low doses of corticosteroids (such as prednisone, 10 to 20 mg per day) can markedly ease symptoms, often within a day or two.

  • The dose should then be slowly reduced to a very low level.
  • Treatment needs to continue for 1 to 2 years. In some people, even longer treatment with low doses of prednisone is needed.

Corticosteroids can cause many side effects such as weight gain, development of diabetes or osteoporosis. You need to be watched closely if you are taking these medicines. If you are at risk for osteoporosis, your health care provider may recommend you take medicines to prevent this condition.

Outlook (Prognosis)

For most people, PMR goes away with treatment after 1 to 2 years. You might be able to stop taking medicines after this point, but check with your provider first.

For some people, symptoms return after they reduce or stop taking corticosteroids. In these cases, another medicine such as methotrexate or tocilizumab may be needed.

Giant cell arteritis may also be present or can develop later. If this is the case, the temporal artery would need to be evaluated and different treatment given.

More severe symptoms can make it harder for you to work or take care of yourself at home.

When to Contact a Medical Professional

Contact your provider if you have weakness or stiffness in your shoulder and neck that does not go away. Also contact your provider if you have new symptoms such as fever, headache, and pain with chewing or loss of vision. These symptoms may be from giant cell arteritis.

Prevention

There is no known prevention.

References

Dejaco C, Singh YP, Perel P, et al. 2015 recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Arthritis Rheumatol. 2015;67(10):2569-2580. PMID: 2635874 pubmed.ncbi.nlm.nih.gov/26352874/.

Hellmann DB. Giant cell arteritis, polymyalgia rheumatica, and Takayasu’s arteritis. In: Firestein GS, Budd RC, Gabriel SE, Koretzky GA, McInnes IB, O’Dell JR, eds. Firestein & Kelley’s Textbook of Rheumatology. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 93.

Salvarani C, Ciccia F, Pipitone N. Polymyalgia rheumatica and giant cell arteritis. In: Hochberg MC, Gravallese EM, Smolen JS, van der Hejjde D, Weinblatt ME, Weisman MH, eds. Rheumatology. 8th ed. Philadelphia, PA: Elsevier; 2023:chap 166.

diabetes-blood-test-bw

Pre-Diabetes

Pre-diabetes occurs in those individuals with blood glucose levels that are higher than normal but not high enough for a diabetes diagnosis.

This condition raises the risk of developing type 2 diabetes, stroke, and heart disease. In fact, people with diabetes are 2 to 4 times more likely than non-diabetic people to develop heart disease.

Pre-diabetes is also called impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or insulin resistance. Some people have both IFG and IGT. In IFG, glucose levels are a little high several hours after a person eats. In IGT, glucose levels are a little higher than normal right after eating.

Pre-diabetes is becoming more common in the U.S., according to estimates provided by the U.S. Department of Health and Human Services (DHHS). Many individuals with pre-diabetes go on to develop type 2 diabetes within 10 years. (See Diabetes)

References

Baker AM, Haeri S, Carmargo CA Jr, et al. First trimester maternal vitamin D status and risk for gestational diabetes mellitus: a nested case-control study. Diabetes Metab Res Rev. 2011. doi: 10.1002/dmrr.1282. [Epub ahead of print].

Baker H. Nutrition in the elderly: nutritional aspects of chronic diseases. Geriatrics. 2007;62(9):21-5.

Batty GD, Kivimaki M, Smith GD, Marmot MG, Shipley MJ. Obesity and overweight in relation to mortality in men with and without type 2 diabetes/impaired glucose tolerance: the original Whitehall Study. Diabetes Care. 2007;30(9):2388-91.

Bay R, Bay F. Combined therapy using acupressure therapy, hypnotherapy, and transcendental meditation versus placebo in type 2 diabetes. J Acupunct Meridian Stud. 2011;4(3):183-6.

Bo S, Ciccone G, Baldi C, et al., Effectiveness of a Lifestyle Intervention on Metabolic Syndrome. A Randomized Controlled Trial. J Gen Intern Med. 2007; [Epub ahead of print].

Bournival J, Francoeur MA, Renaud J, Martinoli MG. Quercetin and sesamin protecct neuronal PC12 cells from high-glucose-induced oxidation, nitrosative stress, and apoptosis. Rejuvenation Res. 2012;15(3):322-33.

Bozkurt O, de Boer A, Grobbee DE, et al. Pharmacogenetics of glucose-lowering drug treatment: a systematic review. Mol Diagn Ther. 2007;11(5):291-302.

Burt MS, Sultan MT. Ginger and its health claims: molecular aspects. [Review]. Crit Rev Food Sci Nutr. 2011;51(5):383-93.

Casellini CM, Vinik AI. Clinical manifestations and current treatment options for diabetic neuropathies. Endocr Pract. 2007;13(5):550-66.

Chen W, Zhang Y, Liu JP. Chinese herbal medicine for diabetic peripheral neuropathy. [Review]. Cochrane Database Syst Rev. 2011;(6):CD007796.

Diabetes Research in Children Network (DirecNet) Study Group, Buckingham B, Beck RW, Tamborlane WV, et al. Continuous glucose monitoring in children with type 1 diabetes. J Pediatr. 2007;151(4):388-93, 393.e1-2.

England L, Dietz P, Njoroge T, Callaghan W, Bruce C, Buus R, Williamson D. Preventing type 2 diabetes: public health implications for women with a history of gestational diabetes mellitus. Amer J of Obstet and Gyn. 2009;200(4).

Erdonmez D, Hautin S, Cizmecioglu, et al. No relationship between vitamin D status and insulin resistance in a group of high school students. J Clin Res Pediatr Endocrinol. 2011;3(4):198-201. doi: 10.4274/jcrpe.507.

Ferri: Ferri’s Clinical Advisor 2016. 1st ed. Philadelphia, PA: Elsevier Mosby; 2015.

Furuya-Kanamori L, Stone JC, Doi SA. Putting the diabetes risk due to statins in perspective: a re-evaluation using the complementary outcome. Nutr metab Cardiovasc Dis. 2014;24(7):705-8.

Guthrie RM. Evolving therapeutic options for type 2 diabetes mellitus: an overview. Postgrad Med. 2012;124(6):82-9.

Herder C, Schneitler S, Rathmann W, et al. Low-Grade Inflammation, Obesity and Insulin Resistance in Adolescents. J Clin Endocrinol Metab. 2007; [Epub ahead of print].

Howes JB, Sullivan D, Lai N. The effects of dietary supplementation with isoflavones from red clover on the lipoprotein profiles of postmenopausal women with mild to moderate hypercholesterolemia. Atherosclerosis. 2000;152(1):143-7.

Hypponen E, Laara E, Reunanen A, Jarvelin MR, Virtanen SM. Intake of vitamin D and risk of type 1 diabetes: a birth-cohort study. Lancet. 2001;358(9292):1500-3.

Kapoor R, Huang YS. Gamma linolenic acid: an antiinflammatory omega-6 fatty acid. Curr Pharm Biotechnol. 2006;7(6):531-4.

Khan A, Khattak K, Sadfar M, Anderson R, Khan M. Cinnamon improves glucose and lipids of people with type 2 diabetes. Diabetes Care. 2003;26:3215-8.

Kim S, Shin BC, Lee MS, et al. Red ginseng for type 2 diabetes mellitus: A systematic review of randomized controlled trials. [Review]. Chin J Integr Med. 2011;17(12):937-44.

Kim TH, Choi TY, Shin BC, et al. Moxibustion for managing type 2 diabetes mellitus: a systematic review. [Review]. Chin J Integr Med. 2011;17(8):575-9.

Krauss RM, Eckel RH, Howard B, Appel LJ, Daniels SR, Deckelbaum RJ, et al. AHA Scientific Statement: AHA Dietary guidelines Revision 2000: A statement for healthcare professionals from the nutrition committee of the American Heart Association. Circulation. 2000;102(18):2284-99.

Kris-Etherton P, Eckel RH, Howard BV, St. Jeor S, Bazzare TL. AHA Science Advisory: Lyon Diet Heart Study. Benefits of a Mediterranean-style, National Cholesterol Education Program/American Heart Association Step I Dietary Pattern on Cardiovascular Disease. Circulation. 2001;103:1823.

Kurowska EM, Spence JD, Jordan J, Wetmore S, Freeman DJ, Piche LA, Serratore P. HDL-cholesterol-raising effect of orange juice in subjects with hypercholesterolemia. Am J Clin Nutr. 2000;72(5):1095-100.

Lee HJ, Chapa D, Kao CW, Jones D, Kapustin J, Smith J, Krichten C, Donner T, Thomas SA, Friedmann E. Depression, quality of life, and glycemic control in individuals with type 2 diabetes. J Am Acad Nurse Pract. 2009;21(4):214-24.

Liang F, Koya D. Acupuncture: is it effective for treatment of insulin resistance? Diabetes Obes Metab. 2010;12(7):555-59.

Malnick SD, Somin M. The VALIDD study. Lancet. 2007;370(9591):931; author reply 931-2.

Marz W, Wieland H. HMG-CoA reducatse inhibition: anti-inflammatory effects beyond lipid lowering. Herz. 2000;25(6):117-25.

McMullan CJ, Schernhammer ES, Rimm EB, Hu FB, Forman JP. Melatonin secretion and the incidence of type 2 diabetes. JAMA. 2013;309(13):1388-96.

Medagama AB, Bandara R. The use of complementary and alternative medicines (CAMs) in treatment of diabetes mellitus: is continued use safe and effective? Nutr J. 2014;13:102.

Mezuk B, Eaton WW, Albrecht S, Golden SH. Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care. 2008;13(12):2383-90.

Mosdol A, Witte DR, Frost G, Marmot MG, Brunner EJ. Dietary glycemic index and glycemic load are associated with high-density-lipoprotein cholesterol at baseline but not with increased risk of diabetes in the Whitehall II study. Am J Clin Nutr. 2007;86(4):988-94.

Murea M, Ma L, Freedman BI. Genetic and environmental factors associated with type 2 diabetes and diabetic vascular complications. Rev Diabet Stud. 2012;9(1):6-22.

Mutlu A, Mutlu GY, Ozsu E, et al. Vitamin D deficiency in children and adolescents with type 1 diabetes. J Clin Res Pediatr Endocrinol. 2011;3(4):179-83. doi: 10.4274/jcrpe.430.

National Cholesterol Education Program. Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-97.

Nutrition Committee of the American Heart Association. AHA Dietary Guidelines. Revision 2000: A Statement for Healthcare Professionals. Circulation. 2000;102:2284-99.

Pedersen BK. IL-6 signalling in exercise and disease. Biochem Soc Trans. 2007;35(Pt 5):1295-7.

Peek ME, Cargill A, Huang ES. Diabetes health disparities: a systematic review of health care interventions. Med Care Res Rev. 2007;64(5 Suppl):101S-56S.

Plat J, van Onselen ENM, van Heugten MMA, Mensink RP. Effects on serum lipids, lipoproteins, and fat soluble antioxidant concentrations of consumption frequency of margarines and shortenings enriched with plant stanol esters. Euro J Clin Nutr. 2000;54:671-7.

Raitakari OT, McCredie RJ, Witting P, Griffiths KA, Letter J, Sullivan D, Stocker R, Celermajer DS. Coenzyme Q improves LDL resistance to ex vivo oxidation but does not enhance endothelial function in hypercholesterolemic young adults. Free Radic Biol Med. 2000;28(7):1100-5.

Rawlings AM, Sharrett AR, Schneider AL, et al. Diabetes in midlife and cognitive change over 20 years: a cohort study. Ann Intern Med. 2014;161(11):785-93.

Ripsin C, Kang H, Urban R. Management of Blood Glucose in Type 2 Diabetes Mellitus. Am Fam Phys. 2009;79(1).

Rotella F, Mannucci E. Depression as a risk factor for diabetes: a meta-analysis of longitudinal studies. J Clin Psychiatry. 2013;74(1):31-7.

Sharma S, Agrawal RP, Choudhary M, et al. Beneficial effect of chromium supplementation on glucose, HbA1C, and lipid variables in individuals with newly onset type-2 diabetes. J Trace Elem Med Biol. 2011;25(3):149-53.

Sjostrom L, Peltonen M, Jacobson P, et al. Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications. JAMA. 2014;311(22):2297-304.

Srivastava AK. Anti-diabetic and toxic effects of vanadium compounds. Mol Cell Biochem. 2000;206(1-2):177-82.

Stevinson C, Pittler MH, Ernst E. Garlic for treating hypercholesterolemia. Ann Intern Med. 2000;133(6):420-9.

Suksomboon N, Poolsup N, Boonkaew, et al. Meta-analysis of the effect of herbal supplement on glycemic control in type 2 diabetes. J Ethnopharmacol. 2011;137(3):1328-33.

Teixeira SR, Potter SM, Weigel R,Hannam S, Erdman Jr. JW, Hasler CM. Effects of feeding 4 levels of soy Protein for 3 and 6 wk on blood lipids and apolipoproteins in moderately hypercholesterolemic men. Am J Clin Nutr. 2000;71:1077-84.

Tofler GH, Stec JJ, Stubbe I, Beadle J, Feng D, Lipinska I, Taylor A. The effect of vitamin C supplementation on coagulability and lipid levels in healthy male subjects. Thromb Res. 2000;100(1):35-41.

Tong Y, Guo H, Han B. Fifteen-day acupunccture treatment relieves diabetic peripheral neuropathy. J Acupunct Meridian Stud. 2010;3(2):95-103.

Willett WC. The role of dietary n-6 fatty acids in the prevention of cardiovascular disease. J Cardiovasc Med (Hagerstown). 2007;8 Suppl 1:S42-5.

Xie W, Du L. Diabetes is an inflammatory disease: evidence from traditional Chinese medicines. [Review]. Diabetes Obes Metab. 2011;13(4):289-301. doi: 10.1111/j.1463-1326.2010.01336.x.

Yamada Y, Uchida J, Izumi H, et al. A non-calorie-restricted lowcarbohydrate diet is effective as an alternative therapy for patients with tpe 2 diabetes. Intern Med. 2014;53(1)13-9.

Zambón D, Sabate J, Munoz S, et al. Substituting walnuts for monounsaturated fat improves the serum lipid profile of hypercholesterolemic men and women. Ann Intern Med. 2000;132:538-46.

Zhang C, Ma YX, Yan Y. Clinical effects of acupuncture for diabetic peripheral neuropathy. J Tradit Chin Med. 2010;30(1):13-4.

senior man with parkinson disease holding walking cane

Parkinson’s Disease

Parkinson’s disease results from certain brain cells dying. These cells help control movement and coordination. The disease leads to shaking (tremors) and trouble walking and moving.

Causes

Nerve cells use a brain chemical called dopamine to help control muscle movement. With Parkinson disease, the brain cells that make dopamine slowly die. Without dopamine, the cells that control movement can’t send proper messages to the muscles. This makes it hard to control the muscles. Slowly, over time, this damage gets worse. No one knows exactly why these brain cells waste away.

Parkinson disease most often develops after age 50. It is one of the most common nervous system problems in older adults.

  • The disease tends to affect men more than women, although women also develop the disease. Parkinson disease sometimes runs in families.
  • The disease can occur in younger adults. In such cases, it is often due to the person’s genes.
  • Parkinson disease is rare in children.

Symptoms

Symptoms may be mild at first. For instance, you may have a mild tremor or a slight feeling that one leg is stiff and dragging. Jaw tremor has also been an early sign of Parkinson disease. Symptoms may affect one or both sides of the body.

General symptoms may include:

  • Problems with balance and walking
  • Rigid or stiff muscles
  • Muscle achesand pains
  • Low blood pressure when you stand up
  • Stooped posture
  • Constipation
  • Sweating and not being able to control your body temperature
  • Slow blinking
  • Difficulty swallowing
  • Drooling
  • Slowed, quieter speech and monotone voice
  • No expression in your face (like you are wearing a mask)
  • Unable to write clearly or handwriting is very small (micrographia)

Movement problems may include:

  • Difficulty starting movement, such as starting to walk or getting out of a chair
  • Difficulty continuing to move
  • Slowed movements
  • Loss of fine hand movements (writing may become small and difficult to read)
  • Difficulty eating

Symptoms of shaking (tremors):

  • Usually occur when your limbs are not moving. This is called resting tremor.
  • Occur when your arm or leg is held out.
  • Go away when you move.
  • May be worse when you are tired, excited, or stressed.
  • Can cause you to rub your finger and thumb together without meaning to (called pill-rolling tremor).
  • Eventually may occur in your head, lips, tongue, and feet.

Other symptoms may include:

Exams and Tests

Your health care provider may be able to diagnose Parkinson disease based on your symptoms and a physical exam. But the symptoms can be hard to pin down, particularly in older adults. Symptoms are easier to recognize as the illness gets worse.

The examination may show:

  • Difficulty starting or finishing a movement
  • Jerky, stiff movements
  • Muscle loss
  • Shaking (tremors)
  • Changes in your heart rate
  • Normal muscle reflexes

Your provider may do some tests to rule out other conditions that can cause similar symptoms.

Treatment

There is no cure for Parkinson disease, but treatment can help control your symptoms.

Medicine

Your provider will prescribe medicines to help control your shaking and movement symptoms.

At certain times during the day, the medicine may wear off and symptoms can return. If this happens, your provider may need to change any of the following:

  • Type of medicine
  • Dose
  • Amount of time between doses
  • The way you take the medicine

You may also need to take medicines to help with:

  • Mood and thinking problems
  • Pain relief
  • Sleep problems
  • Drooling (botulinum toxin is often used)

Parkinson medicines can cause severe side effects, including:

  • Confusion
  • Seeing or hearing things that are not there (hallucinations)
  • Nausea, vomiting, or diarrhea
  • Feeling lightheaded or fainting
  • Behaviors that are hard to control, such as gambling
  • Delirium

Tell your provider right away if you have these side effects. Never change or stop taking any medicines without talking with your provider. Stopping some medicines for Parkinson disease may lead to a severe reaction. Work with your provider to find a treatment plan that works for you.

As the disease gets worse, symptoms such as stooped posture, frozen movements, and speech problems may not respond to the medicines.

Surgery

Surgery may be an option for some people. Surgery does not cure Parkinson disease, but it may help ease symptoms. Types of surgery include:

  • Deep brain stimulation— This involves placing electric stimulators in areas of the brain that control movement.
  • Surgery to destroy brain tissue that causes Parkinson symptoms.
  • Stem cell transplant and other procedures are being studied.

Lifestyle

Certain lifestyle changes may help you cope with Parkinson disease:

  • Stay healthy by eating nutritious foods and not smoking.
  • Make changes in what you eat or drink if you have swallowing problems.
  • Use speech therapy to help you adjust to changes in your swallowing and speech.
  • Stay active as much as possible when you feel good. Do not overdo it when your energy is low.
  • Rest as needed during the day and avoid stress.
  • Use physical therapy and occupational therapy to help you stay independent and reduce the risk of falls.
  • Place handrails throughout your house to help prevent falls. Place them in bathroomsand along stairways.
  • Use assistive devices, when needed, to make movement easier. These devices may include special eating utensils, wheelchairs, bed lifts, shower chairs, and walkers.
  • Talk to a social worker or other counseling service to help you and your family cope with the disorder. These services can also help you get outside help, such as Meals on Wheels.

Support Groups

Parkinson disease support groups can help you cope with the changes caused by the disease. Sharing with others who have common experiences can help you feel less alone.

Outlook (Prognosis)

Medicines can help most people with Parkinson disease. How well medicines relieve symptoms and for how long they relieve symptoms can be different in each person.

The disorder gets worse until a person is totally disabled, although in some people, this can take decades. Parkinson disease may lead to a decline in brain function and early death. Medicines may prolong function and independence.

Possible Complications

Parkinson disease may cause problems such as:

  • Difficulty performing daily activities
  • Difficulty swallowing or eating
  • Disability (differs from person to person)
  • Injuries from falls
  • Pneumoniafrom breathing in saliva or from choking on food
  • Side effects of medicines

When to Contact a Medical Professional

Contact your provider if:

  • You have symptoms of Parkinson disease
  • Symptoms get worse
  • New symptoms occur

If you take medicines for Parkinson disease, tell your provider about any side effects, which may include:

  • Changes in alertness, behavior, or mood
  • Delusional behavior
  • Dizziness
  • Hallucinations
  • Involuntary movements
  • Loss of mental functions
  • Nausea and vomiting
  • Severe confusion or disorientation

Also contact your provider if the condition gets worse and home care is no longer possible.

References

Armstrong MJ, Okun MS. Diagnosis and treatment of parkinson disease: a review. JAMA. 2020;323(6):548-560. PMID: 32044947 pubmed.ncbi.nlm.nih.gov/32044947/

Fox SH, Katzenschlager R, Lim SY, et al; Movement Disorder Society Evidence-Based Medicine Committee. International Parkinson and Movement Disorder Society evidence-based medicine review: update on treatments for the motor symptoms of Parkinson’s disease. Mov Disord. 2018;33(8):1248-1266. PMID: 29570866 pubmed.ncbi.nlm.nih.gov/29570866/

Jankovic J. Parkinson disease and other movement disorders. In: Jankovic J, Mazziotta JC, Pomeroy SL, Newman NJ, eds. Bradley and Daroff’s Neurology in Clinical Practice. 8th ed. Philadelphia, PA: Elsevier; 2022:chap 96.

Okun MS, Lang AE. Parkinsonism. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 381.

Radder DLM, Sturkenboom IH, van Nimwegen M, et al. Physical therapy and occupational therapy in Parkinson’s disease. Int J Neurosci. 2017;127(10):930-943. PMID: 28007002 pubmed.ncbi.nlm.nih.gov/28007002/

nurse with wheelchair

Multiple Sclerosis

Multiple sclerosis (MS) is an autoimmune disease that affects the brain and spinal cord (central nervous system).  It can also be called MS or Demyelinating disease.

MS affects women more than men. The disorder is most commonly diagnosed between ages 20 to 40, but it can be seen at any age.

MS is caused by damage to the myelin sheath. This sheath is the protective covering that surrounds nerve cells. When this nerve covering is damaged, nerve signals slow or stop.

The nerve damage is caused by inflammation. Inflammation occurs when the body’s own immune cells attack the nervous system. This can occur along any area of the brain, optic nerve, and spinal cord.

It is unknown what exactly causes MS. The most common thought is that it is caused by a virus, a gene defect, or both. Environmental factors may also play a role.

You are slightly more likely to develop this condition if you have a family history of MS or you live in a part of the world where MS is more common.

Symptoms

Symptoms vary because the location and severity of each attack can be different. Attacks can last for days, weeks, or months. Attacks are followed by remissions. These are periods of reduced symptoms or no symptoms. Fever, hot baths, sun exposure, and stress can trigger or worsen attacks.

It is common for the disease to return (relapse). The disease may also continue to get worse without remissions.

Nerves in any part of the brain or spinal cord may be damaged. Because of this, MS symptoms can appear in many parts of the body.

Muscle symptoms:

  • Loss of balance
  • Muscle spasms
  • Numbness or abnormal sensation in any area
  • Problems moving arms or legs
  • Problems walking
  • Problems with coordination and making small movements
  • Tremor in one or more arms or legs
  • Weakness in one or more arms or legs

Bowel and bladder symptoms:

  • Constipation and stool leakage
  • Difficulty beginning to urinate
  • Frequent need to urinate
  • Strong urge to urinate
  • Urine leakage (incontinence)

Eye symptoms:

  • Double vision
  • Eye discomfort
  • Uncontrollable eye movements
  • Vision loss (usually affects one eye at a time)

Numbness, tingling, or pain:

  • Facial pain
  • Painful muscle spasms
  • Tingling, crawling, or burning feeling in the arms and legs

Other brain and nerve symptoms:

  • Decreased attention span, poor judgment, and memory loss
  • Difficulty reasoning and solving problems
  • Depression or feelings of sadness
  • Dizziness and balance problems
  • Hearing loss

Sexual symptoms:

  • Problems with erections
  • Problems with vaginal lubrication

Speech and swallowing symptoms:

  • Slurred or difficult-to-understand speech
  • Trouble chewing and swallowing

Fatigue is a common and bothersome symptom as MS progresses. It is often worse in the late afternoon.

Exams and Tests

Symptoms of MS may mimic those of many other nervous system problems. MS is diagnosed by determining if there are signs of more than one attack on the brain or spinal cord and by ruling out other conditions.

People who have a form of MS called relapsing-remitting MS have a history of at least two attacks separated by a remission.

In other people, the disease may slowly get worse in between clear attacks. This form is called secondary progressive MS. A form with gradual progression, but no clear attacks is called primary progressive MS.

The health care provider may suspect MS if there are decreases in the function of two different parts of the central nervous system (such as abnormal reflexes) at two different times.

An exam of the nervous system may show reduced nerve function in one area of the body. Or the reduced nerve function may be spread over many parts of the body. This may include:

  • Abnormal nerve reflexes
  • Decreased ability to move a part of the body
  • Decreased or abnormal sensation
  • Other loss of nervous system functions, such as vision

An eye exam may show:

  • Abnormal pupil responses
  • Changes in the visual fields or eye movements
  • Decreased visual acuity
  • Problems with the inside parts of the eye
  • Rapid eye movements triggered when the eye moves

Tests to diagnose MS include:

  • Blood tests to rule out other conditions that are similar to MS.
  • Lumbar puncture (spinal tap) for cerebrospinal fluid (CSF) tests, including CSF oligoclonal banding may be needed.
  • MRI scan of the brain or the spine, or both are important to help diagnose and follow MS.
  • Nerve function study (evoked potential test, such as visual evoked response) is less often used.

Treatment

There is no known cure for MS at this time, but there are treatments that may slow the disease. The goal of treatment is to stop progression, control symptoms, and help you maintain a normal quality of life.

Medicines are often taken long-term. These include:

  • Medicines to slow the disease
  • Steroids to decrease the severity of attacks
  • Medicines to control symptoms such as muscle spasms, urinary problems, fatigue, or mood problems

Medicines are more effective for the relapsing-remitting form than for other forms of MS.

The following may also be helpful for people with MS:

  • Physical therapy, speech therapy, occupational therapy, and support groups
  • Assistive devices, such as wheelchairs, bed lifts, shower chairs, walkers, and wall bars
  • A planned exercise program early in the course of the disorder
  • A healthy lifestyle, with good nutrition and enough rest and relaxation
  • Avoiding fatigue, stress, temperature extremes, and illness
  • Changes in what you eat or drink if there are swallowing problems
  • Making changes around the home to prevent falls
  • Social workers or other counseling services to help you cope with the disorder and get assistance
  • Vitamin D or other supplements (talk to your provider first)
  • Complementary and alternative approaches, such as acupuncture or cannabis, to help with muscle problems
  • Spinal devices can reduce pain and spasticity in the legs

Support Groups

Living with MS may be a challenge. You can ease the stress of illness by joining an MS support group. Sharing with others who have common experiences and problems can help you not feel alone.

Outlook (Prognosis)

The outcome varies, and is hard to predict. Although the disorder is life-long (chronic) and incurable, life expectancy can be normal or almost normal. Most people with MS are active and function at work with little disability.

Those who usually have the best outlook are:

  • Females
  • People who were young (less than 30 years old) when the disease started
  • People with infrequent attacks
  • People with a relapsing-remitting pattern
  • People who have limited disease on imaging studies

The amount of disability and discomfort depends on:

  • How often and severe the attacks are
  • The part of the central nervous system that is affected by each attack

Most people return to normal or near-normal function between attacks. Over time, there is greater loss of function with less improvement between attacks.

Possible Complications

MS may lead to the following:

  • Depression
  • Difficulty swallowing
  • Difficulty thinking
  • Less and less ability to care for self
  • Need for indwelling catheter
  • Osteoporosis or thinning of the bones
  • Pressure sores
  • Side effects of medicines used to treat the disorder
  • Urinary tract infections

When to Contact a Medical Professional

Call your provider if:

  • You develop any symptoms of MS
  • Your symptoms get worse, even with treatment
  • The condition worsens to the point when home care is no longer possible