How do I cope with the emotions caused by bereavement?

When a loved one dies, it may feel as though your life has changed forever, whatever the circumstances surrounding the death.

The loss of a friend or family member can be very difficult to come to terms with, and you may find that you go through a variety of emotions, and sometimes not even understand your own feelings.

Everybody deals with grief differently. Don't ever feel as though you should be feeling or acting a certain way. It's best to go with your own emotions, accept that this is the way you feel, and find ways to get through it.

There is no time limit on grief, it may take months, years or even longer to come to terms with your loss.

What is oral thrush?

Oral thrush is an infection in your mouth. It's one type of a fungal infection called oral candida. The membranes in your mouth (oral mucosa) become infected with a fungus, usually Candida albicans. (Oral candida is also known as oral candidiasis.)

There are four common types of oral candida; these types have different signs. The four common types are:

• oral thrush - also known as pseudomembranous oral candidiasis,
• acute atrophic oral candidiasis - also known as acute erythematous oral candidiasis,
• denture stomatitis - also known as chronic erythematous oral candidiasis and chronic atrophic oral candidiasis, and
• chronic plaque-like oral candidiasis - also known as chronic hyperplastic oral candidiasis.

These infections are most commonly found in babies, people who wear dentures and elderly people. They are uncommon in other people, and can be a sign of another condition or illness that's not been diagnosed.

Can oral thrush be a symptom of HIV?

Rarely, oral thrush in adults can be an early sign of another condition or illness, such as HIV, cancer, diabetes or anaemia.

However, if you have an oral thrush infection, it doesn't necessarily mean you have HIV, AIDS or any other condition. If your infection is related to another condition, you'll probably have other more serious symptoms as well. So it's important to see your GP.

When your GP assesses your symptoms, they may ask you about other infections such as vaginal thrush or balanitis. Balanitis is inflammation of the head of the penis (the glans), caused by a bacterial or fungal infection. It can be a sign of thrush.

Your GP will also assess any other symptoms you have, to check for any other condition or illness.

If you have oral thrush, your GP will offer you treatment. If you've been at risk of HIV infection but haven't been diagnosed, your GP may also offer you an HIV test.

If you've already been diagnosed with HIV, you should be under the care of a specialist who will keep an eye on your immune status and arrange any treatment you need, such as antiviral medicine to help your immune system. These specialists are usually based in HIV or GUM (genito-urinary medicine) clinics, although GPs are also involved in caring for people with HIV.

HIV (human immunodeficiency virus) can develop into AIDS (acquired immunodeficiency syndrome). If you have AIDS, your immune system is severely weakened by HIV. You will therefore find it harder to fight off illness and infection.

How do these infections affect people with HIV or AIDS?

Oral candida infections affect up to 48% of people with HIV and over 90% of people with AIDS.

If you have HIV and leave oral candida untreated, it can become a serious problem, lasting for months or years.

As well as oral thrush, people with HIV can develop acute atrophic oral candidiasis, another type of oral candida (see above). Sometimes this infection can develop after you have oral thrush.

People with AIDS can also develop thrush infections deeper within their bodies, for example, in their windpipe, throat or lungs.

Age-related macular degeneration

Age-related macular degeneration (AMD) is the leading cause of blindness. It is just one form of macular disease, which affects the eye's retina.

An estimated 500,000 people in the UK suffer from AMD, 40% of these are over the age of 75.

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What is AMD?

AMD is the most common form of macular disease, which affects the central part of the retina.

It is an age-related process and usually develops after a person reaches 50 years.

It generally involves both eyes, although they may not be affected at the same time or to the same degree.

Some 90% of these cases are dry AMD which cannot be treated but 10% are wet ADM.

Dry AMD means visual cells simply stop functioning.

Wet AMD is by far the most aggressive form of the disease.

The condition is caused by the growth of new blood vessels under the centre of the retina.

These can leak fluid, causing scar tissue to form and destroying central vision in a period of between two months and three years.

Peripheral vision is retained. The condition causes problems reading, seeing small objects and distorted vision.

What are the symptoms?

In the early stages of AMD, central vision may be blurred or distorted. Objects may take an unusual size or shape.

This process can happen quickly or develop over several months.

People with the condition may become very sensitive to light or actually see lights that are not there.

There may be some discomfort, although overall the condition is not painful.

How is AMD treated?

There is no treatment for dry AMD, but there are a number of treatments for the wet form of the condition.

Photodynamic therapy involves the injection of a light-sensitive medicine called verteporfin into a vein in the arm.

The medicine is able to identify the abnormal blood vessels in the macula, and attach itself to proteins in those vessels.

The medicine is then activated - by a laser which is shone into the eye - to destroy the rogue vessels.

This stops the vessels from leaking blood or fluid, therefore stopping the damage the vessels are causing to the macula.

The technique is designed to ensure that none of the healthy, but delicate tissues in the eye are damaged.

However, it can only be used on a proportion of patients.

A newer type of drug treatment for wet AMD is known as anti-VGEF (vascular endothelial growth factor) medication.

It works by blocking one of the key chemicals responsible for the growth of the new blood vessels.

The anti-VGEF medication has to be injected into your eye using a very fine needle.

The National Institute for Health and Clinical Excellence (NICE) approved Lucentis, an anti-VGEF medciation, for use in England and Wales in 2008.

Ankylosing spondylitis

Mike Atherton: suffers from the condition

Ankylosing spondylitis is a hereditary back condition that cripples tens of thousands of people in the UK. It affects approximately one in 100 males and one in 250 females and occurs most commonly between the ages of 15 and 35 years. High profile sufferers include the former England cricket captain Michael Atherton.

What is Ankylosing spondylitis?

Ankylosing spondylitis is a painful, progressive rheumatic disease, mainly of the spine. It can also affect other joints, tendons and ligaments and other areas, such as the eyes and heart.

If left untreated, the disease can cause progressive stiffening of the spine, leading to immobility.

It is caused by inflammation in the joints between the vertebrae, and of the sacroiliac joints in the pelvis.

As a reaction to the inflammation, a small amount of bone erosion occurs.

After the inflammation has subsided, new bone is created as part of the healing process.

After repeated attacks, this additional bone growth can surround the disc.

Effectively this means that the bones begin to fuse together, although most sufferers will only experience partial fusion, usually in the pelvic area.

Sufferers initially experience stiffness and mild back pain, which is worse first thing in the morning.

The initial symptoms can be prevented and relieved by regular movement of the areas involved.

If this is not done, the formation of new bone can lead to increased stiffness, and to deformity with stooping posture in the spine.

Eventually the stiffness and deformity become irreversible.

Treating the condition

The best way to stop the progression of ankylosing spondylitis is to regularly exercise all parts of the spine and the chest area.

If started early and continued regularly - every day - the result is excellent with little restriction of movement or deformity.

These exercises are very specialised and have to be done irrespective of the patient's lifestyle.

Additional exercises may also be needed for the shoulders and the hips which are the most frequently affected joints other than the spine.

Swimming is a good sport for patients with spondylitis as it moves the shoulders and hips.

Anti-inflammatory medication may be prescribed to relieve the pain and inflammation, but it is not a substitute for a regular exercise programme.

What causes Ankylosing Spondylitis?

The cause is not yet known. However, it has been discovered that almost all the 80,000 clinically diagnosed people in the UK share the same genetic cell marker HLA B27 (Human Leucocyte Antigen B27).

There is evidence that a normally quite harmless micro-organism, which would be dealt with by our immune system, sets up an adverse reaction after coming into contact with the B27 individual, triggering the condition and causing flare-ups.

Anti-coagulants

Anti-coagulants are prescribed to millions of people to treat and prevent the life-threatening effects of a clot blocking a blood vessel.

How does blood clot?

Blood clotting, the mechanism by which the blood sticks together to form small solid clots is a natural and vital function of the body. Blood coagulation is triggered by blood cells called platelets which, through a series of chemical reactions, produce a substance called thrombin.

This converts a blood protein fibrinogen to fibrin which then create a series of tiny threads which lead the plasma in the blood to become sticky.

The process protects the body from excessive bleeding, ensuring that a clot forms at the site of a wound or injury - either inside or outside the body.

What happens when the clotting mechanism goes wrong?

More than 30 substances in the blood are known to affect clotting and it is essential to get the balance of substances right.

If the blood is prone to clot too little then there is a risk of haemorrhage; too much and there is a risk of clots forming where they are not wanted and leading to life-threatening conditions such as strokes and heart attacks.

What can be done to prevent clots forming?

There are several widely-used drugs which stop clots forming.

These are prescribed to people who are known to be at risk, including

• people with artificial heart valves
• people who have had a heart attack
• people who have had a stroke
• those who have had or are at risk of deep vein thrombosis
• people suffering from atrial fibrillation
• patients undergoing orthopaedic surgery
• people with angina

One of the most commonly used anti-coagulants is aspirin. The blood's natural anti-clotting substance, heparin, is given by injection, while warfarin is the most widely prescribed anti-coagulant taken orally.

How are these drugs used?

Aspirin

As well as its pain-relieving properties, aspirin is increasingly used to help thin the blood.

People who have suffered a heart attack or stroke are given clot-dissolving drugs immediately and will generally be prescribed long term anti-coagulant drugs.Taking low doses of aspirin daily is one of the cheapest and most effective means of preventing a further attack.

In the UK 300,000 people suffer from a heart attack every year and the vast majority will be prescribed low dose aspirin afterwards to try to make platelets in the blood less sticky and prevent a second attack.

People with artificial heart valves often take warfarin

Many of the 1.4 million angina sufferers in the UK are also prescribed low-dose aspirin. Aspirin has also been recommended for those embarking on long haul flights because of the increased risk of a clot forming in the leg during periods of prolonged inactivity.

Heparin

Heparin was first discovered in 1916. It is found naturally in many cells in the body. Heparin comes in two main forms and is routinely given intravenously after a clot has been diagnosed. The two forms act in a slightly different way on the thrombin in the blood and have the effect of prolonging the time a clot takes to form.The newer form, low molecular weight heparin, has been associated with fewer bleeding complications compared to unfractionated heparin.

It can be administered either by drip or injection under the skin. For immediate effect, such as after a DVT or a pulmonary embolism, an intravenous dose is given to ensure it is more rapidly delivered to the blood stream. The effects of heparin on clotting can be measured with a test called APTT and, as with warfarin, the dose needs to be adjusted to make sure it is at the right therapeutic level.

The common APTT ratio is between 1.5 and 2.5.

Warfarin

Warfarin is an anti-coagulant taken in tablet form.

It acts by interfering with vitamin K which is vital for blood clotting and the manufacture of prothrombin in the body. Patients who have undergone major heart surgery, including valve replacement and heart bypass surgery will generally take these ant-coagulants to avoid the chance of a clot forming around the new valve or artery.

Patients will be generally be given heparin for several days followed by 3 to 6 months of warfarin.

Patients taking long term anticoagulant therapy such as warfarin need to have their blood checked regularly to make sure they are on the right dose.

What is the INR?

Warfarin will slow the clotting time of the blood which an be measured by a test called the international normalised ratio or INR, a measurement adopted by the World Health Organization.

The desired INR range is usually between 2.0 - 3.0.

This is calculated by measuring the patient's actual prothrombin or clotting time against a n expected or control time. The individual response to warfarin varies so it is important that INR measurements are closely monitored.

Usually the INR will be measured with a daily blood test when a patient is first prescribed warfarin until doctors are sure the clotting time is within a safe range.

This will then be reduced to two or three times a week, then weekly and eventually monthly or even quarterly for those who are stable and not taking other medications.

Do anti-coagulants have any side-effects?

The main side-effect of taking anti-coagulants is increased likelihood of bleeding - particularly if the INR is above the desired level. The risk of bleeding increases in people aged over 65, those with a history of stroke or gastrointestinal bleeding.

Blood needs to be tested regularly

With aspirin the main complication is gastrointestinal bleeding because of damage to the stomach lining. Low dose aspirin pills are usually given an enteric coating which protects the stomach tissue.

One relatively rare warfarin side-effect is skin necrosis, which usually becomes apparent within a week of starting treatment. Lesions appear on the skin which are due to small clots in the blood vessels under the surface.

Combined treatment with warfarin and aspirin has been recommend in the UK for prevention of heart attacks in people at risk though this may increase the risk of a haemorrhage. Heparin's side effects also include osteoporosis, hair loss and hypersensitivity. Warfarin should be avoided in pregnancy because it crosses the placenta to the baby, though use of heparin in pregnancy is safe.

Warfarin can also interact with other drugs, including some antibiotics, barbiturates and alcohol so it is essential that patients discuss any medications with their doctor.

A diet high in vitamin K which is found in leafy green vegetables may also inhibit some of the warfarin effect.