Normal Pressure Hydrocephalus – Slow and Steady Pressure… Loses the Race

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You may or may not know someone with dementia, but you are most certainly familiar with it – this common disease currently affects 36 million people worldwide. It is a clinical condition in which a patient suffers a decline in mental functioning, and in a preponderance of cases, this process progresses into an inevitable debilitating disease. Yet, many people are unaware of the fact that some types of dementia are reversible. An example of this is Normal Pressure Hydrocephalus (NPH), a syndrome characterized by a triad that includes dementia, difficulty walking, and urinary incontinence. Unfortunately, the presenting symptoms of NPH are similar to those found in many other clinical scenarios witnessed in the elderly population, oftentimes making it difficult to discern the right diagnosis. Patients who undergo prompt treatment for NPH have a 60% chance of clinical improvement. Quick recognition of the signs and symptoms related to this disease enables an earlier intervention and creates a greater probability of a life changing treatment.

In order to understand NPH, we must first learn some basic cerebral physiology. The brain and spinal cord are surrounded by CSF (cerebrospinal fluid), a liquid that acts as a regulator of cerebral blood flow. It is produced within the ventricles (cavities in the brain), runs through the brain and spinal cord, and eventually drains into specialized tissue cells known as arachnoid. Scientists have determined that patients with NPH have damage to the arachnoid tissue and, consequently, the CSF is not adequately absorbed. Gradually, the excess CSF causes a localized increase in pressure over the brain tissue leading to the clinical syndrome. [However, the overall brain pressure does not increase, hence the name “normal pressure” hydrocephalus]. The injury to the arachnoid tissue can occur when a patient suffers brain trauma, intracranial bleeds, infections, cancer, or an inflammatory process. The typical triad seen in the clinical manifestation of NPH involves: A) dementia, characterized by a decrease in attention and concentration abilities, in addition to a general sense of apathy; B) gait abnormalities, in which patients take short steps and have a marked decrease in their stride; and C) urinary incontinence. The diagnostic process involves a cognitive examination and radiographic imaging studies such as CT scans and MRI’s. NPH is treated with a ventricular shunt, a device inserted into the brain (via surgery) designed to remove the excess fluid.

As with any surgical procedure, ventricular shunts incur some complications. For example, patients can develop headaches (due to over drainage of CSF), intracranial bleeds, infections, seizures, or they can have a mechanical device failure requiring shunt replacement. Of note, patients who decide to undergo surgery should have this done within 6 months of the onset of symptoms, as studies have shown better outcomes in this particular subset of patients. So, for anyone with an elderly grandparent, friend, or neighbor who has received a diagnosis of dementia, consideration of the other two classic symptoms may lead to a swift diagnosis of NPH. Your concern and inquisitiveness just might make all the difference in whether someone gets a second chance at their old life.

Urticaria – A Swell Like a River or a Sting Like a Bee

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A man dining at an ocean front restaurant decides to order a shrimp cocktail for an appetizer; however, thirty minutes after ingesting the shrimp, he develops a bizarre skin sensation. He feels an intense urge to scratch his skin and he notices that red welts have begun to develop all over his body. This is the classic presentation of urticaria: a common skin disorder in which a red rash develops as a result of an allergic trigger. This condition is also known as hives, and statistics show that 1 in 5 people are affected by this syndrome. Acute urticaria typically lasts less than 6 weeks, but in a subset of patients, it can become a chronic illness. It is a relatively painless but extremely itchy rash which can oftentimes interfere with daily activities such as work and sleep. Interestingly, urticarial lesions are not always allergic in nature. In fact, there are several diseases and physical conditions that can cause the development of hives. In addition to this, although urticaria is a separate entity from anaphylaxis (a life-threatening allergic reaction in which there is swelling of the throat), they can occur concomitantly. Therefore, not only should patients be able to identify urticarial lesions, but also they should recognize when the condition is affiliated with anaphylaxis, given that if the latter is present, both treatment and severity will vary significantly.

Urticaria occurs when the body is exposed to an agent that triggers an inflammatory reaction, and when this response ensues, there is an activation of the body’s immune cells. Subsequent to this, immune cells release histamine, an organic compound which causes localized swelling and an itching sensation. [Medically speaking, histamine enables white blood cells to fight off pathogens or infected cells.] The most commonly described triggers for urticaria include: medications, such as antibiotics in the penicillin class; food sources such as milk, peanuts, and shellfish; latex; plant products; parasitic infections; and insect bites. Other notable triggers include physical factors such as exposure to cold temperatures, sunlight, pressure to the skin, and exercise. Of note, in a large number of cases, the inciting agent is never found. The characteristic manifestation involves a series of red rounded lesions dispersed all over the body. These may enlarge within minutes to hours and once the lesions resolve, they leave no skin markings. The diagnosis of urticaria is clinical and is based on the patient’s history and a physical examination. Urticaria is treated with anti-histamine medications (e.g. Benadryl) and oral steroids which suppress the inflammatory reaction. Furthermore, if the doctor suspects an allergic cause, the patient will be referred to an allergy specialist for advanced testing.

Urticaria can also be the initial presentation of a disease, as is seen in lupus, rheumatoid arthritis, and thyroid disease. Yet, this is a less common scenario. Luckily, isolated hives is considered a benign condition, and in ⅔ of cases urticarial lesions will resolve spontaneously. Moreover, for patients with persistent lesions, basic symptomatic treatment will generally suffice. On the other hand, if urticarial lesions occur in conjunction with anaphylaxis (where patients manifest difficulty swallowing due to swelling of the oral structures) patients will require emergency treatment and prompt hospitalization.

Decompression Sickness – “You Have to Learn to Pace Yourself…”

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Scuba diving is a popular adrenaline-driven sport practiced by about 9 million recreational divers in the U.S. Yet, this exciting pastime brings about a series of potentially hazardous effects. Among the various associated medical emergencies, decompression sickness (aka “the bends”) remains as one of the most commonly recognized. Patients with this syndrome can present with either minor ailments such as joint pain, or they can develop a series of severe neurologic complications. The precise number of patients affected by decompression sickness remains unclear, given that different sources quote disparate numbers, ranging from 1,000 to 1 million. Nevertheless, irrespective of which is the accurate statistic, the fact is that diving-related injuries can be dangerous and even catastrophic. Those involved in this practice should be able to recognize the signs and symptoms of decompression sickness, but more importantly, they should be able to identify the risk factors leading to the condition.

In order to understand decompression sickness, one must comprehend some basic physics. As a scuba diver descends into the water, while breathing pressurized air (mostly composed of nitrogen and some oxygen), the increase in pressure from the descent causes the gases to solubilize and enter the tissues. When the diver returns to the surface, the gases contained inside the body will be naturally dissipated in a controlled fashion; but, if the diver ascends too quickly, the nitrogen from the tissues will be rapidly discharged in the form of gas bubbles. Nitrogen bubbles are the root cause of injury, and they have the ability to obstruct blood flow as well as cause serious organ damage. The symptoms of decompression sickness are generally noted within twelve hours of surfacing and there are two types of clinical manifestations. Type I is a mild form of the disease and is characterized by localized joint pains, itching over the torso area (from nitrogen bubbles in the skin), and enlarged lymph nodes. The second form, Type II decompression sickness, is more serious. It typically involves neurological emergencies that affect the brain and spinal cord (e.g. stroke and paralysis), or it may cause an obstruction in pulmonary and cardiac blood flow, resulting in circulatory collapse. The treatment involves hydration with intravenous fluids, administration of 100% oxygen, and placement in a hyperbaric oxygen chamber (a tube in which pressurized oxygen is delivered in order to restore oxygenation to the damaged tissues).

Experts have found a variety of risk factors that can predispose patients to diving injuries, which include: poor cardiovascular health; procedural errors such as ascending too quickly; environmental issues, for instance, fighting an unexpected strong current; and equipment failure. It’s important that divers evade air travel for at least 12-48 hours after their last dive. This is because a diver can have asymptomatic bubbles, which when exposed to the variable pressures found on an airplane, can rapidly turn symptomatic and activate the clinical syndrome. Symptoms of decompression sickness may not always be specific and some patients only complain of fatigue and malaise. Therefore, not only should divers be well informed, but also it may be of value to educate friends and fellow water-lovers about decompression sickness, as they might notice it first, and get you the treatment you need.

Kidney Transplant – A Broad Measure of Devotion

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Over the last century, medicine has made some great strides, ranging from the development of vaccines to the ability to perform a facial transplant. In fact, the surgical field of transplantation in particular has enjoyed some of the most significant breakthroughs. We are currently able to successfully transplant a variety of organs, and among these, kidney transplants have become one of the greatest and most commonly performed operations in the U.S. Kidney transplants can be done with either cadaveric kidneys or with those derived from a live donor. Not surprisingly, there is a long waiting list to obtain a viable organ. As a result, it’s important for people to be familiar with the general process of kidney transplantation, given that at some point they might become a recipient or even a feasible candidate to become a donor – an incredibly selfless act that would assuredly prolong another human being’s life.

The kidney is an essential organ whose job is to filter blood and remove dangerous toxins. Kidney failure can occur as a result of genetic causes or it may be a consequence of disease progression. Scientists have delineated a variety of conditions that frequently lead to renal dysfunction and these include: hypertension, diabetes, infections, autoimmune diseases (e.g. lupus, where a patient’s own cells attack different organs), and genetic disorders (e.g. polycystic kidney disease, in which growths replace the kidney tissue). Once a patient has been diagnosed with irreversible disease progression for at least 6-12 months, they will be referred to a specialized transplant center. The patient has the option of enlisting for a cadaveric transplant or they might begin the search for a live organ donor. Patients need to find a compatible kidney, which is done via examination of the blood and tissue type of the potential organ donor. During the actual operation, the new kidney will be placed in the pelvic region (not where the kidney is normally located), and will be attached to a different set of arteries and veins than the original kidney, which is left in its original location. After the operation is performed, the patient will be placed on a variety of drugs which suppress the immune system. This is done in an effort to stop the body’s cells from attacking the “foreign” donor organ.

A kidney transplant is a major operation and there are a number of complications which may ensue. The patient could either reject the transplant, acquire a serious blood infection (given that their immune system is inhibited), or they might develop hazardous side effects to the new medications. However, when a patient has a successful transplant, they will enjoy an improved quality of life, higher energy levels, and a decrease in the risk of death. Notably, in the U.S., one out of three transplants comes from live donors, a significant number given the commitment. In addition to this, donors don’t have to be genetically related. Although you might never need a kidney transplant, it’s worth considering becoming a donor – whether altruistically giving one of your two kidneys in your lifetime; or post-mortem. You never know whose life or loved one your sacrifice might save.

Jimson-weed Poisoning – Pretty Weed But Don’t Misread

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Every year in the U.S., a mind-blowing 1.4 million people under the age of 18 try illicit substances for the first time; and not surprisingly, given the mindset of being bullet-proof, common of minors, they will typically focus on seeking substances that are easily available to them. In an effort to get high, adolescents may go to the pharmacy and purchase over-the-counter products such as cough syrup or they might perform a google search for a term like “herbal drugs”. One such example of a conveniently accessible noxious substance is that of Jimson-weed, an extremely toxic plant taken for its hallucinogenic effects. It is abundant in U.S. soil and can be easily grown in most places. Its effects are comparable to the medical drug class of the anticholinergic family (e.g. diphenhydramine aka Benadryl). Unfortunately, many Jimson-weed users underestimate the plant’s potency, in that they incorrectly assume that anything made by nature must be safe. Therefore, the public needs to realize that the plant’s toxic effects are similar to those of any other harmful drug; but more importantly, everyone should familiarize themselves with the clinical effects of this herb, as it can cause major toxicity, which can result in death if not treated.

The Jimson-weed plant is formally known as Datura Stramonium, an herb that can structurally grow into a 2-5 foot bush. It has a long root, a leafy stem, and cream or violet colored trumpet-shaped flowers. Although the whole plant is considered toxic, the seeds encompass the highest concentration of the chemical ingredient. Once ingested, it can take up to an hour for a patient to develop the manifestation of physical symptoms. This can be considered a long time period for someone who is expecting an immediate mind-altering effect, and consequently, many adolescents unintentionally overdose as they continue to ingest parts of the plant while waiting for the promised hallucinogenic effects. The typical clinical presentation includes dry and red skin, fever, altered mental status, hallucinations, blurry vision, inability to urinate, increased heart rate, seizures, and coma. The diagnosis is based on the clinical history and physical examination because there are no specific tests to easily determine that someone is poisoned with Jimson-weed. The treatment is mostly supportive and involves intravenous fluids for hydration, supplemental oxygenation, and benzodiazepine medications (e.g. Ativan) for agitation and seizures. Even though there is an antidote (based on the chemical similarity to the anticholinergic drug class), this is rarely used due to medical risks.

Adolescents seeking hallucinogenic agents are not the only ones who may present with Jimson-weed poisoning, as there have been documented cases of people inadvertently using the leaves of this plant for seasoning purposes. Since we cannot eliminate all of our surrounding Jimson-weed plants, the focus should be on educating the public. Everyone should be able to recognize the plant and also be able to identify the most common presenting clinical symptoms. This way, if you encounter an adolescent who suddenly acts as intoxicated or worse, you might be the one to realize that there is an association with Jimson-weed poisoning. This critical intervention might save a child’s life.

Food Bolus Impaction: Where Ration is the Right Action

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We have all experienced what an incessantly hectic work-day is like – one in which we don’t even have the time to get a bite to eat; and consequently, when the time finally comes…when we get a hold of that meal, we tend to ingest the food – or rather, inhale it – as quickly as humanly possible in hopes of promptly satiating our stomachs. Yet, when food is devoured quickly and in large quantities it can become obstructed, a condition known as a food bolus impaction. In some cases, the impaction will spontaneously resolve, but when it doesn’t, it becomes a dangerous situation in which patients will require an emergency procedure. Frequently, patients who suffer from a food bolus impaction possess structural abnormalities that predisposes them to an esophageal blockage, and in a preponderance of cases, patients are unaware of these anatomical deformities. Therefore, it is important for the public to learn about all the risk factors associated with a food bolus impaction, as this may someday save them or someone they know from a life-threatening choking episode.

When food is ingested, it has to traverse from the oral cavity into the 10-inch esophageal tube. The esophagus contains three naturally occurring areas of narrowing and, not surprisingly, these are the most common sites of food bolus impactions. In addition to this, patients may also have internal anatomical aberrations which could lead to a blockage, and these include: diverticula (protruding pouches); rings (extraneous tissue that extends from the inner wall); strictures (areas of narrowing due to scar tissue formation); and tumors. Patients with a food bolus impaction will typically present with difficulty swallowing and neck pain. However, in severe cases, they will manifest the following symptoms: choking, drooling, regurgitation of food, wheezing, and respiratory distress. The diagnosis is generally made by direct visualization of the food item via an endoscope, which is a special camera that can be inserted into the esophagus. The treatment involves the use of tools attached to the endoscope which allow the physician to break up the food item, push it forward, or retrieve it. If the gastroenterology specialist detects any of the aforementioned structural abnormalities, they can also treat those via the endoscope.

Food bolus impactions can cause significant complications (e.g. pulmonary aspiration of the food particles), and as a result, these obstructions need to be treated within 12 hours of onset. One may have heard of patients receiving a substance known as a meat tenderizer (a chemical used to degrade meat products) to get rid of an esophageal impaction, but this is no longer recommended as it can cause a perforation of the esophagus. Oftentimes, patients with the aforementioned anatomical abnormalities will have noticed that their food sluggishly treads down the esophagus, a classic warning sign of an inhibiting lesion. Nevertheless, whether you have a predisposing medical condition or not, you can still get a food bolus impaction, so taking proactive measures is an easy alternative. Thus, take your time while eating and make sure that you carefully chew your food, given that this will save you from an untimely Heimlich maneuver and the business end of an operating room endoscope.

Impetigo: The Trials of Job for the Toddler and Child?

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Children have the uncanny ability to transmit infections quickly and easily to those around them – a fact which most of us have witnessed that first hand. Moreover, it seems that whatever disease they get, ends up replicating exponentially. One such example is the disease, impetigo, a superficial bacterial skin infection characterized by its honey-colored crusted lesions around the face. It’s a widespread condition that annually affects around 140 million people worldwide and although it commonly affects children, it is not isolated to this population. Luckily, impetigo is simple to treat, oftentimes only requiring topical antibiotics. Yet, if it is not detected and treated early, impetigo can proceed to cause a deeper infection, one which poses the ability to significantly scar the skin. In addition to this, given its efficient mode of dissemination, the public should take active measures in an effort to prevent the spread of infection.

Impetigo can manifest on normal skin (aka primary impetigo) or it can be the result of a microbial infection on damaged tissue, such as the site of an abrasion or laceration. The most commonly isolated bacteria include staphylococcus aureus (a frequent cause of skin infections) and streptococcus (a microbe that causes strep throat). Impetigo is usually seen in children between the ages of 2-5 and the infection is known to proliferate in warm and humid environments. The clinical manifestation includes an array of small bumps that turn into fluid-filled sacs, all surrounded by a red border, which after about a week, turns into a golden colored crust. Patients can have enlarged lymph nodes around the area of infection but systemic and more common symptoms such as fever are typically absent. Transmission occurs via direct contact of the infected site and the lesions classically appear over the face and extremities. There are other forms of impetigo which are more serious and these usually exhibit deep ulcerated skin lesions. The diagnosis can be made by physical examination alone, but a wound culture could also be obtained if there is a need to determine the specific bacterial source. The treatment for uncomplicated impetigo includes topical antibiotics such as mupirocin; however, if a patient has severe impetigo (e.g. widespread lesions) they will almost certainly require oral antibiotics.

Since impetigo is mostly a disease common among children, it is important for parents to teach their kids proper hygiene and disease prevention. Adhering to the following practices will help avert an infection: frequent hand washing with soap and water; not sharing towels, clothes, or other personal items where bacteria can be present; covering sections of the skin with active infections so that it doesn’t spread to other segments of the body or to other people; and using disposable tissues given that impetigo is frequently found on the face. If your child develops the classic crusted lesions, a topical antibiotic treatment for five days should suffice. Furthermore, it should be emphasized that prompt treatment for impetigo is critical, as it will not only reduce the risk of the infection spreading but will also avoid a potentially embarrassing or even unsightly appearance.

Listeria – Consider the Conspicuous Cautions

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It may come as a surprise that a current outbreak of Listeria monocytogenes has reached 11 states and confirmed to have caused 3 deaths. Consequently, the CDC (Centers for Disease Control and Prevention) has put out a general announcement advising the public to avoid the consumption of prepackaged caramel apples, given that 88% of those currently infected with Listeria reported eating this specific item right before they became ill. Listeria is a well-known bacteria which humans generally acquire through the consumption of contaminated food and, although it can affect anyone, it can be particularly dangerous in pregnant females and those with a weak immune system. Infections with Listeria largely occur as sporadic events but occasional outbreaks, such as with the caramel apples, still occur. It is important to note that among food-borne infections, Listeria has been rated as the third most deadly. Therefore, when the CDC issues an advisory, it’s important that the public pay attention. Additionally, people should familiarize themselves with the general risk factors associated with Listeria in the interest of avoidance.

Listeria’s primary habitat is soil and decaying vegetable matter, with healthy appearing animals often acting as carriers. One of its most interesting properties is that it has the ability to survive and multiply in refrigerated temperatures; so even if a product is initially minimally contaminated, when exposed to this environment it can quickly get saturated with Listeria. The typical clinical manifestation involves a gastroenteritis-type condition in that patients present with fever, vomiting, diarrhea, and joint pain. This occurs within 24 hours of the bacterial ingestion, making it easy for people to decipher the root cause of the infection. On the other hand, if Listeria becomes invasive and spreads throughout the body, patients can develop sepsis (critical illness as a result of bacteria in the bloodstream), brain abscesses, or meningitis. Scientists have delineated a set of risk factors which predispose patients to developing the severe form of illness, which include: pregnancy, steroid treatment, having diseases such as cancer or diabetes, and being at the extremes of age (i.e. an infant or an elderly individual). As opposed to the gastroenteritis manifestation, the bloodstream materialization has an incubation period (time between disease acquisition and manifestation of illness) of approximately 35 days. The diagnosis is made with a combination of the clinical presentation, stool tests, blood culture samples, and spinal fluid analysis. The treatment consists of antibiotic medications.

The public can play an active role in minimizing the chances of infection by adhering to the following measures: washing raw vegetables before consumption, keeping refrigerator temperatures below 40F, cleaning knives and cutting boards after handling uncooked food, eating precooked meals as soon as possible, thoroughly cooking raw food that comes from animals, and drinking pasteurized milk. Moreover, for individuals in the aforementioned high-risk categories, additional practices should include avoiding soft cheeses, refrigerated smoked seafood, and prepackaged salads containing chicken and eggs. For the most part, patients with a normal immune system will fully recover from a Listeria infection. However, for patients at high risk for critical illness, extra precautions need to be taken, as a severe Listeria infection can result in death.

Q Fever – Avoid a Quizzical Quandary

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The mad cow disease epidemic reached its peak in 1993, when authorities reported that they were witnessing an all-time high of 1,000 new cases per week; and consequently, mad cow disease quickly became the subject of headlines throughout the world. Since then, strict regulations have been developed for the cattle industry in an effort to protect the public from developing a critical illness. However, serious disorders brought about by cattle still occur, with some now being far more prevalent than mad cow disease. One such example is that of Q fever, a disease caused by the bacteria coxiella burnetii, distributed worldwide and mostly acquired via farm animals. Its clinical manifestation resembles a variety of other syndromes, making it difficult for physicians to accurately diagnose their patients. Moreover, it also has a long incubation period (time from disease acquisition to presentation), adding another element of complexity given that patients don’t necessarily make an association between the animal exposure and the disease itself. Naturally, being acquainted with the typical symptoms of Q fever is recommended but more importantly, is that people learn to recognize who is at risk for the development of this infection.

The bacteria that causes Q fever is known for its ability to withstand heat and other harsh environments, and as a result of this, they can survive for prolonged periods of time. As mentioned, coxiella burnetii is commonly found in cattle, but can also be seen in sheep and goats. The infected animals shed the bacteria in their urine, feces, milk, and placenta; and because the animals only act as carriers, they don’t portray symptoms of illness. A human acquires the bacteria when they inhale dust that has been contaminated with any of the aforementioned products. Once this occurs, it may take up to 20 days for the patient to develop any physical symptoms. Patients with an acute infection will typically develop fever, cough, malaise, and can proceed to develop pneumonia and hepatitis (liver inflammation). On rare occasion, patients may also develop meningitis and myocarditis (inflammation of the heart muscle). The diagnosis is made with a combination of the physical exam and pertinent historical data (e.g. exposure to farm animals), as well as with a specialized blood test. The treatment includes antibiotic medications, although in some cases patients will have spontaneous resolution of disease.

The bulk of cases witnessed in the U.S. have been verified in the following groups: veterinarians, meat processing plant workers, sheep and dairy employees, livestock farmers, and those working in research facilities. If involved with farm animals, one should make sure there is adequate disposal of high risk tissue (e.g. placenta). Employees of designated research facilities should have an appropriate method to bag and wash laboratory clothing. Lastly, even for those who are not directly involved with farm activity, it’s recommend that they strictly adhere to pasteurized milk products. Although vaccines have been developed for Q fever, the only available type in the U.S. is reserved for those doing specified research with at-risk animals. As with any other disease, the main focus should be on prevention; but if Q fever is acquired, there is no need for panic – the overwhelming majority of patients with this illness enjoy a full recovery.