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Ask the doctor: Is my daughter's sore eye something serious?

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Two-and-a-half years ago my daughter developed a blood clot in her right leg, which then travelled to one of her lungs. She was only 37 and was put on the blood thinner warfarin.   She’s since suffered from severe chest and leg pains. A recent scan revealed slight damage to one of her lungs, but everything else was in order. She’s also developed iritis four times. Blood tests revealed ‘elevated ESR levels’, but the doctor’s secretary had no idea what this was. Can you shed any light on these conditions? Mrs K. Palmer, by email. Iritis is a severe and painful inflammation of the coloured tissue in the eye (the iris)

Your anxiety is understandable — there is uncertainty here, and you have a sense all is not well.

Yet, so far, a diagnosis giving a rational explanation that ties together these events is lacking.

Without that, there can be no treatment to prevent future ill-health.

A deep vein thrombosis leading to a pulmonary embolism (blood clot on the lung) must have an identifiable cause.

Iritis, a severe and painful inflammation of the coloured tissue in the eye (the iris), must also have an underlying cause. The question is: are they connected.

In the case of your daughter, some thought and investigation is needed to unearth this.

I do not know enough of her full medical history, but there must be other factors that her doctor must consider when reaching a diagnosis.

The first question they should ask is whether she has ever suffered a miscarriage.

This may seem an odd question, but one possibility is that she has Hughes Syndrome, also known as sticky blood syndrome (it also carries the medical name anti-phospholipid syndrome).

It’s thought to affect up to 1 per cent of the population, though may be more common in women.

This causes the blood to become sticky and clot more than it should.

What triggers Hughes Syndrome is unclear, but one possibility is that it’s an autoimmune condition — the immune system mistakenly attacks components of the blood, resulting in blood clots.

CONTACT DR SCURR

To contact Dr Scurr with a health query, write to him at Good Health Daily Mail, 2 Derry Street, London W8 5TT or email drmartin@dailymail.co.uk — including contact details.Dr Scurr cannot enter into personal correspondence.His replies cannot apply to individual cases and should be taken in a general context.Always consult your own GP with any health worries.

Another consequence is recurrent miscarriages (due to blood clotting in the vessels of the placenta), and systemic lupus erythematosus (where the immune system starts attacking various parts of the body such as the eye, skin, joints, kidneys and heart).

The latter could possibly explain your daughter’s iritis.

This attack triggers widespread inflammation, which causes an increase in a type of compound called ESR — and it was this that was detected in your daughter’s blood test.

However, reaching a firm diagnosis is the province of a rheumatologist who takes an interest in this area.

I am only theorising, and there may be other important features in your daughter’s history, which is why her case needs investigation.

If Hughes Syndrome is found to be the cause, this condition is treatable with medication, her symptoms may settle and further problems prevented.

Do encourage her to talk to her GP in this context and seek referral. 

For more than 12 years I have been taking the drug alendronic acid after being diagnosed with the brittle bone disease osteoporosis (I believe I am one of the small number of men who have this condition). Recently my GP advised me there were some question marks hanging over alendronic acid and stopped the treatment in favour of calcium tablets. I should be most grateful if you could advise me as to the current thinking about the continued use of  the drug. Gordon Stead, by email.

I last wrote about osteoporosis only two weeks ago, but it is clearly a subject that concerns many readers, to judge by the large number of follow-up letters I’ve since received.

Your particular letter highlights a common worry — the long-term use of alendronic acid, one of a group of medicines called bisphosphonates.

Before I address the issues, let me just recap one or two of the details about osteoporosis.

This condition causes the bones to lose density and, hence, become weaker. Fractures can occur, even from minor trauma, and these may especially affect the spine, wrist or hip.

The condition is six times more common in women than men, as the hormonal changes around the time of the menopause are thought to play a role.

It is diagnosed with a type of X-ray called a Dexa scanning; this technology is also used to monitor how well the bones are responding to treatment, the aim of which is to preserve bone mass and prevent fractures and pain.

This can be achieved with  some medicines, the mainstay being bisphosphonates as you were prescribed.

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Lifestyle changes are also important.

These include increasing the amount of weight-bearing exercise (such as walking), minimising caffeine and alcohol, and stopping smoking.

Taking at least 1,000mg of calcium daily helps maintain bone density, and this is usually taken with vitamin  D, as it boosts absorption.

As your GP has pointed out, concerns have now emerged over the long-term use of bisphosphonates.

There is evidence to suggest that taken for more than five years, the drugs seem to affect the way body maintains bone, and this can lead to fracture.

So we face a contradiction: although these drugs help preserve bone mass and decrease hip and spine fractures by 50 per cent, taking them for more than this time can increase the risk of fracture.

So what are we to do?

The overall balance of risk versus benefit remains in favour of treatment with the alendronic acid or similar, as the number of these fractures caused by bisphosphonates  is outweighed by the number of fractures that the drug prevents.

However, treatment with a bisphosphonate should stop at five years.

But the good news is that the drugs have a lasting protective effect: research has shown the benefits of the treatment will persist long after the drug has been stopped.

By the way . . . The key to good care is seeing just one GP

Thirty years or more ago I had a book on my shelf that detailed more than 100 different modes of psychotherapy.

In that era, much as now, people with emotional, psychological or personality problems would come to me as their GP to seek advice on what type of therapy would be best for them, and then ask for a referral.

The book itself was a detailed appraisal by Anthony Clare of the numerous possibilities for treatment.

Forming a trusting and warm relationship with a patient is a pivotal event, without which not much good can happen

Back then, the focus of psychotherapy  was still the work of Sigmund Freud, Carl Jung and a few others, and was fundamentally about the unconscious sexual motives for behaviour.

Our state of knowledge has moved on.

Now the thinking is that people seek therapy because they want to communicate better with others and want a different perspective on their problems.

A seminal lecture last week given by Peter Fonagy, one of our leading psychoanalysts and clinical psychologists, explained why we now have so many different kinds of psychotherapy — 1,284. Or was it 1,285 or 1,286?

No matter, for the core of all good psychotherapies is the same: the formation of a bond of trust between the therapist and patient — and this applies whatever the mode of psychotherapy.

This connects the old school analysts (those still in the Freud mode of thinking, who analyse your childhood for hope of an explanation to current problems) and today’s cognitive therapists (who deal with the here and now and discuss coping strategies for your problems).

That the sense of trust itself is the start of the healing process is what unites both modes of thinking.

When we heard this, another very senior GP and I agreed that this is also the feature that leads to success in general practice.

Forming a trusting and warm relationship with a patient is a pivotal event, without which not much good can happen.

And what that takes is time . . . and the establishment of something I keep banging on about: continuity of care under one doctor.

There are no shortcuts in good and effective medicine.


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