High Death Toll From Pneumonia

Pneumonia kills over 60,000 Americans every year and it remains a leading cause of death of children worldwide. This is tragic considering the fact that the disease can be cured with early detection and treatment.

Pneumonia is the inflammation of the lung in which the air spaces are filled with mucus and fluid, making breathing difficult. The disease has many causes and can be fatal in very young and very old patients.

Bacterial pneumonia, which is the more dangerous type of the disease, can be caused by infection with pneumococci, staphylococci and other forms of bacte¬ria. This is usually confined to just one area of the lung and is called lobar pneumonia.

“Among children 12 and under, the most frequent cause of pneumonia is the bacteria pneumococcus. Among adolescents and young adults, the most frequent infective agent is a bacteria like microbe called Mycoplasma pneumoniae; symptoms at first are like those of a chest cold, with a dry cough and then a sputum producing cough,” explained Dr. Harold C. Neu, professor of medicine and head of Infectious Dis¬eases in “The Columbia University College of Physicians and Surgeons Complete Home Medical Guide.”

“Bacterial pneumonia can also be a complication of influenza A. Often the symptoms of flu have disappeared, then suddenly the patient is worse with fever, cough, and shortness of breath. The recuperating victim this time has a full-fledged case of bacterial pneumonia and all its distressing symptoms. These secondary infections are most often caused by the pneumoccos, Haemophilus, or worst of all the staphylococcus. This microbe can be so deadly so doctors usually prescribe antibiotics that can destroy all three of the possible microorganisms,” Neu added.

Another type of bacterial pneumonia is caused by streptococci (Diplococcus pneumoniae) and usually follows an upper respiratory tract infection. It is characterized by the sudden onset of chills and high fever.

The risk of acquiring the disease increases in those who have AIDS, heart disease, and diabetes, those who smoke and drink a lot, exposure to certain chemicals or pollutants, and in those who are hospitalized or have had surgery. Treatment depends on the severity of symptoms and the type of pneumonia you have.

“To diagnose pneumonia, the physician will first listen to the chest, checking for fine, crackling noises, and then tap it, being alert for characteristic dull thuds. A certain diagnosis cannot be made, however, without chest x-rays, which will show patches in the lungs where air sacs are filled with fluid and debris instead of air. To determine the particular infective agent, lab tests can be done on blood and sputum samples, but the results are not 100 percent accurate,” Neu said.

“How serious pneumonia is for you depends on your overall health and the type and extent of pneumonia you have. If you’re young and healthy, your pneumonia can usually be treated successfully. But if you have heart failure or lung ailments, especially from smoking, or if you’re older, your pneumonia may be harder to cure. You’re also more likely to develop complications, some of which can be life-threatening,” warned the Mayo Clinic.

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Know Your Anti-Depressants – Even If You Don’t Plan to Take Them

It’s important to know your anti-depressants, before you reject them. Traditional anti-depressants do have their place, when dealing with severe forms of depression – but there are also very real hazards, too.

Serotonin Re-Uptake Inhibitors are modern psychiatrists’ first choice. These include such brand names as:

• Paxil

• Zoloft

• Effexor

• Wellbutrin

• Prozac

• Sarafem

They are considered the least potentially harmful of all the anti-depressants – though Mary P., of Newmarket, Ontario, would no doubt say otherwise, after spending the afternoon “paralyzed, but suspended above my body, feeling insanely powerful”, after her first (and only) dose of one of the above.

Tri-Cyclic Anti-Depressants block cell “receptors” and inhibit reabsorption of serotonin and norepinephrine. Another major job they do – which really works for some people – is to lower their sensitivity to glutamate.

Common Tri-Cyclics include:

• Amitriptyline

• Doxepin

• Imipramine

• Nortriptyline

All anti-depressants can cause common side effects such as:

• Loss of sexual interest and ability

• Constipation

• Headaches

• Weight gain (or loss)

• Exhaustion and lethargy; “loginess”

• Drowsiness

• Insomnia

And several more.

When it comes to taking anti-depressants, it’s really a case of “lesser evils” – the depression or the side effects.

Monoamine oxidase inhibitors (MAO-A inhibitors) are sometimes indicated, when Serotonin Re-Uptake inhibitors don’t work, particularly in cases of Atypical depression, Agoraphobia (fear of open spaces) and “social anxiety”.

MAO-A inhibitors decrease monoamine oxidase, which breaks down monoamine transmitters. Some common brands include:

• Parnate

• Nardil

• Emsam (patch)

With MAO-A inhibitors, there are normally-beneficial natural herbs that are actually contra-indicated:

• Passion Flower (Passiflora Incarnata)

• St. John’s Wort (Hypericum Perforatum)

Also, some foods can actually interact with MAO-A’s in a lethal fashion, causing death. Foods containing Tyramine and Tryptophan are the main offenders (almost everyone on MAO-A inhibitors has been cautioned about eating cheese.)

Fava beans, alcohol and liver are also on the “do not eat” list. Also, so many other medications that you are advised to waste no time in checking with your doctor for a complete list.

The old MAO-A inhibitors permanently destroyed monoamine oxidase, but newer ones do not do this. They are still a powerful drug it’s better not to mess with – and better to be 100% sure that you absolutely have to take! They can also be deadly, if you suffer from diabetes. Natural remedies may be your best solution, in this case. (Check with your health care professional.)

Anti-Psychotics are a class of drug often added to anti-depressants when auditory or visual hallucinations are involved.

This is a complex class of drugs, involving 2 generations. The first consists of 3 major groups: Butyrophenones, Phenothiazines and Thioxanthenes.

The second generation consists of one single group, including brand names such as:

• Zyprexa

• Clozaril

• Risperdal

Never let a doctor prescribe an anti-psychotic without also prescribing an anti-cholinergic medication to neutralize deadly reactions between anti-psychotic and anti-depressant – as patient Rosemary R., of Aurora, Ontario, found out the hard way. Fortunately, a fellow patient was with her when Rosemary suffered an anti-cholinergic reaction, shortly after taking her first dose of Clozapine. Her friend called 911.

I’d love to say everything went right at that point, but the truth is, even the medical staff at the hospital Emergency department completely missed the connection between the anti-psychotic and Rosemary’s Serotonin Re-Uptake inhibitor; and she herself had no idea what the problem was. The staff dismissed her severe shortness of breath, tight chest, racing heart and ominous feelings as a “panic attack” – and she spent “a nasty day” in the emergency ward, until the effects luckily wore off. (They can be fatal!)

Rosemary correctly tied her “attack” to the first dose of anti-psychotic, Clozapine, she had taken, and promptly discontinued the medication – a decision which she is now convinced may have saved her life.

It wasn’t until a week later, when Rosemary was accompanying her new friend and fellow-patient to a psychiatrist’s appointment, that the friend chatted to her own doctor about Rosemary’s frightening experience. Escorting her patient out of the office after the appointment, Dr. S. found Rosemary waiting, and asked her if she had been prescribed an anti-cholinergic, either with her new medication or at the Emergency Ward.

Rosemary’s answer – “What’s an anti-cholinergic?” – told Dr. S. everything she needed to know. She advised Rosemary to speak to her physician immediately.

Rosemary did. Her doctor’s stunning response? “Oops. I forgot about that…”

He also “forgot” to warn her about another potentially serious side effect called agranulocytosis, for which her blood needed to be carefully monitored bi-weekly. (“…Though he did remember to warn me about cheese…”)

The truth is, being informed and aware of what you are about to take is your best bet in making sure your treatment is right for you – and that your depression is severe enough to warrant these powerful, mind-altering drugs.

If your depression is mild to moderate, and you have experienced no suicidal thoughts, you may be much better off visiting a naturopath and looking into natural remedies, instead of blindly taking a heavy-duty anti-depressant.

Trigeminal Neuralgia – Are You Making These 3 Deadly Mistakes Managing Your Trigeminal Neuralgia?

Read on to find out 3 of the deadliest mistakes trigeminal neuralgia sufferers are making, and straight talk on the 6 things you can do instead

Mistake # 1- Being a passive rather than an active patient – The conventional medical model incorporates the notion that the doctor provides instructions and you the patient are expected to follow the instructions. This model has serious shortcomings, especially now that you are dealing with chronic pain. This model not only fails to recognize, let alone address the underlying problems, but your emotional, psychological and social needs are also ignored.

What to do instead: In managing your trigeminal neuralgia, there are 2 things you must do instead;

1. You must take an active role in determining your treatment plan

2. You must take a proactive role in moving beyond drugs and surgery onto the path that leads to optimal health and wellness. This path involves your body, mind and spirit. It is achieved only by following a comprehensive approach that complements your treatment plan with a wellness plan. One way to do this is to follow a step by step program which you can do on your own or with the help of a health coach if you prefer.

Mistake # 2 – Taking a single bullet approach to getting well again – By single bullet approach, I mean looking for that one magic trigeminal neuralgia treatment that is going to make it all right again. This is a set up for frustration and disappointment. Trigeminal neuralgia is a complex problem for which there is no single treatment. No wonder physicians and patients alike who take this single bullet approach are at their wits end.

What to do instead: You must complement your conventional treatment of trigeminal neuralgia with an approach that includes the following 3 things:

1. Destroy the underlying microorganisms

2. Work on rebuilding your immune system

3. Follow a nutritional program that facilities the healing of your nerves and the restoration of the myelin sheath

This is the only approach to the treatment of trigeminal neuralgia pain that gives you any meaningful hope of successfully managing your trigeminal neuralgia and getting well again.

Mistake # 3 – Not finding the cause of trigeminal neuralgia in your particular situation – Conventional medicine treats your trigeminal neuralgia symptoms, but rarely if ever helps you determine the cause of the problem. Neither drugs nor surgery is designed to deal with underlying causes. If the truth be known, there are many causes of trigeminal neuralgia, atypical trigeminal neuralgia and idiopathic trigeminal neuralgia. These causes, when properly addressed, go a long way in ameliorating and in many cases eliminating the pain.

What to do instead: Seriously consider kinesiology testing as this can help you screen for possible causes of nerve deterioration. Kinesiology will help to identify heavy metal toxicity, food sensitivities, microorganisms and electromagnetic frequency sensitivities among other causes. These have all been identified in patients with trigeminal neuralgia and these patients improved significantly when these underlying causes were addressed. Kinesiology testing may be the most important step you can take in determining the cause of your trigeminal neuralgia.

Symptoms of Heart Attack

Heart attack symptoms for women, you know, the typical chest pain (which also applies to men), isn’t always the most noticeable in women. You’d be wondering: A heart attack is a heart attack, does it matter whether it happens to a man or a woman? Why talk about heart attack symptoms specific to women?

Symptoms of Heart Attack in Women: nausea Feeling as though one is about to vomitanxiety a “panic” attack, feeling like there is something wrong but not knowing what it is back pain between the shoulder blades, this often happening INSTEAD of chest pain.

Uncomfortable pressure, fullness, squeezing, or painful sensation in the chest lasting more than a few minutes. Please note that the painfulness may go away temporary but will go back evenly as dreadful if not more painful.

A common sign of an impending heart attack is discomfort or slight pain. The discomfort occurs mostly in the chest area. It is mild to start with and recurs at long intervals. The feeling of discomfort can be a sense of pressure, dizziness, squeezing of the chest and so on. Often this discomfort radiates to other parts of the upper body, like the arms, neck, and back.

The most important treatment for a silent heart attack is restoring the blood flow to the heart. These silent attacks lack the majority of the usual symptoms of a standard heart attack but can still be recognized through ordinary signs such as discomfort in your chest, arms or jaw that seem to go away after resting, fatigue or extreme tiredness, nausea, sweating(particularly cold sweat), breathlessness and dizziness.

Heart disease sneaks up on you when you least expect it. Heart attacks, or myocardial infractions (MI), are the most dramatic manifestation of cardio vascular disease. MI’s will affect approximately 345,000 American women this year. These symptoms are your body’s way of telling you trouble is coming. Women push through their routines for hours or days, using antacids and over the counter pain relievers to mask MI symptoms.

Silent heart attack symptoms do not resemble the classic heart attack symptoms. A known cause of this condition is Silent Ischemia (Decreased blood supply to the heart muscle). When blood flow to the heart is blocked by plaque, the heart muscle in the area of the blockage becomes damaged.

Heart attack symptoms that are important to noteworthy of are chest pain and shortness of breath. Chest pain most especially remains the most important presenting heart disease symptom, it is however important to state that not all chest pains are heart diseases. No!

There are numerous conditions, unrelated to the heart that could give rise to chest pain. These are: Anxiety, pneumonia, pleurisy, peptic ulcers, infection, heartburn, gall bladder, indigestion etc.

There are numerous of panic heart attack symptoms like palpitation and hard breathing pattern. Also, the body responds in a certain way like a person who is frightened. Sample symptoms may include sweating, shaking, and trembling of the hands. Chest pain may also be felt along with dizziness.

Natural Remedies For Phlegm

Common illnesses like flu, cold, sore throat can lead to serious illnesses and diseases if not treated with care. Of course one could always visit the doctor or eat medicine. Recently, I was not sleeping very well and soon, fell sick. This time round, I was determined not to see doctor and allow it to heal naturally. And I did it.

Phlegm Symptoms

In my case, it started off as an uncomfortable at the throat. Whenever I tried to swallow anything, it would felt that there is something stuck in my throat. In the past, it will usually turn into phlegm after a few days and this time round it really did. Although it is not as bad as sore throat, one still needs to take care of the body or it will turn into something worse in the future.

After 1 or 2 days, green phlegm began to formulate especially when I woke up early in the morning. I started to sneeze and before I knew it, I was down with flu. In fact, if you face the same symptoms as me, it usually means that you have eaten too ‘hearty’ food such as chocolates, fried food, potato chips etc. And after eating so much ‘hearty’ food, you also had cold water or very sweet stuff.

You will feel your throat and your nose full of germs and you maybe feeling giddy, sleepy, or even having a fever.

Foods to avoid

If you face the symptoms as what I went through, these are the foods that you should avoid in order to alleviate the illness.

* sweet foods – like cakes, white sugar, honey,

* phlegm inducing fruits – bananas, oranges, plums, grapes, watermelon (does not seem to help)

* ‘hearty’ food – fried stuff, grilled foods, oily, greasy foods

* soft drinks

* cold food or drinks

* chickens, eggs, ducks, pork

* spicy foods

* dairy products

* excessive refined wheat products (usually contained a lot of sugar)

* peanuts

About Pneumonia Symptoms and Treatment

Every year there are people that die of pneumonia, especially older people, those with chronic illnesses or impaired immune systems, but also affects young and healthy people. There are many types of pneumonia with various signs and symptoms that usually appear after a flu or a complicated cold. Pneumonia occurs suddenly with chest pain, chills, fever, cough and shortness of breath. Antibiotics are used to treat the most common forms of bacterial pneumonias, antibiotic-resistant pneumonias are a growing problem.

Signs and symptoms

It is not easy to have a cristal clear diagnosis of pneumonia, because often is mistaken with colds and flus.
Bacterial pneumonia
There are many bacteria that cause pneumonia and you may develop it if you had a viral upper respiratory infection such as influenza, in older people and people with a chronic illness or compromised immune system the symtoms are not that severe and evident as in young people which have shaking chills, sweating, a high fever, chest pain and cough that produces thick, greenish or yellow phlegm.

Viral pneumonia
Viral pneumonia is more often during winter time and is caused by a a dozen different viruses. Its first symptoms are: muscle pain and fatigue, headache, fever, a dry cough all those symptoms are more severe in people with cardiovascular or lung disease. When having a viral pneumonia you are susceptible of developing a secondary bacterial pneumonia, with the progression of the disease you may experience breathless and a cough that produces a whitish phlegm.

Mycoplasma Pneumonia
Mycoplasma is a tiny bacterium that causes symptoms similar to those caused by other bacterial and viral infections but more mild and flu like symptoms. A “walking pneumonia,” is caused by mycoplasma, you may not even know you had pneumonia. Mycoplasma pneumonia spreads easily and affects children, young adults in community. Gives good results if treated with the appropiate antibiotics.


Chlamydia pneumonia is common among school-age children and causes similar symptoms with those of mycoplasma pneumonia. Has a good response in antibiotic therapy, the chlamydia bacterium that causes pneumonia is different from the one that causes sexually transmitted infections. Pneumonia may be caused by some types of fungi which spread through bird droppings, with symptoms of acute pneumonia and chronic pneumonia. Pneumocystis carinii causes infection and pneumonia in people with AIDS. It also affects people with organ transplants, chemotherapy, on corticosteroids or other immune-suppressing drugs. Signs and symptoms include a cough that doesn’t go away, trouble breathing and fever. Some tests need to be done: laboratory test results, X-ray findings, demographics. Home care is possible even in severe cases if the caregivers give the chest therapy and antibiotics intravenous and if good support and home nursing services are assured.

You can find great content regarding pneumonia symptoms, pneumonia vaccine and many moreby visiting http://www.pneumonia-center.com/

What Everyone Should Know About Tonsils And Adenoids

Nearly every adult today can remember clearly whether they still have their tonsils and adenoids, or whether they were removed during their childhood. There was a time when these two organs were removed at the first sign of an infection, but over the years, this practice thankfully has waned to almost non-existence. Now, unless there is a valid reason for adenoids and tonsils to be removed, most children today will grow to adulthood with them intact. They do have a purpose, and should be left intact for various reasons, and it is helpful for parents to know everything they can about these two important organs, so that their children can enjoy the best of health that they can, with or without them.

The Importance of Adenoids and Tonsils

The tonsils and adenoids, although routinely grouped together when it comes to discussions of childhood illnesses, are actually separate organs that play a major role in your child’s health. Both of them are considered to be like lymph nodes, made up of the same tissues that often swell up when your body is carrying an infection of some kind. They are both very important to your child’s immune system, and they both work hard at fighting off upper respiratory infections that plague most children before they reach their teenage years.

Most children will regularly have enlarged tonsils, which can easily be seen hanging at either side of the back of the throat. Having enlarged tonsils is not necessarily a sign of an infection, and if your child does have this condition without a fever, it does not necessarily mean that they have tonsillitis, and further tests should be done before removing them. The adenoids cannot be seen by the naked eye without help, like an endoscope. They are located higher up, between the nose and the throat, and not easily seen. Both of these organs are capable of collecting food and other debris that is brought into the body through the mouth and nose, and both of them are often where sinus infections and other respiratory problems begin, often because of the detritus they collect, like pollen, spores and food crumbs.

When Problems Arise

The majority of infections during childhood are viral, meaning that they are caused by a virus spread from child to child. The remainder are bacterial, like strep throat and mononucleosis. Most of them will affect the tonsils first, and eventually the adenoids, if left untreated. Antibiotics can cure the majority of these infections, if caught in time, without having either the tonsils or the adenoids removed. Frequent infections, however, may cause one or both to be removed for the health of the child.

Infected adenoids can cause fluid to build up in the Eustachian tubes, leading to an ear infection. Tubes will probably be placed in your child’s ears to help with the drainage, but if the infections persist, then the adenoids may need to be removed. Ear pain, a nasal tone to their voice, and mouth breathing are all symptoms of potential adenoid infection. Tonsils become infected more often than the adenoids, mostly because they are the first line of defense in the throat. If they are appear bright red and swollen, your child’s throat hurts, and if they are having difficulty swallowing, it may mean that they have tonsillitis, and will need them removed.

Sometimes the Troublemakers

As we said, some children will have enlarged tonsils for the majority of their lives. While not life threatening, they can still cause problems within the airway. Chronic conditions, like sleep apnea, have symptoms like snoring, breathing restrictions lasting about 10 seconds, and daytime sleepiness are the first signs of potential sleep apnea in your child. Consult with your doctor to determine if removing the tonsils will alleviate the apnea.

Another condition connected to the tonsils and adenoids that appears even into adulthood are tonsil stones. Food particles that get caught up in the crevices of the tonsils do not always dislodge during subsequent swallowing, and can grow hard over time. Bad halitosis is the first sign of this, and gargling with warm water and salt after a meal may help. If not, the tonsils will have to go.

Genetic Phenylketonuria

Phenylketonuria presents one of the most dramatic examples of how the relationship between genotype and phenotype can depend on environmental variables. Phenylketonuria was very first recognized as an inherited cause of mental retardation in 1934, and systematic attempts to deal with the situation were initiated within the 1950s.

The term “phenylketonuria” denotes increased amounts of urinary phenylpyruvate and phenylacetate, which occur when circulating phenylalanine amounts, usually in between 0.06 and 0.one mmol/L, rise above one.a couple of mmol/L. Therefore, the primary defect in phenylketonuria is hyperphenylalaninemia, which by itself has a number of distinct genetic causes. The pathophysiology of phenylketonuria illustrates a number of essential principles in human genetics.

Hyperphenylalaninemia by itself is caused by substrate accumulation, which happens when a regular intermediary metabolite fails to become eliminated correctly and its concentrations turn out to be increased to levels that are toxic. As described later on, one of the most common trigger of hyperphenylalaninemia is deficiency of the enzyme phenylalanine hydroxylase, which catalyzes the conversion of phenylalanine to tyrosine.

People with mutations in phenylalanine hydroxylase generally do not endure from your absence of tyrosine simply because this amino acid could be supplied to the body by mechanisms which are independent of phenylalanine hydroxylase. In other types of phenylketonuria, nevertheless, extra disease manifestations happen like a result of end-product deficiency, which occurs when the downstream product of the specific enzyme is required for a key physiologic procedure.

A discussion of phenylketonuria also helps to illustrate the rationale for, and application of, population-based screening applications for genetic disease. More than 10 million newborn infants per year are tested for phenylketonuria, and also the focus today in treatment has shifted in several respects. Very first, “successful” remedy of phenylketonuria by dietary restriction of phenylalanine is, in basic, accompanied by subtle neuropsychologic defects that happen to be acknowledged only in the last decade.

Therefore, existing investigations concentrate on alternative treatment methods such as somatic gene therapy as nicely as on the social and psychologic elements that affect compliance with dietary management. Second, a generation of females handled for phenylketonuria are now bearing kids, and the phenomenon of maternal phenylketonuria has been recognized by which in utero exposure to maternal hyperphenylalaninemia outcomes in congenital abnormalities regardless of fetal genotype.

The quantity of pregnancies at danger has risen in proportion towards the profitable treatment of phenylketonuria and represents a challenge to public wellness officials, physicians, and geneticists in the future. The incidence of hyperphenylalaninemia varies among various populations. In African Americans, it is about 1:50,000; in Yemenite Jews, about 1:5000; and in most Northern European populations, about 1:10,000.

Postnatal growth retardation, moderate to severe mental retardation, recurrent seizures, hypopigmentation, and eczematous skin rashes constitute the main phenotypic features of untreated phenylketonuria. However, using the advent of widespread newborn screening applications for hyperphenylalaninemia, the major phenotypic manifestations of phenylketonuria these days occur when remedy is partial or when it’s terminated prematurely throughout late childhood or adolescence.

In these cases, there’s generally a slight but significant decline in IQ, an array of particular overall performance and perceptual defects, and an increased frequency of learning and behavioral problems. New child screening for phenylketonuria is carried out on the little amount of dried blood obtained at 24-72 hours of age.

From your initial screen, there is about a 1% incidence of positive or indeterminate test outcomes, and a a lot more quantitative measurement of plasma phenylalanine is then performed prior to a couple of weeks of age. In neonates who undergo a 2nd round of testing, the diagnosis of phenylketonuria is ultimately confirmed in about 1%, providing an estimated phenylketonuria prevalence of one:10,000, even though there is great geographic and ethnic variation (see prior discussion).

The false-negative rate of phenylketonuria newborn screening applications is around one:70; phenylketonuria in these unfortunate people is generally not detected until developmental delay and seizures throughout infancy or early childhood prompt a systematic evaluation for an inborn error of metabolism.

Infants in whom a diagnosis of phenylketonuria is confirmed are generally placed on a dietary regimen by which a semisynthetic formula low in phenylalanine could be combined with regular breast feeding. This regimen is adjusted empirically to maintain a plasma phenylalanine concentration at or beneath 1 mmol/L, which can be nevertheless several times greater than regular but similar to levels observed in so-called benign hyperphenylalaninemia, a biochemical diagnosis which can be not associated with phenylketonuria and has no clinical consequences.

Phenylalanine is definitely an essential amino acid, and even people with phenylketonuria should consume little amounts to prevent protein starvation plus a catabolic state. Most kids need 25-50 mg/kg/d of phenylalanine, and these needs are met by combining organic foods with commercial products created for phenylketonuria treatment.

When nutritional treatment applications were very first implemented, it was hoped that the risk of neurologic damage from your hyperphenylalaninemia of phenylketonuria would have a restricted window and that treatment could be stopped after childhood. However, it now seems that even mild hyperphenylalaninemia in adults (> one.a couple of mmol/L) is associated with neuropsychologic and cognitive deficits; therefore, nutritional remedy of phenylketonuria should most likely be continued indefinitely.

As an increasing quantity of handled females with phenylketonuria reach childbearing age, a new problem-fetal hyperphenylalaninemia by way of intrauterine exposure-has turn out to be apparent. New child infants in this kind of cases exhibit microcephaly and growth retardation of prenatal onset, congenital heart disease, and extreme developmental delay irrespective from the fetal genotype.

Rigorous control of maternal phenylalanine concentrations from before conception until birth reduces the incidence of fetal abnormalities in maternal phenylketonuria, however the level of plasma phenylalanine that is “safe” for a developing fetus is 0.12-0.36 mmol/L-significantly lower than what is regarded acceptable for phenylketonuria-affected children or adults on phenylalanine-restricted diets.

The regular metabolic fate of free of charge phenylalanine is incorporation into protein or hydroxylation by phenylalanine hydroxylase to type tyrosine. Because tyrosine, but not phenylalanine, can be metabolized to create fumarate and acetoacetate, hydroxylation of phenylalanine can be viewed both like a signifies of producing tyrosine a nonessential amino acid and as a mechanism for offering energy by way of gluconeogenesis during states of protein starvation.

In individuals with mutations in phenylalanine hydroxylase, tyrosine becomes an important amino acid. Nevertheless, the clinical manifestations from the disease are caused not by absence of tyrosine (most people get enough tyrosine within the diet in any situation) but by accumulation of phenylalanine.

Transamination of phenylalanine to form phenylpyruvate usually doesn’t happen unless circulating concentrations exceed one.a couple of mmol/L, however the pathogenesis of CNS abnormalities in phenylketonuria is related more to phenylalanine by itself than to its metabolites.

In addition to a direct effect of elevated phenylalanine levels on power production, protein synthesis, and neurotransmitter homeostasis within the developing brain, phenylalanine can also inhibit the transport of neutral amino acids across the blood-brain barrier, leading to a selective amino acid deficiency in the cerebrospinal fluid.

Therefore, the neurologic manifestations of phenylketonuria are felt to become due to a basic effect of substrate accumulation on cerebral metabolism. The pathophysiology of the eczema seen in untreated or partially treated phenylketonuria isn’t nicely understood, but eczema is really a common function of other inborn errors of metabolism by which plasma concentrations of branched-chain amino acids are elevated.

Hypopigmentation in phenylketonuria is most likely caused by an inhibitory effect of excess phenylalanine about the production of dopaquinone in melanocytes, which can be the rate-limiting step in melanin synthesis. Approximately 90% of infants with persistent hyperphenylalaninemia detected by new child screening have standard phenylketonuria brought on by a defect in phenylalanine hydroxylase (see later on discussion).

From the remainder, most have benign hyperphenylalaninemia, by which circulating levels of phenylalanine are in between 0.1 mmol/L and one mmol/L. Nevertheless, around 1% of infants with persistent hyperphenylalaninemia have defects in the metabolic process of tetrahydrobiopterin (BH4), which is a stoichiometric cofactor for the hydroxylation reaction.

Unfortunately, BH4 is required not just for phenylalanine hydroxylase but also for tyrosine hydroxylase and tryptophan hydroxylase. The items of these latter two enzymes are catecholaminergic and serotonergic neurotransmitters; thus, people with defects in BH4 metabolism endure not just from phenylketonuria (substrate accumulation) but additionally from absence of essential neurotransmitters (end-product deficiency).

Impacted individuals develop a severe neurologic disorder in early childhood manifested by hypotonia, inactivity, and developmental regression and are handled not only with nutritional restriction of phenylalanine but also with nutritional supplementation with BH4, dopa, and 5-hydroxytryptophan.

One Type of Bronchitis- Acute Bronchitis

This type of bronchitis, the acute form usually starts about five days after you have had an respiratory infection. If you have had a flu or cold, about five days after, you will experience bronchitis symptoms. The most common symptoms for acute bronchitis are cough, fever tiredness.

Cough is the most common of all the bronchitis symptoms. It can be dry the first time, because it doesn’ t produce any mucus. After a couple of days, it might bring some mucus from the lungs. The color of the mucus as a result of acute bronchitis can be green, clear or yellow. Fever is another symptom for bronchitis, but in the case of acute bronchitis, it is a mild fever. If the temperature is high, that might indicate pneumonia. When suffering from acute bronchitis you will also feel a general tiredness. You will also feel pain in your chest when suffering from bronchitis, which can agravate especially when you cough.
Shortness of breath is also another symptom that you might have when you have acute bronchitis.

To fully understand all the acute bronchitis symptoms, you must understand what causes the disease. When you develop acute bronchitis, the tubes that are used to carry air to your lungs get inflamated. Acute bronchitis is usually caused by a virus and also bronchitis is the result of a respiratory infection that you probably had. This infection has a very well determined path. It moves from your nose, mouth to the bronchial tubes, causing bronchitis. Your improvement in health from bronchitis depends on a few factors, like age, if you are a smoker or not of whether the acute bronchitis was caused by a virus or bacteria. If bronchitis has been caused by
a virus, you will get better sooner than if the acute bronchitis had been caused by bacteria.

As many of the lung related diseases, acute bronchitis can also have complications if not treated. For example, if a case of acute bronchitis indicates ingcreased fatigue, a very high temperature, serious chest pain, it usually indicates that acute bronchitis has developed into pneumonia. Another problem would be repeated episodes of acute bronchitis caused by bacteria.This condition may lead to permanent damage of the bronchial tubes. This case of acute bronchitis gone wrong usually happens to people that smoke of those who have a weak immune system. So be careful how you treat your bronchitis case!

For more resources about bronchitis or especially about asthmatic bronchitis please visit http://www.bronchitis-guide.com/asthmatic-bronchitis.htm

Comparing Diabetic Hypoglycemia and Hyperglycemia

Diabetics must manage their blood glucose levels through medication, diet, exercise, and daily monitoring. Failure to do so can result in wildly fluctuating blood sugars that can lead to either diabetic hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). Both of these conditions are dangerous for the diabetic and can lead to other medical complications.

The following list compares the many symptoms and complications these two conditions can cause.

1. The on set of hypoglycemia is rapid while the onset of hyperglycemia is gradual and can take days.

2. Hypoglycemia will cause the person to be weepy, irritable, nervous and liable and Hyperglycemia causes a person to be lethargic

3. Concentration, coordination, speaking and the ability to focus are all affected with hypoglycemia, Hyperglycemia causes confusion

4. Nightmares, shaking, hunger, headache and dizziness are seen with hypoglycemia. Thirst, abdominal pain, nausea/vomiting and thirst are associated with Hyperglycemia.

5. Hypoglycemia will cause pallor and sweating. Hyperglycemia causes flushing and signs of dehydration

6. With hypoglycemia the mucous membranes will be normal, hyperglycemia the mucous membranes are often dry and crusty.

7. The breath rate remains normal during hypoglycemia and becomes deep and rapid (kussmaul breathing) during hyperglycemia

8. Heart rate with hypoglycemia will become fast (tachycardia). During times of hyperglycemia the heart rate will become slow and weak.

9. Breath odor will be normal with hypoglycemia and smell fruity with hyperglycemia.

10. Hypoglycemia will cause tremors that can later lead to hyperreflexia, dilated pupils and seizure. Paresthesia (a sensation of tingling, prickling, or numbness of the skin) can result from hyperglycemia.

11. If untreated hypoglycemia can lead to shock and coma. Hyperglycemia will progress to acidosis and coma.

12. Hypoglycemia is a blood sugar below 60 mg/dl. Hyperglycemic is a blood sugar of 250 mg/dl or more

13. During hypoglycemia the blood will be negative for ketones and have a high/large amount during hyperglycemia.

14. Osmolarity will remain normal during hypoglycemia. Hyperglycemia will result in a high osmolarity.

15. Blood pH will remain normal during hypoglycemia and be low (7.25 or less) with hyperglycemia.

16. Hematocrit remains normal with hypoglycemia and is increased with hyperglycemia.

17. HCO3 remains normal with hypoglycemia. Hyperglycemia will cause HCO3to become less than 20 mEq/L

18. Urine output will remain normal with hypoglycemia. Polyuria (increased urination) will occur during the early stages of hyperglycemia. Oliguria (low urine output) occurs late with hyperglycemia.

19. Urine is negative for glucose with hypoglycemia and contains a large amount with hyperglycemia.

20. Ketones will be trace or negative in urine during hypoglycemia and high with hyperglycemia.

21. Hyperglycemia will cause blurred vision and hypoglycemia will cause diplopia (double vision).

Looking at the length of this comparative list it is easy to see why monitoring and managing blood glucose levels is so important for anyone with diabetes.

BioSignature for Fat Loss

Biotyping is gaining popularity amongst health care professionals, personal trainers and nutritionists. It is a concept whereby nutrition recommendations are individualised to your metabolism and biochemical individuality to help you lose weight or improve your health. One particular biotyping concept that is gaining popularity is BioSignature Modulation developed by Charles Poliquin. It is a very quick and non-invasive way to establish body composition (body fat percentage compared to muscle mass), regional fat distribution and hormone profiles.

Poliquin believes we accumulate fat in certain areas because certain hormones are too high, too low or just out of balance and is based on 30 years of his own data. There is research to suggest that higher body fat levels disrupt hormones causing diseases such as diabetes, heart disease and cancer and there is also evidence to support some of Poliquin’s assertions of hormones causing regional fat distribution.

The BioSignature system works around 6 different hormones causing regional fat distribution:

  • The androgens – bingo wings and man boobs
  • Insulin – muffin top
  • Oestrogens – saddlebags
  • Cortisol – pooch belly
  • Growth hormone – chubby knees and calves
  • Thyroid hormones – fat over the ribs

Androgen type

In obese men a decline in testosterone is observed, whereas in obese women there are higher levels of testosterone such as those seen in polycystic ovary syndrome (PCOS). However the BioSignature system suggests excess fat on the triceps (back of the upper arm) indicates low androgen levels (male sex hormones) including testosterone.

Research from California on healthy young men found that lowering their circulating testosterone lead to increased fat storage on the appendices and abdomen, whereas elevating testosterone concentrations above normal levels caused fat loss in these areas. Similarly, in male adolescents with lower DHEA – a precursor to androgens – there were significantly lower levels of mid arm muscle mass compared to boys with normal levels of DHEA. Research from the Netherlands reported that free testosterone levels were correlated with the shoulder blade to triceps skin fold ratio in females.

Excess fat on the chest indicates the conversion of male sex hormones to female sex hormones. Research from Canada demonstrated this conversion of hormones was between 6 and 30 times greater on the torso than on the abdomen.The Department of Paediatric Endocrinology at Süleyman Demirel University in Turkey suggested circulating leptin – a hormone released from fat cells – stimulates the conversion of male sex hormones to female sex hormones causing breast tissue to grow in boys. The more body fat you have, the more leptin you release which changes your hormones and tells your body to grow man boobs.

If you have this regional fat distribution on the arms and chest boost your testosterone naturally by consuming more protein, magnesium, zinc and B vitamins and eat foods containing flavonoids that naturally reduce the conversion of male hormones to female hormones. These nutrients include quercetin, naringenin, chrysin, daidzein and genistein found in flax seeds, apples, berries, onions and green tea. Resveratrol, a polyphenol found in red wine has also been found to help.

Insulin type

A regional fat distribution on the shoulder blade and top of the hips – the muffin top – reflects insulin resistance. Research from The Medical College of Wisconsin suggests that the shoulder blade skinfold may help identify pre-menopausal women at risk for type 2 diabetes. Additionally research from Spain reported that both obese pre-pubescent boys and girls had significantly elevated values of insulin and glucose that were correlated with the muffin top and shoulder blade skin fold thickness. Research from the Department of Human Biology at Maastricht University reported that shoulder blade skinfold thickness remained significantly associated with persistent impaired glucose tolerance.

Consume more fish oil and eat a higher protein, lower carbohydrate diet as well as eating regular meals with additional fibre to stabilise blood sugar. The prestigious Journal of the American Medical Associationreported that a low GL diet helps to reduce insulin, triglycerides and aids weight loss in overweight and obese people.

Various herbs such as fenugreek, bitter gourd and gymnema silvestra lower blood sugar, inhibit glucose uptake in the small intestine and have adaptogenic properties on insulin production. The spice cinnamon has been shown to improve insulin function and possess blood sugar lowering properties says a scientific review from Thames Valley. Cambridge University demonstrated that a diet rich in vitamin C lowered the risk of developing diabetes by 62% and chromium deficiency is associated with insulin resistance and type 2 diabetes. Chromium supplementation improves insulin sensitivity, reduces blood pressure and reduces free radical damage to DNA.

Thyroid type

Fat stored on the ribs cage midway between the armpit and the top of the hips reflects levels of thyroid hormones with a low body fat score here indicating a healthy thyroid. There is research to suggest that as waist circumference (generally measured at the narrowest part between the ribs and the hips) and BMI increased T3 and thyroid stimulating hormone (TSH) levels increased whereas T4 levels decreased suggesting a change in thyroid function. However at present more research is needed to support the claims of the rib cage site reflecting thyroid function.

Nutrition recommendations for this site include eating fish, onions, asparagus for iodine and poultry, fish, almonds, pumpkin seeds and sesame seeds for tyrosine as these nutrients make the thyroid hormones. Foods containing selenium, zinc, vitamin A, vitamin D, vitamin E and vitamin B6 help the conversion of the inactive form of thyroid hormone (T4) to the active form (T3).

Cortisol type

Fat on the tummy region reflects excess exposure to the stress hormone cortisol. Research from the University of California demonstrated that women with a higher waist to hip ratio and central obesity reported more chronic stress and secreted significantly more cortisol during a stress test than women with a low waist to hip ratio. Similarly research from Spain demonstrated that disrupted cortisol levels lead to a distribution of fat on the abdominals.

Removing and reducing your exposure to stressors thus reducing cortisol is called for to reduce abdominal fat accumulation. Poliquin suggests one of the most common stressors to our system is the consumption of foods that we are intolerant to. These include wheat, dairy, soy, eggs, nuts, yeast and corn. Simply reducing exposure to these foods may reduce the stress on the gastrointestinal and immune system lowering stress hormone output. Another important stress reducer is controlling blood sugar by eating regular meals that have a well-balanced protein, fat and carbohydrate ratio to support good insulin function.

There are various herbs that are known to help reduce stress, one of the more well known being rhodiola. Vitamin C, B5 and magnesium are also traditionally used to help with stress as they are used up by the adrenal glands to make stress hormones. Supplementing with these nutrients may be of benefit.

Oestrogen type

Fat on the bum and thighs reflects a higher exposure to oestrogen (both self made and environmental) and poor oestrogen metabolism. Research from Denmark has shown that both men and women have oestrogen receptors on fat cells; men having more receptors on fat underneath the skin whereas women have equal numbers of oestrogen receptors on fat around the organs as well as fat beneath the skin, women have also been shown to have a higher number of fat cells on the bum and thighs and have higher enzyme activity that causes absorption of fat from the circulation in this area.

Research studies have also shown that leg fat such as on the bum and thighs increased in response to hormone treatment such as with oestrogen, whereas research conducted on drugs that suppressed the body’s oestrogen production showed there were significant increases of trunk but not leg fat. Oestrogen administered by a drip also demonstrated that the breakdown of fat decreased in fat underneath the skin, particularly on the thighs. These studies support the role played by oestrogen in fat accumulation on the bum and thighs.

Supporting oestrogen metabolism and elimination helps people to lose fat on the bum and thighs. Consuming foods such as broccoli, cabbage and other cruciferous vegetables containing sulphurophane and indoles have been shown to up regulate enzymes in the liver that metabolise oestrogen to the safe 2 hydroxyoestrogen.Other nutrients that are beneficial to oestrogen metabolism are phytoestrogens such as some soy products and flax seeds, omega 3 fats the supplement DIM. Oestrogens are also metabolised by the process of methylation in the liver so consuming foods rich in methyl donors such as B12, B6 and folic acid may also be useful.

Growth hormone type

Excess fat on the knee and calf reflects low levels of growth hormone. Research has found that growth hormone deficient adults had more body fat that normalised after growth hormone replacement therapy, however these sites are not yet well enough researched to provide conclusive answers and we rely on Poliquin’s own data for this association. Growth hormone can be boosted by the use of both glutamine and arginine supplements.

Sports Rehabilitation for Lisfranc Injuries

One of the recent trending injuries in the athletic world especially in among football players which require sport rehabilitation is the lisfranc injury. Lisfranc injuries will require sports rehabilitation because of the prevalence of the injury. The injury occurs because of the ever-increasing speed of the game coupled with the size of the competing athletes, Although most other injuries occur from coincidence, lack of training, the lisfranc injury will require extensive time in NJ physical therapy.

The lisfranc joint is the mid-foot joint complex formed between the metatarsals and the tarsals. The metatarsals are the long bones of the mid-foot while the tarsals are the smaller bones closer to the heel, which comprise of the Lisfranc’s joint. The key reason for the challenge of recovering from a lisfranc injury is because the key bones are located in the middle of the foot and there are few body movements in athletic physical therapy that are solely concentrated on the foot.

The foot has many unique properties that are assessed by NJ Physical therapy. One of which is that are no ligaments connecting the base of the first and second metatarsals. These bones are the innermost of the five long bones in the mid-foot. In sports rehabilitation, it is important for recognize the configuration and tight fit of these bones is the substitutes for the ligaments in providing stability to the foot region. This prevents side-to-side movement of dislocation of the bones in this region. Recovering from the injury at a physical therapy center, the athlete would need to regain the stability and pressure on planting the foot to the ground. Unless the athlete has a second metatarsal, which is generally the longest, the bone is fractured and will require sports physical therapy. The reason it is vulnerable is because the injury is generally at or near the base of the mid-foot. With a fracture, the other inter-metarsal joints may become dislocated and completely separated from each other. The recovery will require surgery followed by spending time in sports therapy.

Though it does not simply connect one bone to another, the primary stabilizer of the joint between the base of the first and second metatarsals is Lisfranc’s ligament. The ligament is taken into careful consideration when post-surgical treatments occur in Sports physical therapy. The ligamentfor the mid-foot is a strong fibrous tissue that extends from the bottom of the foot at a bone closer to the heel. Also taken into consideration during sports physical therapy is the medial, or innermost cuneiform. It is the tarsal bone and it runs diagonally to the bottom of the inner aspect of the second metatarsal.

During sports therapy the combination of at home development with the guidance of a New Jersey Physical Therapist and treatments at the physical therapy center are both needed for the recovery from lisfranc surgery. The New Jersey physical therapist will focus on the increasing the active range of motion while in sports therapy the athlete will work on strength development. Strength development in sports physical therapy will encompass the use of machines and callisthenic training. The end goal is full recovery from the lisfranc injury and open range of motion.

Common Skin Conditions – Dermatitis and Moles

Two of the most common skin conditions are the presence of moles and dermatitis. Moles can have more serious consequences than the irritation of dermatitis.

Moles occur when the cells in the skin that give it its pigment, called melanocytes, grow in clusters. These cells normally grow throughout the skin, but when too many grow in the same place a mole occurs. Most moles appear before the age of 25, but some may appear much later. Moles can remain static or change over time. Although most are not dangerous, some can be malignant and lead to melanoma. Any mole that oozes or becomes painful or sensitive should be checked out by a dermatologist. Moles that suddenly appear after the age of 25 or begin to change or grow should also be evaluated.

When evaluating your moles, keep the following in mind. Moles should be round. If your moles are asymmetrical, or irregular in shape, have it evaluated. If you find a mole that is larger than ¼”, mention it to your doctor or dermatologist. If you find that your mole has an irregular or jagged edge, or is not all one color, have your doctor look at it. Finally, any mole that is red or blue may be cause for concern.

Treating moles is not difficult. If a mole is embarrassing, or becomes irritated under your clothing, you may ask your doctor to remove it. Moles can be frozen with a chemical, after which they dry up and fall off. Other moles can be simply cut off of the skin. Often, doctors will remove entire moles that seem suspicious and test the tissue for cancer. If any malignancy is found, they may cut out a slightly larger area of skin and then suture the site closed.

Check your skin regularly for changes in your moles. If any seem suspicious, or any changes have occurred, let your doctor know. Preventing a problem is as easy as going on “mole patrol.”

Some Angular Cheilitis Remedies From The Home

Angular Cheilitis comes in a bacterial and a fungal form. There are a number of traditional or western medication remedies as well as natural remedies on the market. The following is a list of potential home remedies that some people have had success with, but are by no means guaranteed to work.

  1. Anti-fungal diet. There is an anti-fungal diet that has been used for treating yeast infections that has been known to work on angular cheilitis as well. This involves avoiding refined sugar, bread, yeast, dairy, alcohol and sweets. Rather eat a lot of fresh vegetables and fruit and whole grain foods. It will take a few days to take effect but is rumoured to help immensely.
  2. Short water fast. This means that you drink nothing for two or three days. Be very careful trying this kind of thing as you may dehydrate quite badly which brings along its own assortment of problems. The idea is to starve the fungus of water causing it to dry out and die.
  3. Nappy rash creams. These sooth the skin and help to keep the area moist and pliable. If it is followed with the application of a petroleum based cream to help keep the moisture in it may be even more effective as one of the home angular cheilitis remedies.
  4. Yeast infection cream. Sometimes it is caused by a yeast infection or a fungus that is similar to candida. Some people have had success in curing the problem with a regular yeast infection cream that is available from most pharmacies.
  5. Anti-bacterial cream. If the anti-fungal creams are not working, your cheilitis may be caused by a bacteria. Find a good anti-bacterial cream and apply it a few times a day.
  6. Coco butter. One of the angular cheilitis remedies that can be self applied is coco butter. Coco butter is rich in vitamin B, a deficiency of which has been known to cause angular cheilitis. If this does work for you, you may want to consider taking a vitamin B complex every day to help keep it away.
  7. Bicarbonate of soda. Bicarbonate of soda or baking soda has been used in the treatment of the condition by some who have had no success whatsoever with the various other angular cheilitis remedies available. No one is quite sure why it works, maybe something in the chemical composition is to angular cheilitis like salt is to snails. Be warned, it does burn a little but goes to work immediately.
  8. A silver colloidal topical application. Many scientists have lauded the healing properties of silver. Apparently a silver colloidal cream is also effective against cheilitis.

There are a lot of other home angular cheilitis remedies. Be careful about using any of these remedies as they may actually be potentially dangerous or hazardous to your health. Do a lot of research before trying remedy and make sure you know everything there is to know about the remedy before trying it and potentially making the problem worse.

Shoulder Problems

Shoulder pain is one of the commoner complaints seen by GPs. The shoulder girdle itself comprises five separate joints: the sternoclavicular, acromioclavicular, subacromial, glenohumeral and scapulothoracic joints. Problems in any of these can cause shoulder pain.

Patients may also experience shoulder pain referred from distant areas such as the cervical spine, thoracic inlet, mediastinum and lungs, the diaphragm and even sub-diaphragmatic problems such as hepatic problems. So the clinician needs to keep an open mind as to the cause of shoulder symptoms, although here l will focus on problems within the shoulder girdle.

The sternoclavicular joint
This is a synovial joint with a small meniscus, and is between the manubrium of the sternum and the medial end of the clavicle. Problems with this joint are rare, which is just as well because solutions for sternoclavicular pain tend not to be effective. Degenerative change in this joint is usually post-traumatic and can be treated usually by a series of up to three hydrocortisone injections into the sternoclavicular joint. An excision arthroplasty of the joint can be done in severe cases. Sternoclavicular dislocations are rare and are usually treated conservatively with the patients being managed symptomatically.

If the patient continues to have pain and instability from a long-standing sternoclavicular dislocation or subluxation surgical options include either stabilising the dislocated joint or an excision arthroplasty, but only about half the patients see a significant improvement.

Problems affecting the glenohumeral joint
The glenohumeral joint is the main joint of the shoulder girdle and can be involved in a number of problems.

Glenohumeral osteoarthritis
This presents with a painful, stiff shoulder and is confirmed radiologically with the expected signs of loss of joint space, subchondral sclerosis, cysts and osteophyte formation. Management is usually conservative with analgesics, NSAIDs and intra-articular steroid injections. Joint replacement is rarely required.

Adhesive capsulitis
This is a poorly understood condition, presenting with spontaneous onset of increasing pain and stiffness in the shoulder girdle. The condition affects the normally lax lining of the glenohumeral joint.

Marked inflammation of the lining of the joint leads to the joint capsule tending to glue itself together, producing a marked, restriction in range of movement at the glenohumeral joint. Patients have restricted internal and external rotation compared with the normal side, with a lesser degree of restricted elevation.

The natural history is typically eight months of pain, followed by eight months of pain and stiffness, followed by eight months of stiffness before resolution. Therefore after 24 months, the majority of patients with this condition will settle. The diagnosis is made from the history, examination and normal X-rays.

Management consists of informing the patient about the natural history of the condition, and ,symptoms are managed according to their severity. A few patients are so disabled by this condition that they need a manipulation under anaesthetic and intra-articular steroids.

Glenohumeral instability
The extreme mobility of the glenohumeral joint is achieved because the socket is only one-third of the area of the ball of the humeral head. This architectural arrangement allows great mobility at the expense of stability. Shoulder instability is a therefore a frequent problem.

In 90 to 95 per cent of cases there is an anteroinferior dislocation. Patients who suffer three or more dislocations, that is have become recurrent dislocators, should be referred for consideration of surgical repair. This usually means a Bankart repair, in which the glenoid Iabrum is reattached to the anterior aspect of the glenoid.

An arthroscopic approach is replacing open surgery, although patients should be aware that success rates for arthroscopic surgery are about 70 per cent, whereas open surgery is up to 95 per cent successful. Arthroscopic repair rates continue to improve, however. Patients are managed postoperatively in a sling for six weeks, and this is followed by a six-week rehabilitation programme.

Problems with the subacromial joint
The subacromial joint is the articulation between the top surface of the rotator cuff and the under surface of the acromion, and presents two main problems.

Subacromial impingement syndrome
This is probably the commonest problem affecting the shoulder. Patients report pain in the rcgion of the lateral deltoid or deltoid insertion. It can disturb sleep, be aggravated by lying on the affected shoulder, and typically causes pain whenever the arm is used at or around shoulder height.The patient usually points vaguely to the latcral deltoid area as being the source of the pain. There is often evidence of wasting of supraspinatus and secondary wasting of the deltoid muscle. There are usually no particular tender areas.

Positive findings are of a mid-range painful arc when the arm is elevated through abduction and flexion.The patient may also show an abnormal rhythm of movement when the arm is raised and lowered. This trick is subconsciously learnt by the patient and takes the traumatised part of the rotator cuff away from the under surface of the acromion. A specific test consists of asking the patient to abduct the arm to 30¡ while resisting the movement. This should cause a reproduction of the pain.

Treating impingement syndrome
Conservative treatments include physiotherapy to strengthen the subscapularis and infraspinatus muscles, thereby pulling the inflamed and irritated top surface of the rotator cuff away from the undersurface of the acrimony. Other conservative measures include steroid injections into the subacromial joint. A diagnostic local anaesthetic injection is made into the subacromial joint to help confirm the diagnosis, and this is effective at relieving pain. Up to three hydrocortisone injections can be given at four- to six-week intervals. A combination of physiotherapy and a series of steroid injections will resolve symptoms in about 80 per cent of cases.

If patients fail to respond, referral is indicated as they may need an arthroscopic subacromial decompression to relieve symptoms and prevent rotator cuff rupture. This generates more space in the subacromial joint to stop the inflamed and swollen tendons from being further rubbed. This 40-minute procedure is successful in about 80 per cent of cases, but full recovery takes about 12 weeks.

Rotator cuff rupture
Rupture of the rotator cuff can be either partial or complete.The rotator cuff is a tube of muscle emanating from the shoulder blade and encircling the humeral head. Its function is to pull the humeral head firmly on to the socket of the glenoid as the arm is elevated. Even with a tear, the rotator cuff may still be able to stabilise the humeral head and the glenoid. In these cases the rotator cuff is defined as functionally intact.

A large rupture will not allow the rotator cuff to stabilise the head of the humerus in its socket, and the patient will be unable to abduct the arm at all. This is because when the deltoid contracts, the humeral head is pulled up through the rent in the rotator cuff. Patients with suspected rotator cuff ruptures require referral to an orthopaedic surgeon with an interest in shoulder problems for investigation and possible repair. Rotator cuff repairs are a major undertaking and require extensive rehabilitation programmes.

The acromioclavicular joint
Problems with the acromioclavicular joint (ACJ) are common, and usually involve osteoarthritis or ACJ dislocation.

Patients localise tile pain extremely well to the area of a degenerate joint, usually pointing with one finger at the ACJ. Using the arm when it is raised typically aggravates the pain. Often there is a history of trauma. When examined, the ACJ is tender and pain is reproduced when stressing the ACJ by fully adducting and internally rotating the shoulder.

The patient also complains of pain when the arm is in full elevation in either flexion or abduction. Physiotherapy or oral anti-inflammatory drugs are used initially, but if there is no response a GP can give a series of up to three hydrocortisone acetate injections to the joint.

Injection technique
Injecting a degenerate ACJ can be quite difficult as the joint space is often narrowed. Infiltration around the joint with local anaesthetic is followed by an injection of I-2m1 of lignocaine into the joint. After a minute or so, test movements to ensure that the local anaesthetic block to the ACJ has resolved the patient’s symptoms. It is then usually fairly easy to inject hydrocortisone into the joint without causing undue discomfort. About 70 to 80 per cent of patients will be cured by a series of up to three such procedures at four- to six-week intervals. If the response is unsatisfactory then refer to an orthopaedic surgeon to consider an arthroscopic ACJ arthroplasty or an open ACJ arthroplasty. I prefer the former operation as this preserves the superior joint capsule and is cosmetically more acceptable.

ACJ dislocation
This is a common injury, particularly on the rugby field when players typically fall onto the point of their shoulder. Most patients will have been seen in a casualty department and may have been referred to a fracture clinic. The jury among orthopaedic surgeons is still out regarding the best treatment for ACJ dislocations.

Most patients can be treated conservatively, because even with a dislocated ACJ most patients are able to compensate well and have a normal range of movement and function of the shoulder. Patients with a marked cosmetic deformity, or those engaged in upper-limb sports or work should be counselled concerning the pros and cons of conservative management versus reconstructive surgery.

An ACJ reconstruction is easy to perform if done in the first few weeks. However, by the time an ACJ dislocation has become chronic – that is, after six weeks – then reconstruction becomes more difficult, requiring ligament or coracoid process transfer. Patients who may justify ACJ reconstruction should therefore be referred to a specialist early.

The scapulothoracic joint
Fortunately, problems in the scapulothoracic joint are rare. The commonest complaint is a painful or snapping scapula. In many of these patients no obvious cause for their symptoms can be found, although a small proportion of patients will have pain arising from the supramedial border of the scapula as it moves over the posterior chest wall.

Usually they are investigated with a CT scan. This investigation can provide a three dimensional picture of the architecture of the shoulder girdle.

A physiotherapy programme is the first route to try and improve their Scapulothoracic control, but if patients fail to respond a small proportion of them may be offered excision of the abnormally angled supra-medial border of their scapula. This procedure may help alleviate their symptoms.

Patients likely to benefit from this operation represent only a small proportion of patients with scapulothoracic pain, however. All patients with scapulothoracic pain and clicking should be referred initially for a physiotherapy programme in the first instance to look at their scapulothoracic control.

Only if this fails to alleviate their symptoms is referral to an orthopaedic surgeon with an interest in shoulder problems recommended.

From an original article published in GP, 18TH MAY 2001