BDD BEHAVIOURS – SKIN PICKING More than one third of people with BDD pick their skin. This relatively high frequency isn’t surprising, given that skin concerns are so common in BDD. People with BDD who pick are usually concerned about minimal acne, scars, or scabs, or such things as “large” pores, “bumps,” “small black dots,” “white spots,” “ugly things,” or other supposed imperfections. They pick to make their skin look better—to make it smoother, clearer, more attractive. They pop pimples, dig at white heads or blackheads, or smooth bumps. Some try to remove dirt, pus, or “impurities” from under the skin. While many use their hands to pick, pinch, or squeeze, others use tweezers, needles, pins, razor blades, staple removers, or knives.Picking with implements like these for hours a day can cause major skin damage. One woman picked an actual hole through her nose. Some people have go to the emergency room, because they pick through their facial skin into major blood vessels and need stitches. A colleague told me about a patient who picked so deeply at a pimple on her neck with tweezers that she ruptured her carotid artery, the major blood vessel to the head. She required immediate emergency surgery; the surgeon said that the picking nearly killed her.Even though skin picking can cause extensive skin damage, it’s important to realize that people with BDD don’t intend to mutilate themselves. Rather, they’re trying to improve how their skin looks. The problem is that the behavior is so compulsive that they can’t stop, which is what causes the damage.For some people, picking is a relatively inconsequential aspect of their BDD. But for most, the picking is in and of itself a serious problem; some consider it their major problem. One woman attributed her suicide attempt and psychiatric hospitalization to her belief that she had “ruined (her) face because of picking.” Two woman I know of needed psychiatric hospitalization largely because of their picking and eventually committed suicide.*98\204\8*
ASTHMA AND PREGNANCYPregnant asthmatics are often worried about the effects of their asthma and asthma medications on the unborn child. The ideal would be to have a drug-free pregnancy, but the reality is that most pregnant women with a chronic or persistent illness need to continue with their medication. There are some drugs, including anti-asthma drugs, that should be avoided during pregnancy and preferably no new drugs should be introduced during pregnancy. Fortunately the most commonly prescribed and effective anti-asthma drugs are known to be safe throughout pregnancy — theophylline drugs, Becotide, Pulmicort, Aldecin, Becloforte, Ventolin, Respolin, Atrovent and Bricanyl.IT IS IMPORTANT TO REALIZE THAT LACK OF OXYGEN DURING AN ACUTE ATTACK CAN BE MORE DAMAGING TO THE UNBORN CHILD THAN MEDICATION. UNCONTROLLED ASTHMA IS A MAJOR RISK FACTOR FOR BOTH THE MOTHER AND CHILD. GOOD CONTROL OF ASTHMA DURING PREGNANCY IS VITAL.About one percent of pregnant women are asthmatic. Some pregnant asthmatics report an improvement in their health during pregnancy and are able to reduce their medication. (Reducing your medication should not be done without consultation with your doctor.) Statistics show that, in general, one-third of asthmatic women improve during pregnancy, one-third remain unchanged and another third experience worsening symptoms.It is of the utmost importance that asthma is well-controlled during pregnancy. When an asthmatic woman becomes pregnant, she should consult her doctor immediately and discuss such important issues as medication, general lifestyle and diet, as well as the possible revision of her asthma management plan.Pregnancy, for many women, is a time when they are particularly vulnerable to emotional upheavals and mood swings. The accompanying psychological stresses can exacerbate their asthma, thus causing a need for extra medication. Many doctors advise their patients to practise relaxation techniques such as deep breathing, meditation and suitable yoga exercises. Such techniques can have an overall beneficial effect on the physical and emotional well-being of a pregnant women.During the first three months of pregnancy, the fetus is particularly vulnerable to a number of external influences, including exposure to chemical fumes and cigarette smoke, alcohol, lack of nutrients and X-rays. Care should be taken to avoid these dangers. Women should not smoke at any time during their pregnancy and alcohol should be consumed in moderation, if at all.If pregnant asthmatics adhere to a sensible health regime during their pregnancy, follow their doctors’ advice on necessary medication and avoid the obvious hazards, there is no reason why they cannot expect to have a normal and uncomplicated pregnancy and delivery.*41\148\2*
RISKS OF TYPE 2 DIABETESThe risks of type 2 diabetes are well documented; coronary heart disease, dyslipidaemia, blindness, renal failure, amputation and so on. Failing to diagnose the condition, and thus missing the opportunity to prevent the sequelae, is a costly error and an illustration that obesity must not be ignored; 10% of NHS resources are spent on diabetes and its complications, on behalf of only 3% of the population. WHO fact sheet 138 describes diabetes as the most important consequence of obesity. There are currently estimated to be over 150 million cases worldwide, a number that is likely to double by 2025.One of the most disturbing aspects of the increasing numbers of people with type 2 diabetes is the fact that adult-onset diabetes is now being seen in children as young as 10. Until recently, type 2 diabetes was unknown in children – it was usually restricted to adults over the age of 40. However, because of the increasing levels of childhood obesity it is now being seen in grossly obese children (weighing 20 stone or more). Although the phenomenon was initially reported in the US, the first cases of childhood-onset type 2 diabetes are being seen in the UK. Children such as these have a whole lifetime in which to develop the complications of diabetes, not to mention the comorbidities of obesity itself. Their shortened life expectancy has made some commentators believe that the current generation will be the first in which parents consistently outlive their children.*2/312/5*
A MATTER OF THE HEART: THE CIRCULATIONYou begin to marvel at the way it continues to beat 100000 times a day, continuously pumping about 5 litres of blood per minute around the circulatory system, handling some 7000 litres of blood every 24 hours. That means that, in the average lifetime, nearly 200 million litres are circulated around the body.The basic route of the blood’s remarkable journey is this. Fresh blood (i. e., blood saturated with oxygen (O2) and bright red in colour) is pushed from the left ventricle through the aortic valve into the aorta. It then flows through the arteries to all parts of the body, where it supplies the various tissues with essential oxygen and other nutrients. Once these life-giving nutrients have been expended, leaving in their stead carbon dioxide (CO2), water and other waste-products, the blood, now dark purplish-red (it is often called ‘blue’ or venous blood) flows through the veins back to the heart, entering the right atrium (or receiving area). It then passes through the tricuspid valve into the right ventricle; from here it is pumped through the pulmonary valve into the pulmonary artery, which leads to the lungs. In the lungs the blood is oxygenated and water and CO2 are extracted; it then flows through the pulmonary veins to the left atrium, ready to begin the cycle again.There is, then, a strict route taken by the blood: from the body via the veins to the right side of the heart, from there to the lungs, from the lungs to the left side of the heart and from there back to the body via the arteries. This is where those one-way valves become important, ensuring that the blood does not seep back. And, of course, in order to maintain sufficient driving force the heart has to keep going – the body cannot wait for fresh supplies of oxygenated blood. The wastes soon become toxic unless they are removed and replaced by fresh oxygen.The blood is carried by three kinds of vessels: arteries, which take blood from the heart to the body’s tissues and lungs; veins, which carry it on its return journey to the heart; and capillaries, which act as link roads, as it were, connecting the smaller arteries to the smaller veins. (Note that, while normally veins carry ‘blue’ blood and arteries carry oxygenated blood, the pulmonary vessels are the exception – the pulmonary vein carries red blood and the pulmonary artery carries ‘blue’.) Thus when an artery reaches a muscle, for example, it will branch out into tiny capillaries so that the blood can enter the muscle itself. After being deprived of its oxygen and loaded with waste products, the blood then leaves the muscle through a similar network of capillaries which then join up at a vein. Think of the capillaries as the smallest twigs of a tree, carrying nourishment from the main boughs and larger branches to all the leaves.*5/353/5*
INCIDENCE OF CANCESex does not affect the incidence of the disease. However, proportion of cancer in males and females is roughly 10:12. It also affects the site of growth. In men, cancer is usually found in the intestines, the prostate and the lungs. In women, it occurs mostly in the breast tissues, uterus, gall-bladder and thyroid.Cancer occurs at all ages, from infancy to old age. There is a close relationship between cancer and aging. In the United States, over one-half of all cancers occur in 11 per cent of the population over the age of 65. At the age of 25, the probability of developing cancer within five years is one in 700, while at the age of 65, it is one in 14. The peak incidence and mortality of cancer is in the 60-70 age range.Although deaths attributable to cancer decrease from 30 per cent at age 50 to 10 per cent or less at age 85, this is largely due to rapid increase in death due to other causes with advancing age, and not due to non-prevalence of cancer. Despite the marked increase in cardiovascular related deaths with age, cancer remains the second leading cause of death in those over 65.Cancer is not contagious or infectious. This is clearly evident from the fact that a large number of members of the medical profession and technicians come in close contact and handle cancer tissues in the course of treating patients, but they do not get cancer any more than other sections of the people. No infective agent has so far been detected from cancer tissues.*5/355/5*
JUVENILE RHEUMATOID ARTHRITIS AND CHILDRENAre autoimmune antibodies evident in these children?Yes, for some reason the antibodies found in lupus and other autoimmune disease are found in these children. This does not mean that they have lupus, just that this syndrome is likely to be an autoimmune disorder, like adult RA. The occurrence of these antibodies in children with these diseases can sometimes cause scary confusion.A good pediatric rheumatologist knows the importance of eliminating other illnesses as causes of symptoms.
What are the lifelong consequences in children?Many patients require lifelong therapy with anti-arthritic drugs. The anti-inflammatory agents and the new disease-modifying anti-rheumatic drugs (DMARDs) are very useful in the later life treatment of JRA patients. Problems like stunted limbs or a shortened jaw are only a few side effects of JRA. Today, these skeletal deformities are not as prevalent since early diagnosis and treatment are much more common. Unlike many other aspects of the disease, these growth changes can be irreversible.
What type of doctor should my child with JRA see?Specialists called pediatric rheumatologists would examine, diagnose, and treat your child. They are experts in the childhood forms of arthritis.*21/141/5*
AGING AND POWERFUL MINDS IN HISTORY: LEADERSHIP AND DEMENTIATo fully appreciate the force of these facts, let us also make note of their universal nature. The art is not the only arena in which the masters of their crafts retain their touch despite the crippling effects of the assorted brain diseases of aging. Let us also consider the arena of statesmanship and politics. And here we are stepping into a morally agnostic territory. If the great artists are remembered for their good, at least as public personas, then the important statesmen and politicians can be either heroes or villains, or tangled juxtapositions of both. We will consider examples of all of the above among those aspiring to rule despite their cognitive decline and even early dementia.”First among the virtues found in the state, wisdom comes into view,” wrote Plato in his Republic. We wish! We often think of the rich and the powerful as exempt from the laws of nature, including the laws of physics and biology. What’s more, the rich and the powerful are probably the first to share this belief. This is benevolently known by some as “boundless self-confidence” and less benevolently by others as “hubris.”But whatever may or may not be true for other natural laws, the biological processes causing dementia do not discriminate on the basis of wealth, power, or even moral rectitude. We are only beginning to understand dementia’s biological causes and the processes by which it robs the mind of its powers and turns the most brilliant intellect into a shell, an incoherent and confused wreckage of a human being. Many forms of dementia exist, some causing gradual brain atrophy and others causing a gradual accumulation of small strokes. To make matters worse, they often appear in combinations. All dementias are equal-opportunity scourges, eroding the mind in a variety of insidious ways, without sparing the rich, the powerful, and the righteous. It is amazing how many history-shaping decisions have been made, and continue to be made, by eroding, even dementing minds before the eyes of a power-awed, unsuspecting public.This thought first crossed my mind many years ago, as I was making my diagnosis of Ronald Reagan. A refugee from the former Soviet Union, I had been an anomaly among my friends in the liberal New York intelligentsia as an admirer of Reagan, the man who helped dismantle the “evil empire” I had fled half a lifetime ago. So, when the inkling of Reagan’s dementia first crossed my mind, I was far from gloating; I was genuinely upset. That was well before Reagan’s Alzheimer’s disease became pub-he knowledge or even a matter of public speculation. In fact, it was well before Reagan left the White House.Sometime during his second term, Reagan was quizzed by a journalist about the wreath-laying Bitburg affair, when in 1985 Reagan honored a cemetery full of Nazi SS guards against the advice of his aides. The feeling was that the American president was being manipulated by the then West German chancellor Helmut Kohl, who needed the gesture for his own political ends. As I was watching the interview on TV, Reagan’s responses to the journalist’s questions sounded so staggeringly incoherent that I picked up the phone, called my neurosurgeon friend (and a fellow foreign affairs buff) Jim Hughes, and said: “Reagan has Alzheimer’s!” Jim laughed, not realizing that I meant it literally, and not as a figure of speech.This may have sounded like a snap judgment, gratuitous even, but I was better equipped for making it than most people. A neuropsychologist with (then) almost twenty years of clinical experience and a reputation for diagnostic acumen, I make a living by studying, diagnosing, and treating various brain diseases affecting the mind. I was also doing research, publishing scientific papers, and writing books about the brain and the mind, and the numerous ways in which they may go wrong. The incoherence that so struck me in Reagan’s responses would have raised my diagnostic antennae coming from anyone, and Ronald Reagan was not exempt.My hunch about Reagan was strengthened some time later, during the last day of his presidency, as I was watching George Bush’s inauguration on TV. Reagan walked past the honor guard, approached the imposing leather chair prepared for him, slumped into the chair, and was immediately asleep, his head dropping on his chest instantaneously. “Brain stem gone,” I said to myself, alluding to the part of the brain that is in charge of maintaining the arousal necessary for sound mental activities. At this point I was convinced that a significant portion of Reagan’s second term had taken place in the shadow of his slippage toward early dementia.My conclusion that Ronald Reagan was suffering from Alzheimer’s disease or a similar dementing condition was sealed soon after he left office and well before the first official intimation to that effect. As I was watching Reagan’s interviews about the Iran-Contra affair, I was impressed, almost shocked, by the sincerity of his denial of any memories of the events, by the befuddled and incredulous expression on his face when the events and names of people were being thrown at him by the interviewers. Contrary to the opinion of many commentators, I was convinced that Reagan was not dissembling, that he was not attempting to hide anything. With the confidence of an experienced clinician, I felt that he truly did not remember. Ronald Reagan was suffering from early dementia. Of course, my diagnosis via television was subsequently confirmed when the “official” diagnosis was made in 1994 at Mayo Clinic, and Reagan’s hereditary risk factors revealed (both his mother and older brother had suffered from dementia).The former president’s own courageous admission of his illness earned him my respect and that of many other people. Were my earlier observations of Ronald Reagan indicative of outright dementia, or did they still belong in the gray area of “neuroerosion” or “mild cognitive impairment,” the early prodrome of things to come? Ultimately, this is a matter of semantics more than of substance, since we are talking about a gradual downslide devoid of discrete boundaries and not about an abrupt transition, a decline that came to an end in 2004, ten years after the “official” diagnosis of dementia and considerably longer after it had actually begun to set in.*12\302\2*
INFECTIOUS DISEASES: MALARIA – WIDESPREAD DISEASEAn infectious disease caused by a parasite known as the “Plasmodium” and transmitted by infected mosquitoes of the Anopheles family; several forms of malaria are known. At least four different Plasmodia have been associated with human malaria. These Plasmodia get into the red blood cells and ultimately destroy them. As a part of the process, malarial chills or paroxysms occur, giving rise to the different forms of malaria – the types that are irregular, the types that come regularly every two, three, or four days. A typical malarial paroxysm begins with a feeling of coldness, then of heat and finally of sweating. New drugs have been discovered which are extremely effective against malaria. Most of them are related to quinine. Malaria is probably the most widespread disease in the world. It can be controlled through control of the mosquitoes that spread it. Such control involves the cleaning up of swamps, removal of excess rain water, spraying of areas with oils or insecticides that destroy the mosquito in various stages. People who are constantly exposed to malaria in tropical areas take either quinine or the new drugs every day one hour before sunset. They screen their beds at night and keep the air moving to get rid of the mosquitoes. During the day suitable clothing is worn to prevent access of the mosquito to the skin.*29/318/5*
DIAGNOSIS AND THERAPY OF HERPES SIMPLEX VIRUS (HSV) ENCEPHALITISDiagnosis Routine diagnostic tests are of limited utility in HSV type 1 encephalitis. Examination of cerebrospinal fluid (CSF) often shows a mononuclear cell pleocytosis (10 to 1000 cells/mm3), an elevated protein concentration, and a normal or slightly low glucose level. The most helpful CSF finding, if present, is red blood cells in the absence of a traumatic lumbar puncture. This suggests necrotizing HSV type 1 encephalitis in the appropriate clinical setting. MRI with enhancement demonstrates lesions earlier than computed tomographic scan and is superior in localizing lesions to the orbital-frontal and temporal lobes. The EEG pattern in HSV type 1 encephalitis is distinctive and consists of periodic sharp-and-slow wave complexes emanating from the temporal lobe that occur at regular intervals of 2 to 3 seconds. These discharges can be unilateral or bilateral and are seen in two thirds of pathologically proven cases of HSV encephalitis. Although clinical and imaging studies can suggest HSV type 1 encephalitis, the diagnosis is correct only approximately 50% of the time when based on these criteria. Therefore, laboratory confirmation of the diagnosis is required. Polymerase chain reaction (PCR) on CSF for HSV type 1 is the procedure of choice, and results can be obtained in 1 hour. In one series, PCR was shown to be 98% sensitive and 100% specific. Serum antibodies are unhelpful, and CSF viral culture has low sensitivity. Cerebral biopsy with virus isolation has been the gold standard for diagnosis. It is rarely indicated unless CSF abnormalities are atypical, a CSF PCR study is negative, MRI and EEG are nonspecific, or clinical course is progressive despite acyclovir therapy. If CSF PCR is not available, early stereotactic brain biopsy is favored over empiric antiviral treatment, since the clinical diagnosis is only 50% accurate and alternative treatable diagnoses are found in as many as 15% of cases when biopsy is performed.
TherapyAcyclovir is the treatment of choice for herpes encephalitis and should be instituted upon suspicion of the disease. The effects of the illness can be significantly reduced if acyclovir is begun before there is a major alteration in the patient’s level of consciousness. Therapy has reduced the mortality rate to 19% (versus 70% in untreated control subjects), with 38% of patients returning to normal function. The recommended dose is 10 mg/kg intravenously every 8 hours for 10 to 14 days. The dose should be adjusted in patients with renal failure. Patients with a Glasgow Coma Score below 6 at the beginning of therapy, age older than 30 years, or the presence of encephalitis for more than 4 days before the initiation of treatment have a very poor outcome.Patients who survive herpes encephalitis may have severe, debilitating sequelae, including motor and sensory deficits, aphasia, and problems with cognitive function. Relapse of encephalitis is occasionally seen 1 week to 3 months after completion of acyclovir therapy and initial improvement. Retreatment with acyclovir or acyclovir and vidarabine is indicated in these cases.*22/348/5*