ASK THE DOCTOR: What can I do to stop my hands shaking?
My problem is that my hand has shaken since childhood. Whenever I try to work, it starts shaking. Is there any treatment for this?
Prakash Sharma, by email.
Shaky hands is a symptom of what is technically known as a tremor. Most people have some degree of tremor - you can see this if you hold a piece of paper in your hands: it will flutter very slightly. This is entirely normal.
But when it is more severe - and gradually gets worse over time - it is known as essential tremor. I believe this is your diagnosis.
Shaky hands is a symptom of what is technically known as a tremor. Most people have some degree of tremor
Essential tremor is sometimes known as familial tremor if the patient has a history of the condition in their family. The condition affects up to 5 per cent of people and is typically seen in hands and arms, though some people may find their head, trunk and legs shake, too.
The important point is that the condition will not lead to any other neurological symptoms. However, you do need to understand this is a lifelong problem - there is no cure.
If the tremor is mild and does not cause any real disability, then treatment is not crucial. But when the tremor is so severe as to be disabling, drug treatment can help minimise the extent of the movements.
For those who find stressful situations - such as performing in public - cause the tremor to get worse temporarily, it can help to take medication ahead of the event.
Typically, we prescribe propranolol primidone. Propranolol is a beta blocker, which works by blocking the action of the hormones adrenaline and noradrenaline on muscle fibres.
Primidone is an anticonvulsant, thought to work by calming the nerve supply to muscles, as well as having an action in the brain.
For those who find stressful situations - such as performing in public - cause the tremor to get worse
Clinical studies have found each of these to be effective. In one study, the use of propranolol at a daily dose of 260mg reduced the extent of tremor by an average 35 per cent.
Some people may find that small amounts of alcohol reduce or abolish their tremor.
However, this is not a suitable regular treatment - over time, increasingly larger amounts are needed to achieve the same effect.
This raises the risk of addiction and liver damage, as well as interfering with work and the ability to drive.
If a patient opts for continuous drug treatment, the tremor may worsen again after months or years. In this case, there are other options, including gabapentin and topiramate, which are anticonvulsants.
However, I would advise that a decision to move to this type of drug therapy should be guided by expert advice from a neurologist who has experience in the treatment of movement disorders as it is beyond the experience of most GPs.
After a routine visit to the optician, I was referred to an ophthalmic clinic where a series of tests was carried out, including having dye and drops in my eye. The doctor then said that they would need to do a check every three months as I had freckles behind my eyes. To say I was dumbfounded is an understatement as the only freckles I have ever heard of are on the skin. My GP did not know what they are or whether they are serious. Can you shed any light on this? I am 73.
Mrs Margaret Lomas, by email.
Pigmented cells on the retina are normal. However, these pigmented cells can move out of place and grow
The term 'freckle' is not a medical word. It is not a diagnosis, but merely a label you have been given to describe one or more pigmented spots that were seen during an examination of the retina - the light-sensitive layer of cells at the back of the eye.
Pigmented cells on the retina are normal. However, these pigmented cells can move out of place and grow, like moles on the skin.
When they are found on the choroid - a blood vessel-enriched layer between the retina and the sclera, the tough outer wall of the eyeball - they are known as choroidal naevi (a naevus is the medical term for a mole).
About 5 to 10 per cent of Caucasian people have choroidal naevi - they are probably present from birth, but grow larger over time.
Let me reassure you that they are not an eye disease in themselves, and pose no threat to your vision. But on rare occasions they can turn cancerous, and this is why it is important to identify them and keep them under observation.
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Your eye specialist will continue to monitor them, comparing them with baseline photographs that will have been taken at a previous appointment and looking out for any changes. If the appearance remains stable for the next year or two, the three or six monthly reviews will probably be replaced by an annual check-up.
It is unclear from your letter, and maybe you have not been informed, but it would be interesting to know the number of freckles and whether they are in both eyes.
There is a condition called dysplastic naevus syndrome, used to describe people who have many large and atypical moles on their skin.
Atypical moles are those that are benign but which do have some characteristics of malignant melanomas, such as asymmetry, irregular borders and multiple colours.
These people may be more prone to choroidal naevi, and often have several of them. But you have made no mention of your skin, therefore, I assume that this diagnosis does not apply to you.
After a gastroscopy last summer, I was told I had Barrett's oesophagus. Right away I thought 'cancer'. I have had acid reflux for five years and a hiatus hernia. I am 80.
Name and address withheld.
I sense the anxiety that the diagnosis has caused you, but let me reassure you that you're not in great danger of cancer. A gastroscopy is where a thin, flexible tube is used to look at the inside of the oesophagus and/or stomach.
The tube has a camera and can also remove tiny bites of the lining for examination.
Barrett's oesophagus is where the cells that line the lower part of the gullet change, following repetitive damage from stomach acid.
These changes seem to be a defence mechanism to protect the delicate lining of the oesophagus. The concern is that these changed cells can be a precursor to cancer.
The aim of treatment is to control the acid reflux, stopping the damage caused by stomach acid. For this reason, as you say in your longer letter, you are quite rightly prescribed lansoprazole every day, supplemented by ranitidine at night, which reduce the amount of acid produced by the stomach.
You might also consider avoiding foods that can worsen reflux: fatty foods, alcohol, peppermint, chocolate and excessive tea and coffee. Try eating your evening meal at least two hours before bedtime and avoid lying down after meals.
Your worry is cancerous change. But if this does occur it is gradual. Only five out of every 100 people with the condition will develop cancer each year. You will have a further gastroscopy within the first year.
The worst-case scenario is that you could have early pre-cancerous changes, though it's unlikely.
Your task is to take the medication and remember that progression to cancer is uncommon.
By the way... Five a day? Children should be having TEN
If we are genuinely concerned about illness prevention, the strategy must start earlier in life
When I started practising there was little or no health screening - where we look for risk factors for disease in an otherwise healthy person so as to prevent ill health occurring.
Screening gives us an opportunity to start treatment early in the event of finding a condition that had not previously been apparent as there have been no symptoms.
As doctors we were all aware of the good sense in setting up screening programmes on the basis that prevention is better than cure, yet when I started out, most of the energy and funding of the health service was going towards fighting fires - in other words, dealing with illness, not preventing it.
In the intervening years, screening has taken off in a big way. A considerable proportion of the funds that are paid to GPs are via the mechanism known as QOF (quality and outcomes framework), which offers financial incentives to conduct many forms of health screening and health promotion - such as encouraging patients to stop smoking and, more recently, screening them for dementia.
There are so many of these sorts of schemes that many of us are concerned it interferes with our main task - giving time and skill in the care of the sick and ill.
Moreover, I am of the view that if we are genuinely concerned about illness prevention, the strategy must start earlier in life, rather than waiting for patients to arrive with their own health problems and then hijacking them for screening programmes or tutorials.
We need to start with children. In the BMJ recently, the UK's four Chief Medical Officers published guidelines urging doctors to find ways to help children and young people to do at least 60 minutes of physical activity every day.
But it's not just about doctors. We need to work via the education system. The focus should swing from GPs to teachers - they should be the ones to receive the incentives. There has already been a small start: for example, the Daily Mile, when primary school children run a mile every day,
But it must not stop there. Diet should be a major school subject, with regulation to stop children leaving school at lunchtime to buy junk food, in tandem with a long-term push to improve the quality of school food and an effort to teach children the full benefits of eating healthily, encouraging a nutritious diet at the plant-based end of the spectrum.
Forget the encouragement to eat five portions of fruit or vegetables each day - aim for ten.
Concentrate on teaching children to understand and take care of their bodies, rather than endlessly bickering about the pros and cons of reducing sugar intake by tax arrangements or harping on about salt.
This, surely, is the right place to invest for the future.
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