Diseases, Disorders information

Obsessive-compulsive disorder (OCD. OCD is sort of the hand-washing, the checking, the counting. How many of you have some OCD traits? You don’t have to raise your hand because I know the answer. Probably all of us do. Probably 80-90% of college and professional athletes have some OCD stuff going on. The basketball player who has to bounce the ball three times before he makes a free-throw.

The etiology of OCD. There’s a few things going on. One, there may be some evolutionary components. You know, chimpanzees groom each other. It might be grooming rituals gone nuts.
Canadian pharmacy Lexapro
It’s one of the few things in psychiatry that is very similar in kids as it is in adults. You see a lot of kids with OCD and they think it may be related to strep infections now. Occasionally, one of the things about OCD by definition, is there has to be some un-comfort with it. People have to say, “I know this is stupid.” That’s what differentiates this from psychosis. The schizophrenic, why does he check all the food in the refrigerator before he eats it? Because he thinks the CIA is coming in and tampering with it. The OCD person says, “No, no. I know this is stupid but I feel like I have to check it because otherwise it’s going to be contaminated somehow by germs and if I don’t check it something bad is going to happen.”

Treatment of OCD. It changes all the time, but clomipramine was thought to be a bit more efficacious than the others, Anafranil. That’s the TCA that looks like a TCA but acts like an SSRI. Clomipramine or Anafranil. The trouble with that is no one wants to start a tricyclic antidepressant. It’s like Elavil. Elavil has a lot of side effects. Clomipramine is similar to Elavil online. So we like to use the SSRIs. Currently approved, I think, fluoxetine, sertraline, and paroxetine - Cheap Zoloft, Canadian Pharmacy Paxil, Prozac Online and Luvox. There’s five American SSRIs now and rour of them are approved for OCD. Luvox may be a little better than the others. The other thing is behavior therapy. What you do, just in a nutshell, if the person has a problem with washing their hands all the time you say to them, “Look, I want you to not wash your hands. Here’s your homework. You don’t wash your hands, and you’ve got to touch everything in the house. Go in the mud, not wash your hands, touch the toilet seats.” And if the person is very motivated - they’ve got to be very motivated - they’ll do it and they will have sky-high anxiety for about three or four days and then it will go down to nothing. That’s very good and they won’t relapse all that often. If they just go on Prozac they’ll feel better but you stop the Prozac and it all gets worse again. There is a schism. There’s people who say that the original studies that validated the efficacy of clomipramine were not that good and that in reality cognitive therapy is better.

Post-traumatic stress disorder. Response to a trauma, like assault, rape, or combat. Characterized by flashbacks, nightmares, avoidance. Easy to startle, insomnia, diminished interest in activities. Used to be in the old DSM, the psychiatry …acute stress disorder is just like PTSD but it resolves in four weeks.

It’s not schizoaffective. In a nutshell, what is schizoaffective? We’ll go through the five schizos before we are done. Unfortunately, psychiatrists thought it was a good idea to name five similar disorders starting with schiz and there’s no real easy way to sort that out. So we’ve got to go through them one by one. Basically, here’s schizoaffective. Let’s say you are a schizophrenic and you are like a street person and you hear voices, and you believe that the moon is made out of cheese or whatever, and you get depressed. You are not a schizophrenic with major depressive illness. Psychiatrists won’t allow you to be that. You have to have a new special name and that new special name is schizoaffective disorder. It’s like congestive heart failure can coexist with a broken arm. Well, in psychiatry-land if you are a schizophrenic you can’t have major depressive episodes. You magically become schizoaffective. That’s all that is. Major depressive illnesses differ in that when you treat the person, the schizophrenic goes back to being a street person, but the major depressive disorder goes back to being a housewife. She’s perfectly fine between episodes. The schizophrenic is not fine between episodes.

Dysthymic disorder is basically a low-level depression. This is like people who are chronically depressed. Major depressive illness is, people are going along fine and then boom! They are down there and then you put them on Prozac and they come back up to their baseline. People with dysthymia, they are like down here. They are not way down at the bottom but they are not normal. They just can’t get excited about life.
Canadian pharmacy Antidepressants
Bipolar disorder, formerly manic depression. Mania means episodes of irritable moods, severe enough to cause problems with function. Classically people feel great but judgment is impaired. The symptoms include for bipolar disorder: they are grandiose, diminished need for sleep, pressured speech. What’s pressured speech? It’s like they have this pressure to keep talking. Flight of ideas. It’s just one idea after another, and “I’m going to write a book, I’m going to paint my house …” and just a whole bunch of ideas at once. Very distractible. Increased goal-directed activity but often sloppy and not really productive, and bad judgment. They get involved in driving too fast, spending, sex, involved in crimes sometimes. I had a patient who committed a string of bank robberies and did a lot of time for that, and alleged to me that he was bipolar. That he was having manic episodes when it was happening. I don’t know. Some patients will get psychotic. People will come in and say, “I’m a special messenger from God. I am king of the United States” when they are manic.

In bipolar type II disorder, the person is hypomanic. Hypomanic is they have problems with depression and they don’t have problems with mania, they have problems with hypomania which is sort of a low level mania. When people are manic they are bad. They are out of control, they are dangerous, and they are just not sleeping, they’ve got to be in the hospital basically. Hypomanic people sometimes can do well. They are just really really up and really really enthusiastic. Sometimes it can help their career.

Symptoms of major depressive disorder include problems of sleep, interest, guilt, energy, concentration, appetite, psychomotor symptoms, and suicidal thoughts. Five symptoms of the criteria are needed to make a diagnosis. Commonly in depressive illness you see a lot of anxiety and a loss of libido(erectile dysfunction).

Another important point is what happens to REM sleep during a major depressive episode. REM increases; REM density increases. You are in REM quicker and you are in REM longer when you are depressed. Most antidepressants will decrease REM sleep. An old trick back before there were good antidepressants, a thing you could do for refractory patients was keep them up all night. You would just sleep deprive them and the depression would get better. Because depressed people are spending too much time in REM. But it really didn’t work. They would relapse fairly quickly after being kept awake.

When people get depressed, or manic, they can get psychotic. A thirty-five-year-old housewife comes in says the devil is punishing me. She’s not interested in doing anything anymore. She is sleeping two hours a night. She says she can’t get to sleep. She has a lot of psychomotor retardation, what’s going on? She doesn’t have schizophrenia. She has major depressive illness. When people get too high or too low they can get psychotic. But not everybody who is delusional or hallucinating is schizophrenic.

Alport’s syndrome has glomerular lesions, hematuria and decreased GFR. Underline anterior lenticonus, cataracts, sensorineural deafness. First, lets look at prune-belly syndrome. Here is the prune-belly. Lacks abdominal musculature. Testes are not palpable. Renal abnormalities. Prune-belly syndrome. By the way, what do you notice? Is this a boy or a girl? Boy. Prune-belly syndromes are almost always in boys. And we can talk at some point about why that is, but it’s almost always in boys. Write it down. There are only about five reported cases in girls. And if they ask you that, tell them you want your money back. Prune-belly syndrome, boy, cryptorchidism, absence of abdominal musculature, renal problems. Hearing. Sensorineural high tone hearing loss. Cataract. This is the only condition, the only condition, that gives you anterior lenticonus. Everything else is posterior lenticonus in ophthalmology. This plus the characteristic glomerular lesion is Alport’s syndrome. I’ll go back and remind you, Alport’s syndrome; anterior lenticonus, cataracts, glomerular lesions, hematuria, decreased GFR.

Okay, we have a few more to go. This is a sort of characteristic … you see this little bulls-eye when you do your funduscopic? This is pretty characteristic. This is the lenticonus because what’s happening is you are looking in and the conical-shaped lens is like this, so you are going in and making your cuts in and I’ve never seen it described anywhere, but I’ve seen it a zillion times. And this is what it looks like. It almost looks circumferential. Bulls-eye in nature.

Tuberous sclerosis; you’ve heard about tuberous sclerosis. The renal abnormalities, renal angiomyolipoma, cystic kidneys and renal cell carcinoma. An important clinical link and association. Other features, underline adenoma sebaceae, underline CNS tubers, retinal phacoma and of course some of the skin, the shagreen patches, the White Mountain ash spots. We’ll talk about Drash syndrome, which is diffuse mesangial sclerosis, nephrotic syndrome in end-stage renal disease. The association here is Wilms tumor and male pseudohermaphroditism. So let’s first … looks like I have Drash syndrome up here first. Here’s mesangial sclerosis, diffuse mesangial sclerosis and ambiguous genitalia. If you get a patient, a case, with nephrotic syndrome and ambiguous genitalia like this, what study do you want to do? A renal ultrasound because you want to look for Wilms tumor. And that’s the link and association, a very important link and association here. This is named after Alan Drash, the first person. It’s also called Denny’s Drash syndrome, nephrotic syndrome in childhood, diffuse mesangial sclerosis, Wilms tumor, male pseudohermaphroditism. So these are males that have ambiguous genitalia. The females do not.

Finally, what is this? Recognizable? Anaphylactoid purpura, right. Remember, it is usually classically over the lower limbs and buttocks. It is alliterative, palpable purpura. Write down, as a link and association, palpable purpura. Because you can feel it. Little lumps. Palpable purpura on the lower extremities, crampy abdominal pain, arthralgia, peak at 4-5 years of age. It’s mediated by IgA immune complexes. Histology in the kidney, mesangial proliferation and/or epithelial crescents. The worse the biopsy the worse the prognosis. If you have nephrotic syndrome and nephritis, that is the worst outcome. We biopsy them and if we see crescents, that’s the issue.

I have included in your syllabus a list of syndromes that have renal disease in them and I’m going to highlight some of them here, not all of them, but highlight a few of them and show you some pictures. One or two of them you may see in the photo-quiz outside. I wonder how they got there? So we’ll just go through a few syndromes that will both help you clinically and might help you on the Boards.
A few words about medications. I recommend Cheap Canadian Pharmacy
Anti-Acidity Medications:
Canadian Pharmacy Nexium - NEXIUM works by decreasing the acid produced by acid pumps. NEXIUM deactivates some of the pumps to keep acid production under control. By reducing acid production in the stomach, NEXIUM reduces the amount of acid backing up into the esophagus and causing reflux symptoms.
Achipex - ACIPHEX is used for the treatment of persistent, frequent heartburn and other symptoms associated with acid reflux disease. Persistent and frequent occurrences are classified as 2 or more days a week.
Prevacid - Prevacid works by reducing the amount of acid produced in the stomach.
Syndrome number one, which I don’t have a picture of, is branchio-otorenal syndrome, BOR syndrome. You get dysplasia; unilateral renal agenesis is the renal anomalies, and other findings are branchial fistulas and in particular, preauricular pits and hearing losses. Those are underlined because those are the associations that you want to make. If you see somebody with a little pit in front of their ear and hearing loss, look for renal problems. Potter’s syndrome: renal failure, oligohydramnios. Remember that oligohydramnios tends to be associated with pulmonary hypoplasia. Because there’s not enough amniotic fluid to expand the lungs. You also get small posterior-set ears, micrognathia, beaked nose, wide set eyes. Here is a picture of Potter’s facies. These babies are usually stillborn. Micrognathia, look at the ears. Look how low set they are. This is what the kidneys look like; cystic dysplasia. Another picture of Potter’s facies. Ears are low set, not so low set, beaked nose, micrognathia. Pulmonary hypoplasia is the association.

Prune-belly syndrome; the renal abnormalities, dilated urinary tract, dysplastic, aplastic, multicystic and hydronephrotic kidneys. Underline absence of abdominal musculature, cryptorchidism. That’s called the triad because there are three of them. Cryptorchidism, absence of abdominal musculature, renal abnormalities. The triad.

How do you evaluate type II RTA? Again, hyperchloremia, metabolic acidosis. But the anion gap is negative. Remember I told you that for distal RTA the anion gap was positive. This one is not a problem with making ammonia. This is a problem just with leaking lots of bicarb. So the anion gap is negative. The urine pH is greater than 5.5 when the plasma bicarb is what is normal to you and me, but when the plasma bicarb falls below the threshold, the urine pH is low.

I am going to … this is another way to evaluate it. Again, this is something that pediatric nephrologists do. It’s a fractional excretion but instead of a fractional excretion of sodium, it’s a fractional excretion of bicarbonate. And we can do this, and this allows us to do that. Again, they will not be asking you that.

A quick word about type IV RTA. There is no type III. There was a mistake. Somebody made a mistake and so they called… we called just type IV. Type IV is so-called low-renin hypo-renin hypoaldosteronism. This again is a non-anion gap acidosis but it has hyperkalemia. Urine pH can look like type II RTA with a pH less than 5.5. Highly unlikely that they will ask you about this. Very unusual. It’s caused by true aldosterone deficiency, conditions which decrease renin secretion and conditions where the kidney cannot respond to mineralocorticoids. This is a reiteration; the diagnostic workup of suspected RTA. We look first for he serum anion gap. We see whether it is elevated. The metabolic acidosis is elevated. If it is you work up for a gap acidosis. If there is a normal gap, you want to evaluate for RTA. Then I put in how you go with RTA’s, either type II or type I and type IV. I’m going to skip over this, and I’m going to skip over metabolic alkalosis except to remind you that the laboratory studies for metabolic alkalosis will show you that besides a blood pH that is high, there is a low chloride, a low potassium, increased bicarbonate or CO2 in the blood. The few physical signs; tetany. Underline tetany and convulsions. This is one of the things that can give you tetany and convulsions, metabolic alkalosis.