HLB, NME, M&M OSCE Notes_University of Manchester, WL Gan

Warfarin Treatment in Atrial fibrillation 1. The irregular and fast heart rhythm of AF causes turbulent blood flow within the heart chambers.

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This could lead to a small blood clot forming in a heart chamber. A clot can travel and block the smaller blood vessels in the brain. Part of the blood supply to the brain may then be interrupted, which causes a stroke. Warfarin helps to thin the blood and prevents the formation of blood clot. Warfarin treatment can prevent about two-thirds or 6 in 10 strokes that would have occurred in people with AF. Most people with AF who have a high or medium risk of having a stroke are advised to take warfarin. Those with low risk of having stroke are advised to take aspirin as it is less likely to cause serious problems. High risk means that, without treatment, you have about a 6-12 in 100 chance of having a stroke in the next year. People in the high risk group include those: a. who have already had a stroke b. are aged 75 years or older who also have one of the following risk factors: high blood pressure, diabetes or a cardiovascular disease c. who have a heart valve problem or heart failure Moderate risk ( 3-5 in 100 chance of having a stroke ). a. aged 65 years or older (with no high risk factors) b. who are of any age (up to age 75 when the risk is high) but who also have either high blood pressure, diabetes or a cardiovascular disease Low risk ( 1-2 in 100 chance or less of having a stroke ) People in the low risk group are all people with AF aged less than 65 and who do not have any risk factors As with all treatments, there is a small risk if you take warfarin. The main risk is bleeding. Other side effects include nausea, vomiting and diarrhoea. You will need regular blood tests including the test for INR to check on how quickly your blood clots when you are taking warfarin. The INR is a blood test that measures your blood clotting ability. You should remember to bring along the booklet for the appointments. The aim is to get the dose of warfarin just right so your blood does not clot as easily as normal, but not so much as to cause bleeding problems. You should aim to take warfarin orally at the same time each day. If you are prescribed or buy any other drug, tell the doctor, nurse or pharmacist that you are on warfarin. This is because some drugs interfere with the way warfarin works and your dose of warfarin may need to be altered. Two commonly eaten foods that are known to interact with warfarin are cranberry and grapefruit. You should seek advice promptly if you become pregnant or are planning a pregnancy. Warfarin can cause harm to unborn babies. For safety reasons warfarin should be stopped and an alternative drug called heparin is likely to be used instead.

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The University of Manchester|W.L. Gan | 2012

Myocardial infarction 1. An MI is sometimes called a heart attack or a coronary thrombosis. 2. The heart is mainly made of special muscle. The heart pumps blood into arteries which take the blood to every part of the body. Like any other muscle, the heart muscle needs a good blood supply. The coronary arteries take blood to the heart muscle. If you have an MI, a coronary artery or one of its smaller branches is suddenly blocked. The part of the heart muscle supplied by this artery loses its blood and oxygen supply. This part of the heart muscle is at risk of dying unless the blockage is quickly undone. 3. The common cause of an MI is a blood clot that forms inside a coronary artery, or one of its branches. Treatment with 'clot busting' drugs or a procedure called angioplasty can break up the clot and restore blood flow through the artery. If treatment is given quickly enough this prevents damage to the heart muscle, or limits the extent of the damage. 4. The most common symptom of an MI is severe chest pain, which often feels like a heavy pressure feeling on your chest. The pain may also travel up into your jaw and down your left arm or down both arms. You may also sweat, feel sick and feel faint. You may also feel short of breath. The pain may be similar to angina, but it is usually more severe and lasts longer. 5. Risk factors that can be modified and may help to prevent an MI include smoking, high blood pressure, diabetes, high cholesterol, excessive alcohol consumption and obesity. 6. Treatment to restore blood flow in the blocked coronary artery - emergency angioplasty is, ideally, the best treatment if it is available and can be done within a few hours of symptoms starting. In this procedure a tiny wire with a balloon at the end is put into a large artery in the groin or arm. It is then passed up to the heart and into the blocked section of a coronary artery using special X-ray guidance. The balloon is blown up inside the blocked part of the artery to open it wide again. A stent may be left in the widened section of the artery. A stent is like a wire mesh tube which gives support to the artery and helps to keep the artery widened. An injection of a 'clot busting' drug is an alternative to emergency angioplasty. 7. The severity of MI often depends on the amount of heart muscle that is damaged. In many cases only a small part of the heart muscle is damaged which heals as a small patch of scar tissue. The heart can usually function normally with a small patch of scar tissue. A larger MI is more likely to be life-threatening or cause complications.

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Post MI Medication and Management 1. If you have had a myocardial infarction, you will usually be advised to take four medicines namely, aspirin, beta-blocker, ACE inhibitor and statin for the long term to reduce the chance of another MI and to help prevent heart disease from getting worse. 2. If a blood clot forms inside a blood vessel that takes blood to the heart muscle, it will block the blood flow and cause a heart attack. Aspirin reduces the chance of blood clots forming within blood vessels. If you are allergic to aspirin, clopidogrel may be used instead. The main risk is gastric bleeding. If you have ever had a stomach or duodenal ulcer, you may be advised to take another tablet that reduces stomach acid to protect the gut. A small number of people with asthma cannot take aspirin as it brings on asthma symptoms. The benefits of taking aspirin following an MI usually greatly outweigh the risk of any possible side effects. 3. Beta blockers reduce the force of heart beat and prevent the heart rate from going too fast. Side effects are cool hands and feet, sleeping problems, impotence and tiredness. If you have asthma, you should not take beta-blockers. This is because beta-blockers may narrow the airways and make breathing symptoms worse. Sometimes the heart rate can go too slow and make you dizzy or feel faint. 4. ACE inhibitors dilate blood vessels and lower the blood pressure, which ease the burden on the heart. After the very first dose, on the first day you start an ACE inhibitor, stay indoors for about four hours as occasionally some people feel dizzy due to sudden drop of blood pressure. A blood test is usually done before starting an ACE inhibitor, and about two weeks after the first dose to check the function of the kidneys. Taken once daily. Side effect – persistent dry cough. If patient cannot tolerate, consider angiotensin receptor blockers. 5. Statins work by reducing the amount of cholesterol that is made in the liver. You should have a blood test before starting treatment to check if your liver is working properly. After starting treatment, you should have a blood test within 1-3 months, and again at 12 months. The blood test is to check that the liver has not been affected by the medication. Taken once daily at night. Tell your doctor if you i. Have any unexpected muscle pains, tenderness, cramps or weakness – a severe form of muscle inflammation ii. Develop chest symptoms such as unexplained shortness of breath or cough – rare side effect of statin is interstitial lung disease. 6. Lifestyle changes include stop smoking, take regular exercise, lose weight if you are overweight, eat a healthy diet and drink alcohol in moderation. 7. Driving after having acute coronary syndrome i. Successfully treated with coronary angioplasty – start after 1 week ii. Not successfully treated with coronary angioplasty – start after 4 weeks iii. CABG – start after 4 weeks 3

The University of Manchester|W.L. Gan | 2012

Hypertension 1. Blood pressure is the pressure of blood in your arteries ( blood vessels ). The pressure in the arteries depends on how hard the heart pumps, and how much resistance there is in the arteries. It is thought that slight narrowing of the arteries increases the resistance to blood flow, which increases the blood pressure. 2. Blood pressure is measured in millimetres of mercury (mmHg). Your blood pressure is recorded as two figures. For example, 120/80 mmHg. This is said as '120 over 80'. 3. High blood pressure is a blood pressure that is 140/90 mmHg or above each time it is taken. If one reading is found to be high, it is usual for your doctor to advise a time of observation. This means several blood pressure checks at intervals over time. 4. High blood pressure usually causes no symptoms. You will not know if you have high blood pressure unless you have your blood pressure checked. 5. High blood pressure is a risk factor for developing a cardiovascular disease ( heart attack or stroke ) and kidney damage in the future. The higher the blood pressure, the greater the risk. 6. Lifestyle modifications - lose weight if you are overweight, regular physical activity, a healthy diet, moderate alcohol consumption, stop smoking, and a low salt and caffeine intake. 7. Drug treatment to lower blood pressure is usually advised for: i. All people who have a blood pressure that remains at 160/100 mmHg or above after a trial of any relevant lifestyle changes. ii. People with a blood pressure that remains at 140/90 mmHg or above after a trial of any relevant lifestyle changes AND who have diabetes, or an existing cardiovascular disease, or a 2 in 10 risk or more of developing a cardiovascular disease within the next 10 years. 8. For most people who are otherwise well, the target is to reduce blood pressure to 140/90 or below. For those with cardiovascular disease, diabetes or chronic kidney disease, the target is to get the blood pressure is even lower ( 130/80 ). 9. Further tests : i. A urine test to check if you have protein or blood in your urine. ii. A blood test to check that your kidneys are working fine, and to check your cholesterol level and sugar level. iii. A heart tracing ( ECG ). 10. In most cases, medication is needed for life. However, in some people whose blood pressure has been well controlled for three years or more, medication may be able to be stopped. 11. Younger than 55 yo start with ACE inhibitor; 55 or above start with calcium channel blocker or diuretics → A+C or A+D → A+C+D → add potassium sparing diuretic, alpha blocker, beta blocker

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The University of Manchester|W.L. Gan | 2012

Anemia 1. Anemia is a condition in which the number of red blood cells is low. Red blood cells contain hemoglobin, a protein that enables them to carry oxygen from the lungs and deliver it to all parts of the body. When the number of red blood cells is reduced, the blood cannot carry an adequate supply of oxygen. An inadequate supply of oxygen in the tissues produces the symptoms of anemia. Symptoms include tiredness, feeling faint, easily breathless, palpitations and looking pale. 2. The most common cause of anaemia is a lack of iron. Iron is needed to make haemoglobin. Anaemia caused by a lack of iron is called iron deficiency anaemia. Anaemia is common in women of all ages who have heavy periods. Bleeding into the gut is a common cause in older people. Iron is usually found in meats, fish, poultry, beans and green leafy vegetables ( spinach ). A restricted diet such as a vegan sometimes does not contain enough iron. 3. Treatment for iron deficiency anemia - start ferrous sulphate 200 mg two to three times per day. Side effects of iron supplementation are constipation, black stools, diarrhea, nausea, abdominal pain. Drink plenty of fluids if constipation develops. Once the blood level is back to normal, you should continue to take iron for at least three further months. This will ensure that reserves of iron are built up in your body. Remember to keep iron tablets away from children. An overdose of iron tablets can be very dangerous in children. 4. Pernicious anaemia is the most common cause of B12 deficiency. It is classed as an autoimmune disease. The immune system normally makes antibodies to attack bacteria, viruses and other germs. If you have an autoimmune disease, the immune system makes antibodies against certain tissues of your body. If you have pernicious anaemia, antibodies are formed against your intrinsic factor, or against the cells in your stomach which make intrinsic factor. This stops intrinsic factor from attaching to vitamin B12, and so the vitamin cannot be absorbed into your body. Pernicious anaemia usually develops over the age of 50. Women are more commonly affected than men, and it tends to run in families. It occurs more commonly in people who have other autoimmune diseases such as thyroid diseases, Addison's disease and vitiligo. It is unusual to lack vitamin B12 if you eat a normal balanced diet. Strict vegans who take no animal or dairy products ( fish, meats, egg, milk ) may not eat enough vitamin B12. 5. You will need vitamin B12 injections. Normally, about six injections are given at first, one every 2-4 days. This quickly builds up the body's store of vitamin B12. Vitamin B12 is stored in the liver. Once a store of vitamin B12 is built up, this can supply the body's needs for several months. An injection is then only usually needed every three months to top up the supply. If you have pernicious anaemia the injections are needed for life. You should have no side-effects from the treatment as it is simply replacing a vitamin that you need. You may be advised to have a blood test every year or so. This will check that the anaemia is being treated successfully. A blood test may also be done to see that your thyroid gland is working well. Because thyroid problems are more common in people with pernicious anaemia. 6. If the cause of your lack of vitamin B12 is diet-related rather than due to pernicious anaemia then treatment may be different. That is, after the initial treatment with injections of vitamin B12, dietary supplements of vitamin B12 (cyanocobalamin tablets) may be advised instead of injections.

The University of Manchester|W.L. Gan | 2012

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Chronic Obstructive Pulmonary Disease 1. COPD is a long term condition affecting the lungs which is caused by smoking. In COPD, you will have difficulty in breathing because of the narrowing in your airways. Smoking causes persistent inflammation of the airways and damage to the air sacs of the lungs. This condition is irreversible once the airways are damaged. It is common in patients aged over 35. Patients might get frequent cough with phlegm due to the extra mucus produced in the airways. 2. Chest infections are more common if you have COPD and a short course of antibiotics is usually prescribed to the patient. 3. COPD can be diagnosed using spirometry. This test estimates lung volumes by measuring how much air you can blow out into a machine. 4. Once symptoms start, if you continue to smoke, there is usually a gradual decline over several years. You tend to become more and more breathless. In time your mobility and general quality of life may become poor due to increasing breathing difficulties. 5. Stopping smoking is the most important treatment. If you stop smoking in the early stages of COPD it will make a huge difference. Damage already done to your airways cannot be reversed, but stopping smoking prevents the disease from worsening. An inhaler with a bronchodilator medicine is often prescribed. These relax the muscles in the airways to open them up as wide as possible. A steroid inhaler may help in addition to a bronchodilator inhaler if you have more severe COPD or regular flare-ups ( exacerbations ) of symptoms. Steroids reduce inflammation of the airways and may help to prevent flare-ups. Side-effects of steroid inhalers include oral thrush, sore throats and a hoarse voice. These effects can be reduced by rinsing your mouth with water after using these inhalers. 6. General advices – yearly flu-jab against influenza and chest infection, lose weight if overweight and regular exercise. Studies have shown that people with COPD who exercise regularly tend to improve their breathing, ease symptoms, and have a better quality of life. A daily brisk walk is a good start if you are not used to exercise. 7. You may be referred for pulmonary rehabilitation or be under the care of a community respiratory team. You will be given exercises and advice to try to help you stay as fit as possible. 8. Management for acute exacerbation of COPD a. 24% oxygen b. Nebulised bronchodilators c. Antibiotics d. Steroids e. Consider theophylline if poor response to nebulised bronchodilators f. Non-invasive ventilation for severe hypercapnea

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Asthma 1. Asthma is caused by inflammation in the airways. The inflammation irritates the muscles around the airways, and causes them to constrict. This causes narrowing of the airways. It is then more difficult for air to get in and out of the lungs. This leads to wheezing and breathlessness. The inflammation also causes the lining of the airways to make extra mucus which causes cough and further obstruction to airflow. 2. The typical symptoms are wheeze, cough, chest tightness, and shortness of breath. 3. Things that may trigger asthma symptoms include infections, pollens, exercise, certain medication ( aspirin ), smoking, emotion, pests and house dust mites. 4. A reliever inhaler is taken as required to ease symptoms. The drug in a reliever inhaler relaxes the muscle in the airways. This makes the airways open wider, and symptoms usually quickly ease. The inhaler is usually blue in colour. Take 1-2 puffs each time up to 4 times daily. However, if you need a reliever inhaler three times a week or more to ease symptoms, a preventer inhaler is usually advised. Side effects are fine tremors, nervousness, dry mouth, headache and fast heartbeat. 5. A preventer inhaler is taken every day to prevent symptoms from developing. Steroids work by reducing the inflammation in the airways. When the inflammation has gone, the airways are much less likely to become narrow and cause symptoms. Available in brown, purple, red, pink or orange colour. It takes 7-14 days for the steroid in a preventer inhaler to build up its effect. Therefore, it will not give any immediate relief of symptoms. You should then continue with the preventer inhaler every day even when your symptoms have gone - to prevent symptoms from coming back. If you rinse your mouth with after using a steroid inhaler you are less likely to develop oral thrush. You might also notice that your voice becomes more hoarse. If you use a high dose of inhaled steroid over a long time it may be a risk factor for developing osteoporosis. 6. Meter dose inhaler i. Remove mouth cover and shake the inhaler well ii. Standing up straight or sitting straight iii. Take a deep breath out and place mouthpiece in your mouth with your lips forming a firm seal around it iv. Press down the canister to release the drug and breathe in slowly and deeply to inhale the spray. Hold your breath for 10 seconds v. If you face difficulties with coordination, a spacer device is recommended. 7. Peak flow meter - you must put the marker to zero, take a deep breath, seal your lips around the mouthpiece, then blow as hard and as fast as you can into the device 8. Exercise or sport causes symptoms, then a dose of a reliever inhaler just before the exercise usually prevents symptoms.

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The University of Manchester|W.L. Gan | 2012

Diabetic Foot Care

1. A skin ulcer is where an area of skin has broken down and you can see the underlying tissue. Most skin ulcers occur on the lower legs or feet. The skin normally heals quickly if it is cut. However, in some people with diabetes the skin on the feet does not heal so well and is prone to developing an ulcer. 2. Your nerves may not work as well as normal because even a slightly high blood sugar level can, over time, damage some of your nerves. If you lose sensation in parts of your feet, you may not know if you damage your feet. 3. If you have diabetes you have an increased risk of developing narrowing of the arteries which can reduce the blood supply to the feet. Skin with a poor blood supply does not heal as well as normal and is more likely to be damaged. 4. Although foot ulcers can be serious, they usually respond well to treatment. However, foot ulcers can get worse and can take a long time to heal if you have diabetes, particularly if your circulation is not so good. In addition, having diabetes means you are more likely to have infections and an infection in the ulcer can occur. Occasionally, more serious problems can develop, such as gangrene. However, foot ulcers can often be prevented by taking care of your feet. 5. As a rule, the better the control of your diabetes, the less likely you are to develop complications such as foot ulcers. In particular, if you smoke, you are strongly advised to stop smoking. 6. Good foot care a. Looking carefully at your feet each day, including between the toes. If you cannot do this yourself, you should get someone else to do it for you b. Wash your feet regularly and dry them carefully, especially between the toes to prevent fungal infection. c. Do not walk barefoot, even at home. You might tread on something and damage your skin. d. Always wear socks with shoes or other footwear. a. Always feel inside footwear before you put footwear on (to check for stones, rough edges, etc). a. Footwear should have broad fronts with plenty of room for the toes and have low heels to avoid pressure on the toes. 7. Management of foot ulcer a. The ulcer is usually covered with a protective dressing. b. A nurse will normally examine, clean and re-dress the ulcer regularly. c. A podiatrist may need to remove any hard skin that prevents the ulcer from healing. d. You may also be advised to wear special shoes or have a cast made for your foot to keep the pressure off the ulcer. e. Antibiotics will be advised if the ulcer, or nearby tissue, becomes infected. f. Occasionally, the tissue in parts of the foot cannot survive and the only solution then is to amputate the affected part. The University of Manchester|W.L. Gan | 2012

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Diabetes Mellitus 1. Diabetes is a condition where the amount of glucose ( sugar ) in your blood is too high because the body cannot use it properly. Insulin is the hormone produced by the pancreas that allows glucose to enter the body’s cells, where it is used as fuel for energy. It is vital for life. Either your pancreas does not produce any insulin to help the glucose enter your body’s cells or the insulin that is produced does not work properly ( insulin resistance ). 2. Symptoms include going to toilet frequently, feeling excessive thirsty, feeling excessively tired, slow healing of cuts and wounds, genital itching. 3. Dietary advices - You should try to eat starchy or complex carbohydrates where possible, as these are broken down and absorbed into your bloodstream more slowly than refined carbohydrate such as sugary snacks and drinks. Examples of complex carbohydrate are whole grain cereals, wholemeal bread, brown rice, potatoes, beans and nuts. Reduce the salt and fat intake in your diet. Eat more fruits and vegetables preferably 5 portions a day. 4. The Glycaemic Index (GI) is a ranking of foods based on their overall effect on blood glucose levels. Slowly absorbed foods have a low GI rating, whilst foods that are more quickly absorbed will have a higher rating. Choosing slowly absorbed carbohydrates can help even out blood glucose levels and control your appetite by making you feel full for longer, with the result that you eat less. 5. Smoking with diabetes can increase your chance of developing cardiovascular complications (heart attack). You should stop smoking. Drink alcohol in moderation. 6. If your diabetes is treated with insulin, you must inform the DVLA. You should not drive if you have difficulty recognising the early signs of hypoglycaemia, problems with your eyesight or numbness or weakness in your limbs. 7. Hypoglycaemia occurs when the level of glucose becomes too low. People with diabetes who take insulin are at risk of having a hypo. A hypo may occur if you have too much diabetes medication, have delayed or missed a meal. Symptoms of hypoglycaemia include trembling, sweating, anxiety, blurred vision, pale, mood change or confusion. To treat hypoglycaemia you should take either a glass of Lucozade, a glass of fruit juice or jelly babies, then eat a starchy snack eg. sandwich. 8. The blood test that is mainly used to keep a check on your blood glucose level is called the HbA1c test. This test is commonly done every 2-6 months by your doctor or nurse. The target level is usually between 6.5% and 7.5%. 9. Regular checks may include checking levels of blood glucose, HbA1c, cholesterol and blood pressure, ongoing advice on diet and lifestyle, checking for early signs of complications, eg. eye checks, urine tests for kidney damage and foot checks to help to prevent foot ulcers.

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Hyperthyroidism 1. Thyroxine is a body chemical (hormone) made by the thyroid gland. It is carried round the body in the bloodstream. It helps to keep the body's working at the correct pace. 2. Hyperthyroidism means an overactive thyroid gland. When your thyroid gland is overactive it makes too much thyroxine. The extra thyroxine causes many of your body's functions to speed up. 3. Symptoms - being restless, nervous, emotional, irritable, poor sleep, hand tremor, losing weight despite an increased appetite, palpitations, sweating, heat intolerance, diarrhea, hair thinning, menstrual changes - your periods may become very light or infrequent, a swelling of your thyroid gland in the neck, eye problems if you have Graves' disease. 4. If you have untreated hyperthyroidism, you have an increased risk of developing heart problems such as abnormal heart rhythm, angina and heart failure. 5. It is more common in women. About 1 in 100 women and 1 in 1,000 men develop hyperthyroidism at some stage of their life. 6. Graves’ disease is the most common cause. It is an autoimmune disease. The immune system normally makes antibodies to attack bacteria, viruses and other germs. In autoimmune diseases, the immune system makes antibodies against tissues of the body. If you have Graves' disease, you make antibodies that attach to the thyroid gland. Usually, a blood test can diagnose hyperthyroidism. 7. The main aim of treatment is to reduce your level of thyroxine to normal. Carbimazole can reduce the amount of thyroxine made by the overactive thyroid gland. It may take 4 to 8 weeks of treatment for your thyroxine level to come down to normal. Carbimazole is usually taken for 1218 months at first. After this, in about half of cases, the condition will have settled down and the carbimazole can be stopped. In about half of cases, carbimazole needs to be continued long-term to control symptoms. If you miss a dose, take it as soon as you remember. If your next dose is due, you may take both doses together. 8. Common side effects are stomach upset, feeling sick, and headache. Carbimazole can, rarely, affect your white blood cells which fight infection. If you develop a fever, sore throat or mouth ulcers whilst taking carbimazole, you should stop taking it and see a doctor urgently for a blood test. 9. Beta blockers can help to reduce symptoms of tremor, palpitations, sweating, agitation and anxiety. 10. Surgery can be done to remove part of your thyroid gland. It may be a good option if you have a large thyroid swelling which is causing problems in your neck. If too much thyroid tissue is removed then you will be given thyroxine tablets to keep your thyroxine level normal. It is usually a safe operation. But, as with all operations, there is a small risk. 11. Regular checks are recommended, even after you finish a successful treatment. It is very important to have a regular blood test at least every year to check that you have the right level of thyroid hormone in your blood. 10

The University of Manchester|W.L. Gan | 2012

Hypothyroidism 1. Hypothyroidism means that the thyroid gland does not make enough thyroxine. It is often called an underactive thyroid. This causes many of the body's functions to slow down. 2. Symptoms include tiredness, weight gain, constipation, feeling cold, dry skin, brittle hair, fluid retention, mental slowing, and depression. Less common symptoms include a hoarse voice, irregular or heavy menstrual periods in women, infertility and memory loss or confusion in the elderly. Symptoms usually develop slowly, and gradually become worse over months or years as the level of thyroxine in the body gradually falls. 3. If you have untreated hypothyroidism, you may have an increased risk of developing heart disease because low thyroxine level causes the blood cholesterol to rise. 4. About 1 in 50 women, and about 1 in 1000 men develop hypothyroidism at some time in their life. It most commonly develops in adult women, and becomes more common with increasing age. 5. Causes include Hashimoto’s thyroiditis, surgery, radioactive treatment, iron deficiency, medications ( lithium, amiodarone ). 6. Usually, a blood test can diagnose hypothyroidism. 7. The treatment is to take levothyroxine tablets each day. Levothyroxine is usually taken once daily, before breakfast. This replaces the thyroxine which your thyroid gland is not making. Most people feel much better soon after starting treatment. Ideally, take the tablet on an empty stomach. This is because some foods rich in calcium or iron may interfere with the absorption of levothyroxine from the gut. Treatment is usually for life. 8. If you forget to take a dose, take it as soon as you remember if this is within 2 or 3 hours of your usual time. If you do not remember until after this time, skip the forgotten dose. Do not take two doses together to make up for a missed dose. 9. If you take too much levothyroxine it can lead to symptoms and problems of an over-active thyroid. For example, palpitations, diarrhoea, irritability, and sweating, and increases the risk of developing osteoporosis. This is why you need blood tests to check that you are taking the correct dose. Have a blood test once a year if you take levothyroxine tablets after your dose has become stabilised.

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Explaining and gaining consent for procedures Colonoscopy Explain the procedure A colonoscopy is a test where the operator looks into your large bowel using a thin, flexible telescope called the colonoscope. It is about the size of your little finger. A tiny camera is attached within the telescope which transmits pictures on to a TV monitor for the operator to look at. It will be passed through your bottom and up into your large bowel. Colonoscopy is usually done as an outpatient or day case. It is a routine test which is commonly done. You will usually be given a sedative to help you to relax. This is usually given by an injection into a vein in the back of your hand. The sedative can make you drowsy but it does not 'put you to sleep'. It is not a general anaesthetic. The operator may take small samples of some parts of the inside lining of the colon and it is painless. The biopsy samples are sent to the lab for testing, and to look at under the microscope. A colonoscopy usually takes about 20-30 minutes. However, you should allow at least two hours for the whole appointment to prepare, give time for the sedative to work, for the colonoscopy itself, and to recover. A colonoscopy does not usually hurt, but it can be a little uncomfortable, particularly when the colonoscope is first passed into the anus. Benefits of the procedure A colonoscopy is advisable if you have symptoms such as bleeding from the anus, persistent diarrhoea, or changes in bowel habit with unexplained weight loss. It can help us to detect any abnormalities for example, Crohn’s disease, ulcerative colitis, polyps, diverticula or cancer of the large bowel. Risks of the procedure Every procedure carries a small risk. Occasionally, the colonoscope may cause damage to the colon. This may cause bleeding, infection and, rarely, perforation (0.1%). If you experience severe abdominal pain, fever or passing out a lot of blood from anus within 48 hours after a colonoscopy, consult a doctor immediately. Preparation for the procedure The colon needs to be empty so that the operator can get a clear view. You will be given some laxatives to take. You will need somebody to accompany you home, as you will be drowsy with the sedative. Obtain consent Make sure the patients understood the procedure and allow them to ask questions. Obtain their signature if they have agreed to have the procedure. Please remind the patients that they can change their decision at any time. 12

The University of Manchester|W.L. Gan | 2012

Gallstones 1. The gallbladder is a small saclike organ in the upper right part of the abdomen. It is located under the liver, just below the front rib cage on the right side. Bile is a fluid made by the liver to help in the digestion of fats. Bile is stored in the gallbladder. 2. Gallstones occur when bile, which is normally fluid, forms stones. Gallstones can be any size, from tiny as a grain of sand to large as a golf ball. 3. Most people with gallstones do not know they have them. It is common to have stones in the gallbladder that cause no symptoms. Symptoms include severe pain in the right upper abdomen which is often aggravated after meal especially fatty food. 4. There are two types of gallstones, namely the cholesterol stones and the pigment stones. Patients with cholesterol stones are more common. They form when there is too much cholesterol in the bile. 5. It is often best to leave gallstones alone if they cause few or no symptoms. Once gallstones start giving symptoms, surgery is the best treatment. However, you may be given painkillers and antibiotics through a drip if the gallbladder gets infected. 6. You do not need a gallbladder to digest food. Bile still flows from the liver to the gut once the gallbladder is removed. However, there is no longer any storage area for bile between meals. The flow of bile is therefore constant, without the surges of bile that occur from a gallbladder when you eat a meal. You can usually eat a normal diet without any problems after your gallbladder is removed. However, up to half of people who have had their gallbladder removed have some mild abdominal pain or bloating. This may be more noticeable after eating a fatty meal. Because there is nowhere to store bile, sometimes bile flows into the intestine when it is not needed. This does not cause a problem for most people, but some people notice an increase in the frequency of passing stools after their gallbladder is removed. It can be treated by antidiarrhoeal medication if it becomes troublesome. 7. Medications eg. ursodeoxycholic acid - drugs made from bile acids are used to dissolve the gallstones. These drugs work best for cholesterol stones However, it may take months or even years for the gallstones to all dissolve. The stones often come back after this treatment. They cause mild diarrhea in many people. This treatment is usually offered only to people who are not able to have surgery. 8. Extracorporeal shockwave lithotripsy (ESWL): A device that generates shock waves is used to break gallstones up into tiny pieces. These tiny pieces can pass through the biliary system without causing blockages. This is usually done in conjunction with ERCP to remove some stones. Many people who undergo this treatment suffer attacks of intense pain in the right upper part of the abdomen after treatment. 9. Most gallbladders are removed by laparoscopic cholecystectomy. The gallbladder is removed through a small slit in the abdomen using small tube-like instruments. The tube-like instruments have a camera and surgical instruments attached, which are used to take out the gallbladder with the stones inside it. This procedure causes less pain than open surgery. It is less likely to cause complications, and has a faster recovery time.

The University of Manchester|W.L. Gan | 2012

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Kidney stones / UTI / Cystitis 1. The kidney acts as a filter for blood, removing waste products from the body and making urine. Many waste chemicals are dissolved in the urine. The chemicals sometimes form tiny crystals in the urine which clump together to form a small stone. Kidney stones can form within the kidney, within the ureter or in the bladder. They can be many different sizes and shapes. 2. In most cases, there is no known reason why a stone forms. Most stones are made of calcium. However, in most cases, the amount of calcium and other chemicals in the urine is normal. You are more likely to form a stone if your urine is concentrated. 3. In some cases a kidney stone lies in a kidney and causes no symptoms. You may not be aware that a stone has formed. If symptoms do occur, you might get intense pain in the side of your abdomen. The pain may spread down into the lower abdomen or groin. You may see blood in your urine. Infections can cause fever, pain on passing urine and increased frequency of passing urine. 4. If you have symptoms that suggest a kidney stone, special X-rays or scans of the kidneys and ureters may be done. These tests aim to detect a stone and to check that a stone is not blocking the flow of urine. 5. Most stones that cause renal colic are small and pass out with the urine in a day or so. You should drink plenty of fluids to encourage a good flow of urine. Strong painkillers are often needed to ease the pain until you pass the stone. No other treatment is usually needed. Some stones become stuck in a ureter or kidney and cause persistent symptoms. Extracorporeal shock wave lithotripsy (ESWL) uses high energy 'shock waves' which are focused onto the stones from a machine outside the body to break up stones. You then pass out the tiny broken fragments when you pass urine. Another option for a stone made purely from uric acid is to dissolve the stone. This can be done by drinking plenty of fluids and making the urine alkaline with medication. 6. Cystitis means inflammation of the bladder. It is usually caused by an urine infection. Women are eight times more likely to have cystitis than men, as their urethra is shorter and opens nearer the back passage. Other risk factors for cystitis include having diabetes mellitus, being pregnant and being sexually active. 7. For the majority of cases, cystitis is a self-limiting condition that improves without any complications. Without antibiotics, cystitis, particularly mild cases, often resolves in a few days. A three-day course of antibiotic is a common treatment. Symptoms usually improve within a day or so after starting treatment. 8. Ways to prevent recurrent urinary tract infection in females : a. Drink lots of water to flush out your bladder frequently b. Cranberry juice is thought to prevent certain bacteria from attaching to cells that line the bladder. c. Wiping your back passage from front to back after you pass a stool

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Chronic kidney disease 1. Chronic kidney disease (CKD) is a long-term condition where the kidneys progressively lose 2.

3. 4.

5. 6.

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their function. Functions of the kidneys – filter out waste products from the bloodstream to be passed out in the urine, control blood pressure, produce vitamin D, which is used to keep the bones healthy and a substance called erythropoietin, which helps stimulate the production of red blood cells. The most common causes of CKD are diabetes, hypertension and ageing kidneys. Symptoms tend to develop when CKD becomes severe (stage 4) or worse. The symptoms may include feeling tired, poor appetite, weight loss, dry, itchy skin, muscle cramps, fluid retention which causes swollen feet and ankles, puffiness around the eyes, being pale due to anaemia and feeling sick. A simple blood test can estimate the volume of blood that is filtered by the glomeruli in your kidneys over a given period of time. A normal eGFR > 90 ml/min/1.73 m. To prevent or delay the progression of CKD, your blood pressure must be well controlled. Target < 130/80 mmHg. People with CKD have an increased risk of developing cardiovascular diseases. This is why reducing any other cardiovascular risk factors is so important. If you have high levels of protein in your urine then you may be advised to take medication even if your blood pressure is normal. ACE inhibitor has been shown to be beneficial as it can prevent further worsening of the function of your kidneys. Most people with kidney disease will be given iron supplements ( ferrous sulphate tablets ) because iron is needed for the production of red blood cells. You may be given an injection of erythropoietin to help your body produce more red blood cells. Epoetin alfa is given once a week. If you have kidney disease, you can get a build-up of phosphate in your body because your kidneys are unable to get rid of it. You may be asked to limit the amount of phosphate in your diet. Foods that are high in phosphate include red meat, dairy produce, eggs, and fish. You may be given phosphate binders which bind to the phosphate in the food inside your stomach and stop it from being absorbed into your body. People with kidney disease can have low levels of vitamin D, which is needed for healthy bones. You may be given a vitamin D supplement ( alfacalcidol or calcitriol ), to help boost your vitamin D levels and to help reduce the risk of bone damage. If you have kidney disease, you may be asked to restrict your daily fluid intake as as your kidneys will not be able to get rid of fluid as well as they did before. The excess fluid that occurs as a result of kidney disease often builds up in your ankles, or around your lungs. You may be given diuretics (water tablets), such as furosemide, that will help to get rid of the excess fluid from your body. If end-stage kidney failure develops, you are likely to need kidney dialysis or a kidney transplant to survive. People with stage 3 CKD or worse should be immunised against influenza each year, and have immunisation against pneumococcus. People with stage 4 CKD should be immunised against hepatitis B.

The University of Manchester|W.L. Gan | 2012

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Dyspepsia / GORD / Peptic ulcer disease 1. The main symptom of dyspepsia is usually pain or discomfort in the upper abdomen. Other symptoms include heartburn (a burning sensation felt in the lower chest area), bloating, belching, quickly feeling 'full' after eating, feeling sick (nausea) or vomiting. Symptoms are often related to eating. The term gastro-oesophageal reflux disease (GORD) means acid reflux. A peptic ulcer is an ulcer caused by stomach acid. 2. Lifestyle changes to prevent GORD – avoid food or drinks which might cause dyspepsia, give up smoking, exercise to reduce weight, avoid eating before bedtime. Offer patients who have GORD a full-dose PPI ( acid suppressing medication ) for 1 or 2 months. 3. Infection by Helicobacter pylori is the cause in about 8 in 10 cases of stomach ulcer. In some people this bacterium causes an inflammation in the lining of the stomach or duodenum. This causes the defense mucus barrier to be disrupted which allows the acid to cause inflammation and ulcers. Therefore, a main part of the treatment is to clear this infection. If this infection is not cleared, the ulcer is likely to return once you stop taking acid-suppressing medication. You need to take a 'combination therapy’ or 'triple therapy' for a week. For patients who test positive, provide a 7-day, twice-daily course of treatment consisting of a full-dose PPI with either metronidazole 400 mg and clarithromycin 250 mg or amoxicillin 1 g and clarithromycin 500 mg. 4. Proton pump inhibitors are a class of drugs that reduce the production of acid in your stomach. Side-effects include nausea, vomiting, abdominal pain, flatulence, diarrhoea, constipation and headache. 5. Many people take an anti-inflammatory drug for arthritis, muscular pains, etc. Aspirin is also used by many people to protect against blood clots forming. However, these drugs sometimes affect the mucus barrier of the stomach and cause an ulcer. If possible, you should stop the antiinflammatory drug. This allows the ulcer to heal. You will also normally be prescribed an acidsuppressing drug for several weeks. This stops the stomach from making acid and allows the ulcer to heal. However, in many cases the anti-inflammatory drug is needed to ease symptoms of arthritis or other painful conditions, or aspirin is needed to protect against blood clots. In these situations, one option is to take an acid-suppressing drug each day indefinitely. This reduces the amount of acid made by the stomach, and greatly reduces the chance of an ulcer forming again. 6. Complications – bleeding ulcer, perforation ( this usually causes severe pain and is a medical emergency )

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Constipation 1. Constipation refers to a decrease in the frequency of bowel movements or difficulty in passing stools. The stool of a constipated person is typically hard because it contains less water than normal. Constipation is a symptom, not a disease. 2. Causes of constipation are low fiber, inadequate water intake ( not drinking enough water can lead to hard, dry stools ), poor bowel habits ( ignoring the desire to have bowel movements may initiate a cycle of constipation ), medication ( aluminium hydroxide, iron tablets, morphine, antidepressants ), pregnancy, underactive thyroid problem, old age ( poor diet and insufficient intake of fluids, lack of exercise, prolonged bed rest, habitual use of enemas and laxatives ). 3. Treatment plan i. Eat foods that contain plenty of fibre. Fibre adds bulk and some softness to the stools. Highfibre foods include wholemeal bread, wholegrain cereals, fruit and vegetables. Make sure you have lots to drink when you eat a high-fibre diet or fibre supplements. Drink at least two litres (about 8-10 cups) per day. ii. Regular physical activity is an important component in bowel health iii. Drink plenty of fluids, especially water and fruit juices. iv. Bowel Hygiene: Go to the toilet at the same time every day, preferably after meals, and allow enough time as not to strain. v. Try to avoid laxatives containing senna because long-term intake may damage the lining of the bowel and injure nerve endings to the colon. vi. Medications a. Treatment with a bulk-forming laxative is usually tried first. b. If faeces remain hard despite using a bulk-forming laxative, then an osmotic laxative tends to be tried, or used in addition to a bulk-forming laxative. c. If faeces are soft but you still find them difficult to pass then a stimulant laxative may be added in. d. Once the constipation eases, you should normally stop the laxative. 4. Bulk-forming laxatives / fibre supplements. These increase the bulk of your faeces in a similar way to fibre. Eg. ispaghula husk (psyllium), methylcellulose, sterculia, inulin fibre. Very rarely, lots of fibre or bulk-forming laxatives and not enough fluid can cause an obstruction in the gut. You may notice an increase in wind (flatulence) and abdominal bloating. 5. Stimulant laxatives. These stimulate the nerves in the large bowel and cause the muscle in the wall of the large bowel to squeeze harder than usual. Possible side-effects include abdominal cramps, and long-term use can lead to a bowel that is less active on its own. This can be thought of as a 'lazy bowel'. Stimulant laxatives include bisacodyl, dantron, docusate, glycerol, senna and sodium picosulfate. 6. Osmotic laxatives. These work by retaining fluid in the large bowel by osmosis. Lactulose can take up to two days to have any effect so it is not suitable for the rapid relief of constipation. Possible side-effects include abdominal pain and bloating. 7. Faecal softeners. These work by wetting and softening the faeces. The most commonly used is docusate sodium.

The University of Manchester|W.L. Gan | 2012

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Addison’s disease 1. Addison's disease is a condition in which your adrenal glands do not make enough of certain

2.

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hormones. The adrenal glands are two small, triangular-shaped glands that sit on top of the kidneys. Cortisol is a hormone that is vital for health. It has many functions which include: o helping to regulate blood pressure o helping to regulate the immune system o helping to balance the effect of insulin in regulating the blood sugar level o helping the body to respond to stress. Aldosterone helps to regulate salts in the blood and helps to control blood pressure. About 7 in 10 cases are due to an 'auto-immune' disease. The immune system normally makes antibodies to attack bacteria, viruses, and other 'germs'. In auto-immune diseases the immune system makes antibodies against part or parts of the body. In auto-immune Addison's disease, you make antibodies which attach to cells in the adrenal cortex. These destroy the cells which make cortisol and aldosterone. If you have auto-immune Addison's disease you have a higher than average chance of other autoimmune diseases developing such as thyroid problems, vitiligo, and pernicious anaemia. TB is an infection which usually affects the lungs. In some cases the infection can spread to, and gradually destroy, the adrenals. In many cases the symptoms develop gradually over weeks or months. You might experience general weakness and becoming easily tired, darkened areas of skin, blood pressure is low and falls further when you stand which can make you dizzy, feeling sick and vomiting from time to time, abdominal pains which may come and go, diarrhoea or constipation which may come and go, cramps and pains in muscle, craving for salt. You need steroid medication to replace the cortisol which you no longer make. This is usually with a medicine called hydrocortisone which is very similar to cortisol. The amount is usually about 15-25 mg each day. Some people need more than this, and others less. The daily amount is broken up into two or three doses each day with a higher dose taken in the morning than in the evening. You should never miss taking your medication. Fludrocortisone is a substitute medicine for aldosterone. This helps to regulate blood pressure and blood salt level. It is also a good idea to wear a medical alert bracelet or necklace that informs people that you have Addison’s disease. Adrenal crisis is a medical emergency and must be treated immediately. If it is left untreated, it can lead to coma and death. You and a partner or family member may be trained to administer an injection of hydrocortisone in an emergency. You may need to increase the dosage of your medication if you experience an illness or infection - particularly if you have a high temperature of 37.5C, an accident, you need to have an operation or you are taking part in some strenuous exercise.

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Coeliac Disease

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1. Coeliac disease is a condition that causes inflammation in the lining of the small intestine. It is an autoimmune disease which means that the immune system which normally protects the body from infections mistakenly attacks itself. The lining of the small intestine contains millions of tiny tube-shaped structures called villi. These help food and nutrients to be absorbed more effectively into the body. In coeliac disease, these villi are flattened due to the inflammation of the lining of the gut. This then means that the food and nutrients cannot be so readily absorbed into the body. 2. Coeliac disease affects about 1 in 100 people in the UK. Anyone, at any age, can develop coeliac disease. It is due to sensitivity to gluten. Gluten occurs in common foods including wheat, barley, rye, certain breads, pasta and biscuits. 3. People with coeliac disease make antibodies against gluten. Antibodies are proteins in the immune system that normally attack bacteria and viruses. In effect, the gut 'mistakes' gluten to be harmful, and reacts against it as if it were fighting off a germ. These antibodies lead to inflammation developing in the lining of the small intestine. Poor absorption of food may cause deficiencies of vitamins, iron, and other nutrients. Anaemia due to poor absorption of iron is common. Other common symptoms include abdominal pains which tend to 'come and go', excess wind, bloating, diarrhoea, tiredness and weight loss. Mouth ulcers may occur. 4. If coeliac disease is suspected, a blood test to detect a certain antibody that occurs in coeliac disease may be advised by your doctor. If the blood test is positive, then you may be referred to a specialist who may arrange for a biopsy to be taken. The biopsy is small sample of tissue that is taken from the inside lining of the small intestine. This is looked at with a microscope to see if the typical changes of coeliac disease are present. 5. The main treatment for coeliac disease is to not to eat any food that contains gluten for the rest of your life. The symptoms then usually go within a few weeks. The main foods to stop are any that contain wheat, barley, or rye. Many common foods contain these ingredients such as breads, pasta, cakes, pastries and some cereals. Potatoes, rice, corn, fruit, dairy products and soya-based foods should be fine. You should get advice from a dietician. You can buy special gluten-free flour, pasta, bread and other foods. These are also available on prescription. Food labels will often say whether the food contains gluten or not. Avoiding gluten is for life. If you eat gluten again, symptoms will return. Even small amounts of gluten can sensitise the gut again. To avoid symptoms and complications, you must be strict about avoiding all foods that contain gluten. 6. People with coeliac disease have an increased risk of Developing osteoporosis ('thinning of the bones') due to the nutritional deficiencies which occur with coeliac disease. Developing lymphoma (a type of cancer) of the gut in later life. This is rare though. Developing other immune-related diseases such as type 1 diabetes, an underactive thyroid and primary biliary cirrhosis. 19

The University of Manchester|W.L. Gan | 2012

Statins for Hypercholesterolemia 1. Cholesterol is a type of fat that is made in the liver from fatty foods that we eat. A certain amount of cholesterol is present in the bloodstream. You need some cholesterol to keep yourself healthy. It is also important for the absorption of essential vitamins into your body. 2. In most people, your cholesterol level reflects the amount of fat that you eat. In some people, a very high level of cholesterol runs in the family due to an inherited genetic problem with the way cholesterol is made. One example is called familial hypercholesterolaemia. 3. In long term, these fatty substances will deposit around the lining of your blood vessels. This can cause narrowing of the vessels which supply blood to your heart muscle and brain. You are at a higher risk of developing complications, for examples, angina, heart attack, and stroke. In some cases, the conditions are life threatening. 4. It is important to reduce the blood cholesterol level to prevent you from developing the complications. Lifestyle advices - stop smoking, eat a healthy diet ( reduce fatty foods and salt intake ), regular physical exercise, reduce weight, cut down alcohol consumption. Control your blood pressure if you have high blood pressure. 5. If you are found to have a high risk of developing heart disease or stroke then you will usually be advised to take a statin drug to lower your cholesterol level. As a rule, no matter what your cholesterol level is, lowering the level reduces your risk. 6. Statin is a medication which reduces the blood cholesterol produced by the liver. You have to take the tablets everyday at night. 7. You should have a blood test before starting treatment to check if your liver is working properly. After starting treatment, you should have a blood test within 1-3 months, and again at 12 months. The blood test is to check that the liver has not been affected by the medication. The blood may also be checked to measure the cholesterol level to see how well the statin is working. 8. Tell your doctor if you have any unexpected muscle pains, tenderness, cramps or weakness. This is because a rare side-effect of statins is a severe form of muscle inflammation. You should not take a statin if you have active liver disease, if you are are pregnant or intend to be pregnant, or if you are breast-feeding. 9. Do not eat grapefruit or drink grapefruit juice if you are taking a statin. A chemical in grapefruit can increase the level of statin in the bloodstream which can make side-effects from the statin more likely. 10. Various other drugs that you may take may interfere with statin drugs. For example, some antibiotics and ciclosporin. Therefore, if you are prescribed another drug, remind the doctor or pharmacist that you are on a statin in case it is one where an interaction may be possible. 11. Tell a doctor if you develop chest symptoms such as unexplained shortness of breath or cough. This is because, in very rare cases, statins may cause a disease called interstitial lung disease. 12. Statin drugs are available on prescription and funded by the NHS if you have a cardiovascular disease, or you have a high risk of developing a cardiovascular disease. 20

The University of Manchester|W.L. Gan | 2012

Explaining and gaining consent for procedures Gastroscopy Explain the procedure A gastroscopy is a test where the operator looks into your foodpipe, stomach and small bowel using a thin, flexible telescope called the endoscope. It is about the size of your little finger. A tiny camera is attached within the telescope which transmits pictures on to a TV monitor for the operator to look at. It will be passed through your mouth and down into your stomach. A gastroscopy does not usually hurt, but it can be a little uncomfortable, particularly when the gastroscope is first passed through the foodpipe. However, we will give you some local anesthetic spray into your throat which tastes a little bit bitter. You will also be given a mouthpiece to hold it between your lips to keep your mouth open and make sure that you do not bite on the endoscope during the procedure. We will monitor your heartbeat, blood pressure and oxygen level in your body throughout the whole procedure. Gastroscopy is usually done as an outpatient or day case. It is a routine test which is commonly done. You will usually be given a sedative to help you to relax. This is usually given by an injection into a vein in the back of your hand. The sedative can make you drowsy but it does not 'put you to sleep'. It is not a general anaesthetic. The operator may take small samples of some parts of the inside lining of the stomach and it is painless. A gastroscopy usually takes about 20-30 minutes.

Benefits of the procedure A gastroscopy is advisable if you have symptoms such as persistent heartburn, difficulty swallowing, or vomiting of blood with unexplained weight loss. It can help us to detect any abnormalities for example, peptic ulcer, GORD, or cancer of the stomach or esophagus. Risks of the procedure Every procedure carries a small risk. Some patient might experience sore throat after the procedure. Occasionally, the gastroscope may cause damage to the lining of your foodpipe or stomach. This may cause bleeding, infection and, rarely, perforation (0.1%). If you experience severe abdominal pain, fever or vomiting out a lot of blood within 48 hours after a gastroscopy, consult a doctor immediately. Preparation for the procedure The stomach needs to be empty so that the operator can get a clear view. You are advised not to eat or drink preferably 6 hours before the procedure. You will need somebody to accompany you home, as you will be drowsy with the sedative. 21

The University of Manchester|W.L. Gan | 2012

Bipolar Disorders 1. Bipolar disorder is a condition that affects your mood which can swing from one extreme to another. You will have periods of depression where you feel very low or mania where you feel very high. 2. Unlike simple mood swings, each extreme episode of bipolar disorder can last for several weeks or longer. The high and low phases of the illness are often so extreme that they interfere with everyday life. 3. Bipolar disorder is a relatively common condition with around one person in 100 being diagnosed with the condition 4. During an episode of depression, you may have overwhelming feelings of worthlessness, which often lead to thoughts of suicide 5. During a manic phase of bipolar disorder, you may feel very happy and have lots of ambitious plans and ideas. You may spend large amounts of money on things that you cannot afford. Not feeling like eating or sleeping, talking quickly and becoming annoyed easily are also common characteristics of the manic phase of bipolar disorder. 6. The pattern of mood swings in bipolar disorder varies widely between individuals. For example, some people will only have a couple of bipolar episodes in their lifetime, and will be stable in between, while others may experience many episodes. 7. Bipolar disorder is widely believed to be the result of chemical imbalances in the brain. Bipolar disorder seems to run in families with the family members of a person with the condition having an increased risk of developing it themselves. A stressful situation is usually required to trigger the onset of the symptoms of bipolar disorder. 8. Medications to help stabilise mood swings including lithium carbonate, anti-convulsants (valproate, carbamazepine, lamotrigine) and anti-psychotics (olanzapine, quetiapine, risperidone). 9. If you have bipolar disorder, it is possible to learn to recognise the warning signs of an approaching episode of mania or depression. This will not prevent the episode occurring, but it will enable you to get help in time.

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Lithium Therapy

1. Lithium is used to help prevent the recurrence of severe swings in mood, after an acute episode of bipolar illness has settled. Lithium may take several weeks, months or even up to two years to reach its full potential effect as a mood stabiliser. 2. Before you are started on lithium therapy, we will check your kidney, thyroid and heart functions. 3. You will usually be prescribed with a low dose 200mg to 400mg at night, and the dose will be increased as required to reach the right lithium level for you. Try to get into the habit of taking lithium at the same times each day. 4. Check with your doctor before taking if your dose has been changed or if you are being given a different brand of lithium. 5. If you are taking lithium tablets, swallow them whole. Do not crush or chew lithium tablets because this could cause you to absorb too much from them. 6. While you are taking lithium you need to have regular blood tests to see how much lithium is in your blood. Blood sample will be taken every week for the first few weeks and every three months thereafter. Depending on your age and the illness you have, the level the doctor is aiming for is between 0.4 mmol/L and 1.0 mmol/L of lithium in your blood. For the blood test to be reliable, it must be taken at least 12 hours after the last dose of lithium. This works out quite well for people who take their lithium at night. 7. Your doctor will also do a blood test every six months to check that your kidneys and thyroid are working well. 8. Side effects include sickness, vomiting, diarrhoea, upset stomach, fine shake of your hands, metallic taste in your mouth, dry mouth, weight gain, swollen ankles, feeling more thirsty than usual and passing a lot of urine. 9. Very high blood levels may lead to lithium toxicity. Levels of lithium in the blood can be altered by dieting or changes in your diet, fluid or salt intake; certain medicines, infections; or by changing brands. Every time you are prescribed a new medicine, always check that it is safe to take with your lithium. 10. If you experience blurred vision, loss of appetite, being sick, diarrhoea, muscle weakness, drowsiness, feeling of being slow, shakiness and lack of co-ordination, fainting, inability to pass water, slurred speech or convulsions you may have too much lithium in your blood and you should seek urgent medical attention. 11. When you first begin treatment with lithium you will be given an information booklet about lithium treatment, a lithium alert card for you to carry with you at all times and to show to any healthcare professional who is treating you, and a booklet for keeping a record of your blood tests. These are all to help make sure you continue to receive the correct dose of lithium. 12. Lithium is not addictive. But when it's stopped, it should be reduced gradually to minimise the chances of the illness coming back. 13. During treatment with lithium it is important that you are well hydrated. You need to make sure that you are drinking enough fluid especially in situations where you could become dehydrated such as in hot weather or if you have an infection. 14. The use of lithium during pregnancy is not recommended. If you are taking lithium and you could become pregnant, you must use effective contraception. The University of Manchester|W.L. Gan | 2012

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Lithium and Pregnancy Risks to foetus  First trimester – increased incidence of cardiovascular malformations such as Ebstein's anomaly (incidence rate of 0.1% which is approximately 20 times the risk in the general population). However, the defect typically is detectable in utero by ultrasonography and often is surgically correctable after birth.  Third trimester – shallow respiration, muscle flaccidity, hypotonia, absent Moro's reflex, lethargy, cyanosis, poor suck and grasp reflexes in neonates, congenital goitre, neonatal hypothyroidism Risks of discontinued lithium therapy  Disturbed behaviour and physical harm to the unborn child  Poor antenatal care  Increased risk-taking behaviour, drug and alcohol misuse, deliberate self-harm and suicide and disturbed behaviour during labour and delivery  Potential hazards to the foetus of exposure to drugs and to electroconvulsive therapy used in the treatment of an acute relapse

The patient can only make the decision after a full discussion of possible risks to the foetus from lithium, balanced against the dangers of a relapse of affective illness should the medication be discontinued. If pregnancy is planned, ideally lithium should be avoided throughout the period including the time of conception. If lithium is to be discontinued in this context, it is advisable to taper it off slowly over the course of at least two weeks as the likelihood of relapse is far greater when withdrawal is abrupt. One option in a planned pregnancy is to omit lithium during the period of conception and embryogenesis, then recommence it in the second trimester. In continuing lithium during pregnancy, the rationale is to maintain a stable mental state on the minimum dose of lithium possible. When the use of lithium is unavoidable, the risk of teratogenicity can be minimized by monotherapy with the lowest effective dose for the shortest duration, use of a sustained-release preparation of lithium, careful monitoring of lithium levels, close collaboration with the obstetrician, and screening for anomalies using ultrasonography and fetal echocardiography between 16 and 18 weeks of gestation.

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Schizophrenia 1. Schizophrenia is a long-term mental health condition that causes a range of different psychological symptoms. They often hear or see things that do not exist. They hold unusual beliefs that are not based on reality and often contradict the evidence. Patients may not be able to distinguish their own thoughts and ideas from reality. Behaviour may become more disorganised and unpredictable, and appearance or dress may seem unusual to other people. People with schizophrenia may behave inappropriately or become extremely agitated and shout or swear for no reason. 2. The illness may develop slowly. The first signs of schizophrenia, such as becoming socially withdrawn and unresponsive or experiencing changes in sleeping patterns, can be hard to identify. 3. The exact cause of schizophrenia is unknown. However, most experts believe that the condition is caused by a combination of genetic and environmental factors. 4. Two of the most common misconceptions about schizophrenia are people with schizophrenia have a split or dual personality and people with schizophrenia are violent. Schizophrenia is not split personality. A person with schizophrenia is far more likely to be the victim of violent crime.

5. If a diagnosis of schizophrenia is suspected, your GP will probably refer you to your local community mental health team (CMHT). CMHTs are made up of different mental health professionals who support people with complex mental health conditions. 6. The earlier the symptoms are identified and treatment is started, the better the outlook. People with complex mental health conditions, such as schizophrenia, are usually entered into a treatment process known as a care programme approach (CPA). Stages of CPA include i. Assessment - your health and social needs are assessed. ii. Care plan - a care plan is created to meet your health and social needs. iii. Appointment of a care co-ordinator iv. Reviews - your treatment will be regularly reviewed and, if needed, changes to the care plan can be agreed. 7. Treatment for schizophrenia usually involves a combination of antipsychotic medicines and psychological therapies. 8. Antipsychotics are usually recommended as the initial treatment for the symptoms of an acute schizophrenic episode. Antipsychotics work by blocking the effect of the chemical dopamine on the brain. Antipsychotics can usually reduce feelings of anxiety or aggression within a few hours of use, but they may take several days or weeks to reduce other symptoms, such as hallucinations or delusional thoughts. 9. Most people take medication for one or two years after their first psychotic episode to prevent further acute schizophrenic episodes occurring and for longer if the illness is recurrent. It is important to take your medication as prescribed, even if you start to feel better. Continuous medication can help prevent relapses. 10. Psychological treatment, such as cognitive behavioural therapy (CBT) or family therapy, can help people with schizophrenia cope better with the symptoms of hallucinations or delusions. 25

The University of Manchester|W.L. Gan | 2012

Olanzapine 

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Schizoprenia is associated with the overactivity of certain chemicals (dopamine) involved in the transmission of messages in the brain. Olanzapine works by blocking the receptors in the brain that the chemicals act on and prevents the overactivity of the chemicals. Olanzapine does not work straight away. It may take several days or even weeks to reduce symptoms of unwanted thoughts and hallucinations. It should help you feel calm and relaxed. It is not addictive. Olanzapine is taken by mouth in the form of tablets. Swallow it whole with a glass of water. Olanzapine may be taken with or without food. Take olanzapine exactly as directed by your doctor. Try to take olanzapine at the same times each day to avoid missing any doses. If you do forget to take a dose, take it as soon as you remember then continue taking it at the usual times. However, if it is nearly time for your next dose, leave out the missed dose and continue as normal. Never take two doses at the same time to compensate. Common side effects (1 in 10) include drowsiness (do not drive or use machinery), weight gain due to increased appetite (optimise diet, exercise) Other side-effects may include stiffness or uncontrollable movements of the body, swollen legs and ankles, constipation, dry mouth, raised blood sugar (diabetes mellitus) and cholesterol levels. Olanzapine may cause a drop in blood pressure when moving from a lying down to standing, which results in dizziness and lightheadedness. While alcohol and drugs may provide short-term relief from your symptoms of schizophrenia, they are likely to make your symptoms worse in the long run. Alcohol can cause depression and psychosis, while illegal drugs may make your schizophrenia worse. Drugs and alcohol can also react badly with antipsychotic medicines. Your doctor may want to monitor your weight, blood sugar, cholesterol levels and liver function while you are taking this medicine. Unless your doctor tells you otherwise, you should not suddenly stop taking this medicine, even if you feel better and think you don't need it any more. This is because the medicine controls the symptoms of the illness but doesn't actually cure it. This means that if you suddenly stop treatment your symptoms could come back. Stopping the medicine suddenly may also rarely cause withdrawal symptoms such as sweating, anxiety, nausea, vomiting, difficulty sleeping or tremor. When treatment with this medicine is stopped, it should be done gradually, following the instructions given by your doctor. The safety of this medicine for use during pregnancy has not been established. It is not recommended for use in pregnancy unless considered essential by your doctor. If you get pregnant or plan to get pregnant while taking this medicine you should seek medical advice from your doctor.

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Dementia 1. There are certain situations that can affect your memory and make you become more forgetful than you normally are. For examples, poor concentration, physical illness, depression, medicines, age and dementia. 2. Dementia is a condition of the brain which causes a gradual loss of mental ability, including problems with memory, understanding, judgement, thinking and language. In addition, other problems commonly develop, such as changes in personality and changes in the way a person interacts with others in social situations. As dementia progresses, a person's ability to look after themselves from day to day may also become affected. 3. Dementia can be caused by various diseases or disorders which affect the parts of the brain involved with thought processes. However, most cases are caused by Alzheimer's disease, vascular dementia, or dementia with Lewy bodies (DLB). 4. Dementia is a common problem. Sometime after the age of 65 about 1 in 20 people in the UK will develop dementia. Over the age of 85, about 1 in 5 people are living with dementia. However, dementia is not a normal part of ageing. It is different to the age-associated memory impairment that is common in older people. 5. The speed in which dementia progresses varies greatly from person to person. It can also depend on the type of dementia that someone has. Typically, symptoms of dementia tend to develop slowly, often over several years. In the early stages of the disease, many people with mild dementia cope with just a small amount of support and care. As the disease progresses more care is usually needed. 6. There is no cure for dementia and no medicine that will reverse dementia. However, there are some medicines that may be used to help in some causes of dementia. Firstly, as treatment to help with symptoms that affect thinking and memory (cognitive symptoms). Secondly, as treatment to help with symptoms that affect mood and how someone behaves (non-cognitive symptoms). 7. Other possible treatments include measure to help simplify daily routine and enhance memory, cognitive stimulation, regular activity and cognitive behavioural therapy. 8. Vehicle drivers who have been diagnosed with dementia are legally required to inform the Driver and Vehicle Licensing Agency (DVLA). They may be able to continue driving a car or a motorcycle safely for some time. But they may be asked to have a driving test and/or their doctor may be asked to complete a medical report for the DVLA. If someone is able to continue to drive, this will usually be reviewed on a yearly basis. Someone who has been diagnosed with dementia will not be able to continue to drive a bus or a lorry or large goods vehicle.

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Alzheimer’s disease 1. Alzheimer's disease is the most common form of dementia, which is a group of symptoms associated with a decline in mental abilities, such as memory and reasoning. Alzheimer’s disease is a progressive condition, which means that it will continue to get worse as it develops. 2. Alzheimer's disease is most common in people over 65 years of age, and affects slightly more women than men. Although there is no cure for Alzheimer’s disease, medication is available that can slow down the development of the condition. 3. Stages of Alzheimer’s disease i. The first section of the brain to start deteriorating is often the part that controls the memory and speech functions. ii. During the moderate stage, you may have difficulty remembering very recent things. Problems with language and speech could start to develop. iii. Someone with severe Alzheimer's disease may seem disorientated and show signs of major confusion. The hallucinations and delusions are often worse at night, and the person with Alzheimer's disease may start to become violent, demanding and suspicious of those around them. During the severe stage of Alzheimer's disease, people often start to neglect their personal hygiene. It is at this stage that most people with the condition will need to have full-time care because they will be able to do very little on their own. 4. Alzheimer's disease affects a person's ability to look after themselves when they are unwell, so another health condition can develop rapidly if left untreated. In many cases, Alzheimer's disease may not be the actual cause of death, but it can be a contributing factor. 5. Alzheimer’s disease is caused by parts of the brain wasting away, which damages the structure of the brain and how it works. 6. Age is the greatest factor in the development of Alzheimer's disease. In cases where Alzheimer's disease is inherited, the symptoms may start to develop at a relatively early age (between 35 and 60 years of age). 7. If you have moderate Alzheimer's disease (if your MMSE score is between 10 and 20), NICE recommends that you are prescribed donepezil. galantamine or rivastigmine (acetylcholinesterase inhibitors). Side effects include nausea, vomiting, diarrhoea , headache, fatigue, insomnia and muscle cramps. 8. Care assessment include whether you can drive safely, whether you can wash, dress and feed yourself, whether you have a support network, such as family and friends, or whether you need any financial assistance.

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Antidepressant (SSRI) 

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Selective serotonin reuptake inhibitor is a group of antidepressant medicines that are used to treat depression. Antidepressants alter the balance of some of the chemicals in the brain called serotonin. It is not addictive. When serotonin is released in the brain, it helps lift mood. It is thought that people with depression release only small amounts of serotonin. About 5-7 in 10 people with moderate or severe depression have an improvement in symptoms within a few weeks of starting treatment with an antidepressant. Before starting SSRIs ensure that patients are aware that they may take a few weeks to work, that they must stop if they develop a rash and that they must get help if agitation or suicidal feelings occur. Patients should be reviewed 1-2 weeks after starting treatment. A trial of at least 4-8 weeks (6 weeks in older patients) should be given before deciding to discontinue/change an agent. A normal course of antidepressants lasts at least six months after symptoms have eased. If you stop the medicine too soon, your symptoms may rapidly return. Some people with recurrent depression are advised to take longer courses of treatment. Common side effects (1 in 10 patients) include diarrhoea, feeling sick, dry mouth, dizziness, agitation, anxiety and difficulty sleeping. SSRI can cause drowsiness and blurred vision. You must be aware of the possibility, especially if you are a driver as it may impair your ability to drive safely. SSRIs are associated with a small increased risk of bleeding into the gut. This is especially in older people and in people taking other medicines that have the potential to damage the lining of the gut or interfere with clotting. Therefore, ideally, SSRIs should be avoided if you take aspirin, warfarin or non-steroidal anti-inflammatory drugs such as ibuprofen, naproxen, etc. Antidepressants may cause some problems with sexual function. For example, problems getting an erection, vaginal dryness and decreased sex drive. It is important to take the medication each day at the dose prescribed. Some people develop withdrawal symptoms if the medication is stopped abruptly. Symptoms such as dizziness, anxiety and agitation, sleep disturbance, headaches, pins and needles, diarrhoea, palpitations and sweating are unlikely to occur if you reduce the dose gradually over about 4 weeks. If withdrawal symptoms do occur, they will usually last less than two weeks. Some SSRIs may be taken during pregnancy, but only with caution and after weighing up the benefits to the mother against the risks to the unborn baby. In particular, the newborn baby may have withdrawal effects if the mother was taking an SSRI during the later stages of pregnancy.

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Methotrexate 

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Methotrexate is used to suppress inflammation which helps to reduce joint pain and swelling in rheumatoid arthritis. It may prevent or reduce the progression of joint damage but it cannot cure your condition. You may need to take it for life to keep your symptoms controlled. Methotrexate does not work immediately. It may take up to 3 months before you notice any benefit. It is usually necessary to take NSAIDs or painkillers until benefit occurs. Methotrexate is usually taken once a week. Make sure that you understand when, and how often, you need to take Methotrexate. Depending on your response to the medicine, how the medicine works and the goals of your treatment, your prescriber may vary your dose. Methotrexate is usually given as weekly 2.5 mg tablets or injection. The tablets should be swallowed whole with a drink of water whilst sitting upright or standing. Possible side effects include sickness, diarrhoea, skin rash, mouth ulcers and hair loss. Do not drive or use machines if you experience any side effect (e.g. dizziness, drowsiness or blurred vision) which may lessen your ability to do so. Alcohol increases the risk of liver damage with methotrexate and it should be avoided during the full period of treatment. While you are taking methotrexate, and for a while after you stop treatment, do not have any immunisations (vaccinations) without talking to your doctor first. Methotrexate lowers the body's resistance and there is a chance that you may get an infection from some vaccines. Keep your regular appointments with your doctor so that your progress can be monitored. You will need to have regular blood tests including full blood count; liver function test and renal function test (2 weekly for 6 weeks then monthly) while you are taking methotrexate. Methotrexate is a medicine which has implications for pregnancy as it may harm a baby. Women must not become pregnant and men must not father a child during treatment and for at least three months after stopping treatment. You must use effective contraception during treatment and for at least three months after stopping treatment with Methotrexate. Treatment with methotrexate may reduce fertility in men and women. Fertility is thought to go back to normal after methotrexate treatment is stopped. Tell your doctor if you have concerns. Women who are taking Methotrexate should not breast-feed. If you develop any of the following, let your doctor know straight away - Sore throat, unusual bruising, mouth ulcers (bone marrow toxicity) - Sickness, abdominal pain, dark urine (hepatotoxicity) - Shortness of breath, cough (pneumonitis) If you are being prescribed antibiotic (co-trimoxazole or trimethoprim), stop methotrexate for the duration of antibiotic therapy. Most doctors prescribe folic acid tablets to patients who are taking methotrexate as this can reduce the likelihood of side-effects. 30

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Multiple Sclerosis 1. MS is a condition of the brain and spinal cord. Each nerve fibre in the central nervous system is surrounded by a substance called myelin. Myelin helps messages from the brain to travel quickly and smoothly to the rest of the body. In MS, the myelin becomes damaged. This disrupts the transfer of these messages. MS is an autoimmune condition. This means that your immune system mistakes the myelin for a foreign substance and attacks it. 2. MS can occur at any age, but symptoms are mostly first seen between the ages of 20 and 40. Women are more than twice as likely to develop MS as men. MS is probably caused by a combination of genetic and environmental factors. About 1 in 1,000 people in the UK develop MS. 3. There are many different symptoms of MS and they affect each person differently. Some of the most common symptoms include blurring of vision, numbness and tingling, problems with mobility and balance, muscle weakness and tightness, musculoskeletal pain, tiredness, bladder and bowel problems. 4. The symptoms of MS are unpredictable and some people's symptoms develop and worsen steadily over time, while for other people they come and go periodically. 5. Relapsing remitting MS is the most common type of MS. It is characterised by numerous relapses and remissions. Periods when your symptoms get worse are known as relapses. Periods when your symptoms improve or disappear are known as remissions. Relapses may last for days, weeks or months. You may experience new symptoms each time, or a recurrence of previous ones. After each relapse, you may recover completely. However, many people's symptoms improve but do not disappear altogether. 6. There is no cure for MS. However, there are many treatments that can relieve the symptoms and relapses and may slow the progression of MS. a. If your symptoms are due to a relapse, you may be given a three- to five-day course of a high-dose steroid, called methylprednisolone, to help speed up your recovery. This can be given either orally as tablets, or intravenously (injected into a vein). They are thought to suppress your immune system so that it no longer attacks the myelin in your central nervous system. As steroids may cause long-term side effects, such as osteoporosis, weight gain and diabetes, you should not take them for more than three weeks at a time. b. Muscle spasms and spasticity can be improved with physiotherapy. If your muscular spasms are more severe, you may be prescribed a medicine that can relax your muscles and reduce spasms. This will usually be either baclofen or gabapentin c. You may be prescribed painkillers (analgesics) for musculoskeletal pain d. People with MS who have depression can be treated with antidepressants. e. Disease-modifying medicines may help to slow the progression of MS, however they are not suitable for everyone with MS. The types of interferon beta licensed for use in the UK are interferon beta-1a and interferon beta-1b. They are given by injection. All interferons can cause mild side effects, such as flu-like symptoms (headaches, chills and mild fever) for 48 hours after they are injected. Interferon beta is not suitable for people under the age of 18 or women who are pregnant or breastfeeding. Both women and men are advised to stop using it at least three months before trying for a baby.

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Giant cell arteritis 1. Giant cell arteritis is due to inflammation in blood vessels, but the cause of this is unknown. In cases of giant cell arteritis, the temporal arteries are usually most affected. It is thought that a combination of genetic and environmental factors is responsible for the condition. 2. Symptoms of giant cell arteritis include severe headache, jaw muscle pain while chewing and vision loss. Up to one in five people with giant cell arteritis develop vision problems, which usually take the form of partial or, less often, complete vision loss in one or both eyes. 3. Giant cell arteritis is regarded as a medical emergency and without prompt treatment it can cause permanent blindness. 4. Giant cell arteritis is an age-related condition. It affects only older adults over the age of 50, and usually it is adults over 65 years old who develop it. 5. Around half of people with giant cell arteritis also develop polymyalgia rheumatica, which is a related but less serious condition. Polymyalgia rheumatica causes inflammation of the muscles and sometimes joints, resulting in symptoms that can include shoulder, neck and hip pain, stiffness of the affected muscles. 6. If giant cell arteritis is treated before vision loss occurs then the outlook is usually good. The condition responds well to steroid. When you start taking prednisolone tablets you will probably be prescribed a relatively high dose (usually between 40 to 60 milligrams). This dose will then be gradually reduced every two to four weeks, depending on how well you respond to treatment. You may need to take prednisolone for up to two years to prevent your symptoms returning. Your symptoms should improve significantly within a few days of starting your treatment. 7. Side effects of steroids include increased appetite that often leads to weight gain, thinning of the bones (osteoporosis), skin thinning, stomach ulcers, increased blood pressure, increased blood sugar (diabetes), muscle weakness and increased risk of infection. 8. Do not stop taking steroid tablets suddenly. It probably does no harm if you forget to take the odd tablet. However, once your body is used to steroids, if you stop the tablets suddenly you may get serious withdrawal effects within a few days. 9. Do not take anti-inflammatory painkillers whilst you take steroids unless advised by a doctor. The two together increase your risk of developing a stomach ulcer. 10. Most people who take regular steroids carry a steroid card. This gives details of your dose, condition in case of emergencies. 11. To reduce the risk of osteoporosis, your GP will usually also prescribe medication (bisphosphonates) and calcium and vitamin D supplements to help compensate for the effects of prednisolone by strengthening your bones. 12. Low dose aspirin is increasingly being recommended as for people who have a history of giant cell arteritis, because this medicine has been found to be effective in preventing complications, such as vision loss or stroke. 13. Your GP will ask you to attend regular follow-up appointments so that they can check how well you are responding to treatment. They will assess whether your dosage of prednisolone needs to be adjusted and how well you are coping with the side effects of the medication. During these appointments, you will have blood tests to check the levels of inflammation inside your body. You may also be referred for a DEXA scan to assess how strong your bones are.

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Parkinson’s Disease 1. Parkinson's disease is a long-term neurological condition which affects the way the brain coordinates body movements, including walking, talking and writing. 2. The risk of getting Parkinson's disease increases with age. Symptoms usually appear in people who are over the age of 50. 3. The symptoms of Parkinson's disease usually begin slowly and develop gradually, in no particular order. Parkinson's disease affects everybody differently. There are three main symptoms of Parkinson's disease, namely, i. Slowness of movement (bradykinesia) - Parkinson's disease can make moving difficult, particularly when you try to start moving, and it can take you longer to perform tasks. You may lack co-ordination in your movements. ii. Shaking (tremor) - Shaking usually begins in one of your hands or arms. It is more likely to occur when the particular part of your body is at rest. Shaking usually decreases when you are using the body part, and it can be more noticeable when you are stressed or anxious. iii. Stiffness of muscles (rigidity) - your muscles may feel tense and you may have trouble performing simple everyday tasks. For example, you may find it difficult to turn around, get out of a chair and roll over in bed. Fine finger movements, facial expressions and body language may also become difficult. 4. Parkinson's disease is caused by a loss of nerve cells in the part of the brain called the substantia nigra. The nerve cells in this part of the brain are responsible for producing a chemical called dopamine. Dopamine acts as a messenger between the brain and the nervous system, and helps control and co-ordinate body movements. 5. Dementia is not a typical early feature of PD. However, if you have PD you have an increased risk of developing dementia. About half of people with PD develop dementia at some stage 6. There is no cure for Parkinson's disease. However, numerous treatments are available to help control your symptoms and maintain your quality of life. These may be supportive therapies (physiotherapy, occupational therapy, speech and language therapy) that help you cope with everyday life or medication to control your symptoms. 7. Three main types of medication are commonly used, namely, Levodopa, dopamine agonists, monoamine oxidase-B inhibitors (selegiline and rasagiline). 8. A low dose of levodopa is usually started at first. Over time, the dose often needs to be increased to control the symptoms. Levodopa is always combined with another drug (carbidopa). These prevent levodopa from being converted into dopamine in the bloodstream. This reduces sideeffects (nausea, vomiting, tiredness and dizziness) and increases the amount that gets to the brain where it is converted to dopamine. 9. Surgery does not cure PD, but may help to ease symptoms when drugs are not working well. For example, chronic deep brain stimulation. 10. The symptoms of PD tend to become gradually worse over time. However, the speed of progression varies greatly from person to person. When symptoms first begin, you may not need treatment when symptoms are relatively mild.

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Epilepsy 1. A seizure is a short episode of symptoms caused by a burst of abnormal electrical activity in the brain. Symptoms that may occur during a seizure can affect your muscles, sensations, behaviour, emotions, consciousness, or a combination of these. 2. If you have epilepsy, it means that you have had repeated seizures. If you have a single seizure, it does not necessarily mean that you have epilepsy. Epilepsy can affect anyone at any age. 3. In many cases, no cause for the seizures can be found. In some cases, an underlying brain condition or brain damage causes epilepsy. Some conditions are present at birth. Some conditions develop later in life. A seizure can also be caused by external factors which may affect the brain. For example, a high fever may cause a 'febrile convulsion'. Other causes of seizures include: lack of oxygen, a low blood sugar level, certain drugs, poisons, and a lot of alcohol. 4. You may need an electroencephalogram (EEG), which can detect unusual brain activity associated with epilepsy. Or you may have a MRI scan, which can spot any defects in the structure of your brain. 5. There is no cure for epilepsy. Anti-epileptic drugs (AEDs) are usually the first choice of treatment. About 70% of people with epilepsy have their seizures controlled with AEDs. Usually, AED treatment will not begin until after you have had a second seizure. 6. The older first-line AEDs, which include sodium valproate, carbamazepine, phenytoin, phenobarbital and primidone, are tried first to control seizures. 7. Newer second-line AEDs are recommended if there is a reason why you cannot take AEDs, if there is concern about an older AED interacting with other drugs (such as contraceptive pill), or if you are thinking of having a baby. Newer AEDs include gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate and vigabatrin. 8. Side effects are common when starting treatment with AEDs. However, they are short term and usually pass in a few days. Side effects include nausea, abdominal pain, drowsiness, dizziness, irritability and mood changes. Some side effects, which produce symptoms that are similar to being drunk, occur when the dose of AEDs is too high. They include unsteadiness, poor concentration, drowsiness, vomiting and double vision. 9. Your specialist will start you on a low dose of the AED, then gradually increase it within safe limits until your seizures stop. If one AED does not control seizures, another will be tried by gradually introducing the new drug and slowly reducing the dose of the old drug. The aim is to achieve maximum seizure control with minimum side effects, using the lowest possible dose of a single drug. Never suddenly stop taking an AED because doing so could cause a seizure. 10. If your epilepsy is still poorly controlled after two years of treatment, you may be referred to a specialist epilepsy centre to see if you are suitable for brain surgery. 11. If you have a seizure, you have a legal responsibility to inform the Driving and Vehicle Licence Authority (DVLA). You will usually not be able to hold a group one driving licence, required for private cars and motorcycles, until you have not had a seizure for a year. 12. Some anti-epileptic drugs can reduce the effectiveness of some types of contraception. If you are sexually active and you want to avoid pregnancy, ask your GP or epilepsy specialist whether your AEDs could affect any of these methods of contraception. You may need to use another form of contraception such as a condom or coil.

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13. There is no reason why women with epilepsy cannot have a healthy pregnancy. However, it is always preferable if the pregnancy is planned. The main risk is that some AEDs are known to increase the chances of a serious birth defect occurring, such as spina bifida, cleft lip or a hole in the heart. It may be possible to change the AED you are taking to minimise any risks. Taking 5mg of a folic acid supplement a day can also help reduce risks of birth defects. If you discover you are pregnant, do not stop taking your medicine. The risks to your baby from uncontrolled seizures are far higher than any risks associated with your medicines. 14. Heavy drinking can cause seizures, as well as interact with anti-epileptic drugs, making them less effective. AEDs can heighten the effects of alcohol, while alcohol can make the side effects of AEDs worse.

Sodium Valproate 1. Sodium valproate works by stabilising electrical activity in the brain, thus help to control seizures. 2. When you first start taking sodium valproate you may be started on a low dose which will then be increased slowly until your doctor finds the dose that is best for you. 3. Try to take sodium valproate at the same times each day to avoid missing any doses. 4. Valproate is a ‘preventative medicine’. It is therefore important that you keep taking valproate until your doctor tells you to stop. Do not stop taking it just because you feel better. If you stop them before you are advised to do so your fits or symptoms may get worse. 5. Side effects include weight gain (increased appetite), temporary hair loss, stomach upset (take the medication with food or after food), feeling sick, drowsiness (do not drive or use machinery), liver problems, feeling shaky, unsteadiness, confusion, easy bruising. 6. For the first six months of treatment you will need a regular blood test (e.g. every month) to check that the drug is not affecting your liver. 7. Unplanned pregnancy is not desirable in women receiving sodium valproate. You should use an effective method of contraception and talk to your doctor before planning pregnancy. Women taking sodium valproate during pregnancy have a higher risk than other women of having a child with an abnormality. Women who take sodium valproate during pregnancy may be more likely to have a baby with spina bifida. This is an abnormality of the spinal cord. Taking folic acid 5mg each day as soon as you stop contraception may lower the risk of having a baby with spina bifida. Side effects of Valproate       

Appetite (weight gain) Liver (hepatotoxicity) Pancreatitis Reversible hair loss Oedema Tremor, teratogenic, thrombocytopenia Encephalopathy

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Migraine 1. Migraines affect one in four women and one in 12 men in the UK. Everyone will experience migraines differently. Some people have attacks frequently, up to several times a week. Other people only have a migraine occasionally. 2. About one third of people with migraines have warning symptoms (aura) before the migraine. Aura symptoms typically start between 15 minutes and one hour before the headache begins. These include visual problems (flashing lights, zigzag patterns or blind spots), tingling sensation like pins and needles in your neck, shoulders or limbs and problems with co-ordination. 3. Symptoms associated with a common migraine (migraine without aura) include nausea and increased sensitivity sensitivity to light, sound and/or smells. The symptoms of a migraine can last anywhere between four hours and three days. They will usually disappear when the headache goes. You may feel very tired for up to seven days after a migraine attack. 4. Migraines are thought to be caused by changes in the chemicals of the brain. In particular, levels of a type of chemical called serotonin decrease during a migraine. Low levels of serotonin can make the blood vessels in a part of your brain suddenly contract, which makes them narrower. This may cause the symptoms of aura. Soon after, the blood vessels widen, which is thought to cause the headache 5. Migraine triggers include emotional (stress, depression, anxiety), physical (tiredness, poor sleep, travelling for long period of time, menopause), dietary (dieting, alcohol, irregular meals, caffeine), environmental (bright lights, loud noises, flickering screen, changes in climate) and medicinal factors (contraceptive pills, HRT). 6. There is currently no cure for migraines. Many people who have migraines find that painkillers, such as paracetamol and aspirin, can help to reduce their symptoms. 7. If ordinary painkillers are not helping to relieve your migraine symptoms, triptan and antiinflammatory medicines such as ibuprofen can be used to treat migraine. 8. Sumatriptan relieves the pain of migraine headache by causing the blood vessels in the brain to narrow. The dose of sumatriptan should be taken as early as possible after the migraine headache has started. If the first dose of this medicine doesn't relieve your migraine headache then you should NOT take another dose for the same attack, as trials have shown that this is not effective. Common side effects (1 in 10 people) include sensation of tightness, pressure, tingling, heaviness, heat or pain in any part of the body, including the chest and throat, flushing, drowsiness, nausea, vomiting and increase in blood pressure. 9. Migraine often improves during pregnancy, only to return to its former pattern after delivery. Paracetamol is the drug of choice for use in pregnancy and breast-feeding. Aspirin and triptans should be avoided. 10. Migraines are associated with a small increased risk of ischaemic strokes. Combined oral contraceptive pill increases the risk and medical professionals generally advise women who experience migraine with aura not to use the pill. Migraine is associated with an increased risk of depression, manic depression, anxiety disorder and panic disorder. 11. Keeping a migraine diary is helpful. You may find you tend to have a migraine after eating certain foods or when you are stressed. By avoiding this trigger, you can prevent a migraine. 12. Medications such as propranolol (beta-blocker), amitriptyline (tricyclic antidepressant), topiramate (anticonvulsant) are available to prevent a migraine attack. The University of Manchester|W.L. Gan | 2012

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Stroke 1. A stroke is a serious medical condition that occurs when the blood supply to part of the brain is cut off. Like all organs, the brain needs the oxygen and nutrients provided by blood to function properly. If the supply of blood is restricted or stopped, brain cells begin to die. This can lead to brain damage and possibly death. 2. A stroke is a medical emergency and every second counts. The quicker you're diagnosed and treated, the better your chances of making a full recovery. 3. There are two main causes of strokes – a. ischaemic (accounting for over 80% of all cases): the blood supply is stopped due to a blood clot b. haemorrhagic: a weakened blood vessel supplying the brain bursts and causes brain damage 4. Ischaemic strokes can be treated using a 'clot-busting' medicine called alteplase, which dissolves blood clots (thrombolysis). However, alteplase is only effective if started during the first four and a half hours after the onset of the stroke. However, not all patients are suitable for thrombolysis treatment. You will also be given a regular dose of aspirin, as this makes the cells in your blood, known as platelets, less sticky, reducing the chances of further blood clots occurring. If you are allergic to aspirin, other anti-platelet medicines are available. 5. The damage caused by a stroke can be widespread and long-lasting. Many people need to have a long period of rehabilitation before they can recover their former independence. A team of specialists are available to help, including physiotherapists, psychologists, occupational therapists, speech therapists and specialist nurses and doctors.  

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Strokes can cause weakness or paralysis in one side of the body. As part of your rehabilitation you should be seen by a physiotherapist After having a stroke, many people experience problems with speaking and understanding, as well as with reading and writing. You should see a speech and language therapist as soon as possible for an assessment, and to start therapy to help you with your communication skills. Some strokes damage the part of the brain that controls bladder and bowel movements. This can result in urinary incontinence and difficulty with bowel control. Most people who have had a stroke regain control in a week or so. Stroke can sometimes damage the parts of the brain that receive, process and interpret information sent by the eyes. Some people may have double vision, or lose half of their field of vision in one eye. If you have had a stroke, you cannot drive for one month.

6. A third of people will make an almost full recovery physically and should be encouraged to lead a normal life. A third of people will have a significant amount of disability. This will vary from the severely disabled, e.g. people who need help getting in and out of bed, to milder things, such as needing help with bathing.

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Hip Replacement During a hip replacement, the surgeon removes parts of the bones that make up your hip and replaces them with artificial hip parts (prostheses).  

A total hip replacement is where both sides of the hip joint are replaced (the head of the femur and the acetabulum socket). A hemiarthroplasty is where only the head of the femur is replaced by an artificial part.

The type of surgery you have will depend on:     

the type of fracture you have and where in the femur the fracture is your age how physically mobile you were before the hip fracture your mental ability before the hip fracture, for example if you have dementia the condition of the bone and joint, for example if you have arthritis

A total hip replacement may be considered if you:   

already have a condition affecting your joints, such as osteoarthritis are very active have a reasonable life expectancy

The purpose of a new hip joint is to:   

relieve pain improve the function of your hip and your ability to move around improve your quality of life

Disadvantages of hip replacement  limitation of movements (extreme positions such as squatting are not recommended because of risk of dislocation)  continuing pain around hip after operation (1 in 10)  one leg slightly longer than the other  risks of surgery The surgeons replace the damaged surfaces with artificial parts which may be made of metal, plastic or ceramic materials. The prostheses also come in different shapes and sizes and would be selected depending on the shape of your natural hip. The metal ball and plastic (polyethylene) cup is the most commonly used. Ceramic-on-plastic or ceramic-on-ceramic is often used in younger, more active patients. 38 How the prosthesis is fixed onto the bone can also vary. There are three choices - cemented, uncemented (use of screws, nails or pegs, and/or the use of a coating which encourages the bone to grow and bind onto the surface of the prosthesis) and hybrid (the ball is cemented on while the socket is cementless). The University of Manchester|W.L. Gan | 2012

Before the surgery 

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A pre-operative assessment which may include blood tests, urine tests, an ECG or echocardiogram, and chest X-ray, will check your overall health to make sure you are ready for surgery. You can prepare for the operation by staying as active as you can. Strengthening the muscles around your hip will aid your recovery. You may be referred to a physiotherapist, who can give you helpful exercises. Losing weight will help reduce stress on the new joint in patients who are overweight. Stop smoking is a good idea at any time, but particularly before major surgery in order to help reduce the risk of post-operative lung problems and improve healing. Evaluate post-surgical needs for at-home care. Every patient who undergoes total joint replacement will need help at home for the first few weeks, including assistance with preparing meals and transportation. You may be able to choose the type of anaesthetic you are given during surgery. o o

General anaesthsia – where you are asleep during the operation Epidural anaesthesia – where an injection is given into your spine that numbs the lower half of your body; this is often combined with sedation so you will be unaware of your surroundings and have no memory of the surgery taking place

After the surgery   

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The surgery usually takes around 60-90 minutes to complete. After surgery you will usually be taken from the operating theatre to an orthopaedic ward. You should be given pain relief as needed. Rehabilitation programme aims to increase your mobility and independence so you can wash and dress yourself and use the toilet without help. Rehabilitation will usually involve a multidisciplinary team including physiotherapists, occupational therapists, social workers, orthopaedic surgeon, geriatrician and liaison nurse. How long you need to stay in hospital will depend on how fit you are. If you are otherwise healthy, you may be discharged from hospital after a hip replacement in three to five days. For the first four to six weeks after the operation you will be unable to place any weight on to your new hip so you will need a walking aid, such as crutches, to help support you. Most people are able to resume normal activities within two to three months but it can take up to a year before you experience the full benefits of your new hip. It is best to avoid extreme movements or sports where there is a risk of falling, such as skiing or riding. Being aware of what you cannot do after surgery to minimise the risk of your new hip dislocating, particularly in the first six weeks. o o o

Do not lie on your side. Do not cross your legs. Do not bend the hip excessively (i.e. more than 90 degrees) by sitting upright, or bending your knee towards your chest The University of Manchester|W.L. Gan | 2012

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o o o   

Do not twist the operated leg in or out. Do not rotate your body excessively on the operated leg when standing When walking or turning, keep your foot and knee pointing straight ahead.

You will be given an appointment to check up on your progress, usually six to 12 weeks after your hip replacement. You can usually drive a car after about six weeks, subject to advice from your surgeon. Hip replacements should last for 20 years in 8 out of 10 patients. In more active patients, the joints may wear out more quickly.

Complications 

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Common complications after hip replacement include loosening of joint (common after 10-15 years; 3 in 100 seen at 11 years), hip dislocation (1 in 20; common within first 6 weeks after operation), wear and tear (common in plastic hip socket), joint stiffening, nerve injury. Serious complications of a hip replacement such as blood clots and infection are uncommon (1 in 100). You should seek medical advice straight away if you have pain or swelling in your leg, chest pain or sudden breathlessness. You may be given antibiotics before your operation. This has been found to reduce the risk of your wound becoming infected after surgery. Surgery carries the risk of blood clot formation in a vein. You may be given injections, such as heparin (an anticoagulant, which reduces the ability of the blood to clot) and compression stocking to reduce the risk. Early mobilisation is encouraged to reduce the risk of blood clot in the vein, pressure sore and chest infection.

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The University of Manchester|W.L. Gan | 2012

Osteoporosis 

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Osteoporosis is a condition that affects the bones, causing them to become weak and fragile and more likely to break (fracture). Broken wrists, hips and spinal bones are the most common fractures in people with osteoporosis. Approximately 3 million people in the UK are thought to have osteoporosis. Women are at greater risk of developing osteoporosis than men. This is because changes in hormone levels can affect bone density. The female hormone oestrogen is essential for healthy bones. After the menopause, the level of oestrogen in the body falls, and this can lead to a rapid decrease in bone density.

Other factors that can increase the risk of osteoporosis and broken bones include:         

a family history of osteoporosis a parental history of hip fracture a low body mass index (BMI of 19kg/m2 or less) long-term use of high-dose corticosteroid treatment (widely used for conditions such as arthritis and asthma), which can affect bone strength heavy drinking and smoking rheumatoid arthritis malabsorption problems, as experienced in coeliac disease and Crohn's disease some drugs used in breast cancer and prostate cancer treatment which affect hormone levels long periods of inactivity, such as long-term bed rest

Medical Treatment o

Bisphosphonates

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Bisphosphonates work by slowing the rate at which the cells that break down bone (osteoclasts) work. This maintains bone density and reduces the risk of fracture. They are given as a tablet or as injection. Common side effects (I in 100 people) include diarrhoea, constipation, sickness, stomachache, headache, pain in the joints and muscles. The uncommon side effects (I in 1000 people) include irritation or ulceration of the oesophagus (foodpipe), problem or pain on swallowing, heartburn and stomach pain.

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One 5mg tablet should be taken once a day, preferably in the morning, at least 30 minutes before the first food, drink or medicine of the day. The tablet should be swallowed whole with a glass of plain water while you are sitting or standing in an upright position. Do not crush, chew or suck the tablet. You should not lie down for at least 30 minutes after taking the tablet. You should not eat or drink anything other than plain water for at least 30 minutes after taking the tablet. This is because food and some medicines can interfere with the absorption of the medicine from the gut and hence make it less effective. The University of Manchester|W.L. Gan | 2012

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o

Calcium and vitamin D supplements can benefit older men and women and reduce their risk of hip fracture.

Prevention   

regular weight bearing exercises maintain healthy and balanced diet (calcium and vitamin D) quit smoking and limit alcohol intake

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The University of Manchester|W.L. Gan | 2012

Gout 

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Gout is a common type of arthritis. The symptoms of gout include painful swelling and inflammation in one or more of the joints. Gout usually affects the big toe, but it can develop in any joint in the body. Gout is caused by a build-up of uric acid in the body. Uric acid is a waste product that is produced during the process of metabolism. Usually, uric acid is excreted by the kidneys. People whose kidneys do not excrete uric acid properly, or those who produce too much uric acid, can have high levels of uric acid in their blood. If the level becomes very high, crystals form in the joints. The crystals cause the joints to become inflamed and painful. Gout is one of the most common types of arthritis that affects men. It is estimated that 1% of all men in England will be affected by gout. Men are three to four times more likely to develop it. In men, the symptoms of gout usually begin between the ages of 40 and 60.

Risk factors for gout include    

drinking alcohol (particularly beer) diet that is high in purines (chemicals found in red meat and seafood) medications such as aspirin and diuretics family history

Treatment of gout aims to relieve the symptoms of a gout attack and to prevent further attacks from occurring. 

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Non-steroidal anti-inflammatory drugs (NSAIDs) are a type of painkiller usually recommended as an initial treatment to relieve the symptoms of gout by reducing the levels of pain and inflammation. NSAIDs must be avoided in people with reduced kidney function and only used with great care under medical direction in patients who have had problems with indigestion, stomach ulcers or bleeding. If you are unable or do not want to take NSAIDs, or if NSAIDs are ineffective at treating your symptoms, colchicine can be used instead. Colchicine works by interfering with the uric acid crystals to reduce inflammation. Side effects include nausea, vomiting and abdominal pain. If you experience two or more attacks of gout within a year, you will usually be prescribed a medication to help prevent further attacks. Allopurinol helps lower your uric acid levels by disrupting the enzyme responsible for converting purines into uric acid. However, allopurinol is not a painkiller and will have no effect during a gout attack. If you are prescribed allopurinol, you will have to take it once a day. It usually has to be taken for two to three months before you see any effects. A skin rash is the most common side effect of allopurinol (1 in 10 people). Lifestyle changes - Some foods are high in purines. Avoiding eating them can help reduce your risk of having a gout attack. Losing weight and limiting alcohol intake will help reduce your uric acid levels significantly.

The University of Manchester|W.L. Gan | 2012

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Prolapsed disc 

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The spine is made up of many bones called vertebrae. These are roughly circular and between each vertebra is a 'disc'. The discs are made of strong 'rubber-like' tissue which allows the spine to be fairly flexible. A disc has a stronger fibrous outer part, and a softer jelly-like middle part called the nucleus pulposus. The spinal cord, which contains the nerves that come from the brain, is protected by the spine. Nerves from the spinal cord come out from between the vertebrae to take and receive messages to various parts of the body. When you have a prolapsed disc, the inner softer part of the disc bulges out through a weakness in the outer part of the disc. The bulging disc may press on nearby structures such as a nerve coming from the spinal cord. Some inflammation also develops around the prolapsed part of the disc. Any disc in the spine can prolapse. However, most prolapsed discs occur in the lumbar part of the spine (lower back). The commonest age to develop a prolapsed disc is between 30 and 50 years. Twice as many men as women are affected. Factors that may increase the risk of developing a prolapsed disc include: a job involving lots of lifting, a job involving lots of sitting (especially driving), weight bearing sports (weight lifting, etc), smoking, obesity, and increasing age (a disc is more likely to develop a weakness with increasing age). The back pain is often severe, and usually comes on suddenly. The pain is usually eased by lying down flat, and is often made worse if you move your back, cough, or sneeze. You may feel pain down a leg to the calf or foot because the nerve coming from the spinal cord is pressed on by a prolapsed disc, or is irritated by the inflammation caused by the prolapsed disc. In most cases, the symptoms tend to improve over a few weeks. If you need painkillers, it is best to take them regularly. If you take them regularly the pain is more likely to be eased for much of the time and enable you to exercise and keep active. You are likely to recover more quickly and are less likely to develop chronic back pain if you keep active when you have back pain rather than rest a lot. In only about 1 in 10 cases is the pain still bad enough after six weeks to consider surgery. Cauda equina syndrome is a particularly serious type of nerve root problem that can be caused by a prolapsed disc. This is a rare disorder where the nerves at the very bottom of the spinal cord are pressed on. This syndrome can cause low back pain plus: problems with bowel and bladder function (usually unable to pass urine), numbness in the 'saddle' area (around the anus), and weakness in one or both legs. This syndrome needs urgent treatment to preserve the nerves to the bladder and bowel from becoming permanently damaged. See a doctor immediately if you develop these symptoms.

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The University of Manchester|W.L. Gan | 2012

Ankylosing Spondylitis  

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In ankylosing spondylitis, the spinal joints and ligaments and the sacroiliac joints become inflamed. Inflammation in the spine can cause pain and stiffness in the neck and back. Ankylosing spondylitis can develop at any time from the teenage years onwards. It is three times more common in men than in women. The condition usually occurs between 15 and 35 years of age, and rarely starts in old age. There is no cure for ankylosing spondylitis. Treatments are available which aim to relieve your symptoms, prevent your symptoms from interfering with your daily life and slow the process of stiffening of your spine. o o

o

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physiotherapy – where physical methods, such as massage and manipulation, are used to improve comfort and spinal flexibility medication – helps to relieve pain (NSAIDs, paracetamol, codeine) and control the symptoms (tumour necrosis factor blocker; corticosteroids; sulfasalazine and methotrexate for arthritis) Side effects from adalimumab and etanercept include reactions at the site of the injection, such as redness or swelling, infections, nausea (feeling sick), abdominal pain, headache

The progression of ankylosing spondylitis varies among people. It is estimated that 70-90% of people will remain independent and only minimally disabled by the condition. It is estimated that 4 in 10 people with ankylosing spondylitis will eventually have severely restricted spinal flexibility. Spinal deformities are likely to take at least 10 years to develop. In some people who have severe, long-standing ankylosis, their rib cage can also become stiff and inflexible. Research has shown that most people who have ankylosing spondylitis carry a particular gene known as human leukocyte antigen B27 (HLA-B27). Among people with ankylosing spondylitis, 9 out of 10 have HLA-B27. However, if you have the gene it does not necessarily mean that you will also have the condition. It is estimated that 8 in 100 people in the general population have the HLA-B27 gene but do not have ankylosing spondylitis. Ankylosing spondylitis can run in families, and the HLA-B27 gene can be inherited (passed on) from another family member.

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The University of Manchester|W.L. Gan | 2012