Category Archive Health A – Z

Dementia is a broad category of brain diseases that cause a long-term and often gradual decrease in the ability to think and remember that is great enough to affect a person’s daily functioning. Other common symptoms include emotional problems, problems with language, and a decrease in motivation. A person’s consciousness is usually not affected. A dementia diagnosis requires a change from a person’s usual mental functioning and a greater decline than one would expect due to aging. These diseases also have a significant effect on a person’s caregivers.

Types of Dementia

There are several types of dementia, including:

• Alzheimer’s disease – is characterized by “plaques” between the dying cells in the brain and “tangles” within the cells (both are due to protein abnormalities). The brain tissue in a person with Alzheimer’s has progressively fewer nerve cells and connections, and the total brain size shrinks.
• Dementia with Lewy bodies – is a neurodegenerative condition linked to abnormal structures in the brain. The brain changes involve a protein called alpha-synuclein.
• Mixed dementia – refers to a diagnosis of two or three types occurring together. For instance, a person may show both Alzheimer’s disease and vascular dementia at the same time.
• Parkinson’s disease – is also marked by the presence of Lewy bodies. Although Parkinson’s is often considered a disorder of movement, it can also lead to dementia symptoms.
• Huntington’s disease – is characterized by specific types of uncontrolled movements but also includes dementia.
• Lewy body dementia/Lewy body disease – is caused by Lewy bodies, which are abnormal clumps of certain proteins, accumulating inside of neurons. Forgetfulness and other signs of cognitive decline are the primary features of this condition, but patients can also develop prominent hallucinations which seem very real to them. Some patients with Lewy body disease develop symptoms which look like Parkinson’s disease, such as tremor and slowness.
• Creutzfeldt-Jakob disease – is a rare condition where an abnormal protein leads to the destruction of brain cells and dementia. While most cases occur without an underlying cause, in some patients there is a family history of this disorder. Even less often, patients might be exposed to the abnormal protein. Mad cow disease is one example of external exposure. This condition tends to progress rapidly, over only a few years and is often associated with abnormal muscle movements.
• Mixed dementia – refers to patients who have evidence of two (or more) types of dementia. They are often described as having mixed dementia. Alzheimer’s disease and vascular dementia are the most common causes of mixed dementia.
• Normal pressure hydrocephalus – is an abnormal enlargement of the ventricles, or fluid-filled spaces within the brain, that causes pressure on areas of the brain. This leads to problems with walking, memory, and ability to control urine flow
• Huntington’s disease – causes characteristic abnormal movements, called chorea, in affected individuals. The movements are the hallmark of the diagnosis. However, in some cases, problems with memory can precede the development of the chorea by many years.
• Alcoholic dementia – is caused when patients drink heavily and develop a deficiency in one of the B vitamins. When this happens, brain cells are unable to function normally and memory loss can occur. This is called Korsakoff syndrome. Although it is most commonly seen in alcoholics, patients who are malnourished from other causes are also at risk of developing this disorder.
• Traumatic brain injury (concussion)/dementia pugilistica – can lead to memory problems, as we have learned in recent years. In some cases, recurrent brain injuries or repeated concussions can contribute to the underlying changes identified in Alzheimer’s disease.
• Dementias caused by other conditions – can lead to changes within the brain and associated cognitive decline. These include Parkinson’s disease, HIV (AIDS), multiple sclerosis, Wilson’s disease, meningitis (infection of the brain coverings), blood clots in the brain, and heart attacks. Some patients with brain tumors may develop memory problems which resemble dementia

Other disorders leading to symptoms of dementia include

• Frontotemporal dementia – also known as Pick’s disease.
• Normal pressure hydrocephalus – when excess cerebrospinal fluid accumulates in the brain.
• Posterior cortical atrophy – resembles changes seen in Alzheimer’s disease but in a different part of the brain.
• Down syndrome – increases the likelihood of young-onset Alzheimer’s.

Symptoms of Dementia

• Recent memory loss – a sign of this might be asking the same question repeatedly.
• Difficulty completing familiar tasks – for example, making a drink or cooking a meal.
• Problems communicating – difficulty with language; forgetting simple words or using the wrong ones.
• Disorientation – getting lost on a previously familiar street, for example.
• Problems with abstract thinking – for instance, dealing with money.
• Misplacing things – forgetting the location of everyday items such as keys, or wallets, for example.
• Mood changes – sudden and unexplained changes in outlook or disposition.
• Personality changes – perhaps becoming irritable, suspicious or fearful.
• Loss of initiative – showing less interest in starting something or going somewhere.

Stages of Dementia

• Mild cognitive impairment – Characterized by general forgetfulness. This affects many people as they age but it only progresses to dementia for some.
• Mild dementia- people with mild dementia will experience cognitive impairments that occasionally impact their daily life. Symptoms include memory loss, confusion, personality changes, getting lost, and difficulty in planning and carrying out tasks.
• Moderate dementia- daily life becomes more challenging, and the individual may need more help. Symptoms are similar to mild dementia but increased. Individuals may need help getting dressed and combing their hair. They may also show significant changes in personality; for instance, becoming suspicious or agitated for no reason. There are also likely to be sleep disturbances.
• Severe dementia – at this stage, symptoms have worsened considerably. There may be a loss of ability to communicate, and the individual might need full-time care. Simple tasks, such as sitting and holding one’s head up become impossible. Bladder control may be lost.

Treatment of Dementia

Most medications used to treat difficult behaviors fall into one of the following categories:

Antipsychotics

These are medications originally developed to treat schizophrenia and other illnesses featuring psychosis symptoms.

Commonly used drugs

• Risperidone 
• Quetiapine
• Olanzapine
• Haloperidol
• For a longer list of antipsychotics drugs,

Usual effects – Most antipsychotics are sedating and will calm agitation or aggression through these sedating effects. Antipsychotics may also reduce true psychosis symptoms, such as delusions, hallucinations, or paranoid beliefs, but it’s rare for them to completely correct these in people with dementia.

Risks of use 

The risks of antipsychotics are related to how high the dose is, and include:

• Decreased cognitive function, and possible acceleration of cognitive decline
• Increased risk of falls
• Increased risk of stroke and of death; this has been estimated as an increased absolute risk of 1-4%
• A risk of side-effects known as “extrapyramidal symptoms,” which include stiffness and tremor similar to Parkinson’s disease, as well as a variety of other muscle coordination problems
• People with Lewy-body dementia or a history of Parkinsonism may be especially sensitive to antipsychotic side-effects; in such people, quetiapine is considered the safest choice

Evidence of clinical efficacy – Clinical trials often find a small improvement in symptoms. However, this is offset by frequent side-effects. Studies have also repeatedly found that using antipsychotics in older people with dementia is associated with a higher risk of stroke and of death.

Benzodiazepines – This is a category of medication that relaxes people fairly quickly. So these drugs are used for anxiety, for panic attacks, for sedation, and to treat insomnia. They can easily become habit-forming.

Commonly used drugs

• Lorazepam (brand name Ativan)
• Temazepam (brand name Restoril)
• Diazepam (brand name Valium)
• Alprazolam (brand name Xanax)

Usual effects – In the brain, benzodiazepines act similarly to alcohol, and they usually cause relaxation and sedation. Benzodiazepines vary in how long they last in the body: alprazolam is considered short-acting whereas diazepam is very long-acting.

Risks of use 

A major risk of these medications is that in people of all ages, they can easily cause both physical and psychological dependence. Additional risks that get worse in older adults include:

• Increased risk of falls
• Paradoxical agitation (some older adults become disinhibited or otherwise become more restless when given these drugs)
• Increased confusion
• Causing or worsening delirium
• Possible acceleration of cognitive decline

Stopping benzodiazepines suddenly can provoke life-threatening withdrawal symptoms, so medical supervision is mandatory when reducing this type of medication.

• Evidence of clinical efficacy – A recent review of clinical research concluded there is “limited evidence for clinical efficacy.” Although these drugs do have a noticeable effect when they are used, it’s not clear that they overall improve agitation and difficult behaviors in most people. It is also not clear that they work better than antipsychotics, for longer-term management of behavior problems.
• Mood-stabilizers – These include medications otherwise used for seizures. They generally reduce the “excitability” of brain cells.
• Commonly used drugs – Valproic acid (brand name Depakote) is the most commonly used medication of this type, in older adults with dementia. It is available in short- and long-acting formulations.
• Usual effects – The effect varies depending on the dose and the individual. It can be sedating.

Risks of use

 Valproic acid requires periodic monitoring of blood levels. Even when the blood level is considered within an acceptable range, side-effects in older adults are common and include:

• Confusion or worsened thinking
• Dizziness
• Difficulty walking or balancing
• Tremor and development of other Parkinsonism symptoms
• Gastrointestinal symptoms including nausea, vomiting, and/or diarrhea

Evidence of clinical efficacy

A review of randomized trials of valproate for agitation in dementia found no evidence of clinical efficacy, and described the rate of adverse effects as “unacceptable.” Despite this, some geriatric psychiatrists and other experts feel that valproate works well to improve behavior in certain people with dementia.

Anti-depressants  – Many of these have anti-anxiety benefits. However, they take weeks or even months to reach their full effect on depression or anxiety symptoms.

Commonly used drugs

Antidepressants often used in older people with dementia include

• Selective serotonin reuptake inhibitor (SSRI) antidepressants Citalopram, escitalopram, and sertraline (brand names Celexa, Lexapro, and Zoloft, respectively) are often used in Paroxetine (brand name Paxil) is another often-used SSRI, but as it is much more anticholinergic than the other SSRIs, geriatricians would avoid this medication in a person with dementia
• Mirtazapine (brand name Remeron) is an antidepressant that can increase appetite and sometimes increases sleepiness when given at bedtime
• Trazodone (brand name Desyrel) is a weak antidepressant that is sedating and is often used at bedtime to help improve sleep

Usual effects

The effects of these medications on agitation are variable. SSRIs may help some individuals, but it usually takes weeks or longer to see an effect. For some people, a sedating antidepressant at bedtime can improve sleep and this may reduce daytime irritability.

Risks of use

The anti-depressants listed above are generally “well-tolerated” by older adults, especially when started at low doses and with slow increases as needed. Risks and side-effects include:

• Nausea and gastrointestinal distress, especially when first starting or increasing doses (SSRIs)
• SSRIs may be activating in some people, which can worsen agitation or insomnia
• Citalopram (in doses higher than 20mg/day) can increase the risk of sudden cardiac arrest due to arrhythmia
• An increased risk of falls, especially with the more sedating antidepressants

Evidence of clinical efficacy

A 2014 randomized trial found that citalopram provided a modest improvement in neuropsychiatric symptoms; however, the dose used was 30mg/day, which has since been discouraged by the FDA. Otherwise, clinical studies find that antidepressants are not effective for reducing agitation.

Dementia drugs

These are the drugs FDA-approved to treat the memory and thinking problems associated with Alzheimer’s disease. In some patients, they seem to help with certain neuropsychiatric symptoms.

Practical tips on medications to manage difficult behaviors in dementia

You may be now wondering just how doctors are supposed to manage medications for difficult dementia behaviors.

Here are the key points that I usually share with families

• Before resorting to medication: it’s essential to try to identify what is triggering/worsening the behavior, and it’s important to try non-drug approaches, including exercise. Be sure to consider treating possible pain or constipation, as these are easily overlooked in people with dementia. Geriatricians often try scheduling acetaminophen 2-3 times daily, since people with dementia may not be able to articulate their pain. We also titrate laxatives to aim for a soft bowel movement every 1-2 days.

• No type of medication has been clinically shown to improve behavior for most people with dementia. If you try medication for this purpose, you should be prepared to do some trial-and-error, and it’s essential to carefully monitor how well the medication is working and what side-effects may be happening.

• Antipsychotics and benzodiazepines work fairly quickly, but most of the time they are working through sedation and chemical restraint. They tend to cloud thinking further. It is important to use the lowest possible dose of these medications.

• Benzodiazepines probably increase fall risk more than antipsychotics do, and are habit forming. They are also less likely to help with hallucinations, delusions, and paranoia. For these reasons, if a faster-acting medication is needed, geriatricians usually prefer antipsychotics to benzodiazepines.

• Antidepressants take a while to work, but are generally well-tolerated. Geriatricians often try escitalopram or citalopram in people with dementia.

• It is usually worth trying a dementia drug (such as a cholinesterase inhibitor or memantine) if the person is not already on these medications, as these drugs also tend to be well tolerated.

I admit that although studies find that non-drug methods are effective in improving dementia behaviors, it’s often challenging to implement them.

As for residential facilities for people with Alzheimer’s and other dementias, they vary in how well their staff are trained in non-drug approaches.

What you can do about medications and difficult dementia behaviors

If your relative with dementia is not yet taking medications for behaviors, consider these tips

• Start keeping a journal and learn to identify triggers of difficult behaviors. You will need to observe the person carefully. Your journaling will come in handy later if you start medications, as this will help you monitor for benefit and side-effects.

• Learn to redirect and de-escalate difficult dementia behaviors. Contact your local Alzheimer’s Association chapter or local Area Agency on Aging to find support near year.

• Ask your doctor to help assess for pain and/or constipation. Consider a trial of scheduled acetaminophen, and see if this helps.

• Consider the possibility of depression. Consider a trial of escitalopram or a related antidepressant, but realize any effect will take weeks to appear.

If the person is often very agitated, or very paranoid, or if otherwise, the behavioral symptoms are causing significant distress to the older person or to caregivers, it’s often reasonable to try an antipsychotic.

• Be sure to discuss the increased risk of stroke and death with the doctor and among family members. This can be a reasonable risk to accept, but it’s essential to be informed before proceeding.
• It’s best to start with the lowest dose possible.
• If there have been visual hallucinations or other signs of possible Lewy-Body dementia, quetiapine is usually the safest first choice.

For all medications for dementia behaviors:

• Monitor carefully for evidence of improvement and for signs of side-effects.
• Doses should be increased a little bit at a time.
• Especially for antipsychotics, the goal is to find the minimum necessary dose to keep behavior manageable.

References

Parkinson’s disease (PD) is a long-term degenerative disorder of the central nervous system that mainly affects the motor system. The symptoms generally come on slowly over time. Early in the disease, the most obvious are shaking, rigidity, slowness of movement, and difficulty with walking. Thinking and behavioral problems may also occur. Dementia becomes common in the advanced stages of the disease. Depression and anxiety are also commonly occurring in more than a third of people with PD. Other symptoms include sensory, sleep, and emotional problems. The main motor symptoms are collectively called parkinsonism or a parkinsonian syndrome.

Causes of Parkinson’s Disease

• Your genes – Researchers have identified specific genetic mutations that can cause Parkinson’s disease, but these are uncommon except in rare cases with many family members affected by Parkinson’s disease.
• Environmental triggers – Exposure to certain toxins or environmental factors may increase the risk of later Parkinson’s disease, but the risk is relatively small.
• The presence of Lewy bodies – Clumps of specific substances within brain cells are microscopic markers of Parkinson’s disease. These are called Lewy bodies, and researchers believe these Lewy bodies hold an important clue to the cause of Parkinson’s disease.
• Alpha-synuclein is found within Lewy bodies – Although many substances are found within Lewy bodies, scientists believe an important one is a natural and widespread protein called alpha-synuclein (A-synuclein). It’s found in all Lewy bodies in a clumped form that cells can’t break down. This is currently an important focus among Parkinson’s disease researchers.

Symptoms of Parkinson’s Disease

Primary symptoms include

• tremor,
• stiffness,
• slowness,
• impaired balance,
• and later on a shuffling gait.

Some secondary symptoms include

• anxiety,
• depression, and
• dementia.
• insecurity, and stress
• confusion, memory loss,(more common in elderly individuals)
• constipation
• difficulty swallowing and excessive salivation
• diminished sense of smell
• increased sweating
• male erectile dysfunction
• skin problems
• slowed, quieter speech, and monotone voice
• urinary frequency/urgency
• Most individuals with Parkinson’s disease are diagnosed when they are 60 years old or older, but early-onset Parkinson’s disease also occurs.

Symptom according to motor function

Motor symptoms

• Tremor
• Bradykinesia (slow movement)
• Rigidity and freezing in place
• Stooped posture
• Shuffling gait
• Decreased arm swing when walking
• Difficulty rising from a chair
• Micrographia (small, cramped handwriting)
• Lack of facial expression
• Slowed activities of daily living (for example, eating, dressing, and bathing)
• Difficulty turning in bed
• Remaining in a certain position for a long period of time

Nonmotor symptoms

• Diminished sense of smell
• Low voice volume (hypophonia)
• Difficulty speaking (dysarthria)
• Painful foot cramps
• Sleep disturbance
• Depression
• Emotional changes (fearful and insecure)
• Skin problems
• Constipation
• Drooling
• Increased sweating
• Urinary frequency/urgency
• Male erectile dysfunction

Several staging systems for Parkinson’s disease exist depending upon the organization that treats and researches the disease. The Parkinson’s Foundations supports five stages.

• Stage 1 – Symptoms are mild and do not interfere with the person’s quality of life.
• Stage 2 – Symptoms worsen and daily activities become more difficult and take more time to complete.
• Stage 3 – Is considered mid-stage Parkinson’s disease. The individual loses balance, moves more slowly, and falls are common. Symptoms impair daily activities, for example, dressing, eating, and brushing teeth.
• Stage 4 – Symptoms become severe and the individual needs assistance walking and performing daily activities.
• Stage 5 – Is the most advanced stage of Parkinson’s disease. The individual is unable to walk and will need full-time assistance with living.

With proper treatment, most individuals with Parkinson’s disease can lead long, productive lives for many years after diagnosis. The life expectancy is about the same as people without the disease.

Diagnosis of Parkinson’s Disease

Methods to assist with the diagnosis of PD include

• Neurological examination (including evaluation of symptoms and their severity)
• Trial test of drugs. When symptoms are significant, a trial test of drugs (primarily levodopa ) may be used to further diagnose the presence of PD. If a patient fails to benefit from levodopa, a diagnosis of Parkinson’s disease may be questionable.
• Computed tomography scan (also called a CT or CAT scan) – A diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general X-rays.
• Magnetic resonance imaging (MRI) – A diagnostic procedure that uses a combination of large magnets, radio frequencies, and a computer to produce detailed images of organs and structures within the body.

Treatments of Parkinson’s Disease

Symptomatic drug therapy

• Usually provides good control of motor signs of Parkinson disease for 4-6 years
• Levodopa/carbidopa – The gold standard of symptomatic treatment
• Monoamine oxidase (MAO)–B inhibitors – Can be considered for initial treatment of early disease
• Other dopamine agonists (eg, ropinirole, pramipexole) – Monotherapy in early disease and adjunctive therapy in moderate to advanced disease
• Anticholinergic agents (eg, trihexyphenidyl, benztropine) – Second-line drugs for tremor only

Treatment for nonmotor symptoms

• Sildenafil citrate – For erectile dysfunction
• Polyethylene glycol – For constipation
• Modafinil – For excessive daytime somnolence
• Methylphenidate – For fatigue (potential for abuse and addiction)

Deep brain stimulation

• The surgicall procedure of choice for Parkinson disease
• Does not involve the destruction of brain tissue
• Reversible
• Can be adjusted as the disease progresses or adverse events occur
• Bilateral procedures can be performed without a significant increase in adverse events

In 2010, the AAN released guidelines on the treatment of nonmotor symptoms of Parkinson disease. Recommendations included the following 

• Sildenafil citrate (Viagra) may be considered to treat erectile dysfunction
• Polyethylene glycol may be considered to treat constipation
• Modafinil should be considered for patients who subjectively experience excessive daytime somnolence
• For insomnia, the evidence is insufficient to support or refute the use of levodopa to improve objective sleep parameters that are not affected by motor symptoms; evidence is also insufficient to support or refute the use of melatonin for poor sleep quality
• Levodopa/carbidopa should be considered to treat periodic limb movements of sleep in Parkinson disease, but there are insufficient data to support or refute the use of nonergot dopamine agonists to treat this condition or that of the restless-legs syndrome
• methylphenidate may be considered for fatigue (note: methylphenidate has the potential for abuse and addiction)
• Evidence is insufficient to support or refute specific treatments of orthostatic hypotension, urinary incontinence, anxiety, and RMD

Others treatment

Leukorrhea or leucorrhoea is a thick whitish or yellowish white, sticky, foul-smelling material from the vagina is called Leucorrhoea. This common problem may occur due to unhygienic conditions, infection of the genital tract, or impaired immune function There are many causes of leukorrhea, the usual one being estrogen imbalance. The amount of discharge may increase due to vaginal infection or STDs, and it may disappear and reappear from time to time. This discharge can keep occurring for years, in which case it becomes more yellow and foul-smelling. It is usually a non-pathological symptom secondary to inflammatory conditions of vagina or cervix. Leukorrhea can be confirmed by finding >10 WBC under a microscope when examining vaginal fluid.

Types of Leukorrhea

Physiological leukorrhea

As stated above, this type of leukorrhea normally occurs in adolescents girls at puberty due to hormonal imbalance. This hormone imbalance may occur at the time of ovulation period, before periods and at onset and offset of periods. At this time, a normal vagina discharges slimy and excessive secretions and is a sign of puberty only. It is somewhat necessary for vaginal health and is not an issue of concern.

Pathological leukorrhea

It is also known as abnormal leukorrhea that occurs in a case of infections or diseases of female reproductive system. In this, the patient may suffer from abnormal, thick, and bloody discharge with a foul smell. It needs immediate medical treatment. You should follow personal hygiene strictly. This is a common symptom of vaginitis or cervicitis.

Infectious Leukorrhea

There are few reasons for infectious leukorrhea

• Candida albicans – is a fungus that can easily flourish in moist circumstances and is commonly promoted by synthetic undergarments and poor hygienic conditions.
• Trichomonas vaginalis – is a protozoan parasite that spreads usually through sexual intercourse and moist clothes.
• Gardnerella vaginalis and Chlamydia – are bacteria that are the main cause of bacterial infections. , it is frequently seen in venereal diseases like gonorrhea, syphilis, and AIDS.

Parasitic Leukorrhea

When leukorrhea is caused by trichomonads (protozoan), specifically Trichomonas vaginalis is known as parasitic leukorrhea. Some common symptoms of this disease are burning sensation, itching, and discharge of frothy substance, thick, white, or yellow mucous discharge from the vagina.

Sexually transmitted Leukorrhea

When leukorrhea and excessive discharge from vagina occur due to sexually transmitted disease is called as sexually transmitted leukorrhea. Vulvovaginal candidiasis is such sexually transmitted disease which is a common cause of vaginal discharge.

Stress-related Leukorrhea

Leukorrhea is a complicated issue and needs to be taken care of. Leukorrhea needs to be checked properly whether it occurred due to stress or not? Anxiety has lots of upsetting symptoms and is linked to women’s genital health that needs to be controlled to prevent future consequences.Anxiety and stress are known to create hormone imbalance, healthy bacteria removal, and disturbs immune system which may lead to vaginal discomfort. You can also take an anxiety symptoms test to see your anxiety severity score.

Cervical Leukorrhea

Leukorrhea is a condition of normal mucosal discharge from the vagina which is non-bloody. Sometimes, the discharge from vagina shows slight pathological changes due to malignancy, foreign bodies, constitutional diseases, cervical erosion, bacterial infection or pelvic infections

Causes of Leukorrhea

The causes for leucorrhea While there are a number of reasons for this condition, here are some of the most common ones:

• Unprotected sexual contact
• lack of nutrients
• Poor hygiene
• Injuries to the cervix or any of the tissues in the reproductive system during pregnancy
• Urinary tract infection
• Infections from bacteria, fungi or other parasites. Urinary tract infections are also very common female discharge causes.
• Injuries or trauma to the vagina, the womb or the cervix, which is very common during pregnancy
• Lack of cleanliness or poor hygienic measures
• Irritation from objects like an intrauterine contraceptive device
• The use of sprays, lubricants or jellies
• Contraceptives used by men or women which could cause irritation
• Other infections due to the presence of bacteria or fungi
• Irritation due to contraceptives that are inserted into the vagina
• Irritation due to external contraceptive used by either partners
• Diabetes or anemia
• In an easier and more understandable way, the cause of leucorrhoea has been described as under

A. General Causes

• Poor hygiene
• Malnutrition.
• Anaemia.
• Sedentary habits.
• Chronic illness.
• Excess of tea and coffee.
•  Alcohol.
• Occupation: women serving the whole day long.
• Constipation.
• Diabetes, 
• Intestinal worms in children.

B. Local Causes

• Poor hygiene
• Gonorrhea.
• Cervical erosion
• Displacements of uterus retroversion.
• Prolapsed of uterus.
• Cancer of all types.
• Leukoplakic vulvitis.
• Chronic salpingitis.

Cause of Leucorrhoea in Different Age Group

A. Before puberty

• Unhygienic conditions.
• Worms: oxyuris vermicularis or thread worms.
• Gonorrhoea.

B. Unmarried girls after puberty

• Bad hygienic conditions during menses or otherwise
• Constipation.
• Sedentary habits
• Anemia.
• Any long continued chronic disease.
• Congenital erosion of cervix.

C. In the married women

• Bad hygienic conditions.
• Gonorrhea
• Trichomonas vaginalis
• Displace uterus retroversion.
• Cancer of all types.
• Long continued use of pessaries.
• Chronic cervicitis or erosion.
• Repeated and excessive intercourse.
• Birth control measure.
• Chronic health.

D. After menopause

• Cancer of vulva.
• Cancer of uterus.
• Cancer of cervix.
• Leukoplakic vulvitis.
• Prolapse and decubitic ulcer.
• Gonorrhea.
• Chronic cervicitis.
• Trichomonas vaginalis
• Fungus infection

Symptoms of Leukorrhea

• Fatigue
• Stomach cramps or pain
• Headaches
• Constipation
• Pain in the calves and lumbar region
• Itching
• Pain in the lumbar region
• Thick or thin sticky discharge from the vagina which is white in color is one of the most obvious symptoms of leucorrhoea in young girls.
• When caused due to an infection, leucorrhoea in young girls is yellow in color and has a very foul smell.
• The young girl experiences soreness, swelling and excessive itching in the vagina along with leucorrhea.
• Headache and backache are another common symptom of leucorrhoea in young girls.
• Feeling weak and inactive is commonly seen in young girls having leucorrhea.
• Urination with a burning sensation can be associated with leucorrhoea in young girls.
• Calf and thigh muscles can pain immensely with vaginal discharge.
• Rashes can appear in the genital region with leucorrhea.
• Presence of white discharge on the inside of the undergarment may be noticed when young girls have leucorrhea.
• Irritation and itching in the genital area

Diagnosis of Leukorrhea

1. History

• Duration of the complaint.
• Fungus infection
• Trichomonas.
• Gonorrhea.
• Excessive intercourse
• About the discharge; character, modality etc.

1. 2. External examination — Examination of vulva: bartholin’s glands, urethra, etc.
2. 3. Special examinations

• Gonorrhea.
• Smears from urethra, vagina and cervix.
• Blood examination- CBC, ESR, Hb
• Urine examination.
• Blood pressure examination.
• Biopsy: for evidence of malignancy.
• For Trichomonas, the hanging drop method is done.
• Presence of bacteria: Leukorrhea diagnosis is confirmed by representing gram-negative, intracellular diplococci vaginal smears.
• Vulvar Itching: Leukorrhea, as well as yeast infections, can be suspected when patients complain of vulvar itching and a moderate vaginal discharge.
• Inflamed vagina: Leukorrhea can be diagnosed if the vagina is inflamed and discharge is acidic in nature.
• Wet smear identification: leukorrhea can be identified by wet smear identification of spores and mycelia; however, it is difficult to confirm the diagnosis.

Treatment of Leukorrhea

The treatment are following

• Allopathic remedies for Leucorrhea include – Nystatin, Natamycin, and Povidone.
• Antifungal vaginal cream or gel –  Ketoconazole, Fluconazole
• Anti protozoal drugs – Metronidazole,
• Anti hormonal drugs, Estrogen, – Tamoxifen 20 mg tablet {General Pharm Tamofen 20} – 20mg dailyin a single dosage or in 2 divided dosage. The maximum dosage are 40 mg in divided dosage. or raloxifene is altenate option.
• Anti depression drug – Escitalopram,Citalopram – Losita, Esita, Oxapro 10mg and 20mg in a signgle dosage in night continue 14 days to one month.

Nitric acid

Highly recommended in corrosive leucorrhoea; it is one of our best remedies, and one too often neglected. In fact, all of our remedies are prone to be neglected in leucorrhoea, and their place was taken by far less efficient local application. Nitric acid suits a greenish, fetid, obstinate leucorrhoea; the presence of fig warts and condylomata will further indicate the remedy.

OM 24

OM 24 is a unique combination of natural and advanced resonance homeopathic remedies. This natural supplementary product is traditionally believed to support your reproductive organs by administering Sarcodes (bioenergetic imprints) of ovarian and uterine tissues in an attempt to remind the body of optimal hormonal functions and balance estrogen levels.

Femiforte Tablets

Femiforte is a combination of various herbs that are traditionally believed to regulate the normal structure and functioning of the reproductive parts of the female and also improve energy and vitality. It is a useful tonic for the female reproductive organs.

Femiplex Gel

The Femiplex gel is a combination of time-tested ayurvedic herbs. The herbs are said to arrest excessive vaginal discharge and exert immunity-enhancing actions. Thus, this local application potentially helps improve the functions and immune levels of the female genital tract.

Home Remedies of of Leukorrhea

Banana

Banana is one of the most effective remedies for Leucorrhoea. Having one banana every day can be beneficial to your health. It is even better if you add butter to it. Banana helps the vagina in exuding the baleful microorganisms. This fruit takes active participation in vaginal disinfection. Banana is a healthy food to consume when it comes to cleansing your inner body.

Directions for Usage

• Ingest one or two ripe bananas every day.
• Add clarified butter to one ripe banana. Have it at least twice in a day for faster results.
• Add raw banana to your daily vegetable dishes.
• Have a mixture of fresh banana with Amla extract and sugar. You can add Jaggery for better results.

Lady’s Finger

Lady’s finger is beneficial to Leucorrhoea treatment. Lady’s fingers are of mucilaginous nature. This nature is helpful in removing mucus from your body. By extension, it also helps in decreasing the amount of vaginal secretion. However, just having Okra in your daily diet is not enough. For best results consume Okra extraction.

Directions for Usage

• Take a few ladyfingers and wash them thoroughly. Chop them into little pieces.
• Boil the chopped pieces for about 20 minutes. Wait till the water is decreased in half.
• Let the mixture cool down.
• Strain the extraction and take it twice or thrice every day.
• You may add sugar or honey for taste.

Fenugreek Seeds

Fenugreek seeds help cure some diseases that include Leucorrhoea. The seeds provide comfort to the mucous membranes. As a result, it is extremely useful in managing vaginal discharge. Fenugreek seeds also aid in swelling, irritation, pain, etcetera. It also sustains the pH level in your vagina. Hormonal changes can cause Leucorrhoea. In that case, Fenugreek seeds can help balance the amount of estrogen in your body. Follow the directions below to know more.

Directions for Usage

• Pour 3 to 4 cups of water in a bowl.
• Add 2-3 teaspoons of the seeds.
• Boil the water in medium flame for about 30 minutes.
• Let the water cool down.
• Strain it, and it’s ready to use.
• You can either drink the water or use it to wash your vagina.
• Use this on a daily basis till you get results.

Indian Gooseberry

Indian Gooseberry benefits your health in innumerable ways. It is rich in vitamin C. Vitamin C helps to have an active immunity system. As a result, your body becomes more capable of fighting of deadly microorganisms. Amla also contains antimicrobial features. The antimicrobial nature makes Amla the best organic disinfectant for your body. It can cleanse your entire inner body and go in infection-free. Amla can be taken in some ways.

Directions for Usage

• Take 1-2 teaspoons of Amla powder in a bowl and add a little honey.
• Mix it into a paste and consume it twice, daily or else, you can take one cup full of water. Add a teaspoon of powder.
• Boil till the water is decreased in half.
• Add honey or sugar for taste.
• Drink the water every morning with an empty tummy.

Pomegranate

Pomegranates contain therapeutic features. It helps in driving away the infection from your body. The leaves, fruit and the rind of pomegranate are effective in curing Leucorrhoea. Pomegranate is also very beneficial to your skin. There are ways to consume pomegranate to cure Leucorrhoea.

Directions for Usage

• Drink a glass full of pomegranate juice every day for at least a month.
• Take about 30 pomegranate leaves and add 8 to 10 black pepper.
• Grind it.
• Take half a glass of water.
• Add the ground mixture.
• Strain it and drink it twice daily continue until you notice results.
• Make a powder of the dried pomegranate rinds.
• Take 3 to 4 cups of water in a bowl.
• Add the maximum one tablespoon of the powder in it.
• Spray the solution on your vagina every day.

Cranberry

Cranberry is a package of antioxidants, antimicrobials, and antifungal. These are the properties needed to cure Leucorrhoea. Cranberry consumption can help speed up the process. It removes the bacteria from the wall of the vagina. It keeps the vagina clean, internally.

Directions for Usage

• Make juice out of fresh cranberries.
• Drink the juice twice to thrice a day.

Fig Tree Bark

Figs have laxative properties that help in removing toxins from the body. It also eliminates the waste materials of your body.

Directions for Usage

• Put 5 to 6 figs in a cup of water and soak it overnight.
• Next morning, add water to the figs you soaked and blend it.
• Drink the solution in an empty tummy.
• Or take the bark of the banyan and the fig tree. Grind in the same measurement and make a powder.
• Take three cups of water.
• Add half to one tablespoon of the powder.
• Wash your vagina with the solution on a daily basis for the best results.

Cumin Seeds

Cumin seeds are one of those ingredients that can treat vaginal discharge within a fluke.  Along with it, honey is one of the best elements that can make any woman leave a sigh of relief.

Directions for usage

It is recommended to add a thick mixture of ground cumin seeds and honey around the vulva. It can be washed after the mixture stays for few minutes. Consuming cumin water is another adequate remedy.

Sandalwood Oil

Sandalwood contains anti-infective properties that make it one of the essential oils for offering relief from leucorrhoea. Applying few drops of the oil around the vaginal wall two times in a day is recommended.

Guava Leaves

Another natural home remedy to choose while treating leucorrhoea are Guava leaves. Guava leaves when put inside water and seethed for thirty minutes prove to be effective. It needs to be strained and utilized two times on a regular basis as a sponge over the vulva. With time, the indications will vanish.

Rice Water

Being filled with starch, rice water is equipped with demulcent properties that will heal itching and soreness around the vagina.

Directions for usage

After the rice is washed, the water is strained and adding honey is suggested for making it sweet. Drinking the solution regularly will offer women with relief from itchiness and weakness.

Betel Nut

When it comes to a natural cure, then this is one of the most significant ingredients. One way to consume is to crush Areca Nut (Supari) or Betel Nuts and dried petals of rose as well after accumulating a little amount of sugar candy.

Future occurrence of the disease can be prevented. Betel nut can be chewed after the completion of every meal.

Walnut Leaves

Vaginal infections can be treated in the best possible manner with walnut leaves that contain antifungal properties. Walnut leaves need to be boiled for full twenty minutes and strained. It then becomes like a sponge that needs to be used on the vaginal area three times every day till the itchiness fades away.

Coriander Seeds

This is a highly active ingredient for treating vaginal discharge. Overnight soaking of coriander seeds is the first step. After straining the water has to be consumed when the stomach is empty. Positive results are bound to occur after a week.

Neem

The natural and available herb if consumed on a regular basis, detoxifies the body and helps to solve all issues. It also possesses- pure ingredients, often boosts immunity. Helps to cure dryness and irritation around private parts.

Directions for usage

• Take 2 to 3 neem leaf and grind well.
• Add cumin seeds to it and make a paste of it.
• Consume till three weeks and see the difference.
• Regular drinking of cow milk with few drops of neem oil can also prove to be beneficial.

Aloe Vera

This plant is not only placed at home as a decorative plant but possesses nutrients that treat issues that women face. It is the traditional way of mending problems of leucorrhoea. This is because of its consumption tones up uterine tissues, leaving the part clean and clear.

Directions for usage

• Cut the plant into two halves.
• Wash the same in running water till the bitter part is well washed off.
• Peel off the flesh and add cumin powder to it.
• Let it soak for 3 hours.
• Finally, make juice of this.
• Consume regularly to clear many problems apart from this.

Basil Leaves

This plant or leaves is not only famous for its religious value. It possesses high medicinal importance too – as this prevents one to minimize leucorrhoea faster than other herbs.

Directions for usage

• Take appropriate amount of Basil Leaf and make a paste out of it.
• Add honey to the paste and consume daily for about 2 to 3 weeks continuously.
• This leaf can be well consumed with Milk – everyday consumption would lead to the eradication of the problem.

Dry Ginger

The ground ginger is most useful as the home remedy for treating leucorrhoea. It helps to reduce mucus from the body and finally relieves the issues persisting in the body.

Directions for usage

• Take the dry powder of ginger – boil the same till the residue deposits at the bottom.
• Drink the water for about three weeks and finally get rid of leucorrhoea.

Some additional tips to cure Leucorrhoea are

• Maintain adequately clean hygiene. The genital region should be of paramount consideration.
• Hydrotherapy or Cold-water bath is an efficient way to increase blood circulation in the genital region. The cold water helps lessen the obstruction in your pelvic area. Hydrotherapy on a daily basis can help speed up the process of curing Leucorrhoea.
• Exercise can cure most of the disorders in your body. Exercise also boosts your immunity system to fight off the harmful substances from entering your body. Exercise mains the regularity in blood circulation as well. So, working out daily can have an immense impact on your entire bodily functions.
• Aromatherapy can also be helpful in this situation. Oils extracted from sandalwood, oregano or rosemary is a beneficial remedy for Leucorrhoea. Make sure the oils are anti-infective before you use them.
• Proper rest and sufficient sleep can also provide you with quicker results.
• Drink herbal tea with blackberry or sage leaves to ease the treatment.
• Avoid using deodorants, soaps, sprays, tampons or sanitary napkins during the procedure.
• Change your underwear at least twice every day.
• Use clean and dry undergarments.
• Avoid synthetic and tight underwear.
• Wash your genital area frequently with fresh water.
• Wipe the entire region properly.

Food to Stay Away from

• Some food items can aggravate your situation if taken during the treatment.
• Do not consume any spicy food.
• Avoid deep-fried food.
• Do not eat anything prepared with white flour.
• Stay away from products with white sugar.
• Avoid drinking coffee, regular tea or any other aerated condiments.
• Quit drinking alcohol.
• Do not eat canned or tinned edibles.

Other recommendations for the treatment of leucorrhoea

• Maintain good hygiene, especially in the genital areas to prevent any bacterial infections.
• Hydrotherapy/ Hip bath/Cold sitz bath is effective in increasing blood circulation in the vagina. Coldwater bath also helps relieve congestion in the pelvic region. Take daily hydrotherapy to speed up healing.
• Exercise regime helps in the treatment of leucorrhoea. Exercises improve blood circulation and build immunity to bacterial attacks.
• Aromatherapy with anti-infective essential oils of rosemary, oregano, and sandalwood is an effective natural cure for Leucorrhoea
• Adequate sleep and rest facilitate faster healing.
• Herbal tea such as green tea blended with sage or blackberry leaves facilitates in treatment.
• Avoid sanitary napkins, deodorants, sprays, and other irritants during treatment as they can aggravate leucorrhoea.

In order to treat leukorrhea, consumption of fruits and vegetables is very necessary. Some leukorrhea food include

• Bananas
• Cranberries
• Oranges & Lemons
• Black plums
• Okra
• Leafy green and onions
• Broun rice
• Yoghurt

Spices include: Ginger, garlic, fenugreek, and coriender.

Homeopathic management of leucorrhea

• Calcarea carbonica – indicated by its general symptoms, prominent complaint of this remedy is morning affections, these are morning hunger, acidity of the stomach, cold and damp feet. It corresponds especially to scrofulous person with enlarged cervical glands.
• Sulfur – is another remedy suitable to scrofulous subjects; it has a leucorrhoea which makes the parts sore. It is rather indicated by the general than local symptoms.
• Caulophyllum – has leucorrhoea in little girls which is very profuse and weakness the child very much.
• Calcaria phosphoric – is a fine remedy in the scrofulous diathesis; it has a profuse milky bland leucorrhoea.
• Pulsatilla produces and cures a milky leucorrhoea which becomes watery, acrid, and burning from being retained in the vagina. mucous, thick, creamy, white leucorrhoea sometimes replacing menses, with chilliness, disposition to lie down, and lowness of spirits. It corresponds to a disposition to leucorrhoea and suits leucorrhoea in chlorotic subjects.
• Helonin – For profuse, yellow, thick leucorrhoea with some irritation and itching, in anemic sallow patients with much prostration and general debility, worse from slight colds and excretion, it is the most useful remedy.
• Lilium TIg – has an excoriating, watery, yellowish, or yellowish-brown leucorrhoea, which is profuse and is accompanied by a depression of spirits and bearing down in the pelvic region.
• Hydrastis – suits a tenacious, thick, ropy leucorrhoea with the erosion of the cervix; a mucous leucorrhoea which is profuse and debilitating corresponds to Hydrastis.
• Sepia – Cures a leucorrhoea which is of yellowish-green color, somewhat offensive and often excoriating, due to pelvic congestion of a passive type, milky, worse before menses with bearing down; there are pains in the abdomen and pruritis.
• Kali Bich has a yellow, ropy, stringy leucorrhoea. It is suitable to fat, light-haired persons.
• Kreosote – few medicines have the same power in leucorrhoea as Kreosote. It cures a profuse watery, sometimes a yellowish leucorrhoea. The acridity is marked; it causes excoriation of the parts which come in contact with it, causes soreness and smarting and red spots and itching on the vulva, always with great debility; leucorrhoea preceding menses. It is so acrid that it causes the pudenda and things to swell and itch.

Prevention

There are many precautions that a woman must take in order to prevent leukorrhea. Some of these are as follows:

Washing the genital area with normal water is very important to maintain hygiene conditions. After washing proper drying is also very necessary to avoid retention of any kind of moisture in that area.

• Never use any kind of soap for cleaning the vagina, as soaps can disturb the pH of vagina which is one of the main causes of leukorrhea. Plain water or mild intimate washes are recommended.
• Change your clothing right away in case you get wet in rain.
• Plenty of water is the key to get rid of leukorrhea, as it will flushes out the toxins from the body.
• Cotton clothing is always preferable over nylon clothing, as cotton panties allow the skin to breathe and it do not retain any sweat.
• Engage in a sexual activity only if your partner is completely free from any kind of infection.
• Wash your undergarments only with antibiotic solution and let them dry under the sun.

References

Asthma is a common long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath. These episodes may occur a few times a day or a few times per week. Depending on the person, they may become worse at night or with exercise.

Asthma is a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and an underlying inflammation [Rx]. The interaction of these features of asthma determines the clinical manifestations and severity of asthma [Rx] and the response to treatment.

Asthma is a common chronic disorder of the airways that involves a complex interaction of airflow obstruction, bronchial hyperresponsiveness and an underlying inflammation. This interaction can be highly variable among patients and within patients over time. This section presents a definition of asthma, a description of the processes on which that definition is based—the pathophysiology and pathogenesis of asthma, and the natural history of asthma.

Epidemiology

According to a report from the Centers for Disease Control and Prevention (CDC), 1 in 13 people has asthma. It affects 25.7 million Americans, including 7.0 million children younger than 18 years. It is a significant health and economic burden on patients, families, and society. Important epidemiologic issues include:

• In 2010, 1.8 million people visited an emergency room for asthma-related care, and 439,000 people were hospitalized because of asthma.
• The most recent data obtained from the CDC shows prevalence in males at about 6.5% and in females about 9.1%.
• Regarding race distribution, the prevalence is 7.8% in the white population, 10.3% in the black community and 6.6% in the Hispanic population.
• WHO estimates that 235 million people currently have asthma.
• The annual incidence of occupational asthma ranges from 12 to 170 cases per million worked. The prevalence is reported at 5% to 15% across many different industries.
• Asthma is the most common noncommunicable disease among children.
• Most deaths occur in older adults.

Types of Asthma

• Allergic (extrinsic) – Your doctor may refer to asthma as being “extrinsic” or “intrinsic.” A better understanding of the nature of asthma can help explain the differences between them. Extrinsic, or allergic asthma, is more common and typically develops in childhood. Approximately 70%-80% of children with asthma also have documented allergies. Typically, there is a family history of allergies. Additionally, other allergic conditions, such as nasal allergies or eczema, are often also present. Allergic asthma often goes into remission in early adulthood. However, in many cases, the asthma reappears later.
• Nonallergic (intrinsic) asthma – Intrinsic asthma represents a small amount of all cases. It usually develops after the age of 30 and is not typically associated with allergies. Women are more frequently affected and many cases seem to follow a respiratory tract infection. Obesity also appears to be a risk factor for this type of asthma. Intrinsic asthma can be difficult to treat and symptoms are often chronic and year-round.

Or

Depending on the type of trigger, doctors classify asthma as being either allergic or non-allergic.

• Allergic asthma – is also called “extrinsic asthma” because the trigger comes from outside the body and is breathed in with the air. Different people may have reactions to very different types of triggers, including cigarette smoke (active and passive smoking), plant pollen, animal fur, dust mite excrement, and some kinds of food as well as cold air, perfume, exhaust fumes and certain chemicals.
• Non-allergic asthma –  (also called “intrinsic asthma”) is caused by triggers that come from inside the body. These triggers include bacterial and viral inflammations of the airways in particular. Sometimes taking certain kinds of painkillers causes asthma. These painkillers include acetylsalicylic acid (ASA, the drug in medicines like Aspirin) and other non-steroidal anti-inflammatory drugs (NSAIDs). In some people, physical or emotional stress that makes them breathe faster can also trigger asthma symptoms.

According to the severity

• Mild intermittent – This includes attacks no more than twice a week and nighttime attacks no more than twice a month. Attacks last no more than a few hours to days. Severity of attacks varies, but there are no symptoms between attacks.
• Mild persistent – This includes attacks more than twice a week, but not every day, and nighttime symptoms more than twice a month. Attacks are sometimes severe enough to interrupt regular activities.
• Moderate persistent – This includes daily attacks and nighttime symptoms more than once a week. More severe attacks occur at least twice a week and may last for days. Attacks require daily use of quick-relief (rescue) medication and changes in daily activities.
• Severe persistent – This includes frequent severe attacks, continual daytime symptoms, and frequent nighttime symptoms. Symptoms require limits on daily activities.

Others Types of Asthma

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Asthma exacerbation

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An acute asthma exacerbation is commonly referred to as an asthma attack. The classic symptoms are shortness of breath, wheezing, and chest tightness. The wheezing is most often when breathing out. While these are the primary symptoms of asthma, some people present primarily with coughing, and in severe cases, air motion may be significantly impaired such that no wheezing is heard.In children, chest pain is often present.

Signs occurring during an asthma attack include the use of accessory muscles of respiration (sternocleidomastoid and scalene muscles of the neck), there may be a paradoxical pulse (a pulse that is weaker during inhalation and stronger during exhalation), and over-inflation of the chest. A blue color of the skin and nails may occur from lack of oxygen.

In a mild exacerbation the peak expiratory flow rate (PEFR) is ≥200 L/min, or ≥50% of the predicted best. Moderate is defined as between 80 and 200 L/min, or 25% and 50% of the predicted best, while severe is defined as ≤ 80 L/min, or ≤25% of the predicted best.

• Acute severe asthma – previously known as status asthmaticus, is an acute exacerbation of asthma that does not respond to standard treatments of bronchodilators and corticosteroids. Half of cases are due to infections with others caused by allergen, air pollution, or insufficient or inappropriate medication use.
• Brittle asthma – is a kind of asthma distinguishable by recurrent, severe attacks. Type 1 brittle asthma is a disease with wide peak flow variability, despite intense medication. Type 2 brittle asthma is background well-controlled asthma with sudden severe exacerbations.
• Exercise-induced – Exercise can trigger bronchoconstriction both in people with or without asthma.It occurs in most people with asthma and up to 20% of people without asthma. Exercise-induced bronchoconstriction is common in professional athletes. The highest rates are among cyclists (up to 45%), swimmers, and cross-country skiers. While it may occur with any weather conditions, it is more common when it is dry and cold.Inhaled beta2-agonists do not appear to improve athletic performance among those without asthma, however, oral doses may improve endurance and strength.
• Occupational – Asthma as a result of (or worsened by) workplace exposures is a commonly reported occupational disease. Many cases, however, are not reported or recognized as such. It is estimated that 5–25% of asthma cases in adults are work-related. A few hundred different agents have been implicated, with the most common being: isocyanates, grain and wood dust, colophony, soldering flux, latex, animals, and aldehydes. The employment associated with the highest risk of problems include: those who spray paint, bakers and those who process food, nurses, chemical workers, those who work with animals, welders, hairdressers and timber workers.
• Aspirin-induced asthma – Aspirin-exacerbated respiratory disease, also known as aspirin-induced asthma, affects up to 9% of asthmatics. Reactions may also occur to other NSAIDs. People affected often also have trouble with nasal polyps. In people who are affected, low doses paracetamol or COX-2 inhibitors are generally safe.
• Alcohol-induced asthma – Alcohol may worsen asthmatic symptoms in up to a third of people.This may be even more common in some ethnic groups such as the Japanese and those with aspirin-induced asthma. Other studies have found improvement in asthmatic symptoms from alcohol.
• Nonallergic asthma – Nonallergic asthma, also known as intrinsic or nonatopic asthma, makes up between 10 and 33% of cases. There is negative skin test to common inhalant allergens and normal serum concentrations of IgE. Often it starts later in life, and women are more commonly affected than men. Usual treatments may not work as well

Phenotypes

Owing to the heterogeneity of the disease, a number of different phenotypes can be described. Distinguishing between them can be particularly relevant to the therapy in severe cases:

• Allergic asthma
• Nonallergic asthma
• Pediatric asthma/recurrent obstructive bronchitis
• Late-onset asthma
• Asthma with fixed airflow obstruction
• Obesity asthma
• Occupational asthma
• Asthma in the elderly
• Severe asthma

Classifications by other professional associations (ERS/ATS, European Respiratory Society/American Thoracic Society) tend to focus more on a combination of clinical and pathophysiological aspects (e. g., eosinophilic/neutrophilic asthma, severe allergic asthma etc.)

Causes of Asthma

Asthma triggers are different from person to person and can include:

• Airborne substances, such as pollen, dust mites, mold spores, pet dander or particles of cockroach waste
• Respiratory infections, such as the common cold
• Physical activity (exercise-induced asthma)
• Cold air
• Air pollutants and irritants, such as smoke
• Certain medications, including beta blockers, aspirin, ibuprofen and naproxen 
• Strong emotions and stress
• Sulfites and preservatives added to some types of foods and beverages, including shrimp, dried fruit, processed potatoes, beer and wine
• Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up into your throat
• Asthma is a chronic inflammatory disorder of the airways. This feature of asthma has implications for the diagnosis, management, and potential prevention of the disease.
• The immunohistopathologic features of asthma include inflammatory cell infiltration:
  • Neutrophils (especially in sudden-onset, fatal asthma exacerbations; occupational asthma, and patients who smoke)
  • Eosinophils
  • Lymphocytes
  • Mast cell activation
  • Epithelial cell injury

• Airway inflammation contributes to airway hyperresponsiveness, airflow limitation, respiratory symptoms, and disease chronicity.
• In some patients, persistent changes in airway structure occur, including sub-basement fibrosis, mucus hypersecretion, injury to epithelial cells, smooth muscle hypertrophy, and angiogenesis.
• Gene-by-environment interactions are important to the expression of asthma.
• Atopy, the genetic predisposition for the development of an immunoglobulin E (IgE)-mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma.
• Viral respiratory infections are one of the most important causes of asthma exacerbation and may also contribute to the development of asthma.

Sign Symptoms of Asthma

Early warning signs of asthma include. Intermittent and variable (may also be absent, e.g., during symptom-free intervals or in mild disease)

• Shortness of breath (often in acute episodes)
• Expiratory wheezes
• Chest pressure sensation
• Cough
• Frequent cough, especially at night
• Losing your breath easily or shortness of breath
• Feeling very tired or weak when exercising
• Wheezing or coughing after exercise
• Feeling tired, easily upset, grouchy, or moody
• Decreases or changes in lung function as measured on a peak flow meter
• Signs of a cold or allergies (sneezing, runny nose, cough, nasal congestion, sore throat, and headache)
• Trouble sleeping

Common signs and symptoms of asthma include

• Coughing – Coughing from asthma often is worse at night or early in the morning, making it hard to sleep.
• Wheezing – Wheezing is a whistling or squeaky sound that occurs when you breathe.
• Chest tightness – This may feel like something is squeezing or sitting on your chest.
• Shortness of breath – Some people who have asthma say they can’t catch their breath or they feel out of breath. You may feel like you can’t get air out of your lungs.
• Increasing difficulty breathing – (measurable with a peak flow meter, a device used to check how well your lungs are working)
• Exercise-induced asthma – which may be worse when the air is cold and dry
• Occupational asthma – triggered by workplace irritants such as chemical fumes, gases or dust
• Allergy-induced asthma – triggered by airborne substances, such as pollen, mold spores, cockroach waste or particles of skin and dried saliva shed by pets (pet dander)
• Shortness of breath
• Trouble sleeping caused by shortness of breath, coughing or wheezing
• A whistling or wheezing sound when exhaling (wheezing is a common sign of asthma in children)
• Coughing or wheezing attacks that are worsened by a respiratory virus, such as a cold or the flu

Other symptoms of an asthma attack include

• Severe wheezing when breathing both in and out
• Coughing that won’t stop
• Very rapid breathing
• Chest pain or pressure
• Tightened neck and chest muscles, called retractions
• Difficulty talking
• Feelings of anxiety or panic
• Pale, sweaty face
• Blue lips or fingernails

Diagnosis of Asthma

You may also be given lung (pulmonary) function tests to determine how much air moves in and out as you breathe. These tests may include:

• Spirometry – This test estimates the narrowing of your bronchial tubes by checking how much air you can exhale after a deep breath and how fast you can breathe out.
• Peak flow – A peak flow meter is a simple device that measures how hard you can breathe out. Lower than usual peak flow readings are a sign your lungs may not be working as well and that your asthma may be getting worse. Your doctor will give you instructions on how to track and deal with low peak flow readings.

Additional tests of Asthma

Other tests to diagnose asthma include

• Methacholine challenge – Methacholine is a known asthma trigger that, when inhaled, will cause mild constriction of your airways. If you react to the methacholine, you likely have asthma. This test may be used even if your initial lung function test is normal.
• Imaging tests – A chest X-ray and high-resolution computerized tomography (CT) scan of your lungs and nose cavities (sinuses) can identify any structural abnormalities or diseases (such as infection) that can cause or aggravate breathing problems.
• Allergy testing – This can be performed by a skin test or blood test. Allergy tests can identify allergy to pets, dust, mold and pollen. If important allergy triggers are identified, this can lead to a recommendation for allergen immunotherapy.
• Sputum eosinophils – This test looks for certain white blood cells (eosinophils) in the mixture of saliva and mucus (sputum) you discharge during coughing. Eosinophils are present when symptoms develop and become visible when stained with a rose-colored dye (eosin).
• Provocative testing for exercise and cold-induced asthma – In these tests, your doctor measures your airway obstruction before and after you perform vigorous physical activity or take several breaths of cold air.

Treatment of Asthma

The goals of pharmacotherapy are the suppression of the inflammation of asthma and the reduction of bronchial hyperreactivity and airway obstruction. The medications used for these purposes belong to two groups:

• Relievers (medications taken for symptomatic relief as necessary) include mainly the inhaled, rapidly-acting beta2 sympathomimetic agents, e.g., the short-acting drugs salbutamol, fenoterol, and terbutaline and the long-acting drug formoterol. Inhaled anticholinergic drugs and rapidly-acting theophylline (solution or drops) play a secondary role as relievers.
• Controllers (medications used for preventive, maintenance therapy) include the inhaled corticosteroids (ICS), inhaled long-acting beta2 agonists (LABA) such as formoterol or salmeterol, montelukast, and delayed-release theophylline preparations.

Formoterol can be used as a reliever because of its rapid onset of action or as a controller in combination with corticosteroids.

Medications

Medications used to treat asthma are divided into two general classes: quick-relief medications used to treat acute symptoms; and long-term control medications used to prevent further exacerbation. Antibiotics are generally not needed for sudden worsening of symptoms.

Step-Up Therapy: The Goal of Asthma Control

• Step 1 – For intermittent asthma, preferred therapy is a short-acting inhaled beta2 agonist. For persistent asthma, daily medication is recommended.
• Step 2 – Preferred treatment is a low-dose inhaled corticosteroid.
• Step 3 – A low dose inhaled corticosteroid plus a long-acting inhaled beta2 agonist is recommended, or a medium-dose inhaled corticosteroid.
• Step 4 – The preferred treatment is a medium-dose inhaled corticosteroid plus a long-acting beta2 agonist.
• Step 5 – The preferred treatment is high dose inhaled corticosteroid plus a long-acting beta2 agonist and considering omalizumab for people with allergies.
• Step 6 –The preferred treatment is high-dose inhaled corticosteroid plus a long-acting beta2 agonist plus an oral corticosteroid; consider omalizumab with people with allergies.

For steps 2 to 4, also consider allergy immunotherapy and allergy testing. Leukotriene receptor antagonists, cromolyn sodium, and theophylline can be used as alternative treatments but not preferred agents. Leukotriene inhibitors have shown to improve exercise-induced asthma by 50% for children 12 and older.

Fast–acting

• Short-acting beta₂-adrenoceptor agonists (SABA), such as salbutamol (albuterol USAN) are the first line of treatment for asthma symptoms. They are recommended before exercise in those with exercise induced symptoms.
• Anticholinergic medications, such as ipratropium bromide, provide additional benefit when used in combination with SABA in those with moderate or severe symptoms. Anticholinergic bronchodilators can also be used if a person cannot tolerate a SABA. If a child requires admission to hospital additional ipratropium does not appear to help over a SABA.
• Older, less selective adrenergic agonists, such as inhaled epinephrine, have similar efficacy to SABAs.They are however not recommended due to concerns regarding excessive cardiac stimulation.
• Combination of inhaled anticholinergic and beta2 agonist which have been shown to decrease hospitalization of school-aged children
• Intravenous magnesium sulfate has also been shown to increase lung function and decrease hospitalization in children
• Administering systemic corticosteroids within one hour of an emergency room or urgent care presentation has a significant effect on patients with severe exacerbation and also decreases hospitalization
• Patients should be sent home on oral prednisone after an acute hospitalization [rx]

Long–term control

• Corticosteroids – are generally considered the most effective treatment available for long-term control. Inhaled forms such as beclomethasone are usually used except in the case of severe persistent disease, in which oral corticosteroids may be needed. It is usually recommended that inhaled formulations be used once or twice daily, depending on the severity of symptoms.
• Long-acting beta-adrenoceptor agonists – (LABA) such as salmeterol and formoterol can improve asthma control, at least in adults, when given in combination with inhaled corticosteroids. In children this benefit is uncertain. When used without steroids they increase the risk of severe side-effects, and with corticosteroids, they may slightly increase the risk. Evidence suggests that for children who have persistent asthma, a treatment regime that includes LABA added to inhaled corticosteroids may improve lung function but does not reduce the amount of serious exacerbations. Children who require LABA as part of their asthma treatment may need to go to the hospital more frequently.
• Leukotriene receptor antagonists – (anti-leukotriene agents such as montelukast and zafirlukast) may be used in addition to inhaled corticosteroids, typically also in conjunction with a LABA. Evidence is insufficient to support use in acute exacerbations. For adults or adolescents who have persistent asthma that is not controlled very well, the addition of anti-leukotriene agents along with daily inhaled corticosteriods improves lung function and reduces the risk of moderate and severe asthma exacerbations. Anti-leukotriene agents may be effective alone for adolescents and adults, however, there is no clear research suggesting which people with asthma would benefit from anti-leukotriene receptor alone. In those under five years of age, anti-leukotriene agents were the preferred add-on therapy after inhaled corticosteroids by the British Thoracic Society in 2009. A 2013 Cochrane systematic review concluded that anti-leukotriene agents appear to be of little benefit when added to inhaled steroids for treating children. A similar class of drugs, 5-LOX inhibitors, may be used as an alternative in the chronic treatment of mild to moderate asthma among older children and adults. As of 2013 there is one medication in this family known as zileuton.
• aminophylline – Intravenous administration of the drug does not provide an improvement in bronchodilation when compared to standard inhaled beta-2 agonist treatment. Aminophylline treatment is associated with more adverse effects compared to inhaled beta-2 agonist treatment.
• Mast cell stabilizers – (such as cromolyn sodium) are another non-preferred alternative to corticosteroids.
• For children with asthma which is well-controlled on combination therapy of inhaled corticosteroids (ICS) and long-acting beta₂-agonists (LABA), the benefits and harms of stopping LABA and stepping down to ICS-only therapy are uncertain.
• In adults who have stable asthma while they are taking a combination of LABA and inhaled corticosteroids (ICS), stopping LABA may increase the risk of asthma exacerbations that require treatment with corticosteroids by mouth.
• Stopping LABA probably makes little or no important difference to asthma control or asthma-related quality of life. Whether or not stopping LABA increases the risk of serious adverse events or exacerbations requiring an emergency department visit or hospitalisation is uncertain.

Delivery methods

Medications are typically provided as metered-dose inhalers (MDIs) in combination with an asthma spacer or as a dry powder inhaler. The spacer is a plastic cylinder that mixes the medication with air, making it easier to receive a full dose of the drug. A nebulizer may also be used. Nebulizers and spacers are equally effective in those with mild to moderate symptoms. However, insufficient evidence is available to determine whether a difference exists in those with severe disease. There is no strong evidence for the use of intravenous LABA for adults or children who have acute asthma.

The most commonly used asthma medications include the following

• Short-acting bronchodilators (albuterol) – provide quick relief and can be used in conjunction for exercise-induced symptoms.
• Inhaled steroids fluticasone – mometasone ciclesonide, flunisolide are first-line anti-inflammatory therapy.
• Long-acting bronchodilators – (salmeterol formoterol vilanterol) can be added to ICS as additive therapy. LABAs should never be used alone for the treatment of asthma.
• Leukotriene – modifiers can also serve as anti-inflammatory agents.
• Anticholinergic agents – (ipratropium , tiotropium [Spiriva], umeclidinium [Incruse Ellipta]) can help decrease sputum production.
• Anti-IgE – treatment can be used in allergic asthma.
• Anti-IL5 treatment – (mepolizumab , reslizumab ) can be used in eosinophilic asthma.
• Chromones stabilize mast cells – (allergic cells) but are rarely used in clinical practice.
• Theophylline – also helps with bronchodilation (opening the airways) but is rarely used in clinical practice due to an unfavorable side-effect profile.
• Systemic steroids – (prednisone, prednisolone , methylprednisolone, dexamethasone ) are potent anti-inflammatory agents that are routinely used to treat asthma exacerbations but pose numerous unwanted side effects if used repeatedly or chronically.
• Numerous additional monoclonal antibodies – are also currently being studied and will likely be available within the next couple of years.
• Immunotherapy – or allergy shots have been shown to decrease medication reliance in allergic asthma.
• There are no home remedies that have proven benefit for asthma.

• Acupuncture
• “Alexander technique” training of breathing
• Air moisture control
• Breathing exercises
• Buteyko breathing technique
• Chiropractic manipulation
• Dietary measures: fish oil, fatty acids, mineral supplementation or restriction, vitamin C
• Homeopathy
• Hypnosis
• Ionizers (room-air purifiers)
• Plant extracts (phytotherapeutic agents)
• Relaxation therapy, including progressive relaxation as described by Jacobson, hypnotherapy, autogenic training, biofeedback training, transcendental meditation
• Speleotherapy (living in underground caves and mines)
• Traditional Chinese medicine (rx), (rx).

Others

When asthma is unresponsive to usual medications, other options are available for both emergency management and prevention of flareups. For emergency management other options include:

• Oxygen to alleviate hypoxia if saturations fall below 92%.
• Corticosteroid by mouth are recommended with five days of prednisone being the same 2 days of dexamethasone. One review recommended a seven-day course of steroids.
• Magnesium sulfate intravenous treatment increases bronchodilation when used in addition to other treatment in moderate severe acute asthma attacks. In adults it results in a reduction of hospital admissions.
• Heliox, a mixture of helium and oxygen, may also be considered in severe unresponsive cases.
• Intravenous salbutamol is not supported by available evidence and is thus used only in extreme cases.
• Methylxanthines (such as theophylline) were once widely used, but do not add significantly to the effects of inhaled beta-agonists. Their use in acute exacerbations is controversial.
• The dissociative anesthetic ketamine is theoretically useful if intubation and mechanical ventilation is needed in people who are approaching respiratory arrest; however, there is no evidence from clinical trials to support this.
• For those with severe persistent asthma not controlled by inhaled corticosteroids and LABAs, bronchial thermoplasty may be an option. It involves the delivery of controlled thermal energy to the airway wall during a series of bronchoscopies. While it may increase exacerbation frequency in the first few months it appears to decrease the subsequent rate. Effects beyond one year are unknown.
• Evidence suggests that sublingual immunotherapy in those with both allergic rhinitis and asthma improve outcomes.
• Omalizumab may also be useful in those with poorly controlled allergic asthma.
• It is unclear if non-invasive positive pressure ventilation in children is of use as it has not been sufficiently studied.

Alternative medicine

Acupuncture is not recommended for the treatment as there is insufficient evidence to support its use. Air ionisers show no evidence that they improve asthma symptoms or benefit lung function; this applied equally to positive and negative ion generators.

Manual therapies, including osteopathic, chiropractic, physiotherapeutic and respiratory therapeutic maneuvers, have insufficient evidence to support their use in treating asthma. The Buteyko breathing technique for controlling hyperventilation may result in a reduction in medication use; however, the technique does not have any effect on lung function. Thus an expert panel felt that evidence was insufficient to support its use.

• Inhaled short-acting beta2 sympathomimetic agents – Fine tremor of voluntary muscle; agitation; tachycardia; palpitations
• Inhaled long-acting beta2 sympathomimetic agents (LABA) – Same adverse effects as short-acting agents; also: tolerance of bronchoprotective effect in the presence of bronchoconstricting stimuli (while the bronchodilating effect of the drug is maintained); to be used over the long term only in combination with glucocorticoids (usually ICS)
• Inhaled corticosteroids (ICS) – oropharyngeal candidiasis (thrush); hoarsenessSystemic: depending on the dose and the duration of administration, osteoporosis; cataracts; glaucoma; delayed growth in childhood; suppression of adrenocortical function
• Systemic corticosteroids – Cushing syndrome; osteoporosis; myopathy; glaucoma; cataracts; endocrine psychosyndrome; worsening of diabetes mellitus; sodium retention; hypertension; adrenocortical atrophy; elevated susceptibility to infection
• Montelukast – Abdominal symptoms; a headache; unclear association with Churg-Strauss syndrome, thus the dose of simultaneously administered systemic glucocorticoids should be lowered cautiously
• Theophyllin – Depending on the serum concentration: gastrointestinal disturbances; gastroesophageal reflux disorder; tachycardia; diuresis; agitation; insomnia When the serum concentration exceeds 25 mg/L: epileptic seizures; gastrointestinal bleeding; ventricular arrhythmia; hypotension
• Omalizumab – Local reactions at the subcutaneous injection site; a headache

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References