Monthly Archives: March 2011

Cushing’s syndrome

Alternative Names: Itsenko-Cushing syndrome, hyperadrenocorticism or hypercorticism
Definition:
Cushing’s syndrome is a hormone disorder caused by high levels of cortisol in the blood. This can be caused by taking glucocorticoid drugs, or by tumors that produce cortisol or adrenocorticotropic hormone (ACTH) or CRH

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Cushing’s disease refers to one specific cause of the syndrome, a tumor (adenoma) in the pituitary gland that produces large amounts of ACTH, which in turn elevates cortisol. It is the most common cause of Cushing’s syndrome, responsible for 70% of cases.

This pathology was described by Harvey Cushing in 1932.

Cushing’s syndrome is not confined to humans and is also a relatively common condition in domestic dogs and horses.

Treatments for Cushing’s syndrome can return your body’s cortisol production to normal and noticeably improve your symptoms. The earlier treatment begins, the better your chances for recovery.

Symptoms:
SymptomsMost people with Cushing syndrome will have:

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•Upper body obesity (above the waist) and thin arms and legs
•Round, red, full face (moon face)
•Slow growth rate in children

Skin changes that are often seen:
•Acne or skin infections
•Purple marks (1/2 inch or more wide) called striae on the skin of the abdomen, thighs, and breasts
•Thin skin with easy bruising

Muscle and bone changes include:
•Backache, which occurs with routine activities
•Bone pain or tenderness
•Collection of fat between the shoulders (buffalo hump)
•Thinning of the bones, which leads to rib and spine fractures
•Weak muscles

Woman with cushing syndrome often have:

•Excess hair growth on the face, neck, chest, abdomen, and thighs
•Menstrual cycle becomes irregular or stops

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Men may have:
•Decreased fertility
•Decreased or no desire for sex
•Impotence

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Other symptoms that may occur with this disease:
*Mental changes, such as depression, anxiety and irritability or changes in behavior
*Fatigue
*Headache
*High blood pressure
*Increased thirst and urination
*Muscle weakness
*Loss of emotional control
*Cognitive difficulties
*New or worsened high blood pressure
*Glucose intolerance that may lead to diabetes
*Headache
*Bone loss, leading to fractures over time

Iatrogenic Cushing’s syndrome (caused by treatment with corticosteroids) is the most common form of Cushing’s syndrome. The incidence of pituitary tumors may be relatively high, as much as one in five people, but only a minute fraction are active and produce excessive hormones.

Adults with the disease may also have symptoms of extreme weight gain, excess hair growth in women, high blood pressure, and skin problems. In addition, they may show:

*muscle and bone weakness
*osteoporosis
*diabetes mellitus
*hypertension
*moodiness, irritability, or depression
*sleep disturbances
*menstrual disorders such as amenorrhea in women and decreased fertility in men
*baldness
*hypercholesterolemia

Cause:
There are several possible causes of Cushing’s syndrome.

Exogenous vs. endogenous Hormones that come from outside the body are called exogenous; hormones that come from within the body are called endogenous.

The most common cause of Cushing’s syndrome is exogenous administration of glucocorticoids prescribed by a health care practitioner to treat other diseases (called iatrogenic Cushing’s syndrome). This can be an effect of steroid treatment of a variety of disorders such as asthma and rheumatoid arthritis, or in immunosuppression after an organ transplant. Administration of synthetic ACTH is also possible, but ACTH is less often prescribed due to cost and lesser utility. Although rare, Cushing’s syndrome can also be due to the use of medroxyprogesterone.

Endogenous Cushing’s syndrome results from some derangement of the body’s own system of secreting cortisol. Normally, ACTH is released from the pituitary gland when necessary to stimulate the release of cortisol from the adrenal glands.

*In pituitary Cushing’s, a benign pituitary adenoma secretes ACTH. This is also known as Cushing’s disease and is responsible for 70% of endogenous Cushing’s syndrome.

*In adrenal Cushing’s, excess cortisol is produced by adrenal gland tumors, hyperplastic adrenal glands, or adrenal glands with nodular adrenal hyperplasia.

*Finally, tumors outside the normal pituitary-adrenal system can produce ACTH that affects the adrenal glands. This final etiology is called ectopic or paraneoplastic Cushing’s syndrome and is seen in diseases like small cell lung cancer.

Pseudo-cushing’s syndrome:
Elevated levels of total cortisol can also be due to estrogen found in oral contraceptive pills that contain a mixture of estrogen and progesterone. Estrogen can cause an increase of cortisol-binding globulin and thereby cause the total cortisol level to be elevated. However, the total free cortisol, which is the active hormone in the body, as measured by a 24 hour urine collection for urinary free cortisol, is normal.

Pathophysiology:
The hypothalamus is in the brain and the pituitary gland sits just below it. The paraventricular nucleus (PVN) of the hypothalamus releases corticotropin-releasing hormone (CRH), which stimulates the pituitary gland to release adrenocorticotropin (ACTH). ACTH travels via the blood to the adrenal gland, where it stimulates the release of cortisol. Cortisol is secreted by the cortex of the adrenal gland from a region called the zona fasciculata in response to ACTH. Elevated levels of cortisol exert negative feedback on the pituitary, which decreases the amount of ACTH released from the pituitary gland. Strictly, Cushing’s syndrome refers to excess cortisol of any etiology. One of the causes of Cushing’s syndrome is a cortisol secreting adenoma in the cortex of the adrenal gland. The adenoma causes cortisol levels in the blood to be very high, and negative feedback on the pituitary from the high cortisol levels causes ACTH levels to be very low. Cushing’s disease refers only to hypercortisolism secondary to excess production of ACTH from a corticotrophic pituitary adenoma. This causes the blood ACTH levels to be elevated along with cortisol from the adrenal gland. The ACTH levels remain high because a tumor causes the pituitary to be unresponsive to negative feedback from high cortisol levels.

Cushing’s Syndrome was also the first autoimmune disease identified in humans.

Diagnosis:-
When Cushing’s syndrome is suspected, either a dexamethasone suppression test (administration of dexamethasone and frequent determination of cortisol and ACTH level), or a 24-hour urinary measurement for cortisol offer equal detection rates. Dexamethasone is a glucocorticoid and simulates the effects of cortisol, including negative feedback on the pituitary gland. When dexamethasone is administered and a blood sample is tested, high cortisol would be indicative of Cushing’s syndrome because there is an ectopic source of cortisol or ACTH (e.g.: adrenal adenoma) that is not inhibited by the dexamethasone. A novel approach, recently cleared by the US FDA, is sampling cortisol in saliva over 24 hours, which may be equally sensitive, as late night levels of salivary cortisol are high in Cushingoid patients. Other pituitary hormone levels may need to be ascertained. Performing a physical examination to determine any visual field defect may be necessary if a pituitary lesion is suspected, which may compress the optic chiasm causing typical bitemporal hemianopia.

When any of these tests are positive, CT scanning of the adrenal gland and MRI of the pituitary gland are performed to detect the presence of any adrenal or pituitary adenomas or incidentalomas (the incidental discovery of harmless lesions). Scintigraphy of the adrenal gland with iodocholesterol scan is occasionally necessary. Very rarely, determining the ACTH levels in various veins in the body by venous catheterization, working towards the pituitary (petrosal sinus sampling) is necessary.

Mnemonic:
C – Central obesity, Cervical fat pads, Collagen fibre weakness, Comedones (acne)
U – Urinary free cortisol and glucose increase
S – Striae, Suppressed immunity
H – Hypercortisolism, Hypertension, Hyperglycemia, Hypercholesterolemia, Hirsutism
I – Iatrogenic (Increased administration of corticosteroids)
N – Noniatrogenic (Neoplasms)
G – Glucose intolerance, Growth retardation

Treatment:-
Most Cushing’s syndrome cases are caused by steroid medications (iatrogenic). Consequently, most patients are effectively treated by carefully tapering off (and eventually stopping) the medication that causes the symptoms.

If an adrenal adenoma is identified it may be removed by surgery. An ACTH-secreting corticotrophic pituitary adenoma should be removed after diagnosis. Regardless of the adenoma’s location, most patients will require steroid replacement postoperatively at least in the interim as long-term suppression of pituitary ACTH and normal adrenal tissue does not recover immediately. Clearly, if both adrenals are removed, replacement with hydrocortisone or prednisolone is imperative.

In those patients not suitable for or unwilling to undergo surgery, several drugs have been found to inhibit cortisol synthesis (e.g. ketoconazole, metyrapone) but they are of limited efficacy.

Removal of the adrenals in the absence of a known tumor is occasionally performed to eliminate the production of excess cortisol. In some occasions, this removes negative feedback from a previously occult pituitary adenoma, which starts growing rapidly and produces extreme levels of ACTH, leading to hyperpigmentation. This clinical situation is known as Nelson’s syndrome.

Lifestyle and home remedies:-

The length of your recovery from Cushing’s syndrome will depend on the severity and cause of your condition. Remember to be patient. You didn’t develop Cushing’s syndrome overnight and your symptoms won’t disappear overnight, either. In the meantime, these tips may help you on your journey back to health.

*Increase activities slowly. You may be in such a hurry to get your old self back that you push yourself too hard too fast, but your weakened muscles need a slower approach. Work up to a reasonable level of exercise or activity that feels comfortable without overdoing it. You’ll improve little by little, and your persistence will be rewarded.

*Eat sensibly. Nutritious, wholesome foods provide a good source of fuel for your recovering body and can help you lose the extra pounds that you gained from Cushing’s syndrome. Make sure you’re getting enough calcium and vitamin D. Taken together, they help your body absorb calcium, which can help strengthen your bones, counteracting the bone density loss that often occurs with Cushing’s syndrome.

*Monitor your mental health. Depression can be a side effect of Cushing’s syndrome, but it can also persist or develop after treatment begins. Don’t ignore your depression or wait it out. Seek help promptly from your doctor or a therapist if you’re depressed, overwhelmed or having difficulty coping during your recovery.

*Gently soothe aches and pains. Hot baths, massages and low-impact exercises, such as water aerobics and tai chi, can help alleviate some of the muscle and joint pain that accompanies Cushing’s syndrome recovery.

*Exercise your brain. If you’re recovering from any cognitive difficulties as a result of Cushing’s syndrome, mental exercises, such as math problems and crossword puzzles, may improve your brain function.

Coping and support:-
Support groups can be valuable in dealing with Cushing’s syndrome and recovery. They bring you together with other people who are coping with the same kinds of challenges, along with their families and friends, and offer a setting in which youe can share common problems.

Ask your doctor about support groups in your community. Your local health department, public library and telephone book and the Internet also may be good sources to find a support group in your area.

Prognosis:
Removing the tumor may lead to full recovery, but there is a chance that the condition will return.

Survival for people with ectopic tumors depends on the tumor type. Untreated, Cushing syndrome can be life-threatening.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://en.wikipedia.org/wiki/Cushing’s_syndrome
http://www.mayoclinic.com/health/cushings-syndrome/DS00470
http://www.nlm.nih.gov/medlineplus/ency/article/000410.htm
http://www.bbc.co.uk/health/physical_health/conditions/cushing1.shtml

Cushing’s Syndrome


http://www.potbellysyndrome.com/documents/083EFB330BDDC27C6EEC8354AFFA139607633EB6.html
http://www.wrongdiagnosis.com/c/cushings_disease/book-diseases-7a.htm

http://www.nature.com/eye/journal/v20/n6/fig_tab/6701956f4.html

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Crouzon syndrome

Alternative Name :Branchial arch syndrome.

Definition:-
Crouzon syndrome is a genetic disorder of Chromosome 10.  Specifically, this syndrome affects the first branchial (or pharyngeal) arch, which is the precursor of the maxilla and mandible. Since the branchial arches are important developmental features in a growing embryo, disturbances in their development create lasting and widespread effects.

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This syndrome is named after Octave Crouzon, a French physician who first described this disorder. He noted the affected patients were a mother and her daughter, implying a genetic basis. First called “craniofacial dysostosis”, the disorder was characterized by a number of clinical features. This syndrome is caused by a mutation in the fibroblast growth factor receptor II, located on chromosome 10.

Breaking down the name, “craniofacial” refers to the skull and face, and “dysostosis” refers to malformation of bone.

Now known as Crouzon syndrome, the disease can be described by the rudimentary meanings of its former name. What occurs in the disease is that an infant’s skull and facial bones, while in development, fuse early or are unable to expand. Thus, normal bone growth cannot occur. Fusion of different sutures leads to different patterns of growth of the skull. Examples include: trigonocephaly (fusion of the metopic suture), brachycephaly (fusion of the coronal suture), dolichocephaly (fusion of the sagittal suture), plagiocephaly (unilateral premature closure of lambdoid and coronal sutures), oxycephaly (fusion of coronal and lambdoidal sutures), Kleeblattschaedel (premature closure of all sutures).

In the United States it is estimated to affect 1 per 60,000 live births.It is responsible for approximately 4.8% of all cases of craniosynostosis. Crouzon syndrome affects individuals of all ethnic backgrounds. It may be inherited or it may occur spontaneously.

Incidence of Crouzon syndrome is currently estimated to occur in 1 out of every 25,000 people out of the general population. There is a greater frequency in families with a history of the disorder, but that doesn’t mean that everyone in the family is affected (as referred to above).

Symptoms:-
Crouzon syndrome is usually diagnosed in infancy because of its particular face and skull deformities, which are:

•Early fusion of the bones of the skull (craniosynostosis), causing a misshapen head
•The skull problems may push the brain down (tonsillar herniation), and may obstruct the flow of cerebrospinal fluid (hydrocephalus)
•The nose and upper jaw appear sunken in because of poor bone growth in the face (midface hypoplasia)
•The eyes may appear to pop out (exophthalmos or proptosis) for the same reason (midface hypoplasia)


There may be other internal problems with the face and head such as narrow or absent ear canals, problems with the teeth and palate, and problems with the nose and sinuses. In some individuals with Crouzon syndrome (about 18%), two or more bones of the neck may be fused together.

Some individuals with the syndrome (about 5%) may also have a skin disorder called acanthosis nigricans, in which lesions of darkened, thickened skin are present.

Causes:
Associations with mutations in the genes of FGFR2 and FGFR3 have been identified as cause  of Crouzon syndrome. This FGFR2 gene provides instructions for making a protein called fibroblast growth factor receptor 2. Among its multiple functions, this protein signals immature cells to become bone cells during embryonic development. Mutations in the FGFR2 gene probably overstimulate signaling by the FGFR2 protein, which causes the bones of the skull to fuse prematurely.

The condition is inherited in an autosomal dominant way, so that each child of a person with Crouzon syndrome has a 50 per cent chance of inheriting the condition. However, in about half of all cases the syndrome has resulted from a new mutation (that is, neither parents were affected).

Like Apert syndrome, Crouzon syndrome may be more common among children born to older fathers.

Diagnosis:
Diagnosis of Crouzon syndrome usually can occur at birth by assessing the signs and symptoms of the baby. Further analysis, including radiographs, magnetic resonance imaging (MRI) scans, genetic testing, X-rays and CT scans can be used to confirm the diagnosis of Crouzon syndrome.

Treatment:
Like other genetic conditions, Crouzon’s cannot be ‘cured’. But with the right help and care, most children lead a relatively normal life.

Surgery is typically used to prevent the closure of sutures of the skull from damaging the brain’s development. Without surgery, blindness and mental retardation are typical outcomes. Craniofacial surgery is a discipline of plastic surgery. To move the orbits forward, plastic surgeons work with neurosurgeons to expose the skull and orbits and reshape the bone. To treat the midface deficiency, plastic surgeons can move the lower orbit and midface bones forward (this does not need neurosurgical assistance). For jaw surgery, either plastic surgeons have experience to perform these operations. It is rare to wear a custom-fitted helmet (or cranial band) for several months after surgery as that is only for single-suture “strip craniectomy” repair. Crouzon patients tend to have multiple sutures involved, most specifically bilateral coronal craniosynostoses, therefore an open operation is used rather than the strip craniectomy with helmeting.

Excessive fluid around the brain (hydrocephalus) may need to be drained by inserting a tube called a shunt. Other specialist help, for example, to treat dental, eye or ear, nose and throat problems, is often needed.

Long-term supportive treatments such as speech therapy, psychological and educational help, and genetic counselling for the family are also important in helping the child to reach their potential.

Once treated for the cranial vault symptoms, Crouzon patients generally go on to live a normal lifespan.

You may click to learn more  if you  have specific questions about Crouzon syndrome.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://www.bbc.co.uk/health/physical_health/conditions/crouzon2.shtml
http://en.wikipedia.org/wiki/Crouzon_syndrome
http://emedicine.medscape.com/article/942989-overview
http://rarediseases.about.com/cs/crouzonsyndrome/a/011804.htm

http://emedicine.medscape.com/article/1280034-overview

http://ufacts.blogspot.com/2007/12/real-egg-head-boy.html

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Knees Pain

We often take our knees for granted. They may be hidden under clothing and seem inconspicuous but are, in fact, most important as they balance the entire weight of the body. This makes them prone to injury and malfunction at all ages.

One of the commonest symptoms of any knee problem is pain. This may be acute following a fall. It may occur as a result of an unexpected unbalanced twisting movement in a game of basketball or football. Or the knee may be affected as a result of degenerative osteoarthritis. In autoimmune diseases such as rheumatoid arthritis, generally small joints of the hands and feet are affected. At times, one or both knees may also be swollen. Conditions like gout and pseudogout — which occur when crystals are deposited in the joint space — usually affect the big toe, but again the knee may be affected.

The bones of the knee joint are cushioned by cartilage. Bits of the latter can suddenly break away and form loose bodies inside the joint space. These can get wedged during movement of the knee. There is excruciating pain, and the joint gets “stuck”. It cannot be bent or straightened.

The cartilage may also become worn down and degenerate with constant wear and tear. This exposes the bones. They then tend to grind against each other and produce pain.

Problems in areas like the spine, hip and ankle can produce a change in gait. The person may not balance properly on both feet and may limp. This puts more pressure on one knee. This too can result in pain.

The patella is a triangular bone that sits on top of the knee. Degeneration of the patella or strain of the ligaments that attach it to the bone may cause pain. This is common in children, older people and particularly women athletes.

Bacterial infections which start in other parts of the body can spread via the bloodstream and localise in the knee. This causes an acute infection with redness, pain and fever.

Knee pain can usually be tackled at home. It often disappears with 48 hours of rest. Pain and swelling can be reduced with the application of an ice pack. The pack, however, should not be applied for more than 20 minutes. Ointments containing Capsicain are often effective. They should be applied on the affected joint, followed by an ice pack. Lidnocaine (a local anaesthetic) ointment may also provide relief. Ointments are particularly effective if combined with tablets of paracetamol, ibubrufen or nalidixic acid. Compression of the joint with an “elastocrepe” bandage or a “knee cap” prevents swelling. Elevation of the foot also helps.

Accupressure and acupuncture have been shown to be effective. The first involves application of pressure to specific points around the knee while in the second, needles are inserted into them.

A doctor needs to be consulted if the joint pain is accompanied by fever, there is obvious swelling, it is impossible to bear weight on that knee, or if it cannot be flexed or extended fully.

By examining the knee thoroughly and performing some diagnostic manoeuvres, it is usually possible for the doctor to arrive at a tentative diagnosis. Blood tests may be done to rule out gout or rheumatoid arthritis. X-rays, magnetic resonance imaging (MRI), computed tomography (CT) scans and ultrasound may be needed to clinch the diagnosis.

A combination of physical therapy and medication usually provides great relief. Injections of steroids and other chemicals into the joint space may reduce inflammation and pain. If the problem persists, surgery may be required. Arthroscopy may be done to remove loose bodies and repair tears to the ligaments inside the joint. Surgery for knee replacement — complete or partial — is now common and done in many centres. There are very few contraindications. More and more older people are opting for it and enjoying productive and pain-free lives.

Some knee problems — particularly those resulting from an injury or a systemic disease — may be inevitable and require long-term treatment. The painful arthritis of old age can, however, be prevented with a few lifestyle modifications.

Obesity increases the pressure on the knees. Many years of being overweight take their toll, resulting in degenerative changes. Try to remain as close to your ideal body weight as possible.

Physical activity maintains muscle tone and helps keep the knee joint aligned. Repetitive high impact activity can cause tears in ligaments and cause pain. Runners in particular can develop pain in the ligaments around the joint. This is particularly true if physical activity is not preceded and followed by stretching and strengthening exercises. Cross training helps balance joints and reduce strain and injury. A combination of cycling, swimming, jogging or walking, and yoga is ideal.

Source : The Telegraph ( Kolkata, India)

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Sweet Drag

T.V. Jayan on a new study that confirms that nicotine worsens diabetes-related complications

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If you are diabetic and also enjoy your smoke, it’s a double whammy for you. Diabetic smokers will find it difficult to stave off complications associated with rising blood sugar levels, new research has shown.

The study — by Xian-Chuan Liu, a researcher at the California State Polytechnic University in the US — is the first to establish a strong link between smoking and diabetes-related complications. The work was presented at the 241st annual meeting of the American Chemical Society in Anaheim yesterday. “If you’re a smoker and have diabetes, you should be concerned and make every effort to quit smoking,” says Liu.

Though cigarette smoking is a major health risk factor that significantly increases your chances of heart disease, cancer, and acute and chronic respiratory tract infection, it was hardly implicated in the development of diabetes till very recently. One study in the recent past, however, showed that smokers may be nearly 50 per cent more vulnerable to developing type 2 diabetes than non-smokers. Similarly, children born to smoking mothers will have impaired production of insulin, the hormone required to regulate glucose uptake by cells, and thus may develop type 1 diabetes.

The new study has gone a step further to show that smoking worsens the complications associated with diabetes and how this really happens. Some of the complications linked to diabetes are heart attack, stroke, kidney failure and nerve damage.

According to the Brussels-based International Diabetes Federation, more than 300 million people around the world suffer from diabetes. The figure is expected to reach close to 500 million by 2030.

The study is particularly significant for India, where a large number of diabetics are also smokers. It is estimated that there are more than 50 million diabetics in the country. A study published in the New England Journal of Medicine in 2008 showed that India is home to more than 120 million smokers.

Though doctors have known for years that smoking increases the risk of developing diabetes-related complications, they haven’t been able to pinpoint the exact substance in cigarette smoke responsible for this. Liu and his colleagues suspected it may be nicotine, the chemical that makes smoking addictive.

As diabetes has no cure yet, the only way to ward off complications is to maintain the required blood sugar levels through medicine and lifestyle modification. The gold standard for monitoring long-term blood sugar levels in diabetics is a blood test called the haemoglobin A1c (HbA1c).

The premise for the HbA1c test is as follows. The haemoglobin in red blood cells reacts with glucose molecules to form what is called glycated haemoglobin. In individuals with poorly controlled diabetes, the quantities of these glycated haemoglobins are much higher than in healthy people. Hence, the number of glycated haemoglobins in one’s blood gives a fairly accurate measure of glucose levels in blood.

Used often in conjunction with regular blood sugar monitoring, the HbA1c test reveals the average amount of sugar in blood during a period of up to three months. High HbA1c test results mean that the condition is not well controlled and there is an increased risk of chronic complications.

To explore their theory that nicotine has a role, the scientists set out to check how the chemical influences HbA1c. Using human blood samples, they showed that concentrations of nicotine similar to those found in the blood of smokers did, indeed, raise levels of HbA1c.

Nicotine caused HbA1c levels to rise by as much as 34 per cent,” Liu told Knowhow. In moderate smokers, the increase was about 10 per cent.

“This looks like an important finding. We had so far thought that nicotine had no influence on diabetes-related complications,” says Balbir Singh, cardiologist at Medanta, a private hospital in Gurgaon.

High blood sugar or not, it doesn’t matter. Stub out that cigarette in any case.

Source: The Telegraph ( Kolkata, India)

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Is this Causing Your Chronic Cough?

Vitamin B-12 deficiency is a known cause of central and peripheral nervous system damage. It has been implicated in sensory neuropathy and autonomic nervous system dysfunction — which can in turn have a role in chronic, unexplained coughs.

A recent study showed that vitamin B-12 deficiency patients had a higher prevalence of laryngeal hyperresponsiveness. After being given B-12 supplements, their symptoms and laryngeal, bronchial, and cough thresholds significantly improved.

According to the study in the American Journal of Clinical Nutrition:

“This study suggests that [vitamin B-12 deficiency] may contribute to chronic cough by favoring sensory neuropathy as indicated by laryngeal hyperresponsiveness and increased NGF expression in pharyngeal biopsies of [vitamin B-12 deficiency] patients. [Vitamin B-12 deficiency] should be considered among factors that sustain chronic cough, particularly when cough triggers cannot be identified.”

Source: American Journal of Clinical Nutrition January 19, 2001; 93(3): 542-548

Posted By Dr. Mercola | March 12 2011

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