I don't know where are human right organization from Syria
syrian's should be saved from the dictator Bashar Al Asd, he kills innocent childrens and womens so, he must be punished
Tuesday, 12 March 2013
Save syrian people !
Friday, 8 March 2013
All Conditions of the cornea and their Causes, Epidemiology, Symptoms, Diagnosis and Treatment.
Conditions of the corneaCauses
There are some minor conditions of the cornea for which pharmacists can offer advice and treatment. These are:
allergic conjunctivitis (see Chapter 23)
infective conjunctivitis, caused by:
– viruses (mainly adenovirus or picornavirus)
– bacteria (usually Streptococcus or Haemophilus).
subconjunctival haemorrhage, caused by rupture of a conjunctival capillary causing spread of blood over the cornea. It looks alarming but it is painless, vision is not affected and it is usually of no signifi cance. There is no treatment and the blood cannot be washed out of the eye
dacrocystitis: the lacrimal sac, which drains tears into the nasolacrimal duct in the corner of the eye, becomes blocked or in young children may not open, and tears overfl ow. It may be cleared by gentle massage in the inner corner of eye, but if it does not clear, the patient should be referred.
Signs and symptoms
The features of minor corneal conditions are set out in Table
Differential diagnosis
Glaucoma
Open-angle (chronic) glaucoma results from an increase in ocular pressure due to an imbalance between production and drainage of aqueous humour. It develops slowly and initially is symptomless, but eventually it produces headache and loss of visual fi eld. It affects both eyes and can cause blindness if not treated.
Closed-angle (acute) glaucoma is due to obstruction to drainage of aqueous humour. It presents as severe pain in one eye, accompanied by headache, nausea and vomiting. Visual fi eld is reduced and haloes may be seen around lights.
Episcleritis
In episcleritis there is infl ammation of the sclera, the tissue immediately beneath the conjunctiva, producing a localised patch of redness. It is usually painless or there may be a dull ache. It is most common in young women. It is self-limiting, but could take several weeks to resolve.
Scleritis
Scleritis is of similar appearance to episcleritis but much more painful. It is often associated with autoimmune conditions such as rheumatoid arthritis.
Uveitis (iritis)
Uveitis is infl ammation of the uveal tract (the structures around the iris). There is localised central redness, with pain and photophobia, and vision may be impaired. It may be associated with rheumatoid arthritis or ulcerative colitis.
Keratitis (corneal ulcer)
Infl ammation of the cornea is keratitis. There is severe pain with a watery discharge and photophobia. Redness is concentrated in the centre of the eye. It may result from trauma, long-term use of steroid eye drops or use of soft contact lenses.
Dry eye
Dry eye is a chronic condition, often associated with a systemic disorder such as rheumatoid arthritis. It may cause irritation and photophobia.
Symptoms and circumstances for referral
pain in the eye, as distinct from superfi cial soreness, grittiness or itchiness
redness localised to one area of the eye surface
disturbance of vision
pupils of abnormal shape or uneven pupils
pupils reacting unevenly to light
eye symptoms with headache and/or nausea/vomiting
recurrent subconjunctival haemorrhage
dry eyes.
Essential criteria for distinguishing between minor and potentially more serious eye conditions are set out in Table
Treatment
Allergic conjunctivitis
Infective conjunctivitis
Bacteria and viruses are both causes of infective conjunctivitis and it may be clinically diffi cult to distinguish between them. Over-the-counter treatment of any superfi cial infective conjunctivitis with an antibacterial agent is considered appropriate, as it may help prevent secondary bacterial infection.
Non-prescription antimicrobial compounds available for the treatment of these infections are:
– chloramphenicol
– propamidine and dibromopropamidine isetionates.
Chloramphenicol
Chloramphenicol is active against a wide range of ocular pathogens. It has been the fi rst-choice prescription antibiotic for minor eye infections for many years, and chloramphenicol eye drops were reclassifi ed for pharmacy sale in 2005 for use for adults and children aged 2 years and over.
Dosage is one drop into the infected eye every 2 hours for the fi rst 48 hours and then every 4 hours, during waking hours only. Treatment should be continued for 5 days, if symptoms improve.
Chloramphenicol eye drops should not be used in patients hypersensitive to chloramphenicol, who have experienced myelosuppression during previous exposure to chloramphenicol or with a family history of blood dyscrasias, and it is not recommended for pregnant or breastfeeding women.
Prolonged or frequent intermittent use should be avoided, as it may increase the likelihood of sensitisation and emergence of resistant organisms.
The drops should not be used for more than 5 days, and patients should be referred if symptoms do not improve within 48 hours of starting treatment.
As with all ocular antibiotic and most other eye preparations, contact lenses should not be worn during treatment and soft contact lenses should not be replaced for 24 hours after completing treatment.
In the pharmacy, chloramphenicol eye drops should be stored in a refrigerator at 2–8°C. Once opened, the drops should be discarded after 5 days.
In June 2007, chloramphenicol eye ointment was reclassifi ed from prescription only (POM) to pharmacy sale (P) for the treatment of acute bacterial conjunctivitis. Propamidine and dibromopropamidine isetionates
Propamidine and dibromopropamidine isetionates are aromatic diamidine
antiseptics. They have been used for the treatment of bacterial conjunctivitis for more than 60 years and have always been available without prescription, but chloramphenicol is considered the drug of choice and the British National Formulary regards propamidine and dibromopropamidine as of little value.
Eye drops are formulated with propamidine isetionate 0.1% and eye ointment with dibromopropamidine isetionate 0.15%. Both can be used for adults and
children.
The ointment persists longer on the corneal surface and needs to be applied only twice daily, but can cause stickiness and blurring of vision. Drops are used four times daily. Treatment should be continued for 24 hours after symptoms have cleared. If symptoms do not significantly improve within 48 hours, treatment should be discontinued and the patient referred for medical advice.
Both products should be stored at room temperature and discarded not more than 1 month after opening.
Conditions of the eyelid
There is one minor condition – stye (hordeolum) – for which pharmacists can offer advice and treatment. It is caused by staphylococcal infection of a hair follicle at the base of an eyelash.
Principal symptoms are pain, redness, swelling and irritation. Initially, the whole of the lid may be affected, then swelling becomes localised, and a yellow pustule may develop near the lid margin.
Treatment is with dibromopropanidine isetionate ointment.
Differential diagnosis and factors for referral
Referral should be made if any of the conditions described below are suspected.
Blepharitis
Blepharitis is chronic infl ammation of the lid margins, affecting both eyes. There are three main types: staphylococcal, seborrhoeic (frequently associated with seborrhoea of the scalp, eyebrows and ears) and contact dermatitis (due to cosmetics). The lid margins appear raw and red, with irritation, burning and itching. If contact dermatitis is the cause then there is generally a history of atopy, and other areas of skin may be affected. Scales are frequently seen on the lashes of both upper and lower lids, which tend to be dry in staphylococcal infections and greasy in seborrhoeic blepharitis. The lids become deformed in staphylococcal blepharitis due to ulceration. Lashes are frequently lost or may be distorted, turn inwards and rub on the cornea; this in turn can cause conjunctivitis. Mild seborrhoeic blepharitis can often be managed with eyelid hygiene without prescribed medication. However, medical diagnosis is always necessary fi rst and the condition may not respond to over-the-counter treatment.
Chalazion (meibomian cyst)
A chalazion is a cyst of a meibomian gland: the meibomian gland secretes fl uid to stop the eyelashes sticking together. It may become infected or develop into a sterile chronic granuloma, a fi rm, painless lump in the lid which gradually enlarges. Initially, the chalazion may resemble a stye but is not infl amed. Chalazia usually grow inwards towards the conjunctival surface, which may be slightly reddened or elevated. Infected cysts are treated as styes. A third of cases will resolve spontaneously and virtually all will resorb within 2 years, but they are often surgically removed before then.
Ectropion
This is mainly a condition of old age, as is entropion (see below). Sagging and turning outward of the lower eyelid occur from a natural loss of muscle tone and orbital fat. Tears overfl ow and there is insuffi cient lubrication and protection for the eye. The lower lid may become chronically infected and scarred. This then requires surgical correction.
Entropion
The lower lids turn inwards and lid margins and eyelashes abrade the surface of the eye. Lashes may fall out and susceptibility to infection is increased. Entropion requires surgical correction.
Basal cell carcinoma
Basal cell carcinoma presents as a reddish nodule on the eyelid. There is no pain or discomfort. There may be a history of prolonged exposure to sun or ultraviolet light.
Other eye problems
Sore and ‘tired’ eyes
Redness and mild irritation in the eyes can be caused by activities such as driving and close work, and environmental pollutants, including tobacco smoke.
Several eye drop preparations, based mainly on astringents and vasoconstrictors, are available without prescription:
– Several products contain distilled witch hazel (hamamelis water), obtained from the bark of a shrub, with astringent and anti-inflammatory properties.
– Naphazoline, a sympathomimetic vasoconstrictor, is included in some ophthalmic preparations to shrink the dilated blood vessels that cause redness.
Dry eyes
Dry eye (keratoconjunctivitis sicca) is a chronic condition characterised by dryness of the surface of
Cold sores (oral herpes simplex) Definition, Causes, Symptoms, Diagnosis and Treatment.
Cold sores (oral herpes simplex)
A cold sore is a painful and unsightly, though not normally serious, recurrent virus infection of the area around the lips.
Causes
Cold sores are caused by the herpes simplex virus type 1 (HSV-1).
Transmission of infection is through transfer of the virus via saliva to mucous membranes, e.g. by kissing.
The infection is usually contracted in childhood; it may not manifest clinically for several years or at all, but the virus is never eliminated from the body.
Following attacks, the virus regresses to the ganglia of the trigeminal and lumbosacral nerves, where it lies dormant until one of several trigger factors or lowered immunity allows it to break out again.
Attacks are frequently triggered by the common cold, hence the common name of the condition. Outbreaks also often follow exposure to the sun, giving rise to the other common name, sun blisters.
Other trigger factors include: fatigue; stress; exposure to cold weather and wind; trauma around the mouth; hormonal changes associated with the menstrual cycle.
Epidemiology
Cold sores are very common: about 80% of the population are asymptomatic carriers of the virus, and 20–25% of these (about 8 million people) suffer, on average, two symptomatic outbreaks per year.
Signs and symptoms
Outbreaks may begin with a prodromal phase of up to 24 hours before any visible signs appear, during which the area on or around the lips begins to tingle, burn or itch.
Erythema then develops, followed by the formation of painful and irritating fluid-filled blisters on the lips and skin around the mouth, which break down
into shallow, weeping ulcers within 1–3 days.
The ulcers dry and form crusts, which are shed, and the area heals within a further 2 weeks.
The total length of an episode is usually 10–20 days.
Initial outbreaks in children typically manifest as gingivostomatitis, with lesions all over the inside of the mouth and symptoms of systemic infection. Primary infection in adolescents manifests as pharyngitis, with lesions in the throat and symptoms similar to glandular fever.
Differential diagnosis
Mouth ulcers: these occur on the mucous membranes and tongue inside the mouth, not on the outside of the lip and mouth.
Chickenpox: vesicles can occur both around the outside and inside the mouth, but they are also widespread on other parts of the body.
Impetigo: a bacterial skin infection, more common in children, that usually affects the face but can spread more widely. Lesions are itchy and not confined to the area round the lips, although they may first appear there.
Lip cancer: lesions develop slowly and are initially painless.
Primary chancre of syphilis: sores can occur on the lip. A single hard ulcer appears, which is painless, followed by swelling and hardening of lymph glands in the neck, then spreading to lymph glands elsewhere in the body.
Angular cheilitis: cracks occurring at the corners of the mouth that become inflamed and macerated. It is most common in elderly denture wearers.
Symptoms and circumstances for referral
young children and babies
sores that do not heal within 14 days
painless sores
multiple sores
systemic symptoms
frequent attacks
any eye involvement. HSV in the eyes can cause herpes simplex keratitis, a potentially sight-threatening infection
atopic and immunocompromised patients.
Treatment
Cold sores are difficult to treat – even systemic antiviral therapy has not proven particularly effective. Non-prescription treatments are the antiviral agents, aciclovir and penciclovir, and preparations for symptomatic relief containing antiseptics, astringents and local anaesthetics.
Aciclovir
Aciclovir is presented as a 5% cream.
Cold sores (oral herpes simplex)
Aciclovir is a synthetic analogue of guanine. Its spectrum of activity is specific to human pathogenic viruses that produce thymidine kinase, of which HSV-1 is one.
Aciclovir is converted by thymidine kinase within viral cells to aciclovir triphosphate, which is then incorporated into viral DNA instead of the deoxyguanosine triphosphate required for DNA synthesis and replication.
The cream is applied five times daily, at 4-hourly intervals, starting, if possible, as soon as prodromal symptoms occur. Treatment can be continued for up to 10 days, if necessary.
Evidence of the effectiveness of topical aciclovir has not been convincing, but it may shorten attacks by a day or two if use is begun early enough.
There is limited evidence that aciclovir cream reduces recurrence of cold sores, but little proof that it protects against attacks caused by ultraviolet radiation, one of the most common triggers of the condition.
Aciclovir cream is licensed for use in children and pregnant women.
Penciclovir
Penciclovir is available as 1% cream.
Its antiviral activity and effectiveness are similar to that of aciclovir.
It is applied 2-hourly during waking hours.
Other preparations
Products containing combinations of constituents with local anaesthetic and analgesic effects, such as lidocaine, choline salicylate and phenol, counterirritants such as ammonia solution and menthol, and astringents such as zinc sulphate and tannic acid, are marketed to reduce discomfort and promote faster healing of sores while the infection takes its course. Some are formulated with alcoholic bases, which may have a drying effect on sores and speed up healing. The bland cream bases of some products may have a soothing effect.
Combination preparations for cold sores are relatively innocuous. Creams
can be applied as frequently as necessary, although lotions and gels are limited to three or four applications per day.
Additional advice
To prevent spread of infection to the eyes:
– patients should wash their hands after applying treatment
– women should be very careful when applying eye makeup if they have a cold sore.
To prevent spread of infection to others, people with cold sores should not share towels, face flannels and cutlery with others.
For sufferers whose attacks are triggered by sunlight, an ultraviolet-blocking lip salve or high-factor sunscreen is an effective prophylactic
Bunions Definition, Causes, Symptoms and Treatment
Bunions
Causes
A bunion is an enlargement of the fi rst metatarsal phalangeal joint on the outside of the large toe. The deviation of the joint is known as hallux valgus.
The cause is usually footwear that is too tight with inadequate arch support, and the regular wearing of high heels.
Signs and symptoms
A bunion is initially painless, becoming painful as the toe displacement increases. There may be redness and some swelling.
Motion of the joint may be restricted or painful.
Hard corns, soft corns and calluses may develop on and between the large and second toe as a result of pressure from shoes.
Symptoms and circumstances for referral
Referral is always necessary, for orthotic treatment (support or bracing to correct the deformity) or corrective surgery.
Treatment
In the early stages, use of cushioning products to reduce pressure and wearing of comfortable, well-fi tting shoes may slow or halt progress but cannot reverse it.
Causes
A bunion is an enlargement of the fi rst metatarsal phalangeal joint on the outside of the large toe. The deviation of the joint is known as hallux valgus.
The cause is usually footwear that is too tight with inadequate arch support, and the regular wearing of high heels.
Signs and symptoms
A bunion is initially painless, becoming painful as the toe displacement increases. There may be redness and some swelling.
Motion of the joint may be restricted or painful.
Hard corns, soft corns and calluses may develop on and between the large and second toe as a result of pressure from shoes.
Symptoms and circumstances for referral
Referral is always necessary, for orthotic treatment (support or bracing to correct the deformity) or corrective surgery.
Treatment
In the early stages, use of cushioning products to reduce pressure and wearing of comfortable, well-fi tting shoes may slow or halt progress but cannot reverse it.
Athlete’s foot Definition, Causes, Epidemiology, Diagnosis and Treatment
Athlete’s foot
Tinea pedis (athlete’s foot) is a topical fungal infection of the spaces betwe en the toes.
Causes
Athlete’s foot is the commonest of a group of topical fungal infections caused by dermatophytes, organisms that invade and proliferate on the outermost horny layer (stratum corneum) of the skin, hair and nails. They do not normally penetrate deeper into the skin or tissues. Dermatophytes tend to thrive in areas of the body that are occluded and moist.
The common infecting organisms are Trichophyton, Microsporum and Epidermophyton species.
The infection is easily transmitted in moist or humid locations, e.g. sports clubs, gyms and swimming-pool changing rooms, hence the common name of the condition. It is also associated with the use of occlusive footwear such as trainers.
Epidemiology
Tinea pedis mainly occurs in adolescents and young adults, and is more common in males.
It is more common in the summer months.
Signs and symptoms
Infection usually starts in the toe webs, especially in the fourth web space (next to the little toe), where the tissue can become macerated, white and cracked.
Infection can spread to the soles, heels and borders of the foot.
Painful itching is common.
The skin may fi ssure and allow entry of bacterial infection.
The sole may be affected, making the condition more diffi cult to diagnose and differentiate from psoriasis or eczema.
With persistent infection the toenails may become involved, becoming dull, opaque and yellow in appearance. Over time the nail hardens and then starts to crumble
Differential diagnosis
Eczema: an infl ammatory skin condition characterised by areas of redness, itching and weeping, which can become scaly, crusty and hardened. The condition may be endogenous or caused by an irritant or allergen in contact with the skin.
Psoriasis: a chronic skin condition characterised by well-defi ned red patches covered with white scales.
Erythrasma, a bacterial infection: the usual mild form responds to azole antifungals (see below).
Circumstances for referral
severe infection spreading beyond the toe spaces on to the sole or upper surface of the foot, or to the toenails
signs of secondary bacterial infection
infection unresponsive to antifungal topical treatment
diabetic patients (diabetic patients with any foot problems should always be referred to a chiropodist or doctor:
suspected eczema or psoriasis.
Treatment
Treatments available for the treatment of athlete’s foot are antifungals. Salicylic acid is also included in some preparations.
Terbinafine and the imidazoles are widely accepted as being the most effective treatments for athlete’s foot. Little overall difference in efficacy has been found between them, although terbinafi ne clears infections up to four times more quickly. Griseofulvin has also been found an effective treatment.
Undecenoic acid and its derivatives are thought to be suitable for mild forms of athlete’s foot characterised by dry scaling of tissue, but are less effective where the skin is macerated and moist. Undecenoic acid and tolnaftate have been found to be about equally effective.
Some over-the-counter creams containing an imidazole and hydrocortisone are licensed for the treatment of athlete’s foot and associated infl ammation and irritation.
Antifungals
Compounds available are: imidazoles, terbinafine, griseofulvin, tolnaftate, undecenoates and benzoic acid.
Imidazoles
Imidazoles licensed for treatment of athlete’s foot without prescription are clotrimazole, econazole, ketoconazole, miconazole and sulconazole.
They act by inhibiting the biosynthesis of ergosterol, a constituent of the fungal cell membrane, resulting in disruption of the cell.
These compounds also possess activity against Gram-positive bacteria, which is useful, as secondary bacterial infection may complicate the fungal infection.
Application twice or three times daily is recommended, and treatment for at least a month is generally advised to ensure that this tenacious infection is eradicated.
Terbinafine
Terbinafine is an allylamine derivative with a broad spectrum of antifungal activity.
It is available as a 1% cream which is applied once or twice daily for 1 week, a 1% gel which is used once daily for 1 week, and a cutaneous solution which requires only a single application.
Griseofulvin
Griseofulvin is exclusively active against dermatophytes, through inhibition of cellular mitosis. It also binds to host cell keratin and reduces its degradation by fungal keratinases. It may also interfere with dermatophyte DNA production.
It is available as a 1% topical spray. One spray is applied daily, increasing to three sprays daily for more severe or extensive infection affecting the sides or soles of the feet. Treatment should be continued for 10 days after lesions have disappeared. The treatment period should not exceed 4 weeks.
Tolnaftate
Tolnaftate is believed to act by distorting fungal hyphae and stunting mycelial growth. It is active against all species responsible for athlete’s foot but has no antibacterial activity.
It should be used twice daily and treatment should be continued for up to 6 weeks. It is well tolerated when applied to intact or broken skin, although slight stinging on application is probable. Skin reactions are rare and include irritation and contact dermatitis.
Undecenoates
Both undecenoic acid and zinc undecenoate are used in proprietary athlete’s foot preparations.
Zinc undecenoate has astringent properties, which helps to reduce the irritation and inflammation caused by the infection.
Undecenoic acid, the active antifungal entity, is liberated from the zinc salt on contact with moisture on the skin.
Up to 4 weeks’ treatment may be needed to produce therapeutic results.
Irritation occurs rarely after application of undecenoic acid or its salts.
Benzoic acid
Benzoic acid has antifungal activity, lowering the intracellular pH of infecting organisms.
It is combined with salicylic acid (see below) in an emulsifying ointment
Athlete’s foot
Managing Symptoms in the Pharmacy 50base in Benzoic Acid Ointment Compound BP (Whitfield’s ointment). This preparation has been in use for over 90 years but more cosmetically acceptable products are now available.
Benzoic acid may cause irritation of the skin, and should not come into contact with the eyes or mucous membranes.
Salicylic acid
Salicylic acid alone has little or no antifungal activity but it facilitates the penetration of other drugs into the epidermis. Preparations for athlete’s foot containing salicylic acid therefore also contain antifungal constituents; it is present in Whitfield’s ointment and some proprietary preparations.
At concentrations above 2% salicylic acid has a keratolytic effect, causing the keratin layer of the skin to shed. Keratolysis is achieved by increasing the hydration of the stratum corneum, softening the cells and facilitating dissolution of the intracellular cement that bonds the cells together so that they separate and detach (desquamate). Moisture is essential to this process and is provided by either the water in the formulation or the occlusive effect produced by its application to the skin.
Although salicylic acid is readily absorbed through the skin, salicylate poisoning is highly unlikely to result from application to a small area for the limited period of treatment for athlete’s foot.
Additional advice
Wash and thoroughly dry feet and toes daily, particularly between the toes.
Do not share towels in communal changing rooms.
Wash towels frequently.
Change socks daily.
Wear fl ip-fl ops or plastic sandals in communal changing rooms and showers.
When at home leave shoes and socks off as much as possible.
Tinea pedis (athlete’s foot) is a topical fungal infection of the spaces betwe en the toes.
Causes
Athlete’s foot is the commonest of a group of topical fungal infections caused by dermatophytes, organisms that invade and proliferate on the outermost horny layer (stratum corneum) of the skin, hair and nails. They do not normally penetrate deeper into the skin or tissues. Dermatophytes tend to thrive in areas of the body that are occluded and moist.
The common infecting organisms are Trichophyton, Microsporum and Epidermophyton species.
The infection is easily transmitted in moist or humid locations, e.g. sports clubs, gyms and swimming-pool changing rooms, hence the common name of the condition. It is also associated with the use of occlusive footwear such as trainers.
Epidemiology
Tinea pedis mainly occurs in adolescents and young adults, and is more common in males.
It is more common in the summer months.
Signs and symptoms
Infection usually starts in the toe webs, especially in the fourth web space (next to the little toe), where the tissue can become macerated, white and cracked.
Infection can spread to the soles, heels and borders of the foot.
Painful itching is common.
The skin may fi ssure and allow entry of bacterial infection.
The sole may be affected, making the condition more diffi cult to diagnose and differentiate from psoriasis or eczema.
With persistent infection the toenails may become involved, becoming dull, opaque and yellow in appearance. Over time the nail hardens and then starts to crumble
Differential diagnosis
Eczema: an infl ammatory skin condition characterised by areas of redness, itching and weeping, which can become scaly, crusty and hardened. The condition may be endogenous or caused by an irritant or allergen in contact with the skin.
Psoriasis: a chronic skin condition characterised by well-defi ned red patches covered with white scales.
Erythrasma, a bacterial infection: the usual mild form responds to azole antifungals (see below).
Circumstances for referral
severe infection spreading beyond the toe spaces on to the sole or upper surface of the foot, or to the toenails
signs of secondary bacterial infection
infection unresponsive to antifungal topical treatment
diabetic patients (diabetic patients with any foot problems should always be referred to a chiropodist or doctor:
suspected eczema or psoriasis.
Treatment
Treatments available for the treatment of athlete’s foot are antifungals. Salicylic acid is also included in some preparations.
Terbinafine and the imidazoles are widely accepted as being the most effective treatments for athlete’s foot. Little overall difference in efficacy has been found between them, although terbinafi ne clears infections up to four times more quickly. Griseofulvin has also been found an effective treatment.
Undecenoic acid and its derivatives are thought to be suitable for mild forms of athlete’s foot characterised by dry scaling of tissue, but are less effective where the skin is macerated and moist. Undecenoic acid and tolnaftate have been found to be about equally effective.
Some over-the-counter creams containing an imidazole and hydrocortisone are licensed for the treatment of athlete’s foot and associated infl ammation and irritation.
Antifungals
Compounds available are: imidazoles, terbinafine, griseofulvin, tolnaftate, undecenoates and benzoic acid.
Imidazoles
Imidazoles licensed for treatment of athlete’s foot without prescription are clotrimazole, econazole, ketoconazole, miconazole and sulconazole.
They act by inhibiting the biosynthesis of ergosterol, a constituent of the fungal cell membrane, resulting in disruption of the cell.
These compounds also possess activity against Gram-positive bacteria, which is useful, as secondary bacterial infection may complicate the fungal infection.
Application twice or three times daily is recommended, and treatment for at least a month is generally advised to ensure that this tenacious infection is eradicated.
Terbinafine
Terbinafine is an allylamine derivative with a broad spectrum of antifungal activity.
It is available as a 1% cream which is applied once or twice daily for 1 week, a 1% gel which is used once daily for 1 week, and a cutaneous solution which requires only a single application.
Griseofulvin
Griseofulvin is exclusively active against dermatophytes, through inhibition of cellular mitosis. It also binds to host cell keratin and reduces its degradation by fungal keratinases. It may also interfere with dermatophyte DNA production.
It is available as a 1% topical spray. One spray is applied daily, increasing to three sprays daily for more severe or extensive infection affecting the sides or soles of the feet. Treatment should be continued for 10 days after lesions have disappeared. The treatment period should not exceed 4 weeks.
Tolnaftate
Tolnaftate is believed to act by distorting fungal hyphae and stunting mycelial growth. It is active against all species responsible for athlete’s foot but has no antibacterial activity.
It should be used twice daily and treatment should be continued for up to 6 weeks. It is well tolerated when applied to intact or broken skin, although slight stinging on application is probable. Skin reactions are rare and include irritation and contact dermatitis.
Undecenoates
Both undecenoic acid and zinc undecenoate are used in proprietary athlete’s foot preparations.
Zinc undecenoate has astringent properties, which helps to reduce the irritation and inflammation caused by the infection.
Undecenoic acid, the active antifungal entity, is liberated from the zinc salt on contact with moisture on the skin.
Up to 4 weeks’ treatment may be needed to produce therapeutic results.
Irritation occurs rarely after application of undecenoic acid or its salts.
Benzoic acid
Benzoic acid has antifungal activity, lowering the intracellular pH of infecting organisms.
It is combined with salicylic acid (see below) in an emulsifying ointment
Athlete’s foot
Managing Symptoms in the Pharmacy 50base in Benzoic Acid Ointment Compound BP (Whitfield’s ointment). This preparation has been in use for over 90 years but more cosmetically acceptable products are now available.
Benzoic acid may cause irritation of the skin, and should not come into contact with the eyes or mucous membranes.
Salicylic acid
Salicylic acid alone has little or no antifungal activity but it facilitates the penetration of other drugs into the epidermis. Preparations for athlete’s foot containing salicylic acid therefore also contain antifungal constituents; it is present in Whitfield’s ointment and some proprietary preparations.
At concentrations above 2% salicylic acid has a keratolytic effect, causing the keratin layer of the skin to shed. Keratolysis is achieved by increasing the hydration of the stratum corneum, softening the cells and facilitating dissolution of the intracellular cement that bonds the cells together so that they separate and detach (desquamate). Moisture is essential to this process and is provided by either the water in the formulation or the occlusive effect produced by its application to the skin.
Although salicylic acid is readily absorbed through the skin, salicylate poisoning is highly unlikely to result from application to a small area for the limited period of treatment for athlete’s foot.
Additional advice
Wash and thoroughly dry feet and toes daily, particularly between the toes.
Do not share towels in communal changing rooms.
Wash towels frequently.
Change socks daily.
Wear fl ip-fl ops or plastic sandals in communal changing rooms and showers.
When at home leave shoes and socks off as much as possible.
Acne Definition, Causes, Symptoms, Diagnosis, Epidemiology and Treatment
Acne
Acne vulgaris is a common condition in young people. Although it may sometimes be unsightly and can persist for several years, it is not usually serious and resolves in most patients by the age of 25. However, it can have a significant psychological impact as it affects young people at a stage in their lives when they are especially sensitive about their appearance.
Effective treatments for milder forms of acne are available from pharmacies without prescription.
Causes
Acne vulgaris is the result of several factors combined. The condition arises in the pilosebaceous units in the dermis, which consist of a hair follicle and associated sebaceous gland. These glands secrete sebum, a mixture of fats and waxes that protect the skin and hair by retarding water loss and forming a barrier against external agents. The hair follicle is lined with epithelial cells that become keratinised as they mature.
The main processes involved in acne are:
During puberty the production of androgenic hormones increases in both sexes and testosterone levels rise. Testosterone is taken up into the sebaceous glands where it is converted into dihydrotestosterone, which stimulates the glands to secrete increased sebum.
At the same time, keratin in the follicular epithelial wall becomes unusually cohesive and sebum accumulates to form keratin plugs. These block the follicle openings in the epidermis and cause them to dilate beneath the skin surface.
If the orifice of the follicular canal opens sufficiently, the keratinous material extrudes through it and an open comedone results. This is also known as a blackhead, as the keratinous material darkens in contact with the air. Because this material can escape, the comedone does not become inflamed. If the follicular orifice does not open sufficiently, a closed comedone (whitehead) results, within which inflammation can occur. Most acne sufferers have a combination of both.
Microorganisms, mainly Propionibacterium acnes, cause the follicular wall of closed comedones to disrupt and collapse, spilling their contents into the surrounding tissue and provoking an inflammatory response. In addition, bacterial enzymes decompose triglycerides in the sebum to produce free fatty acids, which also cause inflammation. This process leads to the formation of papules around the follicular openings in the more common, milder form of acne
and to cyst formation in the deeper layers of the skin in the more severe form.
Epidemiology
Acne affects approximately 80% of people aged 11–30 years at some time, with about 60% of those sufficiently affected to seek treatment.
Peak incidence is 14–17 years in females and 16–19 years in males.
The condition normally resolves within 10 years of onset, but up to 5% of women and 1% of men may suffer into their 30s.
The incidence of acne appears to have fallen in recent years; the reasons are unknown.
Signs and symptoms
Distribution: lesions usually occur on the forehead, nose and chin, but the periorbital area is usually spared. In more severe cases, the whole of the face, upper chest and back may be affected.
Severity: acne vulgaris is classified according to its clinical features:
Mild: any or all of the following may be present:
• small, tender, red papules
• pustules
• blackheads (small dark plugs of sebum and keratinised epithelial cells)
• whiteheads (small keratin cysts appearing as white papules).
– Moderate: more frequent papules and pustules, with possibly some scarring
– Severe: nodular abscesses, leading to extensive scarring.
Differential diagnosis
Rosacea, an inflammatory skin condition causing acne-like papules and pustules. However, there are also redness and flushing of the central facial area and cheeks. The condition usually occurs in young to early middle-aged adults.
Circumstances for referral
moderate or severe acne
mild acne, if there is no improvement after 2 months with over-the-counter treatment
acne beginning or persisting outside the normal age range for the condition
(teenage years and early 20s)
suspected drug-induced acne: acne is a possible side effect of lithium, phenytoin, progestogens, azathioprine and rifampicin
suspected occupational causes: frequent or prolonged contact with grease and oils may predispose to acne
suspected rosacea.
Treatment
Non-prescription topical treatments are usually the first line of treatment
for mild to moderate acne. Their overall aim is to remove follicular plugs to allow sebum to flow freely, and to minimise bacterial colonisation of the skin.
Treatments must be used regularly for up to 3 months to produce benefits.
Types of preparation available are: keratolytics, antimicrobials, anti- inflammatory agents and abrasive products.
Keratolytics
Keratolytic agents (also known as comedolytics in relation to acne) promote shedding of the keratinised epithelial cells on the skin surface, although the compounds used may do this via different mechanisms.
Keratolytics prevent closure of the pilosebaceous orifice and the formation of follicular plugs, and facilitate sebum flow. They also possess varying levels of antimicrobial activity, which contribute to their effectiveness.
The keratolytic compounds in over-the-counter acne products are benzoyl peroxide, salicylic acid, sulphur and resorcinol.
Benzoyl peroxide
Benzoyl peroxide is generally accepted as the first-line topical treatment for mild to moderate acne.
It is thought to be both comedolytic, mainly through an irritant effect leading to increased turnover of the follicular epithelial cells and increased sloughing, and bactericidal against P. acnes. Benzoyl peroxide is lipophilic and penetrates the follicle well; once absorbed it releases oxygen, which suppresses the bacteria, and reduces the production of irritant free fatty acids.
Benzoyl peroxide is mildly irritant and may cause redness, stinging and peeling, especially at the start of treatment, but tolerance usually develops with continued use. To minimise these effects, the lowest available strength (usually
5%, but 2.5% is available for highly sensitive skin) should be used and applied at night for the first week so that any erythema subsides by the next morning.
If there is no adverse reaction, frequency of application may then be increased to twice daily. Several weeks of regular application are usually required to produce real benefit. If the lower strength is ineffective, the higher strength (10%) can be tried.
Treatment should not continue beyond 3 months with the 5% preparations or beyond 2 months for 10%. If skin irritation is troublesome the product should be stopped for a day or two, and if there is the same reaction when the product is used again it should be discontinued.
Care should be taken to keep all keratolytics away from the eyes, mouth and other mucous membranes. Benzoyl peroxide is an oxidising agent and may bleach clothing and bedclothes.
Benzoyl peroxide is available as creams, lotions, gels and washes (2.5, 5 and
10%, and a 4% cream). There is little difference in clinical response to these concentrations in terms of reducing the number of inflammatory lesions, but formulation appears to make a difference. The drying effect of an alcoholic gel base enhances the effectiveness of the active constituent, and it is more
effective than a lotion of the same concentration. However, gels have a greater potential for causing skin dryness and irritation than preparations in aqueous bland bases, so water-based preparations may improve compliance.
Salicylic acid
Salicylic acid is used in concentrations of up to 2% for acne.
It exerts its keratolytic effect by increasing the hydration of epithelial cells.
It may also have some bacteriostatic activity and a direct anti-inflammatory effect on lesions. It is believed to enhance penetration into the skin of
other medicaments, and is combined with sulphur in some formulary preparations.
Salicylic acid is a mild irritant and similar precautions should be adopted
as for benzoyl peroxide. Preparations are applied twice or three times a day. Salicylic acid is readily absorbed through the skin and excreted slowly, and salicylate poisoning can occur if preparations are applied frequently, in large amounts and over large areas. Patients who are sensitive to aspirin should avoid these preparations.
Sulphur and resorcinol
Sulphur and resorcinol are claimed to possess keratolytic and antiseptic properties, but this is debatable and there is little evidence of effectiveness. Both can cause skin irritation and sensitisation, and resorcinol can cause other adverse effects. Both substances are now little used.
Antimicrobials
Antimicrobial compounds available in over-the-counter preparations are cetrimide, chlorhexidine, povidone-iodine, triclocarban and triclosan.
As two of the contributory factors to acne are increased sebum production and P. acnes, one approach to treatment is to remove excess sebum from the skin and reduce the bacterial count. To this end, several products are formulated
as astringent lotions and detergent-based washes containing antibacterial or antiseptic ingredients, and there are also some antimicrobial creams.
Abrasives
There is one product containing an abrasive licensed for acne treatment. It contains small, gritty particles in a skin wash, intended to remove follicular plugs mechanically. It is contraindicated in the presence of superficial venules or capillaries (telangiectasia), and overenthusiastic use can cause irritation. There is little evidence of the effectiveness of abrasive preparations in acne.
Anti-inflammatory
Topical nicotinamide is claimed to have anti-inflammatory activity. It appears to be effective. It may produce side-effects of dryness, peeling and irritation similar to those of benzoyl peroxide, and the same precautions in use should be taken.
Prescription treatments
Topical comedolytic, antibacterial and combined comedolytic/antimicrobial preparations.
Oral antibacterials: these can be prescribed if topical therapy alone is ineffective. Tetracycline, oxytetracycline, doxycycline, minocycline, lymecycline, erythromycin and trimethoprim are the agents used. Treatment is long-term – for up to 2 years.
Hormonal treatment: co-cyprindiol, containing cyproterone, an antiandrogen that decreases sebum production, and ethinylestradiol, can be prescribed for women with moderate to severe acne. It also prevents ovulation and, although it is no more effective for acne than oral antibacterials, it is useful for women who also want oral contraception.
Oral isotretinoin is available for severe acne refractive to other forms of treatment. It is effective but is teratogenic and can have severe side-effects. It should be prescribed only by, or under the supervision of, a consultant dermatologist.
Additional advice
There is no evidence that poor hygiene causes acne, but washing the face twice a day with an antibacterial soap or a mild cleanser degreases the skin and removes bacteria, and should help reduce the severity of the condition. Sweat should not be allowed to remain on the skin, but should be washed off as soon as possible.
Avoid hairstyles in which the hair is constantly touching the face, and shampoo hair regularly.
Pimples and blackheads should not be squeezed or pinched with the fingers.
Comedone expressors (blackhead removers) can be used; removal is aided by exposing the skin to steam first.
Natural sunlight is thought to be helpful in reducing acne, but overexposure should be avoided.
Avoid heavy, greasy cosmetics and use water-based moisturisers.
There is no evidence that fatty foods and chocolate cause acne, but no harm is done by seeing if excluding them from the diet has a beneficial effect.
A healthy, balanced diet with plenty of water, and regular exercise, is always
good advice.
Acne vulgaris is a common condition in young people. Although it may sometimes be unsightly and can persist for several years, it is not usually serious and resolves in most patients by the age of 25. However, it can have a significant psychological impact as it affects young people at a stage in their lives when they are especially sensitive about their appearance.
Effective treatments for milder forms of acne are available from pharmacies without prescription.
Causes
Acne vulgaris is the result of several factors combined. The condition arises in the pilosebaceous units in the dermis, which consist of a hair follicle and associated sebaceous gland. These glands secrete sebum, a mixture of fats and waxes that protect the skin and hair by retarding water loss and forming a barrier against external agents. The hair follicle is lined with epithelial cells that become keratinised as they mature.
The main processes involved in acne are:
During puberty the production of androgenic hormones increases in both sexes and testosterone levels rise. Testosterone is taken up into the sebaceous glands where it is converted into dihydrotestosterone, which stimulates the glands to secrete increased sebum.
At the same time, keratin in the follicular epithelial wall becomes unusually cohesive and sebum accumulates to form keratin plugs. These block the follicle openings in the epidermis and cause them to dilate beneath the skin surface.
If the orifice of the follicular canal opens sufficiently, the keratinous material extrudes through it and an open comedone results. This is also known as a blackhead, as the keratinous material darkens in contact with the air. Because this material can escape, the comedone does not become inflamed. If the follicular orifice does not open sufficiently, a closed comedone (whitehead) results, within which inflammation can occur. Most acne sufferers have a combination of both.
Microorganisms, mainly Propionibacterium acnes, cause the follicular wall of closed comedones to disrupt and collapse, spilling their contents into the surrounding tissue and provoking an inflammatory response. In addition, bacterial enzymes decompose triglycerides in the sebum to produce free fatty acids, which also cause inflammation. This process leads to the formation of papules around the follicular openings in the more common, milder form of acne
and to cyst formation in the deeper layers of the skin in the more severe form.
Epidemiology
Acne affects approximately 80% of people aged 11–30 years at some time, with about 60% of those sufficiently affected to seek treatment.
Peak incidence is 14–17 years in females and 16–19 years in males.
The condition normally resolves within 10 years of onset, but up to 5% of women and 1% of men may suffer into their 30s.
The incidence of acne appears to have fallen in recent years; the reasons are unknown.
Signs and symptoms
Distribution: lesions usually occur on the forehead, nose and chin, but the periorbital area is usually spared. In more severe cases, the whole of the face, upper chest and back may be affected.
Severity: acne vulgaris is classified according to its clinical features:
Mild: any or all of the following may be present:
• small, tender, red papules
• pustules
• blackheads (small dark plugs of sebum and keratinised epithelial cells)
• whiteheads (small keratin cysts appearing as white papules).
– Moderate: more frequent papules and pustules, with possibly some scarring
– Severe: nodular abscesses, leading to extensive scarring.
Differential diagnosis
Rosacea, an inflammatory skin condition causing acne-like papules and pustules. However, there are also redness and flushing of the central facial area and cheeks. The condition usually occurs in young to early middle-aged adults.
Circumstances for referral
moderate or severe acne
mild acne, if there is no improvement after 2 months with over-the-counter treatment
acne beginning or persisting outside the normal age range for the condition
(teenage years and early 20s)
suspected drug-induced acne: acne is a possible side effect of lithium, phenytoin, progestogens, azathioprine and rifampicin
suspected occupational causes: frequent or prolonged contact with grease and oils may predispose to acne
suspected rosacea.
Treatment
Non-prescription topical treatments are usually the first line of treatment
for mild to moderate acne. Their overall aim is to remove follicular plugs to allow sebum to flow freely, and to minimise bacterial colonisation of the skin.
Treatments must be used regularly for up to 3 months to produce benefits.
Types of preparation available are: keratolytics, antimicrobials, anti- inflammatory agents and abrasive products.
Keratolytics
Keratolytic agents (also known as comedolytics in relation to acne) promote shedding of the keratinised epithelial cells on the skin surface, although the compounds used may do this via different mechanisms.
Keratolytics prevent closure of the pilosebaceous orifice and the formation of follicular plugs, and facilitate sebum flow. They also possess varying levels of antimicrobial activity, which contribute to their effectiveness.
The keratolytic compounds in over-the-counter acne products are benzoyl peroxide, salicylic acid, sulphur and resorcinol.
Benzoyl peroxide
Benzoyl peroxide is generally accepted as the first-line topical treatment for mild to moderate acne.
It is thought to be both comedolytic, mainly through an irritant effect leading to increased turnover of the follicular epithelial cells and increased sloughing, and bactericidal against P. acnes. Benzoyl peroxide is lipophilic and penetrates the follicle well; once absorbed it releases oxygen, which suppresses the bacteria, and reduces the production of irritant free fatty acids.
Benzoyl peroxide is mildly irritant and may cause redness, stinging and peeling, especially at the start of treatment, but tolerance usually develops with continued use. To minimise these effects, the lowest available strength (usually
5%, but 2.5% is available for highly sensitive skin) should be used and applied at night for the first week so that any erythema subsides by the next morning.
If there is no adverse reaction, frequency of application may then be increased to twice daily. Several weeks of regular application are usually required to produce real benefit. If the lower strength is ineffective, the higher strength (10%) can be tried.
Treatment should not continue beyond 3 months with the 5% preparations or beyond 2 months for 10%. If skin irritation is troublesome the product should be stopped for a day or two, and if there is the same reaction when the product is used again it should be discontinued.
Care should be taken to keep all keratolytics away from the eyes, mouth and other mucous membranes. Benzoyl peroxide is an oxidising agent and may bleach clothing and bedclothes.
Benzoyl peroxide is available as creams, lotions, gels and washes (2.5, 5 and
10%, and a 4% cream). There is little difference in clinical response to these concentrations in terms of reducing the number of inflammatory lesions, but formulation appears to make a difference. The drying effect of an alcoholic gel base enhances the effectiveness of the active constituent, and it is more
effective than a lotion of the same concentration. However, gels have a greater potential for causing skin dryness and irritation than preparations in aqueous bland bases, so water-based preparations may improve compliance.
Salicylic acid
Salicylic acid is used in concentrations of up to 2% for acne.
It exerts its keratolytic effect by increasing the hydration of epithelial cells.
It may also have some bacteriostatic activity and a direct anti-inflammatory effect on lesions. It is believed to enhance penetration into the skin of
other medicaments, and is combined with sulphur in some formulary preparations.
Salicylic acid is a mild irritant and similar precautions should be adopted
as for benzoyl peroxide. Preparations are applied twice or three times a day. Salicylic acid is readily absorbed through the skin and excreted slowly, and salicylate poisoning can occur if preparations are applied frequently, in large amounts and over large areas. Patients who are sensitive to aspirin should avoid these preparations.
Sulphur and resorcinol
Sulphur and resorcinol are claimed to possess keratolytic and antiseptic properties, but this is debatable and there is little evidence of effectiveness. Both can cause skin irritation and sensitisation, and resorcinol can cause other adverse effects. Both substances are now little used.
Antimicrobials
Antimicrobial compounds available in over-the-counter preparations are cetrimide, chlorhexidine, povidone-iodine, triclocarban and triclosan.
As two of the contributory factors to acne are increased sebum production and P. acnes, one approach to treatment is to remove excess sebum from the skin and reduce the bacterial count. To this end, several products are formulated
as astringent lotions and detergent-based washes containing antibacterial or antiseptic ingredients, and there are also some antimicrobial creams.
Abrasives
There is one product containing an abrasive licensed for acne treatment. It contains small, gritty particles in a skin wash, intended to remove follicular plugs mechanically. It is contraindicated in the presence of superficial venules or capillaries (telangiectasia), and overenthusiastic use can cause irritation. There is little evidence of the effectiveness of abrasive preparations in acne.
Anti-inflammatory
Topical nicotinamide is claimed to have anti-inflammatory activity. It appears to be effective. It may produce side-effects of dryness, peeling and irritation similar to those of benzoyl peroxide, and the same precautions in use should be taken.
Prescription treatments
Topical comedolytic, antibacterial and combined comedolytic/antimicrobial preparations.
Oral antibacterials: these can be prescribed if topical therapy alone is ineffective. Tetracycline, oxytetracycline, doxycycline, minocycline, lymecycline, erythromycin and trimethoprim are the agents used. Treatment is long-term – for up to 2 years.
Hormonal treatment: co-cyprindiol, containing cyproterone, an antiandrogen that decreases sebum production, and ethinylestradiol, can be prescribed for women with moderate to severe acne. It also prevents ovulation and, although it is no more effective for acne than oral antibacterials, it is useful for women who also want oral contraception.
Oral isotretinoin is available for severe acne refractive to other forms of treatment. It is effective but is teratogenic and can have severe side-effects. It should be prescribed only by, or under the supervision of, a consultant dermatologist.
Additional advice
There is no evidence that poor hygiene causes acne, but washing the face twice a day with an antibacterial soap or a mild cleanser degreases the skin and removes bacteria, and should help reduce the severity of the condition. Sweat should not be allowed to remain on the skin, but should be washed off as soon as possible.
Avoid hairstyles in which the hair is constantly touching the face, and shampoo hair regularly.
Pimples and blackheads should not be squeezed or pinched with the fingers.
Comedone expressors (blackhead removers) can be used; removal is aided by exposing the skin to steam first.
Natural sunlight is thought to be helpful in reducing acne, but overexposure should be avoided.
Avoid heavy, greasy cosmetics and use water-based moisturisers.
There is no evidence that fatty foods and chocolate cause acne, but no harm is done by seeing if excluding them from the diet has a beneficial effect.
A healthy, balanced diet with plenty of water, and regular exercise, is always
good advice.
Motion Sickness Causes, Epidemiology, Symptoms, Treatment and Additional advices.
Motion sicknessCauses
Motion sickness is a form of vertigo in which autonomic symptoms predominate.
The cause is thought to be disturbance of the vestibular apparatus of the inner ear, which controls balance, brought on by unaccustomed types of movement. During travel confl icting stimuli are received in the brain from the eyes and remembered experience of usual forms of movement, such as walking. This sensory mismatch is interpreted as a noxious stimulus and initiates a physiological response similar to that to substances perceived as poisonous, and a number of autonomic nervous system responses are activated to reject the perceived poison.
The body adapts to unfamiliar types of motion on prolonged or repeated exposure, explaining why seasickness, for example, tends to subside after a few days.
Epidemiology
Motion sickness is more common in women than men.
It is uncommon in children under 2 years and most common in children between 2 and 12, reaching a peak at 12 years. Incidence reduces thereafter and after 21 declines signifi cantly with age.
Women are more susceptible during menstruation and pregnancy.
Signs and symptoms
Muscarinic effects, including:
nausea
vomiting
increased salivation
general malaise
pallor
sweating
yawning
hyperventilation.
Gastric motility is also reduced and digestion impaired.
Differential diagnosis
Nausea and vomiting occur in a wide range of conditions, but the symptoms of motion sickness are usually very clearly associated with travel. Patients will nearly always ask for advice on prevention rather than treatment of current symptoms.
Treatment
Sedating antihistamines and hyoscine are licensed for use without prescription for prophylaxis and treatment of motion sickness. They appear to be of more or less equivalent effi cacy.
They are effective for prevention, but use for treatment is often unsuccessful as vomiting and gastric stasis prevent or substantially reduce their absorption. Hyoscine
Hyoscine competitively inhibits the actions of acetylcholine at the muscarinic receptors of autonomic effector sites innervated by parasympathetic nerves. It has a central as well as a peripheral action, as it is lipid-soluble and crosses the blood–brain barrier.
Sedating antihistamines
The older (fi rst-generation) antihistamines which tend to cause sedation have antimuscarinic side-effects similar to the actions of hyoscine. (Second-generation antihistamines, which generally do notcause drowsiness, do not exert antimuscarinic side-effects and are of no use for motion sickness.)
Sedating antihistamines licensed for the treatment of motion sickness (all P medicines) are:
cinnarizine
meclozine
promethazine hydrochloride
promethazine teoclate.
The length of action, degree of sedation and side-effects vary between the antihistamines
Side-effects and cautions: hyoscine and antihistamines
Hyoscine and antihistamines exhibit the same range of side-effects. However, side-effects tend to be more pronounced with hyoscine, and include:
dry mouth
blurred vision
urinary retention
constipation
sedation (more marked with antihistamines).
Both hyoscine and antihistamines should be avoided in patients suffering from glaucoma or prostatic hypertrophy, are not recommended for use by pregnant or breastfeeding women, and should be used with caution in the elderly and patients with epilepsy or cardiac or cardiovascular disease.
Hyoscine and sedating antihistamines increase the effects of other drugs that cause sedation or have antimuscarinic actions, including many antidepressants and antipsychotic agents.
Alcohol should be avoided when taking medication against motion sickness.
Additional advice
There are several things that people can do to minimise the chance of suffering from motion sickness on journeys.
General
Avoid heavy meals before travelling.
Avoid pungent odours.
Avoid alcohol.
Road travel
Drive, if possible, as drivers very rarely suffer from motion sickness.
If you do not or cannot drive, sit in the front passenger seat if possible.
Sit near the front in a bus or coach.
Keep vehicle windows open.
Do not try to read, and keep looking out of the window. Distract children with games such as I Spy, to make them look out.
Listen to the radio or talk with other passengers.
Sea travel
If possible, stay on deck and keep eyes fi xed on the horizon.
Below deck, stay in the centre of the ship and lie down with eyes closed.
Air travel
Try to sit by the wing.
Headache and Migraine Causes, Symptoms, Diagnosis, Types and Drug Treatment.
Headache and migraineCauses
The causes of most headaches fall into three categories:
1. Tension: the most common cause of headache, thought to be due to pericranial muscle contraction. It is often psychogenic in origin and caused or made worse by tension, anxiety or fatigue.
2. Vascular, caused by dilatation or constriction of blood vessels in the brain and cranium: headaches associated with febrile illnesses are caused by vasodilatation. Migraine is also believed to be vascular in origin, at least in part, although neurochemical pathology also appears to be involved.
3. Traction: infl ammation or compression of the brain and associated structures is responsible for headache associated with meningitis, encephalitis, haematomas (including those resulting from head injury), tumours and cerebral abscesses. Sinusitis, often associated with upper respiratory tract infections and allergic rhinitis, also frequently causes headache from congestion in the frontal and maxillary sinuses exerting pressure on surrounding nerves.
Other causes include:
spasm or fatigue of the ciliary and periorbital muscles of the eye, causing eye strain
glaucoma
referred pain from the jaw; muscle strain and pulled ligaments in the neck or upper back
infl ammation of the temporal arteries in temporal arteritis
neuropathic pain from shingles.
Epidemiology
Headache is the most commonly experienced of all symptoms: 96% of people are estimated to suffer a headache at least once in their life and 80–90% will experience one or more per year.
Migraine is suffered by about 15% of the population overall, with a female:male ratio of incidence of 3:1. Migraine mainly affects younger people: 80% of sufferers have their fi rst attack before the age of 30, and incidence is rare after age 50.
Signs and symptoms
The clinical features of the main types of headache are outlined in Table
Differential diagnosis
Eye strainEye strain can be responsible for frontal headaches. There may be occupational pointers, e.g. people using computers for long periods. Refer to an optometrist. Headache may also be a symptom of glaucoma; if suspected, refer immediately to a doctor.
Meningitis
In meningitis there may be a severe generalised headache associated with fever, nausea, neck stiffness, pain behind knees when extended (Kernig’s sign) and a purpuric rash in later stages. Refer urgently any child with headache, high temperature and who is unable to bend head forward easily.
Cluster headache
This is a condition of unknown cause that predominantly affects men between the ages of 40 and 60. Typically, headaches occur at the same time each day and last for between 10 minutes and 3 hours. About half of sufferers have attacks at night. Pain is sudden in onset, intense and ‘boring’ and localised around one eye. The affected eye becomes red and watery and there may be nasal congestion. Attacks persist for between a few weeks and a few months, with periods of remission of months or years. Refer immediately to a doctor.
Subarachnoid haemorrhage
Subarachnoid haemorrhage is caused by bleeding between the meningeal layers covering the spinal cord. There is sudden intense severe occipital headache, often described as ‘the worst I’ve ever had’. It is often accompanied by nausea and vomiting. There may be transient loss of consciousness. Refer urgently to Accident & Emergency.
Temporal arteritis
Temporal arteritis is infl ammation of the temporal artery running down the side of the head just in front of the ear. It occurs almost exclusively in elderly people. There is severe unilateral pain, and the area of the temple is infl amed and tender to the touch. There may be associated jaw pain and generalised rheumatic pains. Refer immediately to a doctor.
Space-occupying lesions
These lesions may be caused by tumour, haematoma or abscess. The pain can be localised or diffuse. It may be initially mild and get progressively worse. It may be severe on waking in the morning and lessen after getting up. It is made worse by coughing, sneezing or lying down. Refer if suspected. Symptoms may sometimes be confused with sinusitis, but the latter is usually associated with symptoms of upper respiratory tract infection or allergic rhinitis.
Trigeminal neuralgia
Infl ammation of the trigeminal nerve occurs in people mainly over the age of 50 and is more common in women than men. The pain is intensely sharp, and cutting or searing in nature. Pain is experienced in either the forehead or the side of the head, around the eye, with redness and lacrimation, the cheek and upper jaw, or the lower jaw, depending on which branch of the trigeminal nerve is affected. Refer immediately to a doctor.
Symptoms and circumstances for referral
su dden onset and/or very severe headache
headache after head injury
headache of long duration
recurring headaches (excluding diagnosed migraine)
headaches worsening over time
headache accompanied by nausea/vomiting (except as part of diagnosed migraine), drowsiness
vision affected
pupils uneven or not reacting to light
child under 12 (urgent if with neck stiffness, fever or rash)
cluster headache symptoms.
Treatment
This section covers oral non-prescription medicines for most types of pain, including tension headache, migraine, sinusitis, dental pain and musculoskeletal pain. Non-prescription oral analgesics are based on three compounds:
1. aspirin
2. ibuprofen
3. paracetamol.
Clinical evidence shows that all three compounds are effective analgesics and antipyretics, and that ibuprofen is generally the most effective.
Aspirin and ibuprofen
Action and uses
Aspirin and ibuprofen are non-steroidal anti-infl ammatory drugs (NSAIDs).
NSAIDs exert their therapeutic action by blocking the enzyme cyclo-oxygenase, which prevents the formation of prostaglandins from arachidonic acid, produced when tissue is damaged; prostaglandins are major contributors to infl ammation and pain. The action of NSAIDs is local at the site of infl ammation.
NSAIDs also inhibit production of cytoprotective prostaglandins in the gastric mucosa, accounting for their tendency to cause gastrointestinal irritation, although the incidence is much lower with ibuprofen than aspirin.
Aspirin and ibuprofen are licensed for treatment of mild and moderate pain from a wide variety of causes, including dental and musculoskeletal pain and dysmenorrhoea, where their anti-infl ammatory activity is particularly useful. They also have antipyretic action and are used in cold and fl u medicines.
Adverse reactions, cautions and contraindications
Aspirin and ibuprofen have similar side-effects, although side-effects are generally less pronounced with ibuprofen.
The most common side-effects are gastric irritation and bleeding. Both drugs should be avoided by patients with ulcers or a history of gastric problems. Minor gastric side-effects can be reduced by taking the drugs with or after food.
Hypersensitivity reactions to aspirin are much more likely to occur in patients with asthma or allergic problems than in the normal population. One in 10 patients with asthma may be hypersensitive and suffer severe bronchospasm. Other reactions are urticaria, angioedema and rhinitis. The incidence of hypersensitivity to ibuprofen is much lower than with aspirin, but the drug should be avoided by patients with asthma and individuals who are sensitive to aspirin, unless they have taken ibuprofen before without problems.
Aspirin and ibuprofen should not be recommended to patients with renal, cardiac or hepatic disease: both medications may impair both liver and kidney function.
Aspirin and ibuprofen should be used with caution in elderly patients, as renal function tends to decline with age and also because the elderly tend to be particularly vulnerable to gastric side-effects.
Aspirin and ibuprofen should be avoided during pregnancy.
Aspirin has been associated with Reye’s syndrome, a rare but potentially fatal brain condition in infants and children. Aspirin is not licensed for use in children under16 years and it should also be avoided by breastfeeding women. However, there is no evidence of an association between ibuprofen and Reye’s syndrome and it is licensed for sale for use in children and babies from the age of 3 months.
Interactions
Aspirin potentiates the anticoagulant effect of warfarin and other coumarins because of its inhibitory effect on platelet aggregation and inhibition of vitamin K synthesis. Ibuprofen may also enhance the effect of anticoagulants. Patients on anticoagulant therapy should avoid over-the-counter (OTC) aspirin and ibuprofen.
Aspirin and, to a lesser extent, ibuprofen reduce excretion of methotrexate, and can cause life-threatening rises in serum levels. Concurrent administration should therefore be avoided.
Ibuprofen reduces the excretion of lithium and can raise plasma concentrations to toxic levels. It may also antagonise the diuretic and antihypertensive effects of diuretics, and should not be recommended to patients taking these drugs.
Paracetamol
Action and uses
The mechanism of action of paracetamol is not well understood. It has little anti-infl ammatory activity but is an effective analgesic and antipyretic. It may selectively inhibit cyclo-oxygenase in the central nervous system rather than in peripheral tissues. It also appears to act peripherally at pain chemoreceptors. Toxicity
Paracetamol is very safe at normal therapeutic dosages; its only major drawback
is hepatotoxicity in overdose.
Paracetamol is metabolised in the liver, where it is converted to a highly toxic intermediate that is normally detoxifi ed by conjugation with glutathione. In overdose, this detoxifi cation mechanism is overwhelmed and the free toxic metabolite causes hepatitis and necrosis, which can prove fatal.
Paracetamol poisoning is particularly dangerous as the toxic level may not be greatly above the therapeutic level. Also, symptoms of overdose may not appear for 2 days or more, allowing unwitting overdosage to continue.
Fatalities have occurred in patients who were taking large doses, or two or more preparations containing paracetamol, for a minor ailment such as a cold. It is therefore extremely important to ensure that patients do not exceed the recommended dosage and do not use more than one paracetamol-containing product at a time.
OTC pack sizes of products containing aspirin and paracetamol and the total amounts that can be supplied are restricted to reduce the incidence of poisoning (see Medicines Ethics and Practice for details).
Additional constituents
Most proprietary OTC oral analgesics are not simple formulations of aspirin, ibuprofen or paracetamol, but combination products containing other analgesics and sometimes other constituents.
The theory behind combination products is that they will be more effective than one drug used alone and that the dose of each analgesic can be reduced, lessening the possibility of adverse effects. Further additional components are sometimes included to treat symptoms associated with pain.
Leading medical opinion (e.g. as represented in the British National Formulary) does not generally favour combined analgesics, claiming that low doses of additional ingredients may reduce the severity but increase the range of side-effects without producing signifi cant extra pain relief. Clinical evidence indicates that additional constituents add little to analgesic effi cacy.
Codeine and dihydrocodeine
Codeine is combined with aspirin, paracetamol and ibuprofen in many OTC analgesic products, and also in the formulary preparations co-codamol (with paracetamol) and co-codaprin (with aspirin). Dihydrocodeine is included with paracetamol in one OTC product, and at a higher dose in co-dydramol tablets, which are prescription-only medicines (POM).
Codeine and dihydocodeine are opioid analgesics that act directly on opiate receptors in the brain, producing analgesia, respiratory depression, euphoria and sedation. They are weak narcotic analgesics, useful for the treatment of mild to moderate pain. Their major side-effect at non-prescription dosages is constipation.
Caffeine
Many OTC analgesics contain caffeine, the rationale being that, as a central nervous system stimulant, it will alleviate the depression often associated with pain.
Most preparations contain low doses, although they may be suffi cient to add to gastrointestinal adverse effects. Caffeine is also habit-forming and may itself induce headache in large doses or on withdrawal.
Antihistamines
Tension in muscles at the back of the neck is thought to be a contributory factor to tension headache. Sedating antihistamines are included in some products for their claimed muscle-relaxant effect.
Migraine treatments
Migraine can often be treated with paracetamol, ibuprofen or aspirin alone, or with combination products containing them. There are also some non-prescription medicines specifi cally licensed for the treatment of migraine. One such is a co-formulation of paracetamol, codeine and the antihistamine buclizine, included for its antiemetic action. Other specifi c migraine treatments are reviewed below.
Sumatriptan
Sumatriptan is one of a group of compounds known as triptans. Triptans are 5HT1D-receptor agonists; they cause constriction of the cerebral arteries and counteract the cranial vasodilatation thought to be responsible for migraine attacks. Triptans are now established as a fi rst-line treatment for migraine.
Sumatriptan is licensed for pharmacy sale for acute relief of migraine attacks, with or without aura, in adults aged 18–65 years. Treatment may not be supplied for prophylaxis or for patients who:
– are pregnant or breastfeeding
– have existing medical conditions, including cardiovascular conditions, hypertension, peripheral vascular disease, liver or kidney disorders
– have any neurological condition or symptoms, including epilepsy
– are allergic to the drug
– are taking concurrent medication for migraine
– are assessed as having a high cardiovascular risk, using the factors in the
cardiovascular risk prediction charts in the British National Formulary.
The dose is one 50 mg tablet, taken as soon as possible after the onset of an attack. A second dose may be taken after 2 hours if migraine recurs. If there is no response to the fi rst tablet, a second tablet should not be taken for the same attack. Maximum dosage is two tablets in 24 hours.
Referral to a doctor should be made if:
– attacks last longer than 24 hours, become more frequent or symptoms change
– the patient generally has four or more attacks per month
– the patient does not completely recover between attacks
– the patient is over 50 years of age and is suffering a migraine attack for the fi rst time.
Side-effects are usually mild and transient.
Sumatriptan should be avoided by patients taking selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, moclobemide, St John’s wort and other vasoconstrictor migraine treatments, especially ergotamine and methysergide.
Isometheptene mucate
Isometheptene is a sympathomimetic, used in the treatment of migraine and throbbing headache for its vasoconstrictor effect. It is combined with paracetamol in one proprietary product.
The British National Formulary has classifi ed this product as ‘less suitable for prescribing’ and states that other more effective treatments are available.
Prochlorperazine
Prochlorperazine is a phenothiazine derivative.
It is widely used on prescription for the treatment of vertigo and the prevention of nausea and vomiting.
Prochlorperazine maleate buccal tablets are licensed for the non-prescription treatment of nausea and vomiting associated with migraine.
The licensing conditions only permit supply if migraine has already been diagnosed by a doctor, to adults of 18 years and over. It is contraindicated in pregnant and breastfeeding women, and also in patients with impaired hepatic function, narrow-angle glaucoma, prostatic hypertrophy, epilepsy or Parkinson’s disease.
Dental pain Causes, Types, symptoms and treatment.
Dental pain
Causes
Toothache is due to infl ammation of the pulp or periodontal membrane of a tooth. Both structures are well supplied with nerves, which send impulses to the cerebral cortex where pain is perceived.
Causes of toothache include:
dental caries (tooth decay): often as a result of poor oral hygiene and failure to have regular dental check-ups
dental abscess: arising from an infection in decayed dental pulp
pericornitis: infection in the soft tissue covering impacted wisdom teeth. It occurs in young adults between the ages of 18 and 25 years
dry socket: due to poor healing and infl ammation following dental extraction
gingival recession: starting from early middle age the gums begin to recede from the base of the teeth, exposing nerves which are very sensitive to stimuli such as heat, cold or sweetness
trigeminal neuralgia (see above): attacks can sometimes occur following dental treatment.
Signs and symptoms
dental caries: continuous, throbbing paindental abscess: severe continuous pain with localised swelling; the affected tooth may be slightly raised from its socket
pericornitis: localised soreness in the soft tissue overlying the impacted tooth, developing into pain if not treated
dry socket: localised continuous pain in the area of the socket
gingival recession: localised sharp pain of short duration on exposure to heat, cold or sweet stimuli.
Symptoms and circumstances for referralReferral
is necessary in all cases, although analgesics can be recommended until a dentist or doctor can be seen.
Treatment In theory, ibuprofen and aspirin are the most effective analgesics as they act at the site of the pain, rather than centrally, in the manner of paracetamol and opioids. But many people fi nd that paracetamol, perhaps in combination with an opioid, is more effective for them.
Even so, OTC analgesics may provide little relief from severe dental pain. Tooth tinctures and clove oil have a counterirritant effect, producing a sensation of warmth that masks pain for a short period. However, they can cause burns to the gums if used repeatedly.
Stroke Causes, Epidemiology, First aid.
Stroke
Causes
Stroke is caused by the death of brain cells as a result of interruption of blood fl ow to them, causing permanent disability.
80% occur as a consequence of ischaemia, caused either by a thrombus formed inside a cerebral artery as a result of arteriosclerosis, or an embolism formed elsewhere in the body and carried to the brain.
20% of strokes are accounted for by intracerebral haemorrhage due to rupture of a blood vessel, producing a clot displacing normal brain tissue and disrupting function.
Transient ischaemic attacks (TIAs, ‘ministrokes’) last between a few minutes and a few hours, followed by complete recovery.
Epidemiology
Stroke is the third most common cause of death in the UK and accounts for 12% of all deaths.
Incidence increases markedly with age, and each year about 3% of the population over the age of 70 suffer a stroke.
Stroke affects women more than men in a ratio of 2:1. Symptoms and warning signs
diffi culty speaking or understanding speech (aphasia)
diffi culty walking
vertigo
numbness, paralysis or weakness, usually on one side of the body
seizure (relatively rare)
severe headache
sudden confusion
sudden decrease in the level of consciousness
sudden loss of balance or coordination
sudden vision problems (e.g. blurred vision, blindness in one eye)
vomiting.
Emergency aid
For someone who is conscious:
lay the individual down with head and shoulders slightly raised and supported. Incline the patient’s head to one side and place a towel or cloth on the shoulder to absorb any dribbling
dial 999 for an ambulance.
If unconscious:
maintain an open airway, and be prepared to resuscitate if necessary
loosen any clothing that might impede breathing
call an ambulance
Non-prescription medicines for the prevention of cardiovascular disease
Non-prescription medicines for the prevention of cardiovascular disease
Simvastatin
Simvastatin is one of a group of drugs known as statins that act by competitively inhibiting 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, the enzyme that mediates cholesterol synthesis in the liver.
Inhibition of HMG-CoA increases the formation of low-density lipoprotein (LDL) receptors on hepatocyte membranes, leading to increased clearance of LDL cholesterol and reduction in total serum cholesterol.
The main biochemical effect of the statins is to lower LDL cholesterol, but they also raise levels of high-density lipoprotein (HDL) cholesterol, which improves the HDL:LDL cholesterol ratio (a more important index than total serum cholesterol), and they also reduce plasma triglycerides.
Statins have been shown to be safe and effective in lowering cholesterol, and it has been recommended that a statin should be prescribed as secondary prevention for all patients with symptomatic cardiovascular disease.
Statins have also been recommended for all people without symptoms but who are considered to be at moderate risk (i.e. 10–15% risk of developing coronary heart disease (CHD) within the next 10 years); it is possible to determine moderate risk through self-reported risk factors.
Licensed indications
For sale as a P medicine, simvastatin 10 mg at a dose of one 10 mg tablet each night, on a long-term basis is indicated to reduce the risk of a fi rst major coronary event in individuals at moderate risk of CHD, including:
men aged 55–70, with or without risk factors
men aged 45–54, with one or more listed risk factors
postmenopausal women aged 55–70, with one or more risk factors.
The risk factors are:
smoker – currently or within the last 5 years
family history of CHD – father or a brother had a heart attack before age 55, or mother or a sister before age 65
overweight or obese – body mass index above 25, or waist measurement greater than 100 cm (40 in) in men or 87.5 cm (35 in) in women
South-Asian family origin.
Licensing restrictions
Over-the-counter simvastatin is considered not suitable in the following circumstances for the following people, who should be referred to a doctor:
men over 55 years with a family history of CHD and at least one other risk factor, as above
people with, or reporting, any symptoms that might suggest: any cardiovascular, cerebrovascular or peripheral vascular disorder; liver disease or history of abnormal liver function tests; renal impairment; hypothyroidism; myopathy or family history of muscle disorders
people with a known fasting LDL-cholesterol level of 5.5 mmol/l or above (cholesterol testing before sale is not a licensing requirement but is recommended as good practice by the Royal Pharmaceutical Society of Great Britain (RPSGB))
people whose blood pressure is known and within the range for referral in accordance with RPSGB practice guidance (blood pressure testing before sale is not a licensing requirement but is recommended as good practice by the RPSGB)
men who consume more than 4 units and women who consume more than 3 units of alcohol per day, and people who drink more than 1 litre grapefruit juice per day
people who have suffered previous side-effects or allergy when taking cholesterol-lowering medication.
RPSGB good practice recommendations
In addition to the licensing conditions, the RPSGB recommends the following good-practice measures in association with the over-the-counter sale of simvastatin:
Pharmacists should be involved in all initial sales but subsequent sales may be delegated to appropriately trained medicines counter assistants.
Where possible, sales should be recorded in the patient’s medication record.
Lifestyle advice to reduce the risk of CHD should be given to purchasers.
Pharmacists should liaise with local general practitioners and primary-care organisations to fi t in with local policies on management of CHD risk and prescribing of statins; they should encourage purchasers to inform their general practitioner that they are taking simvastatin.
Pharmacists should monitor people who buy simvastatin at least once a year for adverse effects, interactions, changes in risk factors and blood cholesterol levels.
Adverse effects
Simvastatin is generally well tolerated and side-effects are usually rare, mild and transient.
Myopathy and rhabdomyolisis, characterised by generalised muscle pain, tenderness or weakness, have been reported very rarely.
Liver dysfunction, gastrointestinal disturbances and hypersensitivity reactions have also been reported rarely.
Interactions
Simvastatin is metabolised in the liver by the P450 isoenzyme CYP3A4 and interactions can occur with drugs that inhibit this enzyme.
Simvastatin may also increase the anticoagulant effect of warfarin and other coumarins.
Drugs that can cause myopathy or rhabdomyolysis, including fi bric acid derivatives and nicotinic acid, increase the risk of developing these conditions if given in association with simvastatin.
Low-dose aspirin
Low-dose aspirin reduces the risk of MI, increases survival in patients who have had an acute MI and reduces the risk of stroke, through inhibiting thrombus formation within coronary and cerebral blood vessels.
The anti-infl ammatory and antithrombotic effects of aspirin depend on its ability to inactivate the enzyme cyclo-oxygenase. Platelets (thrombocytes) in the blood play an important role in the process of coagulation. Through irreversible inhibition of cyclo-oxygenase, aspirin prevents the synthesis of thromboxane A2 which promotes platelet adhesion and aggregation. Platelets cannot synthesise more thromboxane A2, which is only restored when existing platelets are replaced from the vascular endothelium. Continuous low dosing with aspirin thereby maintains thromboxane A2 at a low level.
Antiplatelet aspirin is indicated for the secondary prevention of thrombotic cerebrovascular and cardiovascular disease, at a dose of 75 mg daily.
Low-dose aspirin is also indicated for primary prevention of MI or stroke when the estimated 10-year cardiovascular disease risk is 20% or greater.
Antiplatelet aspirin therapy should only be initiated on the advice of a doctor.
The same contraindications, cautions and interactions apply as for aspirin at analgesic doses.
Omega-3 triglycerides
Omega-3 triglycerides are derived from fi sh oils. They contain triglycerides of omega-3 fatty acids, particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). These exert an antithrombotic effect by competing with arachidonic acid for inclusion in cyclo-oxygenase and lipoxygenase synthesis pathways, reducing platelet aggregation and decreasing platelet counts. They also lower blood cholesterol levels through reduction of very-low-density-lipoproteins. As cyclo-oxygenase inhibitors they also have anti-infl ammatory activity.
EPA and DHA in fi sh oil have a role in the secondary prevention of cardiovascular disease.
Almost all products containing fi sh oils are marketed as food supplements, not medicines.
Myocardial infarction (MI, heart attack) Causes, Epidemiology, Symptoms and warning signs, Differential diagnosis, Emergency aid
Myocardial infarction (MI, heart attack)
Causes
MI is essentially the death of myocardial tissue, caused by an insuffi ciency of oxygen supply to the myocardium.
It usually results from rupture of an atheromatous plaque in a coronary vessel,leading to thrombus formation, blocking the vessel and causing occlusion of the
vessel and myocardial ischaemia.
Heart muscle begins to die within 20–40 minutes if blood fl ow is not restored, and necrosis is irreversible if the coronary vessel remains occluded for more than 4–6 hours.
Epidemiology
Average UK incidence of MI is about 1 in 200 in the population per year.
Relative incidence in men and women is about 2.2:1.
Mortality is about 25%, and half of those who die never reach hospital.
Symptoms and warning signs
Central chest pain or sensations of severe pressure, fullness, squeezing or discomfort:
lasting for more than a few minutes
of increasing intensity
radiating to the shoulders, neck, arms or jaw
not relieved by rest or cardiac medication
with any or all of the following:
sweating or cool, clammy skin
skin pallor and/or bluish lips
shortness of breath
nausea or vomiting
dizziness or fainting
rapid or irregular pulse
anxiety.
Differential diagnosis
Chest pain may be a symptom of indigestion, pleurisy, pneumonia or other disorders, but the duration, severity of pain, intensity of distress and accompanying symptoms of an MI leave little doubt that, whatever the cause, the situation is an emergency.
Emergency aid
Put patient into a half-sitting position, with head and shoulders supported (e.g. with cushions or pillows) and knees bent.
Dial 999 for an ambulance.
Help patients to use any angina medication they are carrying.
If patient is fully conscious, give a 300 mg aspirin tablet to chew.
Monitor breathing and pulse rate and be prepared to give mouth-to-mouth
ventilation and chest compressions if necessary.
Causes
MI is essentially the death of myocardial tissue, caused by an insuffi ciency of oxygen supply to the myocardium.
It usually results from rupture of an atheromatous plaque in a coronary vessel,leading to thrombus formation, blocking the vessel and causing occlusion of the
vessel and myocardial ischaemia.
Heart muscle begins to die within 20–40 minutes if blood fl ow is not restored, and necrosis is irreversible if the coronary vessel remains occluded for more than 4–6 hours.
Epidemiology
Average UK incidence of MI is about 1 in 200 in the population per year.
Relative incidence in men and women is about 2.2:1.
Mortality is about 25%, and half of those who die never reach hospital.
Symptoms and warning signs
Central chest pain or sensations of severe pressure, fullness, squeezing or discomfort:
lasting for more than a few minutes
of increasing intensity
radiating to the shoulders, neck, arms or jaw
not relieved by rest or cardiac medication
with any or all of the following:
sweating or cool, clammy skin
skin pallor and/or bluish lips
shortness of breath
nausea or vomiting
dizziness or fainting
rapid or irregular pulse
anxiety.
Differential diagnosis
Chest pain may be a symptom of indigestion, pleurisy, pneumonia or other disorders, but the duration, severity of pain, intensity of distress and accompanying symptoms of an MI leave little doubt that, whatever the cause, the situation is an emergency.
Emergency aid
Put patient into a half-sitting position, with head and shoulders supported (e.g. with cushions or pillows) and knees bent.
Dial 999 for an ambulance.
Help patients to use any angina medication they are carrying.
If patient is fully conscious, give a 300 mg aspirin tablet to chew.
Monitor breathing and pulse rate and be prepared to give mouth-to-mouth
ventilation and chest compressions if necessary.
Heart failure (HF) Causes, Epidemiology, Symptoms and warning signs, Emergency aid.
Heart failure (HF)
Causes
HF describes a usually gradual weakening in heart tissue and a decline in its ability to perform its function to pump blood around the body.
There are several causes:
reduced ventricular contractility, as result of myocarditis (infl ammation of the myocardium), cardiomyopathy (hypertrophy of heart tissue) or MI
ventricular outfl ow obstruction, caused by hypertension, narrowing of the aorta (aortic stenosis), pulmonary hypertension or pulmonary valve stenosis
ventricular infl ow obstruction, as a result of stenosis of the mitral and tricuspid valves, among other causes
ventricular volume overload, due to failure of the mitral valve regulating the fl ow of blood into the left ventricle and the septa separating the heart chambers
arrhythmias.
Epidemiology
HF is a disease of the elderly – average age at fi rst diagnosis is 76 years.
Incidence is increasing with increasing life expectancy and higher survival rates following MI.
About 1 in 35 people aged 65–74 years have HF, increasing to about 1 in 15 of those aged 75–84 years, and to 1 in 7 in those over 85.
Symptoms and warning signs
fatigue and shortness of breath after mild exertion
a dry, wheezy, hacking cough occurring a few hours after lying down but stopping after sitting up
when there is pulmonary oedema, there may be a cough producing a pinkish froth
accumulation of fl uid in the feet, ankles, legs and abdomen
weight loss.
Emergency aid
Pharmacists would not normally encounter situations of acute HF, which often occur at night. Symptoms include severe breathlessness, often accompanied by MI symptoms.
Emergency aid is as for MI.
Angina pectoris causes, diagnosis, symptoms, management and treatment.
Angina pectoris
Causes
Angina occurs when myocardial demand for oxygen exceeds the ability of the coronary arteries to supply oxygenated blood. The cause is usually coronary artery obstruction due to atherosclerosis.
The most common form of the condition is stable angina. It is brought on by physical exertion or other forms of stress, including exposure to cold, heavy meals or intense emotion, and is relieved by rest.
Unstable angina is a syndrome of attacks of increasing frequency and severity, occurring on minimal exertion or at rest. It often leads to MI.
Epidemiology
About 1.2 million people in the UK have or have had angina – 9% of men and 5% of women aged 55–64, and 14% of men and 8% of women aged 65–74.
Symptoms and warning signs
The patient may experience a sensation in the centre of the chest variously described as pressure, fullness, squeezing, tightness, burning or a heavy weight.
It may also manifest as pain in the epigastric region, back or jaw, and may radiate to the shoulders, neck or arms.
Pain ranges in intensity from mild to severe.
Other symptoms, as occur with MI (see above), may be experienced.
Unlike MI, pain is reversible on rest; attacks last only a few minutes and are relieved by coronary vasodilators.
Differential diagnosis
As for MI, but may be more diffi cult to distinguish from other conditions causing pain and other symptoms in the chest and epigastric region.
Emergency aid
Sit the person down in a quiet area, make the patient comfortable and reassure.
Allow the person to use any coronary vasodilator medication he or she is carrying. (If the individual has no medication but confi rms that he or she has angina, you may give a glyceryl trinitrate tablet or similar medication.)
Allow the person to rest until the attack is over.
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