Medical Advisor Journals : June 2012

Wednesday, June 20, 2012

Bladder Stone (Vesical calculi)

Bladder Stones (calculus) is a composed of mineral masses formed in the bladder as a result of Concentrated, stagnant urinary, dehydrated causes of crystallization. Small bladder stones in most cases, pass on their own in the flow of urine.

A. Symptoms
The symptoms are as results of irritation of bladder wall or the stones have blocked the flow of the urine causes of infection and complications. In most cases, Bladder stone large and small do not cause any symptoms at all.
1. Inability to walk, constipation and urinary incontinence
There is a report of a case of massive irreducible procidentia with a hard palpable mass in the anterior vaginal wall mimicking an impacted faecal mass in a 57-year-old multiparous, post-menopausal woman with symptoms of Inability to walk, constipation and urinary incontinence as her primary complaints. targeted plain X-ray and ultrasound of the prolapsed mass disclosed the existence of multiple vesical calculi(1).

2. Lower abdominal pain, pain during micturation and pollakuria
There is a report of a 48-year-old man hospitalized with the chief complaints of lower abdominal pain, pain during micturation and pollakuria, plain radiography showed 2 giant bladder stone shadows: one as 6.0 × 5.0 cm and the other one 5.0 × 5.0 cm in size(2).

3. Voiding symptoms (Poor stream, Hesitancy, Terminal dribbling, Incomplete voiding, Overflow incontinence) and hematuria (Blood in your urine)
There is a report of a case of 43 year old man with the diagnosis of giant bladder stone (more than 10 cm diameter) with symptoms of voiding symptoms and hematuria(3).

4. Others symptoms
a. Repeated cloudy or abnormally dark-colored urine as a result of infection of the urinary track.
b. In men, pain or discomfort in the penis due to blockage or infection
c. Etc.

B. Causes and Risk factors
B.1. Causes
1. Primary neurologic deficit
In the study of Medical management of urinary calculi in a stallion with breeding dysfunction, researchers at the University of Pennsylvania, showed that the stallion may have had a primary neurologic deficit affecting bladder control and function that was causing calculi to form secondarily because of delay in movement of urine through the urinary tract(4).

2. Urinary tract calculi and infections
Urinary tract calculi and infections are common causes of presentation to the emergency department. Computed tomography kidney-ureter-bladder is the initial imaging study of choice in patients presenting with symptoms of urinary tract calculi. As clinical evidence of superimposed infection can be atypical or absent, it is crucial to identify subtle imaging findings that suggest this complication(5).

3. The use of urinary catheters
Prolonged period of using urinary catheters can cause infection. There is strong experimental and epidemiological evidence that infection by Proteus mirabilis is the main cause of the crystalline biofilms that encrust and block Foley catheters. The ability of P. mirabilis to generate alkaline urine and to colonize all available types of indwelling catheters allows it to take up stable residence in the catheterized tract in bladder stones and cause recurrent catheter blockage(6).

4. Bladder cancer
There is a report of case of ileovesical fistula caused by a bladder carcinoma is presented. A 66-year-old male was referred with complaints of urinary pain. On admission, fecaluria and urinary tract infection with bladder stone were detected(7).

5. Schistosomiasis
Schistosomiasis is a parasitic infection that affects 200 million people and is directly responsible for an annual death of 20,000 patients. Three species are responsible for most of the morbidity in humans: Schistosoma hematobium in Africa, S. mansoni in Africa and South America, and S. Japonicum in the Far East. Renal involvement occurs mostly with S. hematobium infection as a consequence of fibrosis and calcification of tissue-trapped ova in the lower urinary tract, leading to obstruction, reflux, infection, and stone formation(8).

6. Prostatic hyperplasia (BPH)
Benign prostatic hyperplasia (BPH) is one of the most common diseases to affect older men. Histological disease is present in more than 60% of men beyond their sixties, and more than 40% of men in this age group have lower urinary tract symptoms (LUTS)(9).

7. Kidney stones
As a result of small kidney stones travel down the ureters into the bladder that are not passed through urination

8. Etc.

B.2. Risk factors
1. Cystinuria
Cystinuria is an inherited autosomal recessive disease. There is a report of an unusual cystine stone presented in 24-year-old man. Radiographs showed a giant bladder stone shadow, 8.0 x 10.0 x 5.0 cm in size(10).

2. Age and gender
If you are male and over 30 years of age, you are at increased risk of bladder stone. In the study of a series of 1,354 stones derived from urology departments in Western Algeria was studied by IRTF spectroscopy. Analysis of the results concerned the crystalline composition and anatomical site of the stones and the age and gender of the patients.found that the male/female ratio has remained almost constant at 2.23. The anatomical site has changed with a predominance in the upper tract (77.4% of stones). The nucleus showed that phosphates are predominant in 48.6% of cases versus 35.6% for oxalates. Carbapatite and struvite are more frequent in women, found in 50.8% and 6.7% of cases, respectively, than in man, found in 44.6% and 3.7% of cases, respectively. Calcium oxalate is predominantly found in the upper urinary tract (70.9%) rather than in the bladder (48.3%), regardless of gender. Calcium phosphate is more abundant in the upper tract of females with 23.7% of cases versus 10.7% in the bladder. It is equally distributed between the bladder and the upper tract in males (13.7% and 13.2%, respectively). Examination of the side affected by stones showed a predominance of the left side in both sexes.

4. Bladder outlet obstruction(11)
There is a report of a 48-year-old man was hospitalized with the chief complaints of lower abdominal pain, pain during micturation and pollakuria. Plain radiography showed 2 giant bladder stone shadows: one as 6.0 × 5.0 cm and the other one 5.0 × 5.0 cm in size. That were completely obstructing the bladder outlet and observed several years following pelvic traumahe(12). There are many causes of bladder outlet obstruction but enlarged prostate is one of primary risk factors.

6. Frequent bladder infections
Chronic bladder infections can lead to the formation of bladder stones.

7. Urinary track infection
Urinary tract infection can cause obstruction of the urinany flow that can lead to formation of bladder stone. Urinary tract bacterial infections are common in women. Moreover, they tend to recur throughout life and in the same relatively small group of women. In most cases, bladder and renal infections are asymptomatic and manifest by demonstrating coincidental bacteriuria. In some instances, however, especially with frequent sexual activity, pregnancy, stone disease, or diabetes, symptomatic cystitis or pyelonephritis develops and antimicrobial therapy is indicated(13)

8. Nutritional factors
In teh study to describe clinical cases of childhood bladder stones and associated risk factors. Forty children (9 girls), aged 1-14-years old, (means 4.7 +/- 0.5 years), who underwent surgical stone removal in the Saravane Provincial Hospital during a 13-month period, researchers at the Institut de la Francophonie pour la Médecine Tropicale, showed that the morbidity and social cost of childhood bladder stones may be high. A larger scale prospective and comparative study assessing their incidence and associated nutritional factors is warranted and feasible, and may lead to preventive measures(14).

9. Etc.

C. Complications and Diseases associated with Bladder stone
1. Bladder pain syndrome/interstitial cystitis
In the study of included 9,269 cases who had received their first-time diagnosis of bladder pain syndrome/interstitial cystitis (BPS/IC) between 2006 and 2007 and 46,345 randomly selected controls, BPS/IC was found to be significantly associated with prior urinary calculi (UC) regardless of stone location; the adjusted ORs of kidney calculus, ureter calculus, bladder calculus, and unspecified calculus when compared to controls were 1.58 (95 % CI = 1.38-1.81), 1.73 (95 % CI = 1.45-2.05), 3.80 (95 % CI = 2.18-6.62), and 1.83 (95 % CI = 1.59-2.11), respectively(15).

2. Irreducible uterine prolapse
A vesical calculus in a prolapsed cystocele is rare. There is a report of case of irreducible total uterine prolapse caused by multiple vesical calculi. Bladder stones were removed through vaginal cystolithotomy followed by vaginal hysterectomy(16).

3. Acute renal failure
There is a report of a 39-year-old man with repeated urinary tract infection and lower abdominal pain, kidney-ureter-bladder (KUB) and IVU film showed a huge 450-g elliptical pelvic calculus that was surgically removed with excellent results(17).

4. Enterovesical fistula
Enterovesical fistula is a very rare complication of primary urological malignancies. A case of ileovesical fistula caused by a bladder carcinoma is presented. A 66-year-old male was referred with complaints of urinary pain. On admission, fecaluria and urinary tract infection with bladder stone were detected. Cystography revealed the passage of contrast medium into the small bowel. Under the diagnosis ofileovesical fistula due to suspected inflammatory disease, sigmoidectomy and segmental small bowel resection with partial cystectomy were performed. Histological evaluation revealed a poorly differentiated urothelial carcinoma(18).

5. Spontaneous rupture of the urinary bladder
Spontaneous rupture of the urinary bladder is an uncommon occurrence. There is a report of a 36-year-old man with complaints of pain and progressive distension of abdomen and anuria for 2 days. His abdomen was tense, tender and distended with free fluid. Blood urea was 340 mg% and ascitic fluid urea was 337 mg%. An USG showed massive ascitis, a large vesical calculus and a left renal calculus, according to the study by University College of Medical Sciences and Guru Teg Bahadur Hospita(19).

6. Etc.

D. Diagnosis
After a complete physical examination (incluning rectal examination) and family history are recorded, if you are suspected to have developed bladder stones, the test which your doctor orders, may include
1. Bladder or pelvic x-ray
The aim of the test is to let your doctoe visualize the bladder, urethra (the tube connecting the bladder with the outside of the body), and the ureters (the tubes connecting the kidneys to the bladder) of the patient, for  the bladder's stones and abnormalities in the pelvic, including the a blockage in the urinary path.

2. Cystoscopy
Cystoscopy is the examination of the bladder and urethra with use of cystoscope. In the examination, smaller bladder stone can be removed if found. It is hekpful as smaller bladder stones sometime can not be detected by the X ray.

3. Urinalysis
The aim of the test is to rule out the infectious and other causes of urinary tract symptoms

4. CT scans
CT scans are the better test to identify very small stones not seen by other tests

5. Etc.

E. Prevention
E.1. The do's and do not's list
1. Avoid dehydration
Dehydration can cause increased urine concentration which can lead to crystallization.

2. Drinking 6 - 8 glasses of water or more per day
In most case smaller bladder stones can pass on their own in the flow of urine

3. Avoid eating too much foods contain high amount of axalates which can increase the risk of the risk of bladder stone.

4. Quit smoking
Smoking increased the risk of the accumulation of cadmium on the bladder wall

5. Enlarged prostate
Enlarged prostate is the primary cause of bladder stone in men.

6. Etc.

E.2. Diet to prevent bladder stone
1. Cranberry
Cranberries have long been the focus of interest for their beneficial effects in preventing urinary tract infections (UTIs). Cranberries contain 2 compounds with antiadherence properties that prevent fimbriated Escherichia coli from adhering to uroepithelial cells in the urinary tract(20).

2. Low calcium diet, low sodium diet or low calcium diet plus hydrochlorthiazide
Researchers showed that low calcium diet, low sodium diet or low calcium diet plus hydrochlorthiazide reduced hypercalciuria significantly (P less than 0.01). Low calcium diet combined with hydrochlorthiazide was the most effective treatment for hypercalciuria(21).

3. Balance diet with enough nutrient
In the study to evaluate Reduction of urinary stone in children from north-eastern Thailand, Dr. at the showed that bladder stones in children have decreased now compared with the previous decade. If we promote good nutrition for children, bladder stones will decrease and might be eradicated in the future. A seminar of doctors and health personnel from 19 hospitals in the north-eastern provinces of Thailand was conducted to survey bladder stones in children by weighting and interviewing bladder stone symptoms then giving supplementary diet milk and vitamins and teaching health education about nutrition and urinary stones through referring children with bladder stones to hospitals in north-eastern(22).

4. Water
Drink enough water daily. If you are exercising, drink more water to prevent dehydration as it is the main cause of bladder stone in athletics.

5. Pumpkin seeds
in the study of the effect of pumpkin-seed supplementation on oxalcrystalluria and urinary composition in 20 boys age 2-7 yr from a hyperendemic area of Ubol province in Thailand, found that Pumpkin seeds lowered calcium-oxalate crystal occurrence and calcium level but increased phosphorus, pyrophosphate, glycosaminoglycans, and potassium values in urine as compared with orthophosphate supplementation. Pumpkin seeds provide high phosphorus levels and can be used as a potential agent in lowering the risk of bladder-stone disease(23).

6. Lemon juice
In the study of Can lemon juice be an alternative to potassium citrate in the treatment of urinary calcium stones in patients with hypocitraturia? A prospective randomized study, researchers at the Bakirkoy Research and Training Hospital, showed that lemon juice can be an alternative in the treatment of urinary calcium stones in patients with hypocitraturia. Additionally, dietary recommendations can increase effectiveness of the treatment(24).

7. Etc.

F. Treatment
F.1. In conventional perspective
1. Drinking at least 6 - 8 glasses of water per day to increase urination to help small stones to pass on their own in the flow of urine.

2. If bladder stones are confirmed
2.1. Medication
Medication such as Potassium citrate can help to dissolve uric acid stones. In the study to evaluate by a prospective randomized controlled study the efficacy of the association of potassium citrate and dry extract of couch grass (Agropyrum repens) (CalcoMEV) in renal stone treatment, showed that potassium citrate and couch grass showed a significant reduction in the total number of stones (-1.0 +/- 0.2 vs. 0.0 +/- 0.2 stones) and in the larger diameter of the stones (-3.6 +/- 0.9 mm vs. 0.0 +/- 0.8 mm), as well as a statistically significant reduction of uric acid urinary excretion (-164.7 +/- 45.3 vs -38 +/- 42 mg/24 h). No significant differences in the two groups were observed with respect to urinary citrate, oxalate and calcium urinary excretions and urinary pH(25).

2.2. If possible, laser energy may be used to break up the stones
2.3. Surgery
a. Cystoscope
Smaller stones which can not be passed on their own in urination but discovered by Cystoscopy can be removed with local anesthesia
b. Open surgery
Other larger stone may need open surgery to remove them

F.2. In Herbal medicine perspective
1. Asparagus racemosus Willd
In the study of the ethanolic extract of Asparagus racemosus Willd. for its inhibitory potential on lithiasis (stone formation), induced by oral administration of 0.75% ethylene glycolated water to adult male albino Wistar rats for 28 days, showed that the histopathological findings also showed signs of improvement after treatment with the extract. All these observations provided the basis for the conclusion that this plant extract inhibits stone formation induced by ethylene glycol treatment(26).

2. Goldenrod
Investigations in molecular pharmacology could show new mechanisms responsible for the biological effect of natural product from goldenrod extracts. The use of such herbal preparations with a rather complex action spectrum (anti-inflammatory, antimicrobial, diuretic, antispasmodic, analgesic) is especially recommended for treatment of infections and inflammations, to prevent formation of kidney stones and to help remove urinary gravel. This therapy is safe at a reasonable price and does not show drug-related side-effects, according to the study of the Institut für Pharmazie der Freien Universität Berlin, Berlin(27).

3. Couch grass (Agropyrum repens)
Couch grass showed a significant reduction in the total number of stones (-1.0 +/- 0.2 vs. 0.0 +/- 0.2 stones) and in the larger diameter of the stones (-3.6 +/- 0.9 mm vs. 0.0 +/- 0.8 mm), as well as a statistically significant reduction of uric acid urinary excretion (-164.7 +/- 45.3 vs -38 +/- 42 mg/24 h)(25).

4. Etc.

F.3. In TCM perspective
C.1. According to the article of Chinese medicine Hospital for Chronic and Difficult diseases(25), traditional Chinese medicine defined formation of stones is a condition caused by
1. Qi stagnation
a. The aim of the herbal treatment is to Promotethe circulation of qi, inducing diuresis, relieving strangury and removing the stones.
b. Herbal formula: Modified Pyrrosia Decoction
Lysimachia, Pyrrosia leaf, Plantago seed, Cluster mallow fruit, Oriental water plantain rhizome, Citron fruit, Vaccaria seed, Radish seed and Rhubarb.

2. Damp-Heat Pattern
a. The aim of the herbal formula is to clear heat and dampness, relieve strangury and remove the stones.
b. Herbal formula: Modified Eight Health Restoring Powder
Lysimachia, Prostrate knotweed, Chinese pink herb, Talc, Phellodendron bark, Capejasmine fruit and Plantago seed , Rhubarb and Licorice root tip
3. Kidney deficiency
a. The aim of the herb used to treat kidney stones as a result of kidney deficiency is to tonify qi, reinforce the kidney, relieve stranguria and remove the stones.
b. Herbal formula: Modified Kidney-Reinforcing Decoction
Prepared rehmannia root, Wolfberry fruit, Dogwood fruit, Achyranthes root, Bighead atractylodes. Rhizome eucommia bark, Cinnamon bark, Pilose asiabell root, Lysimachia and Climbing fern spore

C.2. Chinese herbal formula Wu Ling San (Poria, Rhizoma Alismatis, Polyporus, Cortex Cinnamomi, Rhizoma Atractylodis Macrocephalae (stir-baked))
In the study to determine the effects of a traditional Chinese herbal formula, Wulingsan (WLS), on renal stone prevention using an ethylene glycol-induced nephrocalcinosis rat model. Forty-one male Sprague-Dawley (SD) rats were divided into four groups. Group 1 (n=8) was the normal control; group 2 (n=11) served as the placebo group, and received a gastric gavage of starch and 0.75% ethylene glycol (EG) as a stone inducer; group 3 received EG and a low dose of WLS (375 mg/kg); and group 4 received EG and a high dose of WLS (1,125 mg/kg), found that the rats of placebo group gained the least significant body weight; in contrast, the rats of WLS-fed groups could effectively reverse it. The placebo group exhibited lower levels of free calcium (p=0.059) and significantly lower serum phosphorus (p=0.015) in urine than WLS-fed rats. Histological findings of kidneys revealed tubular destruction, damage and inflammatory reactions in the EG-water rats. The crystal deposit scores dropped significantly in the WLS groups, from 1.40 to 0.46 in the low-dose group and from 1.40 to 0.45 in the high-dose group. Overall, WLS effectively inhibited the deposition of calcium oxalate (CaOx) crystal and lowered the incidence of stones in rats (p=0.035). In conclusion, WLS significantly reduced the severity of calcium oxalate crystal deposits in rat kidneys, indicating that Wulingsan may be an effective antilithic herbal formula(28).

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Sources
(1) http://www.ncbi.nlm.nih.gov/pubmed/22531951
(2) http://www.ncbi.nlm.nih.gov/pubmed/21806900
(3) http://www.ncbi.nlm.nih.gov/pubmed/21610285
(4) http://www.ncbi.nlm.nih.gov/pubmed/9743725
(5) http://www.ncbi.nlm.nih.gov/pubmed/22902855
(6) http://www.ncbi.nlm.nih.gov/pubmed/20368711
(7) http://www.ncbi.nlm.nih.gov/pubmed/17131870
(8) http://www.ncbi.nlm.nih.gov/pubmed/12563599
(9) http://www.ncbi.nlm.nih.gov/pubmed/21789983
(10) http://www.ncbi.nlm.nih.gov/pubmed/15198153
(11) http://www.ncbi.nlm.nih.gov/pubmed/16821346
(12) http://www.ncbi.nlm.nih.gov/pubmed/21806900
(13) http://www.ncbi.nlm.nih.gov/pubmed/16260529
(14) http://www.ncbi.nlm.nih.gov/pubmed/15906634
(15) http://www.ncbi.nlm.nih.gov/pubmed/22895546
(16) http://www.ncbi.nlm.nih.gov/pubmed/17103181
(17) http://www.ncbi.nlm.nih.gov/pubmed/20033143
(18) http://www.ncbi.nlm.nih.gov/pubmed/17131870
(19) http://www.ncbi.nlm.nih.gov/pubmed/17136584
(20) http://www.ncbi.nlm.nih.gov/pubmed/15156480
(21) http://www.ncbi.nlm.nih.gov/pubmed/6380301
(22) http://www.ncbi.nlm.nih.gov/pubmed/10659566
(23) http://www.ncbi.nlm.nih.gov/pubmed/3799495
(24) http://www.ncbi.nlm.nih.gov/pubmed/18946667
(25) http://www.ncbi.nlm.nih.gov/pubmed/22908773
(26) http://www.ncbi.nlm.nih.gov/pubmed?term=asparagus%20root%20and%20kidney%20stones
(27) http://www.ncbi.nlm.nih.gov/pubmed/15638071
(28) http://www.ncbi.nlm.nih.gov/pubmed/18040675

Tuesday, June 19, 2012

Selective serotonin re-uptake inhibitor (SSRI) discontinuation syndrome

Article written on request of my twitter friend, UK Garden Designs ‏@UK_GD

Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitor(SSRIs) are a types of antidepressant medications to treat depression and certein neurological disorders, including obsessive-compulsive disorder, panic disorder (PD), generalised anxiety disorder, post traumatic stress disorder (PTSD), and social anxiety disorder (SAD), etc..

SSRI discontinuation syndrome is defined as a condition of a syndrome as a result of interruption, reduced doses or discontinuation of any anti depressant medication, including SSRI (selective serotonin re-uptake inhibitor) and serotonin–norepinephrine reuptake inhibitor (SNRI), researchers showed that The SSRI discontinuation syndrome is a characteristic selective serotonin reuptake inhibitor (SSRI) discontinuation syndrome appears to exist. It is usually mild, commences within 1 week of stopping treatment, resolves spontaneously within 3 weeks, and consists of diverse physical and psychological symptoms, the commonest being dizziness, nausea, lethargy and headache. SSRI reinstatement leads to resolution within 48 h(1).

I. Symptoms and signs
The use of medication duration is usually 1 month with symptoms developing within a few days after SSRI interruption, cessation, or reduction of dosage.
1. Dizziness
The abrupt withdrawal from an SSRI is likely to cause a sudden decrease in serotonin in the VNC, which will disrupt the function of VNC neurons bilaterally, causing dizziness without vertigo(2).

2. Sleep disturbance
The abrupt discontinuation of paroxetine seemed associated with sudden and impairing effects, some patients may experience sleep disturbances and dizziness(3)

3. AQgitation, irritability, vertigo, lightheadedness and fever
There are a report that a 30-year-old man with depression who was treated with paroxetine (Seroxat) developed severe withdrawal symptoms when the medication was gradually diminished and stopped: agitation, irritability, vertigo, lightheadedness and fever up to 40 degrees C. The symptoms disappeared after the medication was reintroduced but recurred after rediscontinuation(4).

4. Visual and auditory hallucinations, headache, insomnia, and nausea
Other report that Discontinuation symptoms can follow the stoppage of almost all classes of antidepressants can experience visual and auditory hallucinations in addition to dizziness, headache, insomnia, and nausea a couple of days after paroxetine discontinuation(5).

5. Balance, sensory abnormalities, and possibly aggressive and impulsive behavior
Other researchers found that the discontinuation of Selective serotonin re-uptake inhibitor (SSRI) also cause the symptoms of Selective serotonin re-uptake inhibitor (SSRI) such as nausea, lethargy, insomnia, and headache, are similar to those reported with tricyclic discontinuation. However, SSRI discontinuation is also associated with novel symptom clusters, including problems with balance, sensory abnormalities, and possibly aggressive and impulsive behavior(6).

6. Sexual dysfunction
Some patients may also experience Post-SSRI sexual dysfunction (PSSD) caused by the previous use of selective serotonin reuptake inhibitor (SSRI) antidepressants. While apparently uncommon, it can last for months, years, or sometimes indefinitely after the discontinuation of SSRIs(7).

II. Causes and risk factors
A. Causes
Dr. Blier P and Dr. Tremblay P. at the University of Ottawa suggested that in the development of animal models to explain the mechanisms of this clinical problem has proved challenging, because less than half of all patients experience any discontinuation symptoms, many of which are subjective in nature. One explanation is that SRI discontinuation symptoms may arise from the rapid decrease in serotonin (5-HT) availability when treatment ends abruptly. Yet, it would appear that discontinuation discomforts may not be mediated exclusively through 5-HT receptors, given the major regulatory role 5-HT exerts on a number of specific chemical receptor systems in the brain(8).
Others showed that one explanation is that antidepressant discontinuation symptoms may arise from the rapid decrease in serotonin availability when treatment ends abruptly. It would appear that discontinuation discomfort may not be mediated exclusively through serotonin receptors, given the major regulatory role serotonin exerts on a number of specific chemical receptor systems in the brain. As a result, attempts to explain the determinants of this phenomenon rely on a certain level of speculation. The article discusses the three systems most likely to account in the symptomatology--the serotonin, the norepinephrine, and the cholinergic systems--and the possible interactions among them(9).

B. Risk factors
Risks of Selective serotonin re-uptake inhibitor (SSRI) discontinuation syndrome are depending to the medication taken. there appears to be less risk with the abrupt interruption of fluoxetine. Paroxetine is the SSRI most often mentioned in the case reports and the reason for this may be as simple as the fact that it is most frequently prescribed. An alternative explanation may involve paroxetine s affinity for cholinergic (muscarinic) receptors, causing cholinergic rebound on discontinuation(10).

III. Diagnosis
There are no specific diagnosis criteria, but researchers in the study of "Selective serotonin reuptake inhibitor discontinuation syndrome: proposed diagnostic criteria", suggested that the criteria are 2 or more of the following symptoms developing within 1 to 7 days of discontinuation or reduction in dosage of an SSRI after at least 1 month's use, when these symptoms cause clinically significant distress or impairment and are not due to a general medical condition or recurrence of a mental disorder: dizziness, light-headedness, vertigo or feeling faint; shock-like sensations or paresthesia; anxiety; diarrhea; fatigue; gait instability; headache; insomnia; irritability; nausea or emesis; tremor; and visual disturbances(11).

IV. Prevention
B. Diet to reduce the symptoms of Selective serotonin re-uptake inhibitor (SSRI) discontinuation syndrome
B.1. Foods to Increase Serotonin
Various fruits boost serotonin and other mood-improving chemicals in the brain, including
The following fruits had a high serotonin concentration (mean +/- SEM) expressed in micrograms/g weight: plantain 30.3 +/- 7.5; pineapple 17.0 +/- 5.1; banana 15.0 +/- 2.4; Kiwi fruit 5.8 +/- 0.9; plums 4.7 +/- 0.8; and tomatoes 3.2 +/- 0.6. Only nuts in the walnut or hickory family had a high serotonin concentration expressed in micrograms/g weight; butternuts 398 +/- 90; black walnuts 304 +/- 46; English walnuts 87 +/- 20; shagbark hickory nuts 143 +/- 23; mockernut hickory nuts 67 +/- 13; pecans 29 +/- 4; and sweet pignuts 25 +/- 8. Ingestion of these fruits and nuts resulted in an increase in urinary 5-hydroxyindoleacetic acid excretion with no change in platelet serotonin concentration(13).
B.2. Serotonin Boost from Protein Sources
Food contain high levels of tryptophan such asTurkey, Lean beef, Salmon, etc. can enhance the production of the levels of serotonin, as trytophan ia a precursor of the sorotonin. Some researchers showed that tryptophan is an antidepressant in mild to moderate depression and a small body of data suggests that it can also decrease aggression. Preliminary data indicate that tryptophan also increases dominant behavior during social interactions. Overall, studies manipulating tryptophan levels support the idea that low serotonin can predispose subjects to mood and impulse control disorders. Higher levels of serotonin may help to promote more constructive social interactions by decreasing aggression and increasing dominance(14).

B.3. Carbohydrate-based Foods and carbohydrate snacking that Increase Serotonin
Carbohydrate-based Foods and carbohydrate snacking found abundantly in foods consists of glucose that can boost serotonin production. Evidence is presented that carbohydrate snacking seems to be related to a "need" to increase the level of brain serotonin; treatment with a drug, d-1 fenfluramine, that increases serotoninergic neurotransmission significantly decreases carbohydrate snack consumption(15).

B.4. Etc.

C. Phytochemicals and antioxidants to reduce the symptoms of Selective serotonin re-uptake inhibitor (SSRI) discontinuation syndrome
1. Tangeretin
Tangeretin, a citrus flavonoid in the oral administration resulted in significant levels of tangeretin in the brain (hypothalamus, striatum and hippocampus). Treatment of the rats with the dopaminergic neurotoxin 6-hydroxydopamine resulted in reduced levels of dopamine, an effect which was reversed by the administration of tangeretin. This study concluded that tangeretin can cross the blood-brain barrier and has a potential use as a neuroprotective agent(16).

2. Epigallocatechin-3-gallate and Polyphenols
Green tea polyphenols (GTPs and epigallocatechin-3-gallate (EGCG) modulation could improve the cognitive impairments induced by psychological stress. The related mechanisms may be involved with the changes of catecholamines, 5-hydroxytryptamine, cytokines and expressions of metallothioneins(17).

3. Furanocoumarins
furanocoumarins found abundantly in grapefruit with CYP2D6 inhibition achieved in the range of 190-900 nM and Anthocyanins and anthocyanidins were shown to be about 1,000-fold less potent, they are unlikely to interfere with drug metabolism by CYP2D6(18).

4. N-acetyl-cysteine and curcumin
N-acetyl-cysteine has been shown to have a significant benefit on depressive symptoms in a randomized placebo-controlled trial. Additionally, curcumin, the yellow pigment of curry, has been shown to strongly interfere with neuronal redox homeostasis in the CNS and to possess antidepressant activity in various animal models of depression, also thanks to its ability to inhibit monoamine oxidases(19)

5. Etc.

V. Treatments
A. In conventional medicine perspective
A.1. Graduation of doses and later discontinued
There are suggestion that symptoms may occur even if the SSRI dose is tapered gradually. In half of 50 reported cases, an attempt was made to taper the SSRI, although details concerning the duration and rapidity of taper were not provided consistently. At this point, it is unclear whether tapering SSRIs will reduce the risk nor is it clear whether we should advocate the routine taper of SSRIs when stopping treatment. The only known effective treatment is the re-introduction of the SSRI which is associated with rapid resolution of symptoms. Unfortunately, the syndrome tends to recur in approximately 75% of patients when the same SSRI is later discontinued(12).

A.2. Treatment depends on symptom severity
If symptoms of SSRI discontinuation are so severe, or do not respond to symptom management, patients may be necessary to reinstate the antidepressants and withdrawn the medication slowly as mention above. Others suggested to switch to a long half-life medication at a relatively low dose and then stop taking SSRI altogether(20).

A.3. Treating the symptoms
Certain medication may be prescribed to treat the symptoms of Selective serotonin re-uptake inhibitor (SSRI) discontinuation syndrome. Please consult with your doctor.

B. In herbal medicine perspective
A. Herbs to treat depresiion
Treatments of Selective serotonin re-uptake inhibitor (SSRI) discontinuation syndrome can try herbs as reinstated medicine and withdrawn them slowly with little or no side effect. Please consult with your doctor before applying.
1. St John Wort
n the analyzing the effects of a chronic hyperforin of of the medicinal plant Hypericum perforatum (St. John's wort).treatment on brain cell, found that Hyperforin stimulated the expression of TRPC6 channels and TrkB via SKF-96365-sensitive channels controlling a downstream signalling cascade involving Ca2+, protein kinase A, CREB and p-CREB. In vivo, hyperforin augmented the expression of TrkB in the cortex but not in the hippocampus where hippocampal neurogenesis remained unchanged. In conclusion, this plant extract acts on the cortical BDNF/TrkB pathway leaving adult hippocampal neurogenesis unaffected. This study provides new insights on the neuronal responses controlled by hyperforin, according to "The antidepressant hyperforin increases the phosphorylation of CREB and the expression of TrkB in a tissue-specific manner" by Gibon J, Deloulme JC, Chevallier T, Ladevèze E, Abrous DN, Bouron A.(21)

2. Rhodiola Rosea
In the evaluation of herbal medicines, other than St. John's wort, in the treatment of depression
found that the combination of lavender and imipramine was significantly more effective than imipramine alone. When compared to placebo, Echium was found to significantly decrease depression scores at week 4, but not week 6. Rhodiola was also found to significantly improve depressive symptoms when compared to placebo, according to "Herbal medicines, other than St. John's Wort, in the treatment of depression: a systematic review" by Dwyer AV, Whitten DL, Hawrelak JA.(22)

3. Etc.

B. Herbs to treat symptoms of Selective serotonin re-uptake inhibitor (SSRI) discontinuation syndrome
1. Lemon Balm
a. Anxiety-like reactivity
In the determination of the effects of chronic (15 consecutive days of treatment) per os administration of Melissa officinalis L. extract (Cyracos, Naturex) on anxiety-like reactivity in mice, found that the Cyracosdose at which it exerted anxiolytic-like effects in the elevated plus maze did not alter exploratory or circadian activities. Therefore, our results demonstrate that Cyracos has anxiolytic-like effects under moderate stress conditions and does not alter activity levels, according to "Effects of chronic administration of Melissa officinalis L. extract on anxiety-like reactivity and on circadian and exploratory activities in mice" by

Ibarra A, Feuillere N, Roller M, Lesburgere E, Beracochea D.(23)

b. Anxiety disorders and insomnia
In the assessment of Cyracos(®), a standardized Melissa officinalis L. extract and it anti-stress and anxiolytic effects found that Cyracos(®) reduced anxiety manifestations by 18% (p < 0.01), ameliorated anxiety-associated symptoms by 15% (p < 0.01) and lowered insomnia by 42% (p < 0.01). As much as 95% of subjects (19/20) responded to treatment, of which 70% (14/20) achieved full remission for anxiety, 85% (17/20) for insomnia, and 70% (14/20) for both, according to "Pilot trial of Melissa officinalis L. leaf extract in the treatment of volunteers suffering from mild-to-moderate anxiety disorders and sleep disturbances" by Cases J, Ibarra A, Feuillère N, Roller M, Sukkar SG.(24)

2 Ginseng Asia
a. Antipsychotic effect
In the investigation of Panax quinquefolium (PQ) and its significant neuroactive properties for its antipsychotic potential found that PQ blocked ketamine induced memory impairment in the passive avoidance paradigm. In the chronic studies, PQ reduced the ketamine induced enhanced immobility in the forced swim test and did not show extra-pyramidal side effects in bar test and wood block test of catalepsy. These behavioural effects were compared with standard drugs haloperidol and clozapine. Further PQ reduced DA and 5-HT content after chronic treatment, but not after acute administration, according to "Evaluation of the Antipsychotic Potential of Panax quinquefolium in Ketamine Induced Experimental Psychosis Model in Mice" by Chatterjee M, Singh S, Kumari R, Verma AK, Palit G.(25)

b. Neuroprotective effect
In the analyzing Panax ginseng C.A. Meyer and its beneficial effects in cerebral ischemia and inhibition of the inflammatory cascade in sepsis found that Ginsenoside Rb1 (GRb1) partially inhibited the activation of nuclear factor-κB (NF-κB) pathway from 6 h to 72 h after ischemia and reperfusion onset, as determined by the expression of total and phosphorylated NF-κB/p65, inhibitor protein of κB (IκB)-α, and IκB-kinase complex (IKK)-α. All these results indicate that suppression of local inflammation after cerebral ischemia might be one mechanism that contributes to the neuroprotection of GRb1, according to "Suppression of local inflammation contributes to the neuroprotective effect of ginsenoside Rb1 in rats with cerebral ischemia" by Zhu J, Jiang Y, Wu L, Lu T, Xu G, Liu X.(26)

3. Ginkgo
a. Brain-cognition effects
Ginkgo Biloba extract (GBE) have exhibited the function of alleviating symptoms of cognitive impairment in aging populationby increasing the SSVEP(state visually evoked potentia) amplitude at occipital and frontal sites and SSVEP latency at left temporal and left frontal sites, according to the study of "Examining brain-cognition effects of ginkgo biloba extract: brain activation in the left temporal and left prefrontal cortex in an object working memory task" by Silberstein RB, Pipingas A, Song J, Camfield DA, Nathan PJ, Stough C., posted in PubMed(27)

b. Acute cognitive effects
Administration of GBE complexed with phosphatidylserine have exerted the results of improingsecondary memory performance and speed of memory task performance, according to the study of "Acute cognitive effects of standardised Ginkgo biloba extract complexed with phosphatidylserine" by Kennedy DO, Haskell CF, Mauri PL, Scholey AB., posted in PubMed(28)

4. Etc.

C. In traditional Chinese medicine perspective
According to APPENDIX 1: Guipi Tang and SSRI Withdrawal Syndrome, Western interpretation of the symptoms as relative deficiency in serotonin availability or an imbalance of neurotransmitters after the drugs are removed. In TCM the withdrawal syndrome may be caused qi and blood deficiency, as a result of the spleen (for qi) and liver (for blood). Treatment of SSRI withdrawal syndrome is depending to the differentiation of the symptom. Herbs used include
Atractylodes (white atractylodes): tonifies qi, resolves damp
Peony (white peony): nourishes blood, vitalizes blood circulation
Tang-kuei: nourishes blood, vitalizes blood circulation
Zizyphus: nourishes liver and heart blood and clams shen
Saussurea: circulates qi, calms shen
Ginseng: tonifies qi, calms shen
Astragalus: tonifies qi, raises yang qi
Polygala: resolves phlegm, calms shen
Fu-shen or Hoelen: resolves damp, calms shen
Pinellia: resolves damp, lowers stomach qi
Citrus: resolves damp, circulates qi

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Sources
(1) http://www.ncbi.nlm.nih.gov/pubmed/10958258
(2) http://www.ncbi.nlm.nih.gov/pubmed/20144124
(3) http://www.ncbi.nlm.nih.gov/pubmed/8602387
(4) http://www.ncbi.nlm.nih.gov/pubmed/10422558
(5) http://www.ncbi.nlm.nih.gov/pubmed/21489048
(6) http://www.ncbi.nlm.nih.gov/pubmed/9219489
(7) http://en.wikipedia.org/wiki/Post-SSRI_sexual_dysfunction
(8) http://www.ncbi.nlm.nih.gov/pubmed/16683857
(9) http://www.ncbi.nlm.nih.gov/pubmed/20214096
(10) http://www.circlemedhealthcare.com/ssri.pdf
(11) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1407715/
(12) http://www.circlemedhealthcare.com/ssri.pdf
(13) http://www.ncbi.nlm.nih.gov/pubmed/2413754
(14) http://www.ncbi.nlm.nih.gov/pubmed/11888576
(15) http://www.ncbi.nlm.nih.gov/pubmed/6381575
(16) http://www.ncbi.nlm.nih.gov/pubmed/11726811
(17) http://www.ncbi.nlm.nih.gov/pubmed/20463297
(18) http://www.ncbi.nlm.nih.gov/pubmed/19357792
(19) http://www.ncbi.nlm.nih.gov/pubmed/22668245
(20) http://onlinelibrary.wiley.com/doi/10.1002/%28SICI%291099-1166%28199806%2913:6%3C421::AID-GPS774%3E3.0.CO;2-Y/abstract;jsessionid=3C78BDD20E857C086A4C305B9880784E.d02t02
(21) http://www.ncbi.nlm.nih.gov/pubmed/22226089
(22) http://www.ncbi.nlm.nih.gov/pubmed/21438645

(23) http://www.ncbi.nlm.nih.gov/pubmed/20171069
(24) http://www.ncbi.nlm.nih.gov/pubmed/22207903
(25) http://www.ncbi.nlm.nih.gov/pubmed/22189635
(26) http://www.ncbi.nlm.nih.gov/pubmed/22173011
(27) http://www.ncbi.nlm.nih.gov/pubmed/21941584
(28) http://www.ncbi.nlm.nih.gov/pubmed/17457961
(29) http://www.dr-bob.org/babble/alter/20100516/msgs/947782.html

Tuesday, June 12, 2012

Muscae Volitantes (Floater)

I. Muscae volitantes or Floater is defined as a condition of pathol moving black specks or threads seen before the eyes, as results of opaque fragments floating in the vitreous humour or a lens defect due to degeneration of the vitreous humour. Floater as it suspends in the vitreous humour, it tends to drift and follows the rapid motions of the eye as a result of damage of the eye that causes material to enter the vitreous humour.

II. Symptoms

1. Seeing a spot or spots, other shapes such as black or gray dots, squiggly lines, threadlike strands, ring shaped, etc. before the eyes

2. Movement of the spots or shapes that parallels eye movement.

3. Etc.

III. Causes and risk factors

A, Causes

There are many causes of floater, including

1. Eyes diseases

Eye diseases can cause damage to the eye of that can lead to muscae volitantes.

2. Vitreous cyst

Vitreous cyst is associated to the cause of floater, although it is rare. The etiology has been theorized to be both congenital and acquired. Acquired cysts may be due to trauma or other forms of intraocular inflammation. Pigmented cysts are believed to originate from the pars ciliaris and nonpigmented cysts are likely to be derived from the remnants of the hyaloidal artery system. The appearances of the cysts are striking and are often seen as clear spherical bodies in the vitreous with interesting interlacing surface patterns. The cysts are benign and are of little significance, except when they encroach on the visual axis and produce visual disturbances (usually floater symptoms)(1).

3. Vitreous syneresis

vitreous normally will undergo liquefaction and changed from jellylike material to fluid like material in a process called syneresis of vitreous and this will cause the collage fibers within the vitreous to form strands. With each eye movements, those strands will also move, causing eye floaters(2).

4. Posterior vitreous detachments (PVD)

Posterior vitreous detachments can cause uscae volitantes. It is a condition of the eye in which the vitreous humor separates from the retina due to aging as the condition is common in older adults and over 75% of those over the age of 65 develop it(3).

5. Retinal detachment

Retinal detachment associated to the causes of floater, is a eye disorder in which the retina peels away from its underlying layer of support tissue(4) and affected mostly in middle-aged or older population.

6. Hyaloid remnant

A rare condition in which there remain some parts of the hyaloid artery. Posteriorly there may be a vascular loop or the thread of an obliterated vessel running forward from the optic disc and floating freely in the vitreous. Anteriorly there may be some fibrous remnants attached to the posterior lens capsule and others sometimes floating in the vitreous. The anterior attachment of the hyaloid artery to the lens may also remain throughout life as a black dot, called Mittendorf's dot, and can be seen within the pupil by direct ophthalmoscopy (it appears as a white dot with the biomicroscope). There is rarely any visual interference although patients may sometimes report seeing muscae volitantes(5).

7. Other causes of Muscae volitantes

a. Patient with oily tears and inpissated meibomian glands may also accumulate debris within the tear layer, which can be reported as floaters.

b. Patients with ocular allergies may also be prime candidates for this phenomenon, since the eye produces excess mucus in order to soothe the eye from the allergic assault.

c. Vitreous haemorrhage. A PVD that encounters an area of vitreoretinal adhesion can cause a tractional tear in the retina. If a retinal blood vessel is involved, subsequent leakage into the vitreous cavity and retrohyaloid space will occur.

d. A relatively common vitreous anomaly that occasionally causes floaters is asteroid hyalosis. Asteroid bodies are calcium soaps that attach to the vitreous framework(6).

8. Etc.

B, Risk factors

1. Aging

People who are over age of 50 are at the increased risk of Muscae volitantes as a result of Posterior vitreous detachments (PVD).

2. Myopia

People who are with Myopia are also in the higher risk to develop Muscae volitantes as a result of eye strain and tearing.

3. Eye damage

Damage to the eye due to what ever reason, including punch in the eye can cause floater.

4. Eye surgery

Eye surgery patients are at increased risk to develop floater, recently had eye surgery, laser eye surgery, etc.

5. Diabetes

If you are diabetic, you are at higher risk to develop floater and other eye diseases such as glaucoma and cataracts.

6. Etc.

IV. Diagnosis

If you are experience floater as you you can see them if look at the blue sky or a white wall. Your Ophthalmologists can diagnose floaters by the use of an ophthalmoscope or slit lamp

V. Preventions

The aim of prevention of floater is to enhance the immune function to fight inflammation causes and strengthen the eye connective tissues and blood circulation to prevent leaking causes of floater.

A. Diet to prevent floater

1. Pineapple

a. Connective tissues

In the study to investigate pineapple plant which contains the enzyme bromelain acclaimed to reduce pain and swellings following acute muscle injurie showed that the flesh and bark extract induced a proliferation of tenoblasts which however was not significantly different from that of the untreated tendon while the leaves and core extracts reduced the population of the tenocytes. The flesh extract significantly (p < 0.05) reduced the MDA level while the leaves and core extract significantly (p < 0.001) increased it. The bark extract had no significant impact on the MDA level compared with the untreated tendon(7).

b. Immune function
Bromelain also increases the immune function in fighting the invasion of foreign substances such as bacteria and virus, thus decreasing the risk of inflammation and infection according to the study of "Bromelain treatment reduces CD25 expression on activated CD4+ T cells in vitro" by Secor ER Jr, Singh A, Guernsey LA, McNamara JT, Zhan L, Maulik N, Thrall RS., posted in PubMed(8)

c. Small blood vessel wall protectionThe high amount of vitamin C also increase the flexibility of small vessel, thus decreasing the risk of internal bleeding, heart diseases and stroke, according to the study of "Effects of benfluorex-vitamin C supplementation on cutaneous capillaries of diabetic rats" by Sari Kiliçaslan SM, Ozer C., posted in PubMed(9)

d. Manganese
Manganese beside is a mineral essential for energy production and metabolism of foods, it also helps to improve immune-system functioning that reduces the risk of inflammation, according to the study of "The effects of 3, 4 or 5 amino salicylic acids on manganese-induced neuronal death: ER stress and mitochondrial complexes" by Yoon H, Lee GH, Kim DS, Kim KW, Kim HR, Chae HJ(10)

2. Ginger

Ginger (Zingiber officinale) or ginger root is the genus Zingiber, belonging to the family Zingiberaceae, native to Tamil. It has been used in traditional and Chinese medicine to treat dyspepsia, gastroparesis, constipation, edema, difficult urination, colic, etc.

a. Anti-Inflammatory effects

In the classification of the effect of ginger extract on the expression of NFκB and TNF-α in liver cancer-induced rats found that ginger extract significantly reduced the elevated expression of NFκB and TNF-α in rats with liver cancer. Ginger may act as an anti-cancer and anti-inflammatory agent by inactivating NFκB through the suppression of the pro-inflammatory TNF-α, according to "Ginger Extract (Zingiber Officinale) has Anti-Cancer and Anti-Inflammatory Effects on Ethionine-Induced Hepatoma Rats" by Shafina Hanim Mohd Habib,I Suzana Makpol, Noor Aini Abdul Hamid, Srijit Das, Wan Zurinah Wan Ngah, and Yasmin Anum Mohd Yusof 11)

b. Delay of diabetic cataract

In the demonstration of antiglycating activity and ginger (Zingiber officinalis) found that ginger was effective against the development of diabetic cataract in rats mainly through its antiglycating potential and to a lesser extent by inhibition of the polyol pathway. Thus, ingredients of dietary sources, such as ginger, may be explored for the prevention or delay of diabetic complications, according to "Antiglycating potential of Zingiber officinalis and delay of diabetic cataract in rats" by Megha Saraswat, Palla Suryanarayana, Paduru Yadagiri Reddy, Madhoosudan A. Patil, Nagalla Balakrishna, and Geereddy Bhanuprakash Reddy(12)

c, GINGER for EYE disorders: Taking Ginger will increase blood circulation so that more nutrition can reach your eye.(13)

3. Brussels sprouts

Brussels sprout is a spcies of wild cabbage (Brassica oleracea), belong to the family of Brassicaceae and was cultivated since ancient Rome.

a. Antioxidants
In the evaluation of consumption of the sprouts and its antioxidant effects found that Serum vitamin C levels were increased by 37% after sprout consumption but no correlations were seen between prevention of DNA-damage and individual alterations of the vitamin levels. Our study shows for the first time that sprout consumption leads to inhibition of sulfotransferases in humans and to protection against PhIP and oxidative DNA-damage, according to "Consumption of Brussels sprouts protects peripheral human lymphocytes against 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP) and oxidative DNA-damage: results of a controlled human intervention trial"by Hoelzl C, Glatt H, Meinl W, Sontag G, Haidinger G, Kundi M, Simic T, Chakraborty A, Bichler J, Ferk F, Angelis K, Nersesyan A, Knasmüller S.(14)

b. Type 2 diabetes
In the determination of young broccoli sprouts improve oxidative stress status in diabetic condition found that 63 patients in three groups were included in the analysis: 10 g/d BSP (n=21), 5 g/d (n=22) and placebo (n=20). After 4 weeks, consumption of BSP resulted in significant decrease in malondialdehyde (MDA) (P=0.001 for treatment effect), oxidized low density lipoprotein cholesterol (P=0.03 for treatment effect), OSI (P=0.001 for treatment effect) and significant increase in Serum total antioxidant capacity (TAC) (P=0.001 for treatment effect), according to "Broccoli sprouts reduce oxidative stress in type 2 diabetes: a randomized double-blind clinical trial" by Bahadoran Z, Mirmiran P, Hosseinpanah F, Hedayati M, Hosseinpour-Niazi S, Azizi F.(15)

c. Vitamin C

In the study to assess, whether or not, vitamin C, required during the collagen synthesis, would influence the Achilles tendon healing in a healthy rat model, showed that high-dose vitamin C supplementation once for every 2 days has stimulating effects on the Achilles tendon healing because of early angiogenesis and increased collagen synthesis in a healthy rat model. Further studies are needed to make clear the mentioned encouraging effects of the vitamin C on the Achilles tendon healing(16).

4. Strawberries

Strawberries is a genius of Fragaria × ananassa belongs to the family Roseaceae. They have been grown all over the world with suitable climate for commercial profits and for health benefits.

a. Antioxidant enzymes
In the identification of essential nutrient and beneficial phytochemicals of strawberry and their effects on gastrointestinal disorders such as gastric ulcer, colorectal cancer and inflammatory bowel disease found that Strawberry extracts prevented exogenous ethanol-induced damage to rats' gastric mucosa. These effects seem to be associated with the antioxidant activity and phenolic content in the extract as well as with the capacity of promoting the action of antioxidant enzymes. A diet rich in strawberries might exert a beneficial effect in the prevention of gastric diseases related to generation of reactive oxygen species, according to "Strawberry polyphenols attenuate ethanol-induced gastric lesions in rats by activation of antioxidant enzymes and attenuation of MDA increase" by Alvarez-Suarez JM, Dekanski D, Ristić S, Radonjić NV, Petronijević ND, Giampieri F, Astolfi P, González-Paramás AM, Santos-Buelga C, Tulipani S, Quiles JL, Mezzetti B, Battino M.(17)

b. Anti inflammationIn the observation of Ethanolic extract of Fragaria vesca (EFFV) of Fragaria vesca L. and its effect on Ulcerative colitis and Crohn's disease (chronic recurrent inflammatory bowel disease (IBD)) found that EFFV at 500 mg/kg showed significant amelioration of experimentally induced IBD, which may be attributed to its antioxidant and anti-inflammatory properties, according to "Effect of fruit extract of Fragaria vesca L. on experimentally induced inflammatory bowel disease in albino rats" by Kanodia L, Borgohain M, Das S.(18)

c. Human health
In the review and update of the current knowledge on the potential impact of strawberry on human health, found that the mechanisms responsible for the potential health-promoting effects of strawberry may not be necessarily searched in the activity of phytochemicals. Particularly, a greater interest should be addressed to show whether a prolonged strawberry consumption may effectively improve the folate status and reduce the incidence of folate-related pathological conditions. Furthermore, the hypouricaemic effects of cherries need to be evaluated also in respect to strawberry intake, and the mechanisms of actions and anti-gout potentialities need to be studied in detail. Future investigations involving human trials should be aimed at following these underestimated scientific tracks, according to "Impact of strawberries on human health: insight into marginally discussed bioactive compounds for the Mediterranean diet" by Tulipani S, Mezzetti B, Battino M.(19)

5. Etc.

B.. Antioxidants to prevent floater(20)

1. Antioxidant enzymes

a. Super oxide dismutase (both Cu-Zn and Mn)
Super oxide dismutase is an important antioxidant defense in nearly all cells exposed to oxygen by converting superoxide into oxygen and hydrogen peroxide depending on the metal cofactor such as both Cu-Zn and Mn.

b. Glutathione peroxidase
The function of glutathione peroxidase is to protect the organism from oxidative damage by reducing lipid hydroperoxides, an oxidation of lipid cell membranes which can easily break and form free radicals of the form RO and converting free hydrogen peroxide to oxygen and water.

c. Glutathione reductase
Glutathione reductase, an enzyme reduces pair of sulfur atoms glutathione to the a organosulfur compound form of antioxidant (consisting of three amino acids joined by peptide bonds) which helps to prevent damage of important cellular components caused by free radicals and peroxides.

d. Etc.

2. Metals binding proteins(21)

a. Ceruloplasmin
Ceruloplasmin, the major copper-carrying protein in the blood plays a role in iron metabolism. It prevents the oxidation that leads to the forming of oxidation from Fe²⁺ (ferrous iron) into Fe³⁺ (ferric iron) by exhibiting a copper-dependent oxidase activity, causing mutations in the ceruloplasmin gene cause of iron overload in the brain, liver, pancreas, and retina.

b. Ferritin
Ferritin, the protein produced by almost all living organisms, acts as a component to fight against iron deficiency and iron overload, keep in a soluble and non-toxic form and transport it to the body needs, including organs. It enhances the immune system in the presence of an infection or cancer and prevent the infectious agent attempts to bind iron to become free radicals by migrating from the plasma to within cells.

c. Etc.

3. Common Free Radical Scavengers

a. Vitamin A
Vitamin A occurs in the form retinol and is best known for its function in maintaining the health of cell membrane, hair, skin, bone, teeth and eyes. It also plays an important role as an antioxidant as it scavenges free radicals in the lining of the mouth and lungs; prevents its depletion in fighting the increased free radicals activity by radiation; boosts immune system in controlling of free radicals; prevents oxidation of LDL and enhances the productions of insulin pancreas.

b. Vitamin C
Vitamin C beside plays an important role in formation and maintenance of body tissues, it as an antioxidant and water soluble vitamin, vitamin C can be easily carry in blood, operate in much of the part of body. By restoring vitamin E, it helps to fight against forming of free radicals. By enhancing the immune system, it promotes against the microbial and viral and irregular cell growth causes of infection and inflammation.
Vitamin C also is a scavenger in inhibiting pollution cause of oxidation.

c. Vitamin E
Vitamin E is used to refer to a group of fat-soluble compounds that include both tocopherols and tocotrienols discovered by researchers Herbert Evans and Katherine Bishop. It beside is important in protecting muscle weakness, repair damage tissues, lower blood pressure and inducing blood clotting in healing wound, etc, it also is one of powerful antioxidant, by moving into the fatty medium to prevent lipid peroxidation, resulting in lessening the risk of chain reactions by curtailing them before they can starts.

d. Vitamin D
Reseacher found that vitamin D, a group of fat-soluble secosteroids is also a membrane antioxidant, with the ability to inhibit iron-dependent lipid peroxidation in liposomes compared to cholesterol.

e. Etc.

C. Phytochemicals to prevent floater

1. Curcumin is a phytochemical found abundant in the plant. In acidic solutions (pH <7.4) it turns yellow, whereas in basic (pH > 8.6) solutions it turns bright red.

a Anti-inflammatory agent
According to the study of evaluation of anti-inflammatory property of curcumin (diferuloyl methane) in patients with postoperative inflammation. by Satoskar RR, Shah SJ, Shenoy SG., poated in US National Library of Medicine National Institutes of Health, researchers wrote that In this model of postoperative inflammation, the anti-inflammatory activity of curcumin (diferuloyl methane) was investigated in comparison with phenylbutazone and placebo. Phenylbutazone and curcumin produced a better anti-inflammatory response than placebo.

b. Antioxidants
In a study of `Protective Role of Curcumin Against Oxidative Stress,Immunosuppressive and Cytotoxic Effects of Lead Exposure` by Mahmoud El-sherbiny, Azza Araffa, Mona Mantawy and Hany M. Hassan (Therapeutic Chemistry Department, National Research Centre - Dokki, Giza, Egypt. Immunology Department, Animal Reproduction Research Institute (ARRI), Giza, Egypt), posted in World Applied Sciences Journal 12 (10): 1832-1838, 2011, researchers found that
ground, curcumin's benefits on tumorigenesis are thought to be mediated by its antiinflammatory activity; however, these effects have not been well characterized in a mouse model of colon cancer. Briefly, curcumin is efficacious for chronic nonbacterial prostatitis in rats and the action mechanism may be associated with its decreasing effect on the proinflammatory cytokines IL-8 and TNF-alpha in the blood and tissues. Curcumin has protective effect on DNA of pulmonary cells. There was direct evidence for an involvement of curcumin in reducing arsenic and lead induced oxidative stress in Swiss albino mice by virtue of its antioxidant potential and trapping of free radicals. The current investigation concluded that curcumin has protective role against cytotoxic, immunosuppressive , oxidative and immunosuppressive profile that perform due to lead acetate exposure.

c. Cellular Processing
According to the research of `Evidence against the rescue of defective DeltaF508-CFTR cellular processing by curcumin in cell culture and mouse models.`by Song Y, Sonawane ND, Salinas D, Qian L, Pedemonte N, Galietta LJ, Verkman AS. (Source from Department of Medicine and Physiology, Cardiovascular Research Institute, University of California, San Francisco, California 94143, USA. Copyright 2004 American Society for Biochemistry and Molecular Biology, Inc.) posted in US National Library of Medicine National Institutes of Health, researchers found that assay of serum curcumin by ethyl acetate extraction followed by liquid chromatography/mass spectrometry indicated a maximum serum concentration of 60 nm, well below that of 5-15 microm, where cellular effects by sarcoplasmic/endoplasmic reticulum calcium pump inhibition are proposed to occur. Our results do not support further evaluation of curcumin for cystic fibrosis therapy.

2. Theaflavin-3-gallate, a theaflavin derivative, is phytochemicals of Flavan-3-ols, in the group of Flavonoids (polyphenols) found abundantly in black tea.

a. Antioxidant capacities
In the comparison of TF derivatives (theaflavin (TF(1)), theaflavin-3-gallate (TF(2)A), theaflavin-3'-gallate (TF(2)B), and theaflavin-3,3'-digallate (TF(3))) in scavenging reactive oxygen species (ROS) in vitro, indicated that positive antioxidant capacities of TF(2)B on singlet oxygen, hydrogen peroxide, hydroxyl radical, and the hydroxyl radical-induced DNA damage in vitro were found, according to "Evaluation of the antioxidant effects of four main theaflavin derivatives through chemiluminescence and DNA damage analyses" by Wu YY, Li W, Xu Y, Jin EH, Tu YY.(22)

b. Anti inflammation
found that a single topical application of equimolar of black tea constituents (TF, theaflavin-3-gallate, theaflavin-3'-gallate, and theaflavin-3,3'-digallate) strongly inhibited TPA-induced edema of mouse ears. Application of TFs mixture to mouse ears 20 min prior to each TPA application once a day for 4 days inhibited TPA-induced persistent inflammation, as well as TPA-induced increase in IL-1beta and IL-6 protein levels. TFs also inhibited arachidonic acid (AA) metabolism via both cyclooxygenase (COX) and lipoxygenase pathways, according to "Inhibitory effects of black tea theaflavin derivatives on 12-O-tetradecanoylphorbol-13-acetate-induced inflammation and arachidonic acid metabolism in mouse ears" by Huang MT, Liu Y, Ramji D, Lo CY, Ghai G, Dushenkov S, Ho CT.(23)

3. Gingerole, is also known as gingerol, a phytochemical of Flavonoids (polyphenols) found in fresh ginger. and in variety of other plants. The herb has been used to treat nausea and vomiting of pregnancy, motion sickness, rheumatoid arthritis, relieve migraine, etc.

In the investigation of the effectiveness of chemical constituents of Zingiber officinale Rosc. (Zingiberaceae)in treating oxidative stress found that compounds [6]-gingerol, [8]-gingerol, [10]-gingerol and [6]-shogaol of the herb scavenges of 1,1-diphenyl-2-picyrlhydrazyl (DPPH), superoxide and hydroxyl radicals, inhibitsof N-formyl-methionyl-leucyl-phenylalanine (f-MLP) induced reactive oxygen species (ROS) production in human polymorphonuclear neutrophils (PMN), lipopolysaccharide induced nitrite and prostaglandin E(2) production in RAW 264.7 cells, according to the study of "Comparative antioxidant and anti-inflammatory effects of [6]-gingerol, [8]-gingerol, [10]-gingerol and [6]-shogaol" by Dugasani S, Pichika MR, Nadarajah VD, Balijepalli MK, Tandra S, Korlakunta JN(24)

4. Epigallocatechin, including catechins, is a phytochemical of Flavan-3-ols, in the group of Flavonoids (polyphenols), found abundantly in green tea, St John wort, black Tea, carob flour, Fuji apples, etc.

a. Cholesterol
In the examination of the influence of green tea extract, epicatechin (EC), epicatechin galate (ECG) as well as epigallocatechin galate (EGCG) on oxidative modifications of LDL of human blood serum, found that Catechins and green tea abilities to protect lipophilic antioxidant--alpha-tocopherol against oxidation have been also examined. The results reveal that peroxidation of LDL is markedly prevented by green tea extract and in a slightly weaker way by catechins (EGCG in particular), which is manifested by a decrease in concentration of conjugated dienes, lipid hydroperoxides, MDA, dityrosine and by an increase in tryptophan content, according to "The comparison of effect of catechins and green tea extract on oxidative modification of LDL in vitro" by Ostrowska J, Skrzydlewska E.(25)

b. Anti diabetes
In the observation of the effect of tea catechins (epigallocatechin gallate (EGCG), epigallocatechin (EGC), epicatechin gallate (ECG) and epicatechin (EC)) on markers of oxidative stress (malondialdehyde (MDA), reduced glutathione (GSH) and membrane -SH group) in erythrocytes from type 2 diabetics, found that tea catechins protect erythrocytes from t-BHP-induced oxidative stress, the effect being more pronounced in diabetic erythrocytes. The relative effectiveness of individual catechins are in the order of EGCG>ECG>EGC>EC. 7. We hypothesise that a higher intake of catechin-rich food by diabetic patients may provide some protection against the development of long-term complications of diabetes, according to "Protective role of tea catechins against oxidation-induced damage of type 2 diabetic erythrocytes" by Rizvi SI, Zaid MA, Anis R, Mishra N.(26)

c. Antioxidants
In the evaluation of the effects of the main polyphenolic components extracted from green tea leaves, i.e. (-)-epicatechin (EC), (-)-epigallocatechin (EGC), (-)-epicatechin gallate (ECG), (-)-epigallocatechin gallate (EGCG) and gallic acid (GA), against free radical initiated peroxidation of human low density lipoprotein (LDL), found that The antioxidative action of the green tea polyphenols includes trapping the initiating and/or propagating peroxyl radicals with the activity sequence EC>EGCG>ECG>EGC>GA for the AAPH initiated peroxidation, and reducing the alpha-tocopheroxyl radical to regenerate alpha-tocopherol with the activity sequence of ECG>EC>EGCG>EGC>GA and ECG>EGCG>GA>EC>EGC for the AAPH-initiated and BP-photosensitized peroxidations respectively, according to "Antioxidative effects of green tea polyphenols on free radical initiated and photosensitized peroxidation of human low density lipoprotein" by Liu Z, Ma LP, Zhou B, Yang L, Liu ZL.(27)

5. Etc.

VI. Treatments

A. In conventional medicine perspective

Treatment is not necessary, if the diagnosis indicated that the floater is harmless and will do causes nay damage to the eye vision, but in severe case, the following may be recommended

1. Vitrectomy

In the study to to evaluate the role of pars plana vitrectomy (PPV) in patients with persistent vitreous floaters (VF) in phakic (56.7 %) or pseudophakic (43.3 %) eyes, Dr. Roth M, and the research team at the Universitätsspital Bern, showed that PPV to be a safe and effective primary treatment for visually disturbing VF. In spite of the small number of cases with a lower PVA (5 eyes/16.7 %), which in the most severe case corresponded to a reduction of VA from 1.0 to 0.6 due to a nuclear sclerosis of the lens, all patients were satisfied. As vitreoretinal complications may occur, a critical patient selection and a careful preoperative assessment of specific risks of vitrectomy are mandatory(28).

2. Laser vitreolysis

Dr. Y M Delaney and the research team at The Department of Ophthalmology Stoke Mandeville Hospital Aylesbury Buckinghamshire, in the study of Nd:YAG vitreolysis and pars plana vitrectomy: surgical treatment for vitreous floaters, indicated that Patients’ symptoms from vitreous floaters are often underestimated resulting in no intervention. This paper shows Nd:YAG vitreolysis to be a safe but only moderately effective primary treatment conferring clinical benefit in one third of patients. Pars plana vitrectomy, while offering superior results, should be reserved for patients who remain markedly symptomatic following vitreolysis, until future studies further clarify its role in the treatment of patients with floaters and posterior vitreous detachment(29).

There is no need to undergo any eye floaters treatment with respect to the fact that the diagnose is utterly harmless and does not have any influence on worsening of the vision or sight damage. Most of the patients get used to this problem after some time and they begin to ignore it and it ceases to bother them or possibly they perceive it only when they increase the level of concentration for example on some white wall.

The formation of eye floaters depends on the natural changes in the vitreous body and is not caused by any behavior of the patient: neither reading nor working on the computer.

B. In Herbal medicine perspective

The aim of the treatment is to enhance the repaired connective tissues, diabetic complication cause of floater and improve circulation and protect the capillaries from broken off.
1. Repaired connective tissues
Loss of skin elasticity is one of the main problems of ageing. This is a mechanical property influenced by elastin, a protein in the dermis which, together with collagen and glycosaminoglycans, makes up the connective tissue. In the study to investigate the effects of lady's thistle (Silybum marianum GAERTN), alchemilla or yarrow (Alchemilla vulgaris L.), horsetail (Equisetum arvense L.) as well as germinated seeds (Glycine soja Siebold and Zucc., Triticum vulgare Vilars, Medicago sativa L., Raphanus sativus L.), found that t the plant complex presents non-competitive inhibition in the order of 41.0% against PPE and 50.0% against HLE. An in vivo test was made alongside the in vitro test using an SEM 474 Cutometer (Courage & Khazaka) to study the elasticity of the skin, and positive effects were obtained when applying a cosmetic formulation containing 5% of the plant complex. Image analysis of duplicates of the cutaneous surface, before and after treatment began with a product containing 5% of plant complex and showed that wrinkles were decreased by 36.7%(30).

2. Diabetic complicationsa.
Dandelion water extract (DWE), an herbal medication, may exert an effect on the activity and mRNA expression of hepatic antioxidant enzymes and lipid profile in streptozotocin (STZ)-induced diabetic rats. Dr. Cho SY and research team at Yeungnam University suggested that a DWE supplement can improve the lipid metabolism and is beneficial in preventing diabetic complications from lipid peroxidation and free radicals in diabetic rats(31).

3. Circulation enhancers
a. GINGER for EYE disorders: Taking Ginger will increase blood circulation so that more nutrition can reach your eye(32).
b. Garlic for VARICOSE VEINS. Garlic helps to keep your blood from clumping or becoming too sticky, helping your blood move through your blood vessels and reduces the risk of blood clots. One clove a day should do the trick. You can also take garlic capsules. CAUTION: Medication and Garlic could lead to uncontrolled bleeding and spell HEMORRHAGIC STROKES if it occurs in your brain. To avoid this, take caution against taking standardized garlic extract. Experts suggest eating no more than one clove of garlic a day(33).

4. Prevent Eye diseases
Bilberry has been best known for its function in enhancing vision health, according to the study of "Natural therapies for ocular disorders, part two: cataracts and glaucoma" by Head KA., posted in PubMed(4), researcher indicated that B vitamin riboflavin appears to play an essential role as a precursor to flavin adenine dinucleotide (FAD), a co-factor for glutathione reductase activity. Other nutrients and botanicals, which may benefit cataract patients or help prevent cataracts, include pantethine, folic acid, melatonin, and bilberry(34)

5. Other suggested dandelion, milk thistle, Ginkgo Biloba, etc.

C. In traditional Chinese medicine perspective(35)

According tothe article of FLOATERS AND THEIR TREATMENT WITH CHINESE HERBS

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon wrote that

in theEnglish-Chinese Encyclopedia of Practical Traditional Chinese Medicine (2), there is a short section on diseases of the vitreous. The clinical manifestations are said to range from mild cases with black shadows floating up and down like flying flies (but no other change in vision) to severe cases, where the eyes seem to be covered by a membrane. There are three categories of causation listed:

1. Accumulation and steaming up of damp-heat and attack of turbid qi
a. This corresponds to the disorder of the gallbladder described above.
b. A recommended formula is modified San ren Tang (Three Seed Decoction), which have a function to clear damp-heat. Ingredients includes
b.1. Xing Ren (Apricot Seed or Kernel)
b.2. Bai Dou Kou (Round Cardamom Fruit)
b.3. Hou Po (Magnolia Bark)
b.4. Ban Xia (Pinellia Rhizome)
b.5. Yi Yi Ren (Seeds of Job's Tears)
b.6. Tong Cao (Rice Paper Pith, Tetrapanax)
b.7. Dan Zhu Ye (Lophatherum Stem and Leaves)
b.8.Hua Shi (Talcum)

2. Stagnation of liver qi, resulting in blood stasis and extravasation of blood.

a. This corresponds to the leakage of blood into the vitreous cavity, perhaps as a result of retinitis.
b. A recommended formula is modified Jiawei Xiaoyao San (Bupleurum and Peony Formula.
b.1.Radix Bupleuri Chinensis (Chai hu)
b.2. Radix Angelicae Sinensis (Dang gui)
b.3. Radix Paeoniae Lactiflorae (Bai shao)
b.4. Rhizoma Atractylodis Macrocephalae (Bai zhu)
b.5. Sclerotium Poriae Cocos (Fu ling)
b.6. Radix Glycyrrhizae Uralensis (Gan cao)
b.7. Cortex Moutan Radicis (Paeonia Suffruticosa) (Mu dan pi)
b.8. Fructus Gardeniae Jasminoidis (Zhi zi)
b.9. Herba Menthae Haplocalycis (Bo he)

3. Deficiency of kidney and liver, resulting in flaring up of deficiency fire.

a. This corresponds to the weakness of the kidney water, and associated heat that causes drying of the vitreous.
b. The recommended formula is a modified Zhibai Dihuang Tang (Anemarrhena, Phellodendron, and Rehmannia Formula),. Ingredients include
b.1. Radix Rehmanniae Preparata (Shu Di Huang)
b.2. Fructus Corni Officinalis (Shan Zhu Yu)
b.3. Cortex Moutan Radicis (Paeonia Suffruticosa) (Mu Dan Pi)
b.4. Rhizoma Dioscoreae Oppositae (Shan Yao)
b.5. Sclerotium Poriae Cocos (Fu Ling)
b.6. Rhizoma Alismatis Orientalis (Ze Xie)
b.7. Rhizoma Anemarrhenae Asphodeloidis (Zhi Mu)
b.8. Cortex Phellodendri Chinensis (Huang Bo)