Ingrown Nail

Ingrown Nail

Ingrown nail refers to the condition in which the edge of a nail cuts into the adjacent skin fold, causing pain, redness, and swelling.

Ingrown nail (onychocryptosis) occurs when the nail plate (the horny covering) grows into and cuts the skin alongside the nail (lateral nail fold). Ingrown toenails make up 3–5% of all foot problems. Most cases of ingrown nail occur in men between the ages of 10–30 years.

In this age group, males are affected twice as often as females. In older adults, the incidence is equal. There are three major types of ingrown nail: subcutaneous ingrown nail, in which the nail grows under the skin; over-curvature of the nail plate; and hypertrophy (overgrowth) of the lateral nail fold.

Ingrown nails occur most often on the big toe. Penetration of the nail into the skin causes inflammation (swelling and redness). Infection by bacteria or fungi may follow. Severe infection may lead to abscess formation, characterized by an oozing pus-filled blister. Small translucent red bumps called granulation tissue may develop along the lateral nail fold.

Causes and symptoms

Ingrown nails are most commonly caused by incorrect cutting of the nails and wearing poorly-fitting shoes. Other causes of ingrown nail include:

• abnormally long toes
• overcurvature of the nail
• excessive sweating
• shoes that put pressure on the toes (pointed-toe, high heeled)
• poor foot hygiene
• high lateral nail folds
• discrepancy between the widths of the nail and nail bed
• improper alignment of the large toenail
• repeated trauma to the large toe

Persons who are at increased risk of developing ingrown nails include people with arthritis, immune system deficiencies, neoplasms (tumors), obesity, and circulatory disorders.

The symptoms of ingrown nail include swelling, redness, and pain in the lateral nail fold. Increased swelling, pus drainage, and ulceration (tissue destruction) can occur as the condition progresses. Advanced onychocryptosis is characterized by long-term swelling, the formation of granulation tissue, and lateral fold overgrowth.

Diagnosis

Ingrown nail is easily diagnosed in a physical examination done by a family physician, a podiatrist (foot specialist), or a dermatologist (skin specialist).

Treatment

Because of the possibility of serious complications, a physician should be consulted for treatment of severe and/or infected ingrown nails. Alternative treatments for treating ingrown nail include:

• Ayurveda. Ayurvedic principles state that persons whose constitutions are dominated by vata and kapha have stronger nails and are prone to ingrown nails. Ingrown nails are treated with warm water soaks followed by application of a solution of equal parts tea tree and neem oils under the nails.
• Herbal therapy. When an ingrown nail is forming, the toe should be soaked for 15–30 minutes in five drops each of hypericum and calendula tinctures diluted in 1/2 pint of warm water. Afterward, the toe should be wrapped in linen, placing it between the fold and the nail.
• Homeopathy. Preparations of Hepar sulph. or Silica in 6c potency may be taken every 12 hours for two weeks, to reduce the inflammation around the nail.
• Hydrotherapy. To treat ingrown nail, the patient should soak the foot in hot, soapy water for 20 minutes, trim the nail square, wrap the toe in a hot compress, and cover it with a dry cloth overnight. In the morning, the patient should trim the nail into a U shape and place a bit of cotton between the nail and the fold. The cotton should be kept in place until the nail grows out.
• Massage. If an ingrown nail is developing, the patient should gently push the skin away from the nail. Repeated massage of the overgrown lateral nail folds can reduce pain and separate the fold away from the nail.

Allopathic treatment

Nonsurgical

Nonsurgical methods of treating ingrown nails focus on eliminating infection with medications and separating the ingrown nail from the lateral nail fold. Whenever possible, the offending nail is clipped, and the patient is instructed to soak the foot in water containing Epsom salts and povidone-iodine thrice daily.

Procedures used to separate the nail from the fold include inserting a piece of fabric (moistened with antiseptics), plastic, or metal between the nail and the fold until the nail grows out.

Cryotherapy, in which the affected nail fold is frozen with liquid nitrogen, is also used. Cauterization (destruction of tissue using heat) may be performed to eliminate granulation tissue. A metal brace may be worn on the toe for several months to flatten overcurvature.

Surgical

In cases of severe ingrown nail or ineffective nonsurgical treatment, part or all of the nail is surgically removed. Most commonly, only a portion of the nail is removed. Ingrown nail recurs in 60%–80% of the patients.

If nail regrowth is expected to cause a recurrence of ingrown nail, then the nail matrix (where nail growth occurs) is destroyed, which prevents nail regrowth. In most cases, only local anesthesia is needed for surgical treatment.

Expected Results

Although natural remedies can be effective in healing minor ingrown nails, prevention is the best solution. Many cases of ingrown nail require surgical treatment.

Complications of ingrown toenail include infection, osteomyelitis (infection of the bone), and gangrene (tissue death). The elderly are at increased risk of complications because of decreased sensation resulting from such conditions as diabetes, heart disease, or arteriosclerosis (hardening of the arteries).

Prevention

Ingrown nails may be prevented by:

• clipping nails straight across
• leaving the nail edge slightly longer than the end of the toe
• not trimming the sides of nails
• wearing shoes with ample toe space
• not pulling or tearing at the toenails

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Insomnia

Insomnia

Insomnia is the inability to obtain an adequate amount or quality of sleep. The difficulty can be in falling asleep, remaining asleep, or both. People with insomnia do not feel refreshed when they wake up. Insomnia is a common symptom affecting millions of people that may be caused by many conditions, diseases, or circumstances.

According to a 1999 American Medical Association (AMA) report, approximately 30% of adults in the United States suffer occasionally from insomnia and 10% experience chronic insomnia.

Sleep is essential for mental and physical restoration. It is a cycle with two separate states: rapid eye movement (REM), the stage in which most dreaming occurs; and non-REM (NREM).

Four stages of sleep take place during NREM: stage I, when the person passes from relaxed wakefulness; stage II, an early stage of light sleep; stages III and IV, which are increasing degrees of deep sleep. Most stage IV sleep (also called delta sleep), occurs in the first several hours of sleep. A period of REM sleep normally follows a period of NREM sleep.

Sleeplessness or insomnia is a symptom and may be caused by “stress, anxiety, depression, disease, pain, medications, sleep disorders, poor sleep habits .. [and] sleep environment and health habits,” according to the National Sleep Foundation (NSF).

Woman with insomnia

Women are 1.3 times more likely to report insomnia than men, according to the NSF. Women may experience sleeplessness before and at the onset of the menstrual cycle, during pregnancy, and menopause. The foundation reported that people over the age of 65 are “more likely to complain of insomnia than younger people.”

Furthermore, people who are divorced, widowed, or separated are more likely to have the problem than those who are married. In addition, insomnia is more frequently reported by those with lower socioeconomic status.

Insomnia is classified both by its nightly symptoms and its duration. Sleep-onset insomnia refers to difficulty falling asleep. Maintenance insomnia refers to waking frequently during the night or waking early. Insomnia is also classified in relation to the number of sleepless nights.

Short-term or transient insomnia is a common occurrence and usually lasts only a few days. Long-term or chronic insomnia lasts more than three weeks and increases the risk for injuries in the home, at the workplace, and while driving because of daytime sleepiness and decreased concentration. Chronic insomnia can also lead to mood disorders like depression.

Insomnia comes with a high price tag for the nation. NSF in 1999 reported that an estimated $14 billion was spent in one year on such direct costs as insomnia treatment, healthcare services, and hospital and nursing home care.

Annual indirect costs like work loss, property damage from accidents, and transportation to and from health care providers were estimated at close to $28 billion. Furthermore, insomnia accounted for $18 billion in lost productivity, according to a 1997 National Sleep Foundation survey.

Causes and symptoms

Transient insomnia is often caused by a temporary situation in a person’s life, such as an argument with a loved one, a brief medical illness, or jet lag. When the situation is resolved or the precipitating factor disappears, the condition goes away, usually without medical treatment.

Such prescription drugs as asthma medicine, steroids, and anti-depressants can cause insomnia. Sleeplessness may also be a side effect of over-the-counter products like nasal decongestants and appetite suppressants.

Chronic insomnia usually has different causes, and there may be more than one. These include:

• A medical condition or its treatment, including sleep apnea, arthritis, a heart condition, and asthma.
• Use of such substances as caffeine, alcohol, and nicotine.
• Psychiatric conditions like mood or anxiety disorders.
• Stress or depression, such as sadness caused by the loss of a loved one or a job.
• Disturbed sleep cycles caused by a change in work shift.
• Sleep-disordered breathing, such as snoring.
• Periodic jerky leg movements, nocturnal myoclonus, which happen just as the individual is falling asleep.
• Repeated nightmares or panic attacks during sleep.

so much anxiety in bedtime rituals

Another cause is excessive worrying about whether or not a person will be able to fall asleep, which creates so much anxiety that the individual’s bedtime rituals and behavior actually trigger insomnia. This is called psychophysiological insomnia.

Symptoms of insomnia

People who have insomnia do not start the day refreshed from a good night’s sleep. They are tired. They may have difficulty falling asleep, and commonly lie in bed tossing and turning for hours.

Or the individual may go to sleep without a problem but wakes in the early hours of the morning and is either unable to go back to sleep, or drifts into a restless, unsatisfying sleep.

This is a common symptom in the elderly and those suffering from depression. Sometimes sleep patterns are reversed and the individual has difficulty staying awake during the day and takes frequent naps. The sleep at night is fitful and frequently interrupted.

Diagnosis

Insomnia, unlike some medical conditions, is easily recognizable. People know when they aren’t getting enough sleep. The key to treating insomnia is determining its causes. Some people can identify sleep-inhibiting factors such as a death in the family or a hectic work schedule with too much caffeine consumption and not enough exercise. A doctor will take factors such as these into account when making a diagnosis.

The physician’s diagnosis is based on the patient’s reported signs and symptoms. The doctor may review a patient’s health history or order tests to determine if a medical condition is causing the insomnia.

The physician may ask if the patient is depressed, in pain, under stress, or taking medications, according to the National Sleep Foundation. The doctor may ask about disruptions in a patient’s life such as working nontraditional shifts or traveling across different time zones.

It can be useful for the patient to keep a daily record for two weeks of sleep patterns, food intake, use of alcohol, caffeine, nicotine, medications, exercise, and any other information recommended by the physician.

If the patient has a bed partner, information can be obtained about whether the patient snores or is restless during sleep. This record, together with a medical history and physical examination, can help confirm the doctor’s assessment.

A wide variety of healthcare professionals can recognize and treat insomnia, but when a patient with chronic insomnia does not respond to treatment, or the condition is not adequately explained by the patient’s physical, emotional, or mental circumstances, then more extensive testing by a specialist in sleep disorders may be warranted.

Treatment

In both alternative and conventional medicine, treatment of insomnia includes alleviating or coping with any physical and emotional problems that contribute to the condition. Also effective is exploration of changes in lifestyle that will improve the situation.

Changes in behavior

Patients can make changes in their daily routine that are simple and effective in treating insomnia. Eating a healthy diet rich in calcium, magnesium, and the B vitamins is also beneficial. A high protein snack like yogurt before going to bed is recommended.

Patients should go to bed only when sleepy and use the bedroom only for sleep. Activities like reading, watching television, or snacking should take place elsewhere. If people are unable to go to sleep, they should go into another room and do something like reading. People should return to bed only when sleepy.

Patients should set the alarm and get up every morning at the same time, no matter how much they have slept, to establish a regular sleepwake pattern. Naps during the day should be avoided, but if absolutely necessary, than a 30-minute nap early in the afternoon may not interfere with sleep at night.

Another successful technique is called sleep-restriction therapy, restricting the time in bed to the actual time spent sleeping. This approach allows a slight sleep debt to build up, which increases the individual’s ability to fall asleep and stay asleep.

If a patient sleeps five hours a night, the time in bed is limited to 5–5.5 hours. The time in bed is gradually increased in small segments, with the individual rising at the same time each morning; at least 85% of the time in bed must be spent sleeping.

Mind and body relaxation

Incorporating relaxation techniques into bedtime rituals helps a person go to sleep faster and improves the quality of sleep. These, alone or in combination with other relaxation techniques, can safely promote sleepiness. Also effective are massage techniques such as the “cat stroke.”

The masseuse’s hands move gently across the back. Four other types of stress-reducing bodywork were recommended in Spontaneous Healing, the book by Andrew Weil, M.D., who practices natural and preventative medicine.

Weil recommended Feldenkrais, which includes movements, floor exercises, and body work; Rolfing, which involves firm pressure; shiatsu, the traditional Japanese form of body work; and Trager work.

Learning to substitute pleasant thoughts for unpleasant ones (imagery training) helps reduce worrying. Another technique is using audiotapes that combine the sounds of nature with soft relaxing music. Meditation, prayer, and breathing exercises can also be effective.

Many alternative treatments are effective in treating both the symptom of insomnia and its underlying causes. Much treatment is centered around herbal remedies.

The herbs most often recommended for treating insomnia include reishi mushroom, hops, valerian, skullcap, passion flower, lemon balm, ginseng, St. John’s wort, and kava, which is also known as kava kava. Herbs are “generally safe,” but they have not been tested or classified in the United States by the U.S. Food and Drug Administration (FDA).

Herbal teas

Some people treat insomnia by sipping a warm cup of tea made with an herb such as chamomile, hops, passionflower, or St. John’s wort.

Aromatherapy and hydrotherapy

Aromatherapy involves healing through essential oils, the aromatic extracts of plants. Essential oils may be used for a soothing bath; applied to the face, neck, shoulders, and pillow; or diffused in air.

Hydrotherapy consists of a warm bath, scented with an essence such as rose, lavender, marjoram, or chamomile. In the 1998 book Healing Anxiety with Herbs , Harold Bloomfield, M.D., recommended adding 2-15 drops of 10% essential oils into approximately 100°F (38° C) water.

He also recommended using lavender and also suggested using ylang-ylang, neroli (orange blossom), geranium, and patchouli. The bath should be “approached in an unhurried and meditative state,” Bloomfield wrote.

Dream pillows

Another form of aromatherapy involves sleeping on a dream pillow. Also known as a sleep pillow, it can be made by sewing together two 8-inch pieces of fabric. There should be an opening wide enough to insert a tablespoon. Herbs such as hops, chamomile, and lavender are spooned into the dream pillow, which is placed under the bed pillow.

Melatonin

Melatonin is a natural hormone that is secreted from the brain’s pineal gland. The gland regulates a person’s biological clock, particularly day and night cycles. When taken as a 3-mg dose one to two hours before bed for a maximum of four to five days per week, the dietary supplement melatonin is said to be effective in shortening the time before one falls asleep.

The hormone can help to avoid jet lag and to establish sleep patterns for shift workers. However, melatonin is not regulated by the FDA, so there are no regulatory controls. Side effects may include mental impairment, drowsiness, severe headaches, and nightmares.

Traditional Chinese medicine

Traditional Chinese medicine (TCM) treatments for insomnia include acupuncture and herbal remedies. Acupuncture involves the insertion of needles to manipulate energy flows around the body. Acupuncture is also applied to the treatment of conditions including anxiety.

In TCM, herbs are used as remedies in teas and other preparations. Treatments for insomnia include reishi, a medicinal mushroom available in extract form.

Light therapy

In light therapy, natural or artificial light is used to boost serotonin, a neurotransmitter in the brain related to reducing anxiety. This therapy is used to treat seasonal affective disorder, a condition that some people experience when there is less sunlight or fewer daylight hours.

Bright light therapy can be used for people whose insomnia is caused by jet lag or irregular work shifts. In the morning, the person is exposed to artificial lamps with a brightness of more than 2,000 lux. The treatment continues with avoidance of bright light during the evening.

Allopathic treatment

A physician may determine that drug therapy is necessary to treat insomnia. Drugs may be prescribed if the patient is undergoing a crisis or insomnia persists after a patient has made lifestyle changes. However, drug therapy is regarded as a short-term remedy, not a solution.

Conventional medications given for insomnia include sedatives, tranquilizers, and antianxiety drugs. All require a doctor’s prescription and may become habit-forming. They can lose effectiveness over time and can reduce alertness during the day.

The medications should be taken up to four times daily or as directed for approximately three to four weeks. This will vary with the physician, patient, and medication. If insomnia is related to depression, then an antidepressant medication may be helpful.

Drugs prescribed for improving sleep are called hypnotics. This category includes benzodiazepines, which are prescribed for anxiety and insomnia. Benzodiazepines most commonly prescribed for insomnia include Dalmane (fluazepam), Halcion (triazolam), Ativan (lorazepam), Xanax (alprazolam), Restoril (tempazepam), and Serax (oxazepam).

Insomnia is such a widespread problem that “people buy more over-the-counter and prescription sleeping medications than any other drug,” according to CBS Health Watch. Many over-the-counter drugs have anti-histamines as an active ingredient. While these products are not addictive, some experts believe they are not very effective in sustaining stage IV sleep and can affect the quality of sleep.

Over-the-counter sleep products include Nytol, Sleep-Eez, and Sominex. Antihistamines are used in combination with pain relievers in products including Anacin PM, Excedrin PM, Tylenol PM, Unison, and Quiet World.

Expected results

Insomnia has numerous causes and treatments, so the amount of time may vary before results are seen. A prescription drug may bring immediate results to someone coping with a spouse’s death. An herbal remedy may not work immediately for a person who consumed excessive amounts of caffeine to stay awake at work after a sleepless night.

There has been research that provides information about when some treatments take effect:

• Melatonin: a dose of 3-5 mg taken within an hour of retiring will normalize sleep within 1-2 weeks.
• A combination of hops and valerian at bedtime can provide a good night’s sleep.
• A combination of alternative therapies should bring a difference in disturbed sleep within two to four days.
• Valerian extract may take from two to three weeks before “significant benefits” are seen.
• St. John’s wort can take two weeks to take effect.
• Combinations of treatments could more quickly bring about an uninterrupted night of sleep. The person who reduces caffeine intake, walks for 15 minutes and enjoys an herbal bath may discover that that combination brings restful sleep.
• Acupuncture: “A state of deep relaxation is often an immediate benefit of treatment for chronically anxious patients,” William Collinge wrote in The American Holistic Health Association Complete Guide to Alternative Medicine. In addition, positive results were recorded in a study of people who had trouble falling asleep or remaining asleep, according to the an article in the October 1999 issue of the Alternative Medicine Newsletter. Patients received acupuncture for three to five sessions at weekly intervals. While acupuncture appeared effective, a “directive influence by the therapist cannot be excluded,” according to the article.
• Light therapy usually results in earlier bedtimes.

Prevention

Prevention of insomnia centers around promotion of a healthy lifestyle. A balance of rest, recreation, and exercise in combination with stress management, regular physical examinations, and a healthy diet can do much to reduce the risk.

Walking is also recommended. However, exercise should be done no more than three hours before bedtime.

Drinks that contain caffeine such as coffee, tea and colas, chocolate (which contains a stimulant), and alcohol, which initially makes a person sleepy but a few hours later can have the opposite effect should all be avoided.

Maintaining a comfortable bedroom temperature, reducing noise, and eliminating light are also helpful.

Watching television should be avoided because it has an arousing effect. Weil wrote that the news with its “murder, mayhem, and misery” is a major source of turmoil. He sometimes advises “news fasts” as part of a healing program.

Exercise, relaxation, and nutrition should be considered ongoing preventive measures. While life will bring unexpected stresses and pressures, the person who is familiar with relaxation techniques will be more prepared to cope with insomnia.

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Jaundice

Jaundice is a condition in which a person’s skin and the whites of the eyes are discolored yellow due to an increased level of bile pigments in the blood resulting from liver disease. Jaundice is sometimes called icterus, from a Greek word for “the condition.”

In order to understand jaundice, it is useful to know about the role of the liver in producing bile. The most important function of the liver is the metabolic processing of chemical waste products like cholesterol, and excreting them into the intestines as bile.

The liver is the premier chemical factory in the body—most incoming and outgoing chemicals pass through it. It is the first stop for all nutrients, toxins, and drugs absorbed by the digestive tract.

The liver also collects chemicals from the blood for processing. Many of these outward bound chemicals are excreted into the bile. One particular substance, bilirubin, is yellow. Bilirubin is a product of the breakdown of hemoglobin, which is the protein inside red blood cells.

If bilirubin cannot leave the body, it accumulates and discolors other tissues. The normal total level of bilirubin in blood serum is between 0.2 mg/dL and 1.2 mg/dL. When it rises to 3 mg/dL or higher, the person’s skin and the whites of the eyes become noticeably yellow.

Bile is formed in the liver. It then passes into the network of hepatic bile ducts, which join to form a single tube. A branch of this tube carries bile to the gallbladder, where it is stored, concentrated, and released on a signal from the stomach.

Food entering the stomach is the signal that stimulates the gallbladder to release the bile. The tube, which is called the common bile duct, continues to the intestines.

Before the common bile duct reaches the intestines, it is joined by another duct from the pancreas. The bile and the pancreatic juice enter the intestine through a valve called the ampulla of Vater. After entering the intestine, the bile and pancreatic secretions together help in the process of digestion.

Causes and symptoms

There are many different causes for jaundice, but they can be divided into three categories based on where they start—before (pre-hepatic), in (hepatic), or after (post-hepatic) the liver. When bilirubin begins its life cycle, it cannot be dissolved in water.

Thus, the liver changes it so that it is soluble in water. These two types of bilirubin are called unconjugated (insoluble) and conjugated (soluble). Blood tests can easily distinguish between these two types of bilirubin.

Hemoglobin and bilirubin formation

Bilirubin begins as hemoglobin in the blood-forming organs, primarily the bone marrow. If the production of red blood cells (RBCs) falls below normal, the extra hemoglobin finds its way into the bilirubin cycle and adds to the pool.

Once hemoglobin is in the red cells of the blood, it circulates for the life span of those cells. The hemoglobin that is released when the cells die is turned into bilirubin. If for any reason the RBCs die at a faster rate than usual, then bilirubin can accumulate in the blood and cause jaundice.

Hemolytic disorders

Many disorders speed up the death of red blood cells. The process of red blood cell destruction is called hemolysis, and the diseases that cause it are called hemolytic disorders. If red blood cells are destroyed faster than they can be produced, the patient develops anemia.

Hemolysis can occur in a number of diseases, disorders, conditions, and medical procedures:

• Malaria. The malaria parasite develops inside red blood cells. When it is mature it breaks the cell apart and swims off in the blood. This process happens to most of the parasites simultaneously, causing the intermittent symptoms of the disease. When enough cells burst at once, jaundice may result from the large amount of bilirubin formed from the hemoglobin in the dead cells. The pigment may reach the urine in sufficient quantities to cause “blackwater fever,” an often lethal form of malaria.
• Side effects of certain drugs. Some common drugs can cause hemolysis as a rare but sudden side effect. These medications include some antibiotic and antituberculosis medicines; drugs that regulate the heartbeat; and levodopa, a drug used to treat Parkinson's disease.
• Certain drugs in combination with a hereditary enzyme deficiency known as glucose–6–phosphate dehydrogenase (G6PD). G6PD is a deficiency that affects more than 200 million people in the world. Some of the drugs listed above are more likely to cause hemolysis in people with G6PD. Other drugs cause hemolysis only in people with this disorder. Most important among these drugs are such antimalarial medications, as quinine, and vitamins C and K.
• Poisons. Snake and spider venom, certain bacterial toxins, copper, and some organic industrial chemicals directly attack the membranes of red blood cells.
• Artificial heart valves. The inflexible moving parts of heart valves damage RBCs as they flutter back and forth. This damage is one reason to recommend pig valves and valves made of other organic materials.
• Hereditary RBC disorders. There are a number of hereditary defects that affect the blood cells. There are many genetic mutations that affect the hemoglobin itself, the best known of which is sickle cell disease. Such hereditary disorders as spherocytosis weaken the outer membrane of the red cell. There are also inherited defects that involve the internal chemistry of RBCs.
• Enlargement of the spleen. The spleen is an organ that is located near the upper end of the stomach and filters the blood. It is supposed to filter out and destroy only wornout RBCs. If it has become enlarged, it filters out normal cells as well. Malaria, other infections, cancers and leukemias, some of the hereditary anemias mentioned above, obstruction of blood flow from the spleen—all these and many more diseases can enlarge the spleen to the point where it removes too many red blood cells.
• Diseases of the small blood vessels. Hemolysis that occurs in diseased small blood vessels is called microangiopathic hemolysis. It results from damage caused by rough surfaces on the inside of the capillaries. The RBCs squeeze through capillaries one at a time and can easily be damaged by scraping against the vessel walls.
• Immune reactions to RBCs. Several types of cancer and immune system diseases produce antibodies that react with RBCs and destroy them. In 75% of cases, this reaction occurs all by itself, with no underlying disease to account for it.
• Transfusions. If a patient is given an incompatible blood type, hemolysis results.
• Kidney failure and other serious diseases. Several diseases are characterized by defective blood coagulation that can destroy red blood cells.
• Erythroblastosis fetalis. Erythroblastosis fetalis is a disease of newborns marked by the presence of too many immature red blood cells (erythroblasts) in the baby’s blood. When a baby’s mother has a different blood type, antibodies from the mother may leak into the baby’s circulation and destroy blood cells. This reaction can produce severe hemolysis and jaundice in the newborn. Rh factor incompatibility is the most common cause.
• High bilirubin levels in newborns. Even in the absence of blood type incompatibility, the newborn’s bilirubin level may reach threatening levels.

Normal jaundice in newborns

Normal newborn jaundice is the result of two conditions occurring at the same time—a prehepatic and a hepatic source of excess bilirubin. First of all, the baby at birth immediately begins converting hemoglobin from a fetal type to an adult type.

The fetal type of hemoglobin was able to extract oxygen from the lower levels of oxygen in the mother’s blood. At birth the infant can extract oxygen directly from his or her own lungs and does not need the fetal hemoglobin any more. So fetal hemoglobin is removed from the system and replaced with adult hemoglobin.

The resulting bilirubin loads the system and places demands on the liver to clear it. But the liver is not quite ready for the task, so there is a period of a week or so when the liver has to catch up. During that time the baby is jaundiced.

In 2002 new studies found that infants younger than eight weeks old with jaundice often had hidden (asymptomatic) urinary tract infections. Previous studies have shown that newborn jaundice may be an early sign of bacterial infections in infants. The study recommended that pediatricians routinely test young infants with jaundice for urinary tract infections.

Hepatic jaundice

Liver diseases of all kinds threaten the organ’s ability to keep up with bilirubin processing. Starvation, circulating infections, certain medications, hepatitis, and cirrhosis can all cause hepatic jaundice, as can certain hereditary defects of liver chemistry, including Gilbert’s syndrome and Crigler-Najjar syndrome.

Post-hepatic jaundice

Post-hepatic forms of jaundice include the jaundices caused by failure of soluble bilirubin to reach the intestines after it has left the liver. These disorders are called obstructive jaundices. The most common cause of obstructive jaundice is the presence of gallstones in the ducts of the biliary system.

Other causes have to do with birth defects and infections that damage the bile ducts; drugs; infections; cancers; and physical injury. Some drugs—and pregnancy on rare occasions—simply cause the bile in the ducts to stop flowing.

Symptoms and complications associated with jaundice

Certain chemicals in bile may cause itching when too much of them end up in the skin. In newborns, insoluble bilirubin may get into the brain and do permanent damage.

Long-standing jaundice may upset the balance of chemicals in the bile and cause stones to form. Apart from these potential complications and the discoloration of skin and eyes, jaundice by itself is inoffensive. Other symptoms are determined by the disease producing the jaundice.

Diagnosis

Physical examination

In many cases, the diagnosis of jaundice is suggested by the appearance of the patient’s eyes and complexion. The doctor will ask the patient to lie flat on the examining table in order to feel (palpate) the liver and spleen for enlargement and to evaluate any abdominal pain. The location and severity of abdominal pain and the presence or absence of fever help the doctor to distinguish between hepatic and obstructive jaundice.

Laboratory tests

Disorders of blood formation can be diagnosed by more thorough examination of the blood or the bone marrow, where blood is made. Occasionally a bone marrow biopsy is required, but usually the blood itself will reveal the diagnosis. The spleen can be evaluated by an ultrasound examination or a nuclear scan if the physical examination has not yielded enough information.

Imaging studies

Disease in the biliary system can be identified by imaging techniques, of which there are many. X rays are taken a day after swallowing a contrast agent that is secreted into the bile. This study gives functional as well as anatomical information. There are several ways of injecting x-ray dye directly into the bile ducts.

It can be done through a thin needle pushed straight into the liver, or through a scope passed through the stomach that can inject dye into the ampulla of Vater. CT and MRI scans are very useful for imaging certain conditions, such as cancers in and around the liver, or gallstones in the common bile duct.

Liver disease is usually assessed from blood studies alone, but again a biopsy may be necessary to clarify less obvious conditions. A liver biopsy is performed at the bedside. The doctor uses a thin needle to take a tiny core of tissue from the liver. The tissue sample is sent to the laboratory for examination under a microscope.

Assessment of jaundice in newborns

Newborns are more likely to have problems with jaundice if:

• They are premature.
• They are of Asian or Native American descent.
• They have been bruised during the birth process.
• They have lost too much weight during the first few days.
• They are born at a high altitude.
• The mother has diabetes.
• Labor had to be induced.

In 2003, research was continuing to find noninvasive methods to determine bilirubin levels in newborns so that physicians did not have to rely on visual examination alone to determine which infants should receive blood tests.

Once these measurements of skin pigment can be shown effective and cost-effective in clinical practice, they may become more widely available. Another study used this measurement method incorporated into home health visits to monitor babies within 24 hours of discharge from the hospital following birth.

Treatment

Jaundice is often an early warning sign of serious liver damage. Alternative medicine treatments should not be used as a substitute for conventional medical treatment.

Patients should contact their doctors for diagnosis and treatment immediately if experiencing signs and symptoms of jaundice. Alternative therapies may be helpful as complementary measures for patients who have an underlying disease that already has been diagnosed.

Nutritional therapy

Naturopaths or nutritionists may recommend the following dietary changes:

• Drinking fresh vegetable or fruit juices during the first several weeks after diagnosis and eating a diet consisting mostly of raw fruits and vegetables, seeds, and nuts during the next month. These fruits and vegetables are easy to digest and contain lots of antioxidants, vitamins and minerals. They help the body remove toxins from the blood, and decrease stress/strain on the liver for digestion/metabolism.
• Fasting intermittently.
• Eliminating alcohol from the diet for good, and avoiding foods that are processed and high in fat. These foods are bad for the liver.
• Drinking a cup of lemonade (without sugar) early in the morning to improve liver and bile function.
• Incorporating olive oil or lemon oil into the diet as a liver flushing regimen.
• Taking nutritional supplements, such as multivitamins or minerals, vitamin C, vitamin B complex, other antioxidant-containing supplements, supplements containing alpha lipoic acid, protein supplements, essential fatty acids (EFAs), and digestive enzymes with bile (for patients having pale stools).

Traditional Chinese medicine

Depending on a patient’s specific condition, an expert Chinese herbalist may prescribe herbal remedies that can help improve liver function. Animal studies have shown the following Chinese herbs may have liver protective effects:

• Bupleurum chinense
• Phellodendron wilsonii
• Clementis chinensis

Herbal therapy

Patients should consult an experienced herbalist for specific herbal treatments that may include milk thistle or artichoke.

Homeopathy

For homeopathic therapy, patients should consult a homeopathic physician who will prescribe specific remedies based on knowledge of the underlying cause.

Juice therapy

Juice therapy helps the liver detoxify toxins to be eliminated from the body. Patients should mix one part of pure juice with one part of water before drinking. Daily consumption of the following juices may be helpful:

• carrot and beet juice with a touch of radish or dandelion root juice
• grapes, pear, and lemon
• carrot, celery, and parsley
• carrot, beet, and cucumber

Aromatherapy

Essential oils of rosemary, lemon, and geranium may help improve liver function and relax the body. They can be given as inhalants, a soothing bath, or soak.

Other therapies

Other alternative treatments that may be help improve liver function include fasting, Ayurveda, hydrotherapy, and acupuncture.

Allopathic treatment

Jaundice in newborns

Newborns are the only major category of patients in whom the jaundice itself requires attention. If there is reason to suspect increased hemolysis in the newborn, the bilirubin level must be measured repeatedly during the first few days of life.

If the level of bilirubin shortly after birth threatens to go too high, treatment must begin immediately. Exchanging most of the baby’s blood was the only way to reduce the amount of bilirubin until a few decades ago.

Jaundiced babies are now fitted with eye protection and placed under bright fluorescent blue lights. The light chemically alters the bilirubin in the blood as it passes through the baby’s skin so that it may be more easily eliminated in the urine.

In 2003 researchers were testing a new drug called Stanate that showed promise in blocking bilirubin production. However, debate concerning the use of the drug for treatment of only those infants with jaundice or as a preventive measure was delaying its FDA approval and widespread use.

Hemolytic disorders

Hemolytic diseases are treated, if at all, with medications and blood transfusions, except in the case of an enlarged spleen. Surgical removal of the spleen (splenectomy) can sometimes cure hemolytic anemia. Drugs that cause hemolysis or arrest the flow of bile must be stopped immediately.

Hepatic jaundice

Most liver diseases have no specific cure, but the liver is so robust that it can heal from severe damage and regenerate itself from a small remnant of its original tissue.

Posthepatic jaundice

Obstructive jaundice frequently requires a surgical cure. If the original passageways cannot be restored, surgeons have several ways to create alternate routes. To create alternate passageways, a surgeon will sew an open piece of intestine over a bare patch of liver.

Tiny bile ducts in that part of the liver will begin to discharge their bile into the intestine, and pressure from the obstructed ducts elsewhere will find release in that direction. As the flow increases, the ducts grow to accommodate it. Soon, all the bile is redirected through the open pathways.

Prevention

Erythroblastosis fetalis can be prevented by giving an Rh-negative mother a gamma globulin solution called RhoGAM whenever there is a possibility that she is developing antibodies to her baby’s blood.

G6PD hemolysis can be prevented by testing patients before giving them drugs that can cause it. Medication side effects can be minimized by early detection and immediate cessation of the drug.

Malaria can often be prevented by taking certain precautions when traveling in tropical or subtropical countries. These precautions include staying in after dark; using such prophylactic drugs as mefloquine; and protecting sleeping quarters with mosquito nets treated with insecticides and mosquito repellents.

In 2003, new studies showed promise for a possible vaccine against malaria. Early trials showed that vaccination combination might stimulate T-cell activity against malaria, the best type of protection that researchers can hope to find. However, further studies will have to be done.

New research in 2002 linked a popular antidepressant drug called paroxetine (Paxil) to several newborn complications, including jaundice. Although research is preliminary, pregnant women might want to discuss use of the drug with their physicians to prevent complications like jaundice in their newborn babies.

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Jet lag

Jet lag is a condition marked by fatigue, insomnia, and irritability that is caused by air travel through changing time zones. It is commonplace: a 2002 study of international business travelers (IBTs) found that jet lag was one of the most common health problems reported, affecting as many as 74% of IBTs.

Living organisms are accustomed to periods of night and day alternating at set intervals. Most of the human body’s regulating hormones follow this cycle, known as circadian rhythm.

The word circadian comes from the Latin, circa, meaning about, and dies, meaning day. These cycles are not exactly 24 hours long, hence the “circa.” Each chemical has its own cycle of highs and lows, interacting with and influencing the other cycles.

Body temperature, sleepiness, thyroid function, growth hormone, metabolic processes, adrenal hormones, and the sleep hormone melatonin all cycle with daylight. There is a direct connection between the retina (the light-sensitive structure at the back of the eye) and the part of the brain that controls all these hormones.

Artificial light has some effect but sunlight has much more. Disruption of circadian rhythms affects the sleep-wake cycles of night-shift workers as well as travelers.

When people are without clocks in a compartment that is completely closed to sunlight, most of them fall into a circadian cycle of about 25 hours. Normally, all the regulating chemicals follow one another in order like threads in a weaving pattern.

Every morning the sunlight resets the cycle, stimulating the leading chemicals and thus compensating for the difference between the 24-hour day and the 25-hour innate rhythm.

When traveling through a number of time zones, most people reset their rhythms within a few days, demonstrating the adaptability of the human species. Some people, however, have upset circadian rhythms that last indefinitely.

Causes and symptoms

Traveling through a few time zones at a time is not as disruptive to circadian rhythms as traveling around the world can be. The foremost symptom of jet lag is altered sleep pattern—sleepiness during the day, and insomnia during the night.

Jet lag may also include indigestion and trouble concentrating. Individuals afflicted by jet lag will alternate in and out of a normal day-night cycle.

Treatment

Exposure to bright morning sunlight cures jet lag after a few days in most people. A few will have prolonged sleep phase difficulties. For these, there is a curious treatment that has achieved success.

By forcing one’s self into a 27 hour day, complete with the appropriate stimulation from bright light, all the errant chemical cycles will be able to catch up during one week.

When selecting an international flight, individuals should try to arrange an early evening arrival in their destination city. When an individual is traveling to a destination in the east, he or she can try going to bed and waking up a few hours earlier several days before their flight.

If travel is to the west, going to bed and waking up later than usual can help the body start to adjust to the upcoming time change. More specific recommendations are available as of 2002, tailored to whether the person is traveling through six time zones, 7–9 zones, or 10 or more.

The following precautions taken during an international flight can help to limit or prevent jet lag:

• Stay hydrated. Drink plenty of water and juices to prevent dehydration. Beverages and foods with caffeine should be avoided because of their stimulant properties. Alcohol should also be avoided.
• Stretch and walk. As much movement as possible during a flight helps circulation, which moves nutrients and waste through the body and aids in elimination.
• Stay on time. Set watches and clocks ahead to the time in the destination city to start adjusting to the change.
• Sleep smart. Draw the shade and sleep during the evening hours in the destination city, even if it is still daylight outside of the airplane. Earplugs and sleep masks may be helpful in blocking noise and light. Many airlines provide these items on international flights.
• Dress comfortably. Wear or bring comfortable clothes and slippers that will make sleeping during the flight easier.

Once arriving in their destination city, individuals should spend as much time outdoors in the sunlight as possible during the day to reset their internal clock and lessen the symptoms of jet lag.

Bedtime should be postponed until at least 10 P.M., with no daytime naps. If a daytime nap is absolutely necessary, it should be limited to no more than two hours.

To promote a restful sleeping environment in a hotel setting, travelers should request that the hotel desk hold all phone calls. Because sleeping in too late can also prolong jet lag, an early wake up call should be requested if an alarm clock is not available.

If the hotel room is noisy, a portable white noise machine can help to block outside traffic and hallway noises. A room air conditioner or fan can serve the same purpose. The temperature in the room should also be adjusted for sleeping comfort.

New information shows that exercise when at the destination can also help. When headed westbound, travelers should exercise for one hour in the evening. If going eastbound, they do best by exercising in the morning.

All antioxidants help to decrease the effects of jet lag. Extra doses of vitamins A, C, and E, as well as zinc and selenium, two days before and two days after a flight help to alleviate jet lag. Melatonin, a hormone that helps to regulate circadian rhythms, can also help to combat jet lag.

Melatonin is available as an over-the-counter supplement in most health food stores and pharmacies. Reports in 2002 show that the drug is safe for short-term use and recommend 5 mg between 10 pm and midnight at the destination to help fall asleep and to sleep better.

If weather prevents an individual from spending time in the sunlight, light therapy may be beneficial in decreasing jet lag symptoms. Light therapy, or phototherapy, uses a device called a light box, which contains a set of fluorescent or incandescent lights in front of a reflector.

Typically, the patient sits for 30 minutes next to a 10,000-lux box (which is about 50 times as bright as an ordinary indoor light). Light therapy is safe for most people, but those with eye diseases should consult a healthcare professional before undergoing the treatment.

In 2002, a team from Flanders University invented new jet lag sunglasses equipped with a vision device that used light to stimulate travelers’ brains.

They believed that wearing the glasses before and during flights could help the internal human clock adjust more easily to changing time zones. The researchers were looking for a commercial partner to help them further study the glasses and make them widely available.

The effectiveness of glasses or other head-mounted light devices is still uncertain, however. A team of researchers at Columbia University reported in the fall of 2002 that the use of a head-mounted light visor yielded only modest improvement in the test subjects’ symptoms of jet lag.

Allopathic treatment

In cases of short-term insomnia triggered by jet lag, a physician may recommend sleeping pills or prescription medication. Such medication should be taken only under the guidance of a health care professional.

A newer medication that is considered investigational is a melatonin agonist presently known as LY 156735. An agonist is a drug that stimulates activity at cell receptors that are normally stimulated by such naturally occurring substances as melatonin. LY 156735 was found to speed up the readaptation time of volunteer subjects following a simulated 9-hour time shift.

Another new area of research involves the genes that encode the proteins governing circadian rhythms. It is known as of late 2002 that differences among individuals in adaptability to time zone changes are to some extent genetically determined. Targeting the genes that affect this adaptability may yield new treatments for jet lag and other disorders of circadian rhythm.

Expected results

Jet lag usually lasts 24–48 hours after travel has taken place. In that short time period, the body adjusts to the time change, and with enough rest and daytime exposure to sunlight, it returns to normal circadian rhythm.

Prevention

Eating a high-protein diet that is low in calories before intended travel may help reduce the effects of jet lag.

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Juvenile Rheumatoid Arthritis

Juvenile rheumatoid arthritis (JRA) refers to a number of different conditions, all of which strike children, and all of which have immune-mediated joint inflammation as their major manifestation.

JRA is also known as juvenile idiopathic arthritis or JIA. The European League Against Rheumatism, or EULAR, refers to the disorder as juvenile chronic arthritis, or JCA.

The skeletal system of the body is made up of different types of strong, fibrous tissue known as connective tissue. Bone, cartilage, ligaments, and tendons are all forms of connective tissue that have different compositions, and thus different characteristics.

The joints are structures that hold two or more bones together. Some joints (synovial joints) allow for movement between the bones being joined (articulating bones). The simplest model of a synovial joint involves two bones, separated by a slight gap called the joint cavity.

The ends of each articular bone are covered by a layer of cartilage. Both the articular bones and the joint cavity are surrounded by a tough tissue called the articular capsule.

The articular capsule has two components: the fibrous membrane on the outside, and the synovial membrane (or synovium) on the inside. The fibrous membrane may include tough bands of fibrous tissue called ligaments, which are responsible for providing support to the joints.

The synovial membrane has special cells and many capillaries (tiny blood vessels). This membrane produces a supply of synovial fluid that fills the joint cavity, lubricates it, and helps the articular bones move smoothly about the joint.

In JRA, the synovial membrane becomes intensely inflamed. Usually thin and delicate, the synovium becomes thick and stiff, with numerous infoldings on its surface. The membrane becomes invaded by white blood cells, which produce a variety of destructive chemicals.

The cartilage along the articular surfaces of the bones may be attacked and destroyed, and the bone, articular capsule, and ligaments may begin to be worn away (eroded). These processes severely interfere with movement in the joint.

JRA specifically refers to chronic arthritic conditions that affect a child under the age of 16 years, and that last for a minimum of three to six months. JRA is often characterized by a waxing and waning course, with flares separated by periods of time during which no symptoms are noted (remission).

Some literature refers to JRA as juvenile rheumatoid arthritis, although most types of JRA differ significantly from the adult disease called rheumatoid arthritis in terms of symptoms, progression, and prognosis.

Causes and symptoms

A number of different causes have been sought to explain the onset of JRA. There seems to be some genetic link, based on the fact that the tendency to develop JRA sometimes runs in particular families, and based on the fact that certain genetic markers are more frequently found in patients with JRA and other related diseases.

Recent research has shown that several autoimmune diseases, including JRA, share a common genetic link. In other words, patients with JRA might share common genes with family members who have other autoimmune diseases like rheumatoid arthritis, systemic lupus, multiple sclerosis, and others.

Many researchers have looked for some infectious cause for JRA, but no clear connection to a particular organism has ever been made. JRA is considered by some to be an autoimmune disorder.

Autoimmune disorders occur when the body’s immune system mistakenly identifies the body’s own tissue as foreign, and attacks those tissues, as if trying to rid the body of an invader (such as a bacteria, virus, or fungi).

While an autoimmune mechanism is strongly suspected, certain markers of such a mechanism (such as rheumatoid factor, often present in adults with such disorders) are rarely present in children with JRA.

Joint symptoms of arthritis may include stiffness, pain, redness, warmth of the joint, and swelling. Bone in the area of an affected joint may grow too quickly or too slowly, resulting in limbs that are of different lengths. When the child tries to avoid moving a painful joint, the muscle may begin to shorten from disuse. This is called a contracture.

Symptoms of JRA depend on the particular subtype. According to criteria published by the American College of Rheumatology (ACR) in 1973 and modified in 1977, JRA is classified by the symptoms that appear within the first six months of the disorder:

• Pauciarticular JRA: This is the most common and the least severe type of JRA, affecting about 40–60% of all JRA patients. It affects fewer than four joints, usually the knee, ankle, wrist, and/or elbow. Other more general (systemic) symptoms are usually absent, and the child’s growth usually remains normal. Very few children (less than 15%) with pauciarticular JRA end up with deformed joints. Some children with this form of JRA experience painless swelling of the joint. Others have a serious inflammation of structures within the eye, which if left undiagnosed and untreated could even lead to blindness. This condition is known as uveitis, and affects about 20% of children diagnosed with JRA. While many children have cycles of flares and remissions, in some children the disease completely and permanently resolves within a few years of diagnosis.
• Polyarticular JRA:About 40% of all cases of JRA are of this type. It is most common in children up to age three or after the age of 10, and affects girls more often than boys. Polyarticular JRA affects five or more joints simultaneously. This type of JRA usually affects the small joints of both hands and both feet, although other large joints may be affected as well. Some patients with arthritis in their knees will experience a different rate of growth in each leg. Ultimately, one leg will grow longer than the other. About half of all patients with polyarticular JRA have arthritis of the spine and/or hip. Others with polyarticular JRA will have other symptoms of a systemic illness, including anemia (low red blood cell count), decreased growth rate, low appetite, low-grade fever, and a slight rash. The disease is most severe in those children who are diagnosed in early adolescence. Some of these children will test positive for a marker present in other autoimmune disorders, called rheumatoid factor (RF). RF is found in adults who have rheumatoid arthritis. Children who are positive for RF tend to have a more severe course, with a disabling form of arthritis that destroys and deforms the joints. This type of arthritis is thought to be the adult form of rheumatoid arthritis occurring at a very early age.
• Systemic onset JRA: Sometimes called Still disease (after a physician who originally described it), this type of JRA occurs in about 10–20% of all patients with JRA. Boys and girls are equally affected, and diagnosis is usually made between the ages of five and 10. The initial symptoms are not usually related to the joints. Instead, these children have high fevers; a rash; decreased appetite and weight loss; severe joint and muscle pain; swollen lymph nodes, spleen, and liver; and serious anemia. Some children experience other complications, including inflammation of the sac containing the heart (pericarditis), inflammation of the tissue lining the chest cavity and lungs (pleuritis), and inflammation of the heart muscle (myocarditis). The eye inflammation often seen in pauciarticular JRA is uncommon in systemic onset JRA. Symptoms of actual arthritis begin later in the course of systemic onset JRA, and they often involve the wrists and ankles. Many of these children continue to have periodic flares of fever and systemic symptoms throughout childhood. Some children will go on to develop a polyarticular type of JRA.
• Spondyloarthropathy: This type of JRA most commonly affects boys older than eight years of age. The arthritis occurs in the knees and ankles, moving over time to include the hips and lower spine. Inflammation of the eye may occur occasionally but usually resolves without permanent damage.
• Psoriatic JRA: This type of arthritis usually shows up in fewer than four joints, but goes on to include multiple joints (appearing similar to polyarticular JRA). Hips, back, fingers, and toes are frequently affected. A skin condition called psoriasis accompanies this type of arthritis. Children with this type of JRA often have pits or ridges in their fingernails. The arthritis usually progresses to become a serious, disabling problem.

As of 2003, there is some disagreement among specialists about the classification of JRA. Some prefer the EULAR classification, also introduced in 1977, to the ACR system.

In 1997, the World Health Organization (WHO) met in Durban and issued a new classification system for JRA known as the Durban criteria, in an attempt to standardize definitions of the various subtypes of JRA. None of the various classification systems, however, are considered fully satisfactory as of early 2004.


Diagnosis

Diagnosis of JRA is often made on the basis of the child’s collection of symptoms. Laboratory tests often show normal results. Some nonspecific indicators of inflammation may be elevated, including white blood cell count, erythrocyte sedimentation rate, and a marker called C-reactive protein.

As with any chronic disease, anemia may be noted. Children with an extraordinarily early onset of the adult type of rheumatoid arthritis will have a positive test for rheumatoid factor.

Treatment

One of the best natural therapies for JRA is resistance exercises, according to a 1999 study at the University of Buffalo in New York. In the study, children did lower body exercises three times a week for an hour per session. After eight weeks, the children had a 40–60% increase in muscle strength, speed, and endurance. The less fit the child, the more improvement that was shown.

Also, pain was reduced by 50% and medication use was cut by 25%. In a related study, researchers found exercise decreased inflammatory agents while increasing anti-inflammatory compounds in the body, thereby improving immune function. Diet is also believed to play a role in treating juvenile rheumatoid arthritis.

A strict vegetarian diet low in fats and free of glutens can also be helpful, as well as an allergy elimination diet. A number of autoimmune disorders, including JRA, seem to have a relationship to food allergies. Identification and elimination of reactive foods may result in a decrease in JRA symptoms.

Alternative treatments that have been suggested for arthritis include juice therapy, which can work to detoxify the body, helping to reduce JRA symptoms.

Some recommended fruits and vegetables to include in the juice are carrots, celery, cabbage, potatoes, cherries, lemons, beets, cucumbers, radishes, and garlic. Tomatoes and other vegetables in the nightshade family (potatoes, egg-plant, and red and green peppers) are discouraged.

As an adjunct therapy, aromatherapy preparations use cypress, fennel, and lemon. Massage oils include rosemary, benzoin, chamomile, camphor, juniper, eucalyptus, and lavender. Other types of therapy that have been used include acupuncture, acupressure, and body work.

Also shown to be effective in some cases are the essential fatty acids: omega-3 fatty acids in fish oil, and the omega-6 fatty acid gamma liolenic acid (GLA) found in borage oil, currant seed oil, and evening primrose oil.

Several alternative medicine doctors suggest there may be some benefit in taking cartilage supplements, although no definitive studies have been done on this treatment.

Anti-inflammatory spices such as tumeric, ginger, and cayenne may be helpful. Natural remedies such as yucca, burdock root, horsetail, devil’s claw, sarsaparilla, and white willow bark also can be helpful since they have anti-inflammatory and analgesic properties.

Nutritional supplements that may be beneficial include large amounts of antioxidants (vitamins C, A, E, zinc, selenium, and flavenoids), as well as B vitamins and a full complement of minerals (including boron, copper, manganese). One study showed 1,800 International Units (IU) of vitamin E a day could be helpful in relieving symptoms.

Other nutrients that assist in detoxifying the body, including methionine, cysteine, and other amino acids, may also be helpful. Constitutional homeopathy can also work to quiet the symptoms of JRA and bring about balance to the whole person.

Allopathic treatment

Treating JRA involves efforts to decrease the amount of inflammation, in order to preserve movement. Medications that can be used for this include nonsteroidal anti-inflammatory agents (such as ibuprofen and naproxen).

Oral (by mouth) steroid medications are effective, but have many serious side effects with long-term use. Injections of steroids into an affected joint can be helpful. Steroid eye drops are used to treat eye inflammation.

Other drugs that have been used to treat JRA include methotrexate, sulfasalazine, penicillamine, and hydroxychloroquine. Physical therapy and exercises are often recommended in order to improve joint mobility and strengthen supporting muscles. Occasionally, splints are used to rest painful joints and to prevent or improve deformities.

The FDA approved a new drug, etanercept, marketed under the brand name Enbrel, in 1999. It is the most dramatic advancement in treating JRA in recent years. A study by Children’s Hospital Medical Center in Cincinnati, Ohio, released in 1999, showed the drug was effective in 75% of children with severe JRA. The drug eases joint pain, reduces swelling, and improves mobility.

In 2003, a group of Japanese researchers noted that the blood serum of patients with JRA contains elevated levels of interleukin-6, a cytokine (nonantibody protein) that is critical to regulation of the immune system and blood cell formation.

Because interleukin-6 is also associated with inflammation, the researchers think that compounds inhibiting the formation of interleukin-6 might provide new treatment options for JRA.

Expected results

The prognosis for pauciarticular JRA is quite good, as is the prognosis for spondyloarthropathy. Polyarticular JRA carries a slightly worse prognosis. RF-positive polyarticular JRA carries a difficult prognosis, often with progressive, destructive arthritis and joint deformities.

Systemic onset JRA has a variable prognosis, depending on the organ systems affected, and the progression to polyarticular JRA. About 1–5% of all JRA patients die of such complications as infection, inflammation of the heart, or kidney disease.


Prevention

Little is known about the causes of JRA, therefore there are no recommendations available for preventing it.

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Kidney Infections

Kidney infection is a general term used to describe infection of the kidney by bacteria, fungi, or viruses. The infecting microbe may have invaded the kidney from the urinary bladder or from the bloodstream. The disease is characterized by fever, chills, back pain, and, often, the symptoms associated with bladder infection.

As the principle part of the urinary system, the kidneys process the fluid component of blood (called plasma) to maintain appropriate water volume and concentrations of chemicals. The waste product formed from this process is called urine.

Urine travels from the kidney, through tubes called ureters, to the urinary bladder, and is eliminated from the body through a tube called the urethra. The kidneys and ureters comprise the upper urinary tract, and the bladder and urethra comprise the lower urinary tract.

Kidney infection, also called pyelonephritis and upper urinary tract infection, occurs when microbes, usually bacteria, invade the tissues of the kidney and multiply. One or both kidneys may be infected. Infection originating directly from the bladder is called an ascending infection.

Inflammation occurs in response to the infection. As a result of the infection and inflammation, scarring and other tissue damage may occur. Most cases of acute kidney infection resolve without any permanent kidney damage. In severe cases, kidney damage is so extensive that the kidneys can no longer function, a state called renal failure.

Types of kidney infections:

• Acute pyelonephritis: uncomplicated kidney infection that has a short and relatively severe course.
• Chronic pyelonephritis: long-standing disease associated with either active or inactive (healed) kidney infection.
• Emphysematous pyelonephritis: acute infection associated with gas in and around the kidney. This type almost always occurs in persons with diabetes.
• Pyonephrosis: acute or chronic pyelonephritis associated with blockage of the ureter.
• Renal and perinephric abscesses: abscesses (pockets of pus) in and around the kidney.

Kidney infections occur most often in adult females who are otherwise healthy. Urinary tract infections are uncommon in males until old age, when bladder catheterization and other urinary procedures are more commonly performed.

Causes and symptoms

Kidney infection is usually caused by bacteria, although infection by fungi (yeasts and molds) or viruses does occur. The bacteria Escherichia coli (E. coli) is responsible for about 85% of the cases of acute pyelonephritis. Other common causes include Klebsiella, Enterobacter, Proteus, Enterococcus, and Pseudomonas species.

Infection by Proteus species can lead to the formation of stones. E. coli causes only 60% of the acute pyelonephritis cases in the elderly. Kidney infection may also be caused by Mycobacterium tuberculosis or other Mycobacterium species or by the yeast Candida. Kidney infection can be caused by Group B streptococci in newborns.

Certain women are inherently more susceptible to urinary tract infections. Researchers have found that women who have recurrent infections possess certain markers on their blood cells.

Also, the bacteria which commonly cause urinary tract infections stick more readily to the vaginal cells of women who have recurrent infections. Other risk factors for kidney disease include:

• bladder catheterization or instrumentation
• diabetes
• pregnancy
• urinary calculi (stones)
• urinary tract abnormalities
• urinary tract obstruction

The symptoms of kidney infection include fever, shaking chills, nausea, vomiting, and middle to lower back pain which may travel to the abdomen and groin. This pain may be severe. These symptoms may be preceded or accompanied by those associated with bladder infection—frequent, painful urination.

Infants and young children may show fever, irritability, straining on urination, and urine odor. Fewer than half of newborns have fever associated with kidney infection, which makes diagnosis difficult.

In more than 20% of elderly patients with kidney infection, the presenting symptoms are gastrointestinal or pulmonary (lung). Also, one-third of elderly patients do not develop fever.

Diagnosis

Kidney infections can be diagnosed by family doctors, OB/GYN doctors, and urologists (doctors who specialize in the urinary system). The diagnosis of kidney infection is based primarily on symptoms, urinalysis, and urine cultures.

Blood tests may also be performed. Approximately 20% of patients have bacteria in the bloodstream, a condition called bacteremia. Urine dipsticks that detect signs of infection are often used right in the doctor’s office.

Urine would be examined with a microscope for the presence of bacteria and leukocytes (white blood cells). Urine culture would identify which microbe is causing the infection and may also be used to determine which antibiotic would be effective.

Other routine diagnostic procedures to look for signs of infection in the kidney may be used. An x ray of the abdomen may be taken. Ultrasound, which uses sound waves to visualize internal organs, may be used to examine the bladder and kidney. Less routinely performed are intravenous urograms, computerized tomography (CT scan), and scintillation scans.

Treatment

Delays in the diagnosis and treatment of kidney infection can lead to permanent kidney damage. Anyone who suspects kidney infection should seek professional care immediately. Alternative medicine may be used as an adjunct to the appropriate antibiotic treatment.

Dietary changes which may help to control and prevent kidney infection include:

• Drinking eight to 12 glasses of water daily helps to wash out bacteria (although this may also dilute antibacterial factors in the urine).
• Acidifying the urine by eating few alkaline foods (dairy and soda).
• Following a diet rich in grains, vegetables, and acidifying juices, like citrus.
• Eliminating high-sugar foods (sweet vegetables, fruits, sugar, and honey).
• Drinking unsweetened cranberry juice to acidify the urine and provide the antimicrobial agent hippuric acid. Cranberry capsules can substitute for the juice.
• Ingesting at least one clove of garlic (or up to 1,200 mg garlic as a tablet) daily for its anti-infective properties.

Magnesium may be helpful in treating renal disease. Zinc may boost the immune system. A study in rats with ascending pyelonephritis found that the addition of vitamins A and E to standard antibiotic therapy significantly reduced kidney inflammation as compared to antibiotic treatment alone.

Traditional Chinese medicine treats pyelonephritis with acupuncture, herbals, and patent medicines. The Chinese patent medicine Zhi Bai Di Huang Wan (Anemarrhena, Phellodendron, and Rehmannia Pill) is often used to treat kidney infections and disease and bladder infections.

The patient can take eight pills three times daily. Treatment of urinary tract infection often uses one or more of the following herbs in doses of 30 g to 60 g taken once or twice daily (Patients should consult a traditional Chinese medical practioner for the treatment best suited for them.):

• Herba commelinae
• H. plantaginis
• H. patriniae
• H. salviae plebeiae
• H. hedyotis seu oldenlandiae
• H. taraxaci
• H. andrographis

Allopathic treatment

Initiating antibiotic therapy as soon as possible is critical to prevent or reduce damage to the kidneys. Historically, all pyelonephritis patients were treated in the hospital. This has been found to be unnecessary in many cases. Responsible patients who have mild kidney infection can be treated at home with antibiotics taken by mouth.

Patients with high fever, vomiting, evidence of bacteria in the bloodstream, and/or dehydration would be hospitalized and treated with intravenous (IV) antibiotics and fluids. Severe illness, either with or without complications, would require hospitalization for treatment.

The recommended treatment for acute pyelonephritis is two weeks of therapy with the antibiotic combination trimethoprim/sulfamethoxazole. Fluoroquinolones (Cipro, Noroxin, NegGram), ceftriaxone (Rocephin), or gentamicin are other choices. Fluoroquinolones should not be used by pregnant women or children. With treatment, symptoms normally resolve within two to three days.

Abscesses may be resolved with percutaneous (by a needle through the skin) or surgical drainage. Emphysematous pyelonephritis may be treated with antibiotics; however, surgical removal of the kidney (nephrectomy) may be necessary.

Because of the 75% death rate, nephrectomy is the treatment of choice in diabetics with emphysematous pyelonephritis. Urinary stones are eliminated by a percutaneous method which involves stone removal and shock wave treatment.

Expected results

Antibacterial therapy of kidney infection has a 90% cure rate. Severe or chronic infection can lead to kidney damage and renal failure. Renal failure requires hemodialysis, a process which uses a dialysis machine (an artificial kidney) to process the patient’s blood. Patients with severe kidney damage requires kidney transplantation.

Prevention

Researchers are trying to develop a vaccine for UTIs, but as of early 2000, none are ready for human studies. The key to preventing kidney infection is to promptly treat bladder infection. Measures taken to prevent bladder infection may prevent subsequent kidney infection. These include:

• drinking large amounts of fluid
• reducing intake of sugar
• voiding frequently and as soon as the need arises
• proper cleansing of the area around the urethra (females), especially after sexual intercourse
• acupuncture (effective in preventing recurrent lower UTIs in women)
• avoiding use of vaginal diaphragms and spermicidal jelly (females) for contraception

The primary preventive measure specifically for males is prompt treatment of prostate infections. Chronic prostatitis may go unnoticed but can trigger recurrent UTIs. In addition, males who require temporary catheterization following surgery can be given antibiotics to lower the risk of UTIs.

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Kidney stones

Kidney stones are solid accumulations of material that form in the tubal system of the kidney. Kidney stones cause problems when they block the flow of urine through or out of the kidney. When the stones move through the ureter, they cause severe pain.

Urine is formed by the kidneys. Blood flows into the kidneys, and nephrons (specialized tubes) within the kidneys allow a certain amount of fluid from the blood, and certain substances dissolved in that fluid, to flow out of the body as urine.

Sometimes, a problem causes the dissolved substances to become solid again. Tiny crystals may form in the urine, meet, and cling together to create a larger solid mass called a kidney stone.

Many people do not ever find out that they have stones in their kidneys. These stones are small enough to allow the kidney to continue functioning normally, never causing any pain. These are called “silent stones.” Kidney stones cause problems when they interfere with the normal flow of urine. They can obstruct (block) the flow through the ureter (a tube) that carries urine from the kidney to the bladder.

The kidney is not accustomed to experiencing any pressure. When pressure builds from backed-up urine, the kidney may swell (hydronephrosis). If the kidney is subjected to this pressure for some time, there may be damage to the delicate kidney structures.

When the kidney stone is lodged further down the ureter, the backed-up urine may also cause the ureter to swell (hydroureter). Because the ureter is a muscular tube, the presence of a stone will cause the tube to go into a spasm, causing severe pain.

About 10% of all people will have a kidney stone in their lifetime. Kidney stones are most common among male Caucasians over the age of 30, people who have previously had kidney stones, and relatives of kidney stone patients.

Causes and symptoms

Kidney stones can be composed of a variety of substances. The most common types of kidney stones are described here.

Calcium stones

About 80% of all kidney stones fall into this category. These stones are composed of either calcium and phosphate or calcium and oxalate. People with calcium stones may have other diseases that cause them to have increased blood levels of calcium. These diseases include primary parathyroidism, sarcoidosis, hyperthyroidism, renal tubular acidosis, multiple myeloma, hyperoxaluria, and some types of cancer.

Struvite stones

This type accounts for 10% of all kidney stones. Struvite stones are composed of magnesium ammonium phosphate. These stones occur most often in patients who have had repeated urinary tract infections with certain types of bacteria.

These bacteria produce a substance called urease, which increases the urine pH and makes the urine more alkaline and less acidic. This chemical environment allows struvite to settle out of the urine, forming stones.

Uric acid stones

About 5% of all kidney stones are uric acid stones. These occur when increased amounts of uric acid circulate in the bloodstream. When the uric acid content becomes very high, it can no longer remain dissolved and solid particles of uric acid settle out of the urine. A kidney stone is formed when these particles cling to each other within the kidney, slowly forming a solid mass.

About half of all patients with this type of stone also have deposits of uric acid elsewhere in their bodies, commonly in the joint of the big toe. This painful disorder is called gout. Other causes of uric acid stones include chemotherapy for cancer; certain bone marrow disorders in which blood cells are overproduced; and an inherited disorder called Lesch-Nyhan syndrome.

Cystine stones

These account for 2% of all kidney stones. Cystine is a type of amino acid, and people with this type of kidney stone have an abnormality in the way their bodies process amino acids in the diet.

Patients who have kidney stones usually do not have symptoms until the stones pass into the ureter. Prior to this development, some people may notice blood in their urine. Once the stone is in the ureter, however, most people will experience bouts of very severe pain. The pain is crampy and spasmodic, and is referred to as “colic.”

The pain usually begins in the flank region, the area between the lower ribs and the hip bone. As the stone moves closer to the bladder, a patient will often feel the pain radiating along the inner thigh. Women may feel the pain in the vulva, while men often feel pain in the testicles.

Nausea, vomiting, extremely frequent and painful urination, and blood in the urine are common. Fever and chills usually mean that the ureter has become obstructed, allowing bacteria to become trapped in the kidney and cause a kidney infection (pyelonephritis).

Diagnosis

A diagnosis of kidney stones is based on the patient’s history of the severe distinctive pain associated with the stones. Diagnosis includes laboratory examination of a urine sample and an x-ray examination. During the passage of a stone, examination of the urine almost always reveals blood.

A number of x-ray tests are used to diagnose kidney stones. A plain x ray of the kidneys, ureters, and bladder may or may not reveal the stone. A series of x rays taken after injecting iodine dye into a vein is usually a more reliable way of seeing a stone.

This procedure is called an intravenous pyelogram (IVP). The dye “lights up” the urinary system as it travels. In the case of an obstruction, the dye will be stopped by the stone or will only be able to get past the stone at a slow trickle.

An ultrasound can also be used to detect renal blockage. Recently, the use of computed tomography (CT) scans has been added to the diagnosis of some kidney stones, more as a follow-up after treatment to detect how fragile or intact a stone might be.

When a patient is passing a kidney stone, it is important that all of his or her urine is strained through a special sieve to catch the stone. The stone can then be sent to a laboratory for analysis to determine the chemical composition of the stone.

After the kidney stone has been passed, other tests are required to understand the underlying condition that may have caused the stone to form. Collecting urine for 24 hours, followed by careful analysis of its chemical makeup, can often determine the reason for stone formation.

Treatment

It is believed that stones may pass more quickly if the patient is encouraged to drink large amounts of water (2–3 quarts per day).

Herbal remedies that have anti-lithic (stone-dissolving) action can assist in dissolving small kidney stones. These include gravel root (Eupatorium purpureum), hydrangea (Hydrangea arborescens), and wild carrot (Daucus carota).

Starfruit (Averrhoa carambola) is recommended to increase the amount of urine a patient passes and to relieve pain. A Chinese herbal practitioner may use such herbs as Semen Abutili seu Malvae, Semen Plantaginis, and Herba Lygodii Japonici for urinary stones.

Dietary changes can be made to reduce the risk of future stone formation and to facilitate the resorption of existing stones. Supplementation with magnesium, a smooth muscle relaxant, can help reduce pain and facilitate stone passing. Guided imagery may also be used to help relieve pain. Extremely large stones may require surgical intervention.

Allopathic treatment

A patient with a kidney stone will say that the most important aspect of treatment is adequate pain relief. Because the pain of passing a kidney stone is so severe, narcotic pain medications (such as morphine) are usually required.

If the patient is vomiting or unable to drink fluids because of the pain, it may be necessary to provide intravenous fluids. If symptoms and urine tests indicate the presence of infection, antibiotics are required.

Although most kidney stones pass on their own, some do not. Surgical removal of a stone may become necessary when a stone appears too large to pass. Surgery may also be required if the stone is causing serious obstructions, pain that cannot be treated, heavy bleeding, or infection.

Several alternatives exist for removing stones. One method involves inserting a tube into the bladder and up into the ureter. A tiny basket is then passed through the tube, and an attempt is made to snare the stone and pull it out.

Open surgery to remove an obstructing kidney stone was relatively common in the past, but current methods allow the stone to be pulverized (crushed) with shock waves (called lithotripsy). These shock waves may be aimed at the stone from outside of the body by passing the necessary equipment through the bladder and into the ureter.

The shock waves may be aimed at the stone from inside the body by placing the instrument through a tiny incision located near the stone. The stone fragments may then pass on their own or may be removed through the incision.

These methods considerably reduce a patient’s recovery time when compared to the traditional open operation. Some patients may have a follow-up CT scan to determine if the lithotripsy procedure successfully removed all stones.

Expected results

A patient’s prognosis depends on the underlying disorder causing the development of kidney stones. In most cases, patients with uncomplicated calcium stones will recover very well. About 60% of these patients, however, will have other kidney stones.

Struvite stones are particularly dangerous because they may grow extremely large, filling the tubes within the kidney. These are called staghorn stones and will not pass out in the urine. They will require surgical removal. Uric acid stones may also become staghorn stones.

Prevention

Prevention of kidney stones depends on the type of stone and the presence or absence of an underlying disease. In almost all cases, increasing fluid intake so that a person consistently drinks several quarts of water a day is an important preventative measure. Patients with calcium stones may benefit from taking a medication called a diuretic, which has the effect of decreasing the amount of calcium passed in the urine.

While it was once believed that eating a low-calcium diet was helpful for patients with calcium oxalate stones, new research seems to prove otherwise. An Italian study published early in 2002 reported that a low-salt, low-meat diet

Other items in the diet that may encourage calcium oxalate stone formation include beer, black pepper, berries, broccoli, chocolate, spinach, and tea. Uric acid stones may require treatment with a medication called allopurinol.

Struvite stones will require removal and the patient should receive an antibiotic. When a disease is identified as the cause of stone formation, treatment specific to that disease may decrease the likelihood of recurrent stones.

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