1. szöveg
Chronic Pruritus
Chronic pruritus, which is defined as itch persisting for more than 6 weeks is common. It may involve the entire skin (generalized pruritus) or only particular areas, such as the scalp, upper back, arms, or groin (localized pruritus). The incidence of chronic pruritus increases with age. The condition is more common in women than in men and is diagnosed more frequently in Asians than in whites. Chronic pruritus is associated with a markedly reduced quality of life. In a recent study, chronic itch was shown to be as debilitating as chronic pain. Deranged sleep patterns and mood disturbances, including anxiety and depression, are common and may exacerbate the itching.
Chronic pruritus is characteristic of several dermatologic diseases (e.g., atopic eczema, psoriasis, lichen planus, and scabies) but also occurs in a variety of noncutaneous disorders. Itching of any type may elicit secondary skin changes as a result of scratching, rubbing, and picking, so the presence of skin findings does not rule out a systemic cause. Excoriation and nonspecific dermatitis can camouflage both cutaneous and noncutaneous causes of itch. In some cases, the underlying cause is unclear (pruritus of undetermined origin).
The mechanisms underlying the various types of chronic pruritus are complex. A number of mediators are involved in the itch sensation. The itch signal is transmitted mainly by small, itch-selective unmyelinated C fibers originating in the skin. Histamine-triggered neurons and nonhistaminergic neurons may be involved. Misinterpretation of non-noxious stimuli also occurs: touch may be perceived as itch. It is not unusual for patients to report that just taking off or putting on their bedclothes triggers a bout of itching. Strange symptoms like this, combined with the extreme distress of chronic itch, sleep loss, and visits to many physicians, may lead to the erroneous diagnosis of psychogenic itch.
Strategies and Evidence
Evaluation
The first step in the evaluation of chronic pruritus is to determine whether the itch can be attributed to a dermatologic disease or whether an underlying noncutaneous cause is present. The evaluation should start with medical history taking and physical examination. A detailed review of systems (with attention to constitutional symptoms that may point to an underlying systemic illness) should be performed and a thorough drug history (with attention to agents that cause itch, such as opioid analgesics) obtained. Such a review should be repeated at follow-up visits if the diagnosis remains elusive; pruritus is sometimes the first manifestation of a systemic disease, such as Hodgkin's disease or primary biliary cirrhosis, antedating other symptoms by months.
The skin should be examined carefully for primary lesions. Patients with excessively dry skin (xerosis) usually present with minimally detectable changes, but erythematous and scaly inflammatory patches may develop.
In addition to a history taking and physical examination, screening laboratory and imaging studies are suggested.
Management
Treatment of chronic pruritus should be directed at the underlying cause when possible. Itch that is caused by hyperthyroidism or cutaneous T-cell lymphoma, for example, resolves with effective treatment of these conditions. In the absence of a definitive diagnosis, symptomatic treatment is required. Data from randomized, controlled trials of agents for itch treatment are scarce, and in practice, the treatments that are used have variable and often suboptimal effectiveness.
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Forrás: http://www.nejm.org/doi/full/10.1056/NEJMcp1208814
2. szöveg
- We're talking about spinal cord injury which affects about 10,000 new people in
America each year. Dr. Chen, when we talk about spinal cord injury, it's kind of a ..., I see there's sort of a continuum where somebody may have no feeling or ability to move, or they may have something less than a hundred percent. So how does that happen, and maybe help
us understand what are the stops along the way.
- Much depends on the extent to which the tissues within the cord have been injured or damaged. How much is retained sort of depends on how extensive the nerves within the spinal cord have been injured. To what extent can the nerves, the tissues maybe that are putting pressure around them, recover so that feeling and movement can come back? And what time window does that typically happen where you can say it's likely to happen now or it's not going to happen at all?
- That's a terrific question. That is really the key as to how individuals recover and to the extent they recover. You know, the injury to the spinal cord in the great majority of cases are what we call contusion injuries or bruising injuries. There's a misconception in the public that a person who has had a spinal cord injury has had a complete transection of their spinal cord or a complete cut of their spinal cord. In truth, that really very rarely happens. Only in very small percentage of cases do those occur.
And the main reason is because the spinal column or the bone, the vertebral body that surrounds the spinal cord, one of its purposes is to act as a coat of armor in order to protect this vital tissue that carries these signals from the brain to the rest of the body.
But when you look at the nature of how these injuries take place, they're high energy events, motor vehicle crashes, falls from heights. A lot of energy has been transferred to the spinal column, and that energy then, what happens is it causes perhaps a break in the bone, a disruption in the ligaments that hold those bones together, and the bones move on top of each other. And what usually occurs is the spinal cord is bruised. And like any other part of our body, if you've had an ankle sprain, if you've twisted your wrist perhaps by falling on it, there's a natural inflammatory reaction that takes place. The body's reaction is to swell. The same type of event takes place within the spinal cord. And, therefore, because the spinal cord is within that closed space and has nowhere really to expand to, it begins to almost squeeze upon itself, which we believe causes some secondary injury to the spinal cord.
Now, unfortunately, there's really nothing that we can do about the initial injury that takes place. I mean, the ideal would be if you could have prevented the initial event in the first place, but the secondary injury is something that we believe by an individual getting to a trauma center that specializes in spinal cord injury, that way they can begin to focus on trying to minimize the secondary injury that's taking place.
If you, let's say, broke your leg or let's say you broke your arm, in order for it to heal properly you want it in a good alignment. You want it properly placed so that further deformities or
problems don't take place in the future that may cause additional problems.
So frequently surgery is done after an injury, one, is to decompress the spinal cord and to minimize any further secondary damage to the spinal cord. And two is to realign the spine if there has been some disruption in the alignment of the spine and also to solidify the bone and maintain its integrity for the future.
(650 szó) http://www.nmh.org/nm/podcast-spinal-cord-injuries