Health Advisor

American Heart Association changes CPR guidelines

2010-10-20T09:46:00.000-07:00

'If we can just get people to start the compressions, then we can look at saving a lot more lives' says board member of the AHA

By Erin Allday
The San Francisco Chronicle

SAN FRANCISCO — Two of the three pillars of CPR — opening a distressed person's airway and providing mouth-to-mouth breathing — turn out to be not so essential when it comes to saving the life of someone in cardiac arrest.

Cardiopulmonary resuscitation should begin with forceful chest compressions to keep the blood circulating through the body, according to new guidelines released today by the American Heart Association. And people who haven't been trained in CPR need not bother with providing air-passage clearance and mouth-to-mouth breathing at all, the group said.

For the first time in decades, the heart association is shaking up its ABC system: airway, breathing and circulation. Until now, it involved opening the victim's airway first, starting mouth-to-mouth breathing and doing chest compressions last.

Several large studies in the past five years, however, have found that skipping the first two steps and going straight to chest compressions yields better survival rates for people who suffer cardiac arrest. Meanwhile, by discouraging the average citizen from giving mouth-to-mouth emergency treatment, public health experts hope that more people will be willing to provide CPR to strangers.

"This is a major change. If we can just get people to start the compressions, then we can look at saving a lot more lives," said Dr. Gordon Fung, director of cardiac services at UCSF Medical Center and a board member of the San Francisco chapter of the American Heart Association.

The heart association has taught CPR to the public using the ABC system since the 1960s. Sudden cardiac arrest is a common cause of death in the United States, and only about 6 percent of victims whose hearts stop outside of a hospital survive. But CPR may as much as double the chances of survival, studies have shown.

Reluctant bystanders
Two years ago, the heart association began encouraging untrained bystanders to forego mouth-to-mouth and give chest compressions when someone collapses. Multiple studies had shown that any CPR was better than none at all, but lay people were reluctant to step in and help — perhaps in large part because they didn't want to provide mouth-to-mouth breathing.

"But the message is that you don't need to do mouth-to-mouth," said Dr. Ed Kersh, chief of cardiology at California Pacific Medical Center's St. Luke's campus. "The key is getting the circulation going again."

The only time mouth-to-mouth breathing may be necessary is in obvious cases where a person is in respiratory distress — when someone has clearly stopped breathing from drowning, for example, or from a drug overdose.

But because the vast majority of cases where a person collapses and stops breathing are due to cardiac arrest, public health experts say starting chest compressions should almost always be the priority.

In the most recent CPR study, which looked at 4,400 cardiac arrest patients and was published last week in the Journal of the American Heart Association, 13 percent of victims who got CPR using chest compressions alone survived and were eventually discharged from a hospital.

But only 7.8 percent of those who got traditional CPR with rescue breathing were discharged, which wasn't much better than the 5.2 percent of people who received no CPR at all and eventually left the hospital.

The thinking is that rescuers who use traditional CPR waste valuable time — as much as half a minute — adjusting the head to set up an airway and then providing a breath or two before starting chest compressions.

Get the blood moving
The body probably already has enough oxygen in it when a person collapses, meaning breathing usually isn't the immediate concern. What's important is getting the blood moving again and supplying vital organs with oxygen until help arrives in the form of a defibrillator, which can be used to get the heart beating on its own again.

"You're looking to push oxygenated blood to the brain and to the heart," said Dr. George Bulloch, chief of the Kaiser Permanente Redwood City emergency department. "There is enough oxygen intrinsically built in that you can concentrate on just circulating it. You're just trying to buy time until EMS can get there and supply a shock."

The new heart association guidelines also recommend more aggressive chest compressions, including faster and deeper pushes on the sternum. Rescuers should do chest compressions at a rate of 100 per minute, and push a good 2 inches down.

If the rescuer is trained in CPR, he or she may still give mouth-to-mouth assistance, at a rate of two breaths after 30 chest compressions.

One of the other advantages of recommending chest compressions only for most bystanders is that it's easy for a 911 operator to talk someone through the simpler form of CPR.

"If you call 911 and they say bend down and push, that's a quick trick," Bulloch said. "It will be eminently easier to teach."

The new CPR Here are the American Heart Association's new guidelines for cardiopulmonary resuscitation: Before starting, shake the victim's shoulders and shout to see if he responds. If the victim is not breathing, yell for someone to call 911. If you're alone, call 911. Begin chest compressions. Push hard and fast on the center of the chest at a rate of at least 100 compressions a minute which happens to be the beat of the 1977 Bee Gees disco hit "Stayin' Alive". Push down on the chest at least 2 inches with each compression. Make sure you fully release the chest before beginning the next compression. If you have not been trained in CPR, continue chest compressions until help arrives. If you have been trained, after 30 chest compressions open an airway and begin mouth-to-mouth breathing. Give two breaths, then resume chest compressions. Continue sets of 30 chest compressions and two breaths until help arrives.

"This is a major change. If we can just get people to start the compressions, then we can look at saving a lot more lives."

2010 CPR Guidelines
How the American Heart Association's CPR Guidelines Have Changed for 2010

By Rod Brouhard, About.com Guide

Updated October 18, 2010

After a review of the available research published over a 5 year period, the American Heart Association released its 2010 CPR Guidelines. As expected, the focus for CPR is on good quality chest compressions. Here are the differences between the 2005 and the 2010 CPR Guidelines:

A-B-C is for babies; now it's C-A-B!
It used to be follow your ABC's: airway, breathing and chest compressions. Now, Compressions come first, only then do you focus on Airway and Breathing. The only exception to the rule will be newborn babies, but everyone else -- whether it's infant CPR, child CPR or adult CPR -- will get chest compressions before you worry about the airway.
Why did CPR change from A-B-C to C-A-B?
No more looking, listening and feeling.
The key to saving a cardiac arrest victim is action, not assessment. Call 911 the moment you realize the victim won't wake up and doesn't seem to be breathing right.
Trust your gut. If you have to hold your cheek over the victim's mouth and carefully try to detect a puff of air, it's a pretty good bet she's not breathing very well, if at all.
I have a secret to share: paramedics have been doing it this way for years. Rarely have I seen an EMT or a paramedic put her ear to a victim's nose and listen for air movement. We just get to work.
Push a little harder. How deep you should push on the chest has changed for adult CPR. It was 1 1/2 to 2 inches, but now the Heart Association wants you to push at least 2 inches deep on the chest.

Push a little faster. AHA changed the wording here, too. Instead of pushing on the chest at about 100 compressions per minute, AHA wants you to push at least 100 compressions per minute. At that rate, 30 compressions should take you 18 seconds.

Besides the changes under the 2010 CPR Guidelines, AHA continues to emphasize some important points:

Hands Only CPR. This is technically a change from the 2005 Guidelines, but AHA endorsed this form of CPR in 2008. The Heart Association still wants untrained lay rescuers to do Hands Only CPR on adult victims who collapse in front of them. My biggest problem with this campaign is what's left unsaid. What does AHA want untrained lay rescuers to do with all the other victims? In other words, what do you do with the victims that aren't adults or that didn't collapse right in front of you? AHA doesn't provide an answer, but I have a suggestion: Do Hands Only CPR, because doing something is always better than doing nothing.

Recognize sudden cardiac arrest. CPR is the only treatment for sudden cardiac arrest and AHA wants you to notice when it happens.

Don't stop pushing. Every interruption in chest compressions interrupts blood flow to the brain, which leads to brain death if the blood flow stops too long. It takes several chest compressions to get blood moving again. AHA wants you to keep pushing as long as you can. Push until the AED is in place and ready to analyze the heart. When it is time to do mouth to mouth, do it quick and get right back on the chest.

Source:

Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R, Samson RA, Kattwinkel J, Berg RA, Bhanji F, Cave DM, Jauch EC, Kudenchuk PJ, Neumar RW, Peberdy MA, Perlman JM, Sinz E, Travers AH, Berg MD, Billi JE, Eigel B, Hickey RW, Kleinman ME, Link MS, Morrison LJ, O’Connor RE, Shuster M, Callaway CW, Cucchiara B, Ferguson JD, Rea TD, Vanden Hoek TL. "Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care." Circulation. 2010;122(suppl 3):S640–S656.

Urinary Tract Infections

2010-10-07T09:37:00.000-07:00

The urinary tract is the body's filtering system for removal of liquid wastes. Because we have a shorter urinary tract, women are especially susceptible to bacteria that may invade the urinary tract and multiply -- resulting in infection known as a urinary tract infection, or UTI.

Although most UTIs are not serious, they can be a painful nuisance. Approximately 50 percent of all women will have at least one UTI in her lifetime with many women having several infections throughout their lifetime. Fortunately, these infections are easily treated with antibiotics. Some women are more prone to recurrent UTIs than others and for them it can be a frustrating battle.

What Causes Urinary Tract Infections?

The most common cause of UTIs are bacteria from the bowel that live on the skin near the rectum or in the vagina, which can spread and enter the urinary tract through the urethra. Once these bacteria enter the urethra, they travel upward, causing infection in the bladder and sometimes other parts of the urinary tract.

Sexual intercourse is a common cause of urinary tract infections because the female anatomy can make women more prone to urinary tract infections. During sexual activity, bacteria in the vaginal area are sometimes massaged into the urethra.

Women who change sexual partners or begin having sexual intercourse more frequently may experience bladder or urinary tract infections more often than women who are celibate or in monogamous relationships. Although it is rare, some women get a urinary tract infection every time they have sex.

Another cause of bladder infections or UTI is waiting too long to urinate. The bladder is a muscle that stretches to hold urine and contracts when the urine is released. Waiting too long past the time you first feel the need to urinate can cause the bladder to stretch beyond its capacity. Over time, this can weaken the bladder muscle. When the bladder is weakened, it may not empty completely and some urine is left in the bladder. This may increase the risk of urinary tract infections or bladder infections.

Other factors that also may increase a woman's risk of developing UTI include pregnancy, having urinary tract infections or bladder infections as a child, menopause, or diabetes.

What Are the Symptoms of Urinary Tract Infections?

Symptoms of UTI or bladder infection are not easy to miss and include a strong urge to urinate that cannot be delayed, which is followed by a sharp pain or burning sensation in the urethra when the urine is released. Most often very little urine is released and the urine that is released may be tinged with blood. The urge to urinate recurs quickly and soreness may occur in the lower abdomen, back, or sides.

This cycle may repeat itself frequently during the day or night--most people urinate about six times a day, when the need to urinate occurs more often a bladder infection should be suspected.

When bacteria enter the ureters and spread to the kidneys, symptoms such as back pain, chills, fever, nausea, and vomiting may occur, as well as the previous symptoms of lower urinary tract infection.

Proper diagnosis is vital since these symptoms also can be caused by other problems such as infections of the vagina or vulva. Only your physician can make the distinction and make a correct diagnosis.

How Is a Diagnosis of UTI Made?

The number of bacteria and white blood cells in a urine sample is the basis for diagnosing urinary tract infections. Urine is examined under a microscope and cultured in a substance that promotes the growth of bacteria. A pelvic exam also may be necessary.

Note: If you have recurrent UTIs and bladder infections, you may be interested in purchasing an at-home test for UTI, which is available over-the-counter (OTC) without a prescription. The test consists of a dipstick that changes color when you have a urinary tract infection. The test detects the presence of nitrite. Bacteria changes normal nitrates in the urine to nitrite. The test, which works best on first morning urine, is about 90% reliable.

What Is the Treatment for Urinary Tract Infections?

Antibiotics (medications that kill bacteria) are the usual treatment for bladder infections and other urinary tract infections. Seven to ten 10 of antibiotics is usually required, although some infections may require only a single dose of antibiotics.

It's important that all antibiotics are taken as prescribed. Antibiotics should not be discontinued before the full course of antibiotic treatment is complete. Symptoms may disappear soon after beginning antibiotic treatment. However, if antibiotics are stopped early, the infection may still be present and recur.

An additional urine test may be ordered about a week after completing treatment to be sure the infection is cured.

Tips for Preventing Urinary Tract Infections

The most important tip to prevent urinary tract infections, bladder infections, and kidney infections is to practice good personal hygiene. Always wipe from front to back after a bowel movement or urination, and wash the skin around and between the rectum and vagina daily. Washing before and after sexual intercourse also may decrease a woman's risk of UTI.
Drinking plenty of fluids (water) each day will help flush bacterium out of the urinary system.
Emptying the bladder as soon as the urge to urinate occurs also may help decrease the risk of bladder infection or UTI.
Urinating before and after sex can flush out any bacteria that may enter the urethra during sexual intercourse.
Vitamin C makes the urine acidic and helps to reduce the number of potentially harmful bacteria in the urinary tract system.
Wear only panties with a cotton crotch, which allows moisture to escape. Other materials can trap moisture and create a potential breeding ground for bacteria. Avoid thongs.
Cranberry juice is often said to reduce frequency of bladder infections, though it should not be considered an actual treatment. Cranberry supplements are available over-the-counter and many women find they work when an UTI has occurred; however, a physician's diagnosis is still necessary even if cranberry juice or related herbals reduce pain or symptoms.
If you experience frequent urinary tract infections changing sexual positions that cause less friction on the urethra may help. Some physicians prescribe an antibiotic to be taken immediately following sex for women who tend to have frequent UTIs.

Things to Remember...

Although urinary tract infections are common and distinctly painful, they usually are easy to treat once properly diagnosed and only last a few days. When treated promptly and properly, UTIs are rarely serious.

Source:

Urinary Tract Infection. Medline Plus. http://www.nlm.nih.gov/medlineplus/ency/article/000521.htm. Accessed 10/7/2010.

Sexual Health Conditions - Paraphilias

2010-07-09T08:59:00.000-07:00

Paraphilias are problems with controlling impulses that are characterized by recurrent and intense sexual fantasies, urges, and behaviors involving unusual objects, activities, or situations not considered sexually arousing to others. In addition, these objects, activities, or situations often are necessary for the person's sexual functioning. With a paraphilia, the individual's urges and behaviors cause significant distress and/or personal, social, or occupational dysfunction. Someone with a paraphilia may be referred to as "kinky" or "perverted," and these behaviors may have serious social and legal consequences.

What Behaviors Are Considered Paraphilias?

Exhibitionism ("Flashing")

Exhibitionism is characterized by intense, sexually arousing fantasies, urges, or behaviors involving exposure of the individual's genitals to an unsuspecting stranger. The individual with this problem, sometimes called a "flasher," feels a need to surprise, shock, or impress his victims. The condition usually is limited to the exposure, with no other harmful advances made, although "indecent exposure" is illegal. Actual sexual contact with the victim is rare. However, the person may masturbate while exposing himself or while fantasizing about exposing himself.

Fetishism

People with this problem have sexual urges associated with non-living objects. The person becomes sexually aroused by wearing or touching the object. For example, the object of a fetish could be an article of clothing, such as underwear, rubber clothing, women's shoes, women's underwear, or lingerie. The fetish may replace sexual activity with a partner or may be integrated into sexual activity with a willing partner. When the fetish becomes the sole object of sexual desire, sexual relationships often are avoided. A related disorder, called partialism, involves becoming sexually aroused by a body part, such as the feet, breasts, or buttocks.

Frotteurism

With this problem, the focus of the person's sexual urges is related to touching or rubbing his genitals against the body of a non-consenting, unfamiliar person. In most cases of frotteurism, a male rubs his genital area against a female, often in a crowded public location. This disorder also is a problem because the contact made with the other person is illegal.

Pedophilia

People with pedophilia have fantasies, urges, or behaviors that involve illegal sexual activity with a prepubescent child or children (generally age 13 years or younger). Pedophilic behavior includes undressing the child, encouraging the child to watch the abuser masturbate, touching or fondling the child's genitals and forcefully performing sexual acts on the child. Some pedophiles are sexually attracted to children only (exclusive pedophiles) and are not attracted to adults at all. Some pedophiles limit their activity to their own children or close relatives (incest), while others victimize other children. Predatory pedophiles may use force or threaten their victims if they disclose the abuse. Health care providers are legally bound to report such abuse of minors.

This activity constitutes rape and is a felony offense punishable by imprisonment.

What Behaviors Are Considered Paraphilias? continued...

Sexual Masochism

Individuals with this disorder use sexual fantasies, urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, or otherwise made to suffer in order to achieve sexual excitement and climax. These acts may be limited to verbal humiliation, or may involve being beaten, bound, or otherwise abused. Masochists may act out their fantasies on themselves -- such as cutting or piercing their skin, or burning themselves -- or may seek out a partner who enjoys inflicting pain or humiliation on others (sadist). Activities with a partner include bondage, spanking, and simulated rape.

Sadomasochistic fantasies and activities are not uncommon among consenting adults. In most of these cases, however, the humiliation and abuse are acted out in fantasy. The participants are aware that the behavior is a "game," and actual pain and injury is avoided.

A potentially dangerous, sometimes fatal, masochistic activity is autoerotic partial asphyxiation, in which a person uses ropes, nooses, or plastic bags to induce a state of asphyxia (interruption of breathing) at the point of orgasm. This is done to enhance orgasm, but accidental deaths sometimes occur.

Sexual Sadism

Individuals with this disorder have persistent fantasies in which sexual excitement results from inflicting psychological or physical suffering (including humiliation and terror) on a sexual partner. This disorder is different from minor acts of aggression in normal sexual activity; for example, rough sex. In some cases, sexual sadists are able to find willing partners to participate in the sadistic activities.

At its most extreme, sexual sadism involves illegal activities such as rape, torture, and even murder, in which case the death of the victim produces sexual excitement. It should be noted that while rape may be an expression of sexual sadism, the infliction of suffering is not the motive for most rapists, and the victim's pain generally does not increase the rapist's sexual excitement. Rather, rape involves a combination of sex and gaining power over the victim. These individuals need intensive psychiatric treatment and may be jailed for these activities.

Transvestism

Transvestism, or transvestic fetishism, refers to the practice by heterosexual males of dressing in female clothes to produce or enhance sexual arousal. The sexual arousal usually does not involve a real partner, but includes the fantasy that the individual is the female partner, as well. Some men wear only one special piece of female clothing, such as underwear, while others fully dress as female, including hair style and make-up. Cross-dressing as a transvestite is not a problem, unless it is necessary for the individual to become sexually aroused or experience sexual climax.

Voyeurism ("Peeping Tom")

This disorder involves achieving sexual arousal by observing an unsuspecting and non-consenting person who is undressing or unclothed, and/or engaged in sexual activity. This behavior may conclude with masturbation by the voyeur. The voyeur does not seek sexual contact with the person they are observing. Other names for this behavior are "peeping" or "peeping Tom."

How Common Are Paraphilias?

Most paraphilias are rare, and are more common among males than among females (about 20 to 1 of males to females). However, the reason for this disparity is not clearly understood. While several of these disorders are associated with aggressive behavior, others are not aggressive or harmful. Some paraphilias -- such as pedophilia, exhibitionism, voyeurism, sadism and frotteurism -- are criminal offenses.

Having paraphilic fantasies or behavior, however, does not always mean the person has a mental illness. The fantasies and behaviors can exist in less severe forms that are not dysfunctional in any way, do not impede the development of healthy relationships, do not harm the individual or others, and do not entail criminal offenses. They may be limited to fantasy during masturbation or intercourse with a partner.

What Causes Paraphilia?

It is not known for certain what causes paraphilia. Some experts believe it is caused by a childhood trauma, such as sexual abuse. Others suggest that objects or situations can become sexually arousing if they are frequently and repeatedly associated with a pleasurable sexual activity. In most cases, the individual with a paraphilia has difficulty developing personal and sexual relationships with others.

Many paraphilias begin during adolescence and continue into adulthood. The intensity and occurrence of the fantasies associated with paraphilia vary with the individual, and may decrease as the person ages.

How Is Paraphilia Treated?

Most cases of paraphilia are treated with counseling and therapy to help these people modify their behavior. Medications may help to decrease the compulsiveness associated with paraphilia, and reduce the number of deviant sexual fantasies and behaviors. In some cases, hormones are prescribed for individuals who experience frequent occurrences of abnormal or dangerous sexual behavior. Many of these medications work by reducing the individual's sex drive.

How Successful Is Treatment for Paraphilia?

To be most effective, treatment must be provided on a long-term basis. Unwillingness to comply with treatment can hinder its success. It is imperative that people with paraphilias of an illegal nature receive professional help before they harm others or create legal problems for themselves.

Reviewed by the doctors at The Cleveland Clinic Department of Psychiatry and Psychology.

http://www.webmd.com/sexual-conditions/paraphilias

Swine Flue

2009-05-21T10:27:00.000-07:00

WebMD Provides Answers to Your Questions About Swine Flu
By Miranda Hitti
WebMD Health News
Reviewed by Louise Chang, MD
The swine flu virus in the U.S. is the same one causing a deadly epidemic in Mexico. What is swine flu? What can we do about it? WebMD answers your questions.

• What is swine flu?
• What are swine flu symptoms?
• Who is at highest risk of H1N1 swine flu?
• If I think I have swine flu, what should I do?
• How does swine flu spread?
• How is swine flu treated?
• Is there a vaccine against the new swine flu virus?
• I had a flu vaccine this season. Am I protected against swine flu?
• How can I prevent swine flu infection?
• How long does the flu virus survive on surfaces?
• Can I still eat pork?
• What else should I be doing?
• How severe is swine flu?
• Why has the swine flu infection been deadlier in Mexico than in other countries?
• Have there been previous swine flu outbreaks?
• I was vaccinated against the 1976 swine flu virus. Am I still protected?
• How many people have swine flu?
• How serious is the public health threat of a swine flu epidemic?

What is swine flu?
Like people, pigs can get influenza (flu), but swine flu viruses aren't the same as human flu viruses. Swine flu doesn't often infect people, and the rare human cases that have occurred in the past have mainly affected people who had direct contact with pigs. But the current swine flu outbreak is different. It's caused by a new swine flu virus that has changed in ways that allow it to spread from person to person -- and it's happening among people who haven't had any contact with pigs.

What are swine flu symptoms?

Symptoms of swine flu are like regular flu symptoms and include fever, cough, sore throat, runny nose, body aches, headache, chills, and fatigue. Many people with swine flu have had diarrhea and vomiting. Nearly everyone with flu has at least two of these symptoms. But these symptoms can also be caused by many other conditions. That means that you and your doctor can't know, just based on your symptoms, if you've got swine flu. It takes a lab test to tell whether it's swine flu or some other condition.

Who is at highest risk from H1N1 swine flu?

Most U.S. cases of H1N1 swine flu have been in older children and young adults. It's not clear why, and it's not clear whether this will change.
But certain groups are at particularly high risk of severe disease or bad outcomes if they get the flu:
• Pregnant women
• Young children, especially those under 12 months of age
• People with heart disease or risk factors for heart disease
• People with HIV infection
• People with chronic diseases
• People taking immune suppressing drugs, such as cancer chemotherapy or anti-rejection drugs for transplants
People in these groups should seek medical care as soon as they get flu symptoms.

If I think I have swine flu, what should I do? When should I see my doctor?

If you have flu symptoms, stay home, and when you cough or sneeze, cover your mouth and nose with a tissue. Afterward, throw the tissue in the trash and wash your hands. That will help prevent your flu from spreading.
If you've got flu symptoms, and you live in or recently visited an area where H1N1 swine flu cases have been identified, CDC officials recommend that you see your doctor. If you have flu symptoms but you haven't been in a high-risk area, you can still see a doctor -- that's your call.
Keep in mind that your doctor will not be able to determine whether you have swine flu, but he or she may take a sample from you and send it to a state health department lab for testing to see if it's swine flu. If your doctor suspects swine flu, he or she would be able to write you a prescription for Tamiflu or Relenza. Those drugs aren't a question of life or death for the vast majority of people. Most U.S. swine flu patients have made a full recovery without antiviral drugs.
But there are emergency warning signs.
Children should be given urgent medical attention if they:
• Have fast breathing or trouble breathing
• Have bluish or gray skin color
• Are not drinking enough fluids
• Are not waking up or not interacting
• Are so irritable that the child does not want to be held
• Have flu-like symptoms that improve but then return with fever and a worse cough
• Have fever with a rash
Adults should seek urgent medical attention if they have:
• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting

How does swine flu spread? Is it airborne?

The new swine flu virus apparently spreads just like regular flu. You could pick up germs directly from an infected person, or by touching an object they recently touched, and then touching your eyes, mouth, or nose, delivering their germs for your own infection. That's why you should make washing your hands a habit, even when you're not ill. Infected people can start spreading flu germs up to a day before symptoms start, and for up to seven days after getting sick, according to the CDC.
The swine flu virus can become airborne if you cough or sneeze without covering your nose and mouth, sending germs into the air.
The U.S. residents infected with swine flu virus had no direct contact with pigs. The CDC says it's likely that the infections represent widely separated cycles of human-to-human infections.

How is swine flu treated?

The new swine flu virus is sensitive to the antiviral drugs Tamiflu and Relenza. The CDC recommends those drugs to prevent or treat swine flu; the drugs are most effective when taken within 48 hours of the start of flu symptoms. But not everyone needs those drugs; many of the first people in the U.S. with lab-confirmed swine flu recovered without treatment. The Department of Homeland Security has released 25% of its stockpile of Tamiflu and Relenza to states. Health officials have asked people not to hoard Tamiflu or Relenza.

Is there a vaccine against the new swine flu virus?

No. But the CDC and the World Health Organization are already taking the first steps toward making such a vaccine. That's a lengthy process -- it takes months.
I had a flu vaccine this season. Am I protected against swine flu?
No. This season's flu vaccine wasn't made with the new swine flu virus in mind; no one saw this virus coming ahead of time.
If you were vaccinated against flu last fall or winter, that vaccination will go a long way toward protecting you against certain human flu virus strains. But the new swine flu virus is a whole other problem.

How can I prevent swine flu infection?

The CDC recommends taking these steps:
• Wash your hands regularly with soap and water, especially after coughing or sneezing. Or use an alcohol-based hand cleaner.
• Avoid close contact with sick people.
• Avoid touching your mouth, nose, or eyes. That's not easy to do, so keep those hands clean.
• If you feel ill, stay home.
How long does the flu virus survive on surfaces?
Flu bugs can survive for hours on surfaces. One study showed that flu viruses can live for up to 48 hours on hard, nonporous surfaces such as stainless steel and for up to 12 hours on cloth and tissues. The virus seems to survive only for minutes on your hands -- but that's plenty of time for you to transfer it to your mouth, nose, or eyes.
Can I still eat pork?
Yes. You can't get swine flu by eating pork, bacon, or other foods that come from pigs.

What else should I be doing?

Keep informed of what's going on in your community. Your state and local health departments may have important information if swine flu develops in your area. For instance, parents might want to consider what they would do if their child's school temporarily closed because of flu. Don't panic, but a little planning wouldn't hurt.

How severe is swine flu?

The severity of cases in the current swine flu outbreak has varied widely, from mild cases to fatalities. Early cases in the U.S. were mild, but there has been at least one U.S. death from swine flu. And it's impossible to know whether the virus will change, either becoming more or less dangerous. Scientists are watching closely to see which way the new swine flu virus is heading -- but health experts warn that flu viruses are notoriously hard to predict, as far as how and when they'll change.
But there's a lot of planning you can do. CDC officials predict that just about every U.S. community will have H1N1 swine flu cases. It's possible some schools in your community may temporarily close. So make contingency plans just in case you are affected.

Why has the swine flu infection been more severe in Mexico than in other countries?

That's not clear yet. Researchers around the world are investigating the differences between the cases in Mexico and those elsewhere.

Have there been previous swine flu oubtreaks?

Yes. There was a swine flu outbreak at Fort Dix, N.J., in 1976 among military recruits. It lasted about a month and then went away as mysteriously as it appeared. As many as 240 people were infected; one died.
The swine flu that spread at Fort Dix was the H1N1 strain. That's the same flu strain that caused the disastrous flu pandemic of 1918-1919, resulting in tens of millions of deaths.
Concern that a new H1N1 pandemic might return in winter 1976 led to a crash program to create a vaccine and vaccinate all Americans against swine flu. That vaccine program ran into all kinds of problems -- not the least of which was public perception that the vaccine caused excessive rates of dangerous reactions. After more than 40 million people were vaccinated, the effort was abandoned.
As it turned out, there was no swine flu epidemic.
Even though it's an H1N1 type A flu bug, the new swine flu is a different virus than the ones that emerged in 1918 and in 1976.

I was vaccinated against the 1976 swine flu virus. Am I still protected?

Probably not. The new swine flu virus is different from the 1976 virus. And it's not clear whether a vaccine given more than 30 years ago would still be effective.

How many people have swine flu?

That's a hard question to answer because the figure is changing so quickly. If you want to keep track of U.S. cases that have been confirmed by lab tests and reported to the CDC, check the CDC's web site. If you're looking for cases in other countries, visit the World Health Organization's web site. And when you hear about large numbers of people who are ill, remember that lab tests may not yet have been done to confirm that they have swine flu. And there may be a little lag time before confirmed cases make it into the official tally.

How serious is the public health threat of a swine flu epidemic?

The U.S. government has declared swine flu to be a public health emergency.
It remains to be seen how severe swine flu will be in the U.S. and elsewhere, but countries worldwide are monitoring the situation closely and preparing for the possibility of a pandemic.
The World Health Organization has not declared swine flu to be a pandemic. The WHO wants to learn more about the virus first and see how severe it is and how deeply it takes root.
But it takes more than a new virus spreading among humans to make a pandemic. The virus has to be able to spread efficiently from one person to another, and transmission has to be sustained over time. In addition, the virus has to spread geographically.
How serious is the public health threat of a swine flu epidemic? continued...
The H1N1 swine flu outbreak comes at the end of the U.S. flu season. The virus has spread across the nation. Nobody knows whether it will stick around all summer or whether it will get worse when flu season begins again this fall.
Scientists are closely watching the Southern Hemisphere to see whether the H1N1 swine flu begins to circulate there. If it does, it will be important to see whether the virus changes over time, and whether it spreads more efficiently in the winter months.

WebMD senior writer Daniel J. DeNoon contributed to this report.

Coronary bypass surgery

2008-09-22T01:53:00.000-07:00

This article is requested by Mr. Ayoub Motaeri Nejad.

Definition
Coronary bypass surgery is a procedure to allow blood to flow to your heart muscle despite blocked arteries. Coronary bypass surgery uses a healthy blood vessel taken from your leg, arm, chest or abdomen and connects it to the other arteries in your heart so that blood is bypassed around the diseased or blocked area. After a coronary bypass surgery, normal blood flow is restored. Coronary bypass surgery is just one option to treat heart disease.

Just like all the other organs in your body, your heart needs blood and oxygen to do its job. Coronary arteries snake across the surface of your heart, delivering a constant supply of blood and oxygen to the heart muscle. When one or more of these arteries become narrowed or blocked, blood and oxygen are reduced and heart muscle is damaged. Coronary bypass surgery can minimize this damage.

Why it's done
If lifestyle changes and medication haven't relieved your heart disease symptoms of angina, or if you have life-threatening blockages, you and your doctor will need to consider whether coronary bypass surgery or another artery-opening procedure such as angioplasty or stenting is right for you.
Coronary bypass surgery is an option if:
You have severe chest pain caused by narrowing of several of the arteries that supply your heart muscle, leaving the muscle short of blood during even light exercise or at rest. Sometimes angioplasty and stenting will bring relief in this situation, but for some types of blockages, coronary bypass surgery may be the best option.
You have more than one diseased coronary artery and the heart's main pump — the left ventricle — is not functioning well.
Your left main coronary artery is severely narrowed or blocked. This artery supplies most of the blood to the left ventricle.
You have an artery blockage for which angioplasty isn't appropriate, you've had a previous angioplasty or stent placement that hasn't been successful, or you've had stent placement but the artery has narrowed again (restenosis), then your doctor may recommend coronary artery bypass surgery.
Coronary bypass surgery doesn't cure the underlying heart disease that caused blockages in the first place. This disease is referred to as atherosclerosis or coronary artery disease. Even if you have coronary bypass surgery, lifestyle changes are still a necessary part of treatment after surgery. Medications are routine after coronary bypass surgery to lower your blood cholesterol, reduce the risk of developing a blood clot and help your heart function as well as possible.

Risks
Although they rarely occur, the most common complications of coronary bypass surgery are:
1. Bleeding
2. Heart rhythm irregularities (arrhythmias)
3. Kidney failure
4. Infections of the chest wound
5. Memory loss or troubles with thinking clearly, which often go away within six to 12 months
6. Stroke
Your risk of developing these complications depends on your health before the surgery. Talk to your doctor to get a better idea of the likelihood of experiencing these risks.
If you're having a scheduled coronary bypass surgery, your risk of death is usually low, but still depends on your overall health. The risk is higher if the operation is done as an emergency or if you have other significant medical conditions such as emphysema, kidney disease, diabetes or peripheral vascular disease.

How you prepare
To prepare for coronary bypass surgery, your doctor will give you specific instructions about any activity restrictions and changes in your diet or medications you should follow before surgery. You'll need several presurgical tests, often including chest X-rays, blood tests, an electrocardiogram and a coronary angiogram, which is a special type of X-ray procedure that uses dye to visualize the arteries that feed your heart. Most people are admitted to the hospital the morning of the day of surgery.
Be sure to make arrangements for the weeks following your surgery. It will take about four to six weeks for you to recover to the point when you can resume driving, going to work and performing daily chores.

What you can expect
During the procedureCoronary bypass surgery generally takes between three and six hours and requires general anesthesia. On average, surgeons repair two to four coronary arteries. The number of bypasses required depends on the location and severity of blockages in your heart.
Most coronary bypass surgeries are done through a large incision in the chest while blood flow is diverted through a heart-lung machine (called on-pump coronary bypass surgery).
The surgeon makes an incision down the center of the chest, along the breastbone. The rib cage is spread open to expose the heart. After the chest is opened, the heart is temporarily stopped and a heart-lung machine takes over blood circulation to the body.
The surgeon takes a section of healthy blood vessel, often from inside the chest wall (the internal mammary artery) or from the lower leg, and attaches the ends above and below the blocked artery so that blood flow is diverted (bypassed) around the narrowed portion of the diseased artery.
There are other methods your surgeon may use if you're having coronary bypass surgery:
1. Off-pump or beating-heart surgery. This procedure allows surgery to be done on the still-beating heart using special equipment to stabilize or quiet the area of the heart the surgeon is working on. This type of surgery is challenging because the heart is still moving. Because of this, it's not an option for everyone. The long-term outcome of this type of procedure is not yet known, and there have been no proven benefits of this technique over standard coronary bypass using the heart-lung machine in the average patient.
2. Minimally invasive surgery. In this procedure, a surgeon performs coronary bypass through a smaller incision in the chest, often with the use of robotics and video imaging that help the surgeon operate in a small area. Variations of minimally invasive surgery may be called port-access or keyhole surgery.
Once you're anesthetized, a breathing tube is inserted through your mouth. This tube attaches to a ventilator, which breathes for you during and immediately after the surgery.
After the procedureCoronary bypass surgery is a major operation. Expect to spend a day or two in the intensive care unit after coronary bypass surgery. Here, your heart, blood pressure, breathing and other vital signs will be continuously monitored. Your breathing tube will remain in your throat for a few hours after surgery, so you won't be able to speak. You can communicate with hand gestures and notes. The breathing tube will be removed as soon as you are awake and able to breathe on your own.
Barring any complications, you'll likely be discharged from the hospital within a week, although even after you've been released, you may find it difficult to perform everyday tasks, or even walk a short distance. If, after returning home, you experience any of the following signs or symptoms, call your doctor. They could be warning signs that your chest wound is infected:
1. A fever higher than 100.4 F (38 C)
2. Rapid heart rate
3. New or worsened pain around your chest wound
4. Reddening, bleeding, or other discharge from your chest wound
Expect a recovery period of about six to 12 weeks. In most cases, you can return to work, begin exercising, and resume sexual activity after six weeks, but make sure you have your doctor's OK before doing so.

Results
After surgery, most people have improvement or complete relief of their symptoms and remain symptom-free for as long as 10 to 15 years. Over time, however, it's likely that other arteries or even the new graft used in the bypass will become clogged, requiring another bypass or angioplasty.
Although bypass surgery improves blood supply to the heart, it doesn't cure underlying coronary artery disease. Your results and long-term outcome will depend in part on following healthy lifestyle recommendations and taking your medication as directed. Healthy lifestyle recommendations include:
1. Stop smoking.
2. Follow a healthy-eating plan, such as the DASH diet.
3. Reduce cholesterol levels.
4. Maintain a healthy weight.
5. Control blood pressure.
6. Manage diabetes.
7. Exercise.

Ref: Mayo clinic

The Outcome of Anorexia Nervosa in the 20th Century

2008-09-14T10:19:00.000-07:00

Review and Overview by Hans-Christoph Steinhausen, M.D., Ph.D

http://ajp.psychiatryonline.org/

Abstract

OBJECTIVE: The present review addresses the outcome of anorexia nervosa and whether it changed over the second half of the 20th century. METHOD: A total of 119 study series covering 5,590 patients suffering from anorexia nervosa that were published in the English and German literature were analyzed with regard to mortality, global outcome, and other psychiatric disorders at follow-up. RESULTS: There were large variations in the outcome parameters across studies. Mortality estimated on the basis of both crude and standardized rates was significantly high. Among the surviving patients, less than one-half recovered on average, whereas one-third improved, and 20% remained chronically ill. The normalization of the core symptoms, involving weight, menstruation, and eating behaviors, was slightly better when each symptom was analyzed in isolation. The presence of other psychiatric disorders at follow-up was very common. Longer duration of follow-up and, less strongly, younger age at onset of illness were associated with better outcome. There was no convincing evidence that the outcome of anorexia nervosa improved over the second half of the last century. Several prognostic features were isolated, but there is conflicting evidence. Most clearly, vomiting, bulimia, and purgative abuse, chronicity of illness, and obsessive-compulsive personality symptoms are unfavorable prognostic features. CONCLUSIONS: Anorexia nervosa did not lose its relatively poor prognosis in the 20th century. Advances in etiology and treatment may improve the course of patients with anorexia nervosa in the future.

Introduction
Anorexia nervosa received its present name only in the late 19th century (1). In the 20th century, critical analyses of epidemiological data showed that a true increase in the incidence and prevalence rates of anorexia nervosa over time was questionable (2, 3). Currently, the etiology of anorexia nervosa is not fully understood, with present models emphasizing its multifactorial origin, coupled with multiple determinants and risk factors and their interactions within a developmental framework (3).
Treatment of anorexia nervosa shifted in the second half of the 20th century from a purely medical approach that included reliance on neuroleptics in the 1950s and 1960s to a strong emphasis on individual psychotherapy (4), taking into account both a developmental and a biological framework (5) and the need for a multifaceted treatment approach (6). Later, both behavioral and cognitive interventions were added to treatment programs (7). In younger patients, the inclusion of family therapy has been advocated since the 1970s (3, 8). At the end of the 20th century, medications played a role in the treatment of some patients with anorexia nervosa, but they have been rarely used as the exclusive mode of intervention (9).
Selection criteria for the inclusion of studies in the present review were the following: 1) the study contained data on at least one of 15 outcome measures, and/or 2) the study contained data on any prognostic factor. Previous reviews of the outcome of anorexia nervosa by my associates and myself covered 45 studies (with 46 series of patients) published between 1953 and 1989 (10–56) and 23 additional follow-up studies (with 24 series of patients) published between 1981 and 1989 (57–80). Furthermore, Fichter and Quadflieg (81) discussed 22 additional series of anorectic patients (82–99; unpublished 1991 paper presented by Halmi). In addition to these three reviews, and based on a systematic search with PUBMED, I identified an additional 27 series of patients in outcome studies published between 1993 and 1999 (100–125). Thus, a total of 119 patient outcome series on anorexia nervosa were suitable for the present analysis. A preliminary and descriptive report on 108 patient outcome series published before 1996 (126) was used as a starting point for the present analysis. In addition to the 119 outcome series, there were five studies (127–131) that contained only data on prognostic factors suitable for the present review.

Study Characteristics

The 119 outcome series were composed of 5,590 patients (group size: mean=47.0, SD=30.8, range=6–151). There were considerable differences among the studies in design, group size, and methods. Few studies were prospectively organized. There was only one study based exclusively on male patients (65). Diagnostic categories changed considerably over the period of the studies, with virtually no official criteria existing at the time of the first study, to the appearance of the first research criteria, by Feighner et al. (132), and ending with more recent criteria offered by DSM-III, DSM-III-R, DSM-IV, and ICD-10.
Because of the global descriptions of age at onset in the studies, precise age parameters could not be computed. For the present review, the following two age groups were formed: 1) patient series containing only younger adolescent patients, i.e., no older than 17 years at illness onset (N=37), and 2) series containing both younger and older patients, i.e., adolescents and adults (N=82).
Duration of follow-up was also quite difficult to compute from the original studies. Besides missing data, this problem was due to variations in the definition of the starting point or to the general practice of providing only ranges instead of precise group parameters. Similarly, data on the follow-up period, which ranged from less than 1 year to a maximum of 29 years, did not allow a more precise calculation of group parameters. Almost all groups were characterized by a marked heterogeneity regarding the duration of follow-up. Thus, the present review classified not the mean but the entire range of follow-up duration for arrangement of the studies into the following groups: 1) 20 series with follow-up after less than 4 years, 2) 45 series with follow-up from 4 to 10 years later, 3) seven series with follow-up after more than 10 years to 20 years, 4) four series with follow-up after more than 20 years, and 5) 42 series with variable follow-up periods that did not fit into the other group). Because of low frequencies, groups 3 and 4 had to be collapsed for data analysis; because of the heterogeneity of data, group 5 was excluded from the analyses on the impact of duration of follow-up. There was one study with no clear description of the length of follow-up.
There were a general lack of control conditions and a scarcity of precise information on treatment in these studies. Different treatment and psychotherapeutic approaches were used. The diversity of interventions precluded any definite evaluation of treatment effects.

Outcome Measures

The majority of outcome studies on anorexia nervosa reported crude mortality rates; a small number of studies presented standard mortality ratios. The crude mortality rates may have been slightly inflated; not all studies reported the cause of death, so causes other than the eating disorder might have led to subject death. In the surviving patients, outcome was most frequently described as one or more of the following three categories: 1) global, 2) normalization of the core symptom characteristics of anorexia nervosa, i.e., involving weight, menstruation, and eating behavior, and 3) psychiatric diagnoses other than eating disorders.
The most common scheme of global outcome classification in anorexia nervosa was the trichotomy between good, fair, and poor outcome. Although the studies varied regarding criteria, there was a general agreement that a good outcome stands for recovery from all essential clinical symptoms of anorexia nervosa, whereas a fair outcome represents improvement with some residual symptoms, and a poor outcome is synonymous with chronicity of the disorder. A substantial number of studies used the criteria of Morgan and Russell (37), whereas other studies used more idiosyncratic definitions or did not report data for all three categories. The sum of the three categories did not necessarily round up to precisely 100%. In the present analysis, all reported data were included in calculations of the basic findings across studies. The original data that included mortality as a fourth outcome criterion in calculations of outcome percentages were adjusted into a three-category outcome, with mortality as a separate criterion. Thus, the potential inflation of crude mortality rates and the nonreported causes of death in some studies did not affect the outcome rates in the surviving patients.
In a substantial number of studies, psychiatric diagnoses in addition to eating disorders were mentioned. However, with the wide span of the dates of publication, a certain variation of criteria in the clinical assessment of psychiatric disorders other than the eating disorders needed to be accepted. The following eight psychiatric diagnoses were extracted from the outcome studies: 1) a broad category of affective disorders, 2) other neurotic disorders, including unspecified anxiety disorders and phobias, 3) obsessive-compulsive disorders, 4) schizophrenia, 5) histrionic personality disorder, 6) unspecified personality disorders, including borderline states, 7) obsessive-compulsive personality disorder, and 8) substance abuse disorders.

Statistical Analyses

A total of 15 outcome variables were calculated in percentages that were rounded to the nearest whole. In order to take into account the large variation of group sizes, weighted percentages were calculated by weighting each reported rate with the size of the study group. With the help of SPSS (SPSS, Chicago), data for all studies were converted into individual data for performance of statistical analyses. The following variables that may have influenced outcome were used in analyses of variance (ANOVAs): 1) dropout rate, 2) duration of follow-up, 3) age at illness onset, and 4) period effects. The ANOVAs were supplemented by post hoc comparisons and calculations of effect sizes by computing the percentage of variance (sum of squares between the groups divided by the total), according to the procedure introduced by Cohen (133). According to Cohen, 1.0%–5.9% variance is small, 6.0%–13.9% is medium, and >14.0% is large.

Results
Effects of Dropout Rates
In a large number of studies, conclusions were jeopardized by a relatively high dropout rate at follow-up. The mean dropout rate for the 105 patient series with some relevant information was 12.3% (SD=14.7, range=0–77). An analysis of dropout effects revealed an inconsistent pattern, with no clear indication that studies with high dropout rates tended to have better results because of nonparticipating patients with poor outcomes (data available on request).

Mortality and Global Outcome

Two important issues were considered. First, the sizes of the patient groups differed significantly for the various outcome measures, because not all variables were assessed in all studies. Second, for each measure, there were rather wide standard deviations with extreme ranges across the studies, so that the means reflected only a central trend.
The mean crude mortality rate was 5.0% (Table 1). In the surviving patients, on average, full recovery was found in only 46.9% of the patients, while 33.5% improved, and 20.8% developed a chronic course of the disorder. Outcome was slightly better for the core symptoms, with normalization of weight occurring in 59.6% of the patients, normalization of menstruation in 57.0%, and normalization of eating behavior in 46.8%. However, these slightly higher rates of normalization of the core symptoms, compared to the global outcome rating, may be largely due to the smaller total group sizes. Nevertheless, this gap remained, even after adaptation for group size (when only the studies that reported both global outcome ratings and normalization of the core symptoms were considered).

Other Psychiatric Disorders

The findings presented in Table 1 show that at follow-up a large proportion of anorectic patients suffered from additional psychiatric disorders. Frequent diagnoses at follow-up were neurotic disorders, including anxiety disorders and phobias, affective disorders, substance use disorders, obsessive-compulsive disorder (OCD), and unspecified personality disorders, including borderline states. A few studies reported a high rate of obsessive-compulsive personality disorder and a less pronounced rate of histrionic personality disorder. Schizophrenia was only rarely observed at follow-up.

Effect Variables

It was possible to control for three major factors that might have affected outcome. Their influence is reported only for mortality and the global outcome of the eating disorder in order to avoid conclusions that might be biased due to incomplete data or a markedly smaller group size for other outcome variables. Furthermore, only 61 studies that reported three global outcome categories (recovery, improvement, and chronicity) were considered for these analyses.
The first factor tested was duration of follow-up. Findings are shown in Table 2. All four outcome parameters were significantly affected by duration of follow-up, and all four effect sizes were large. With increasing duration of follow-up, mortality rates also increased. In the surviving patients, there was a strong tendency toward recovery with increasing duration of follow-up. The rate of recovery increased, while the rates of improvement and chronicity declined. With the exception of the test on improvement rates in groups 1 and 2, all post hoc tests indicated that group differences were significant. Given the significance of the follow-up duration, this variable was controlled in two-way ANOVAs in the additional analyses on the impact of age at onset of illness and the effects of period.

When I compared the group of patients with adolescent onset and the group with a much wider age range at onset of illness, there was a significantly lower mortality rate in the group with the younger patients, as shown in Table 3. The rates of recovery, improvement, and chro

nicity were more favorable in the group with the younger patients. However, in each instance, in addition to duration of follow-up, the interactions between duration of follow-up and each outcome variable were significant, as shown in Fig ure 1.

The interaction effects showed that the differences between the subgroups with different onsets of illness were wider or narrower or even inverted for the four outcome measures, depending on the duration of follow-up. A comparison of the two effect sizes, as shown in Table 3, indicates that the effect of age at onset was stronger for mortality, whereas the effect of duration of follow-up was stronger for recovery, improvement, and chronicity.

The third effect tested was a potential period effect or time trend. The studies were divided into large groups, as follows: 1) studies from 1950 to 1979, 2) studies from 1980 to 1989, and 3) studies from 1990 to 1999. Mortality showed a complex pattern associated with time trends (Table 4). It was absent both for very short and very extended study courses in the early studies (with only one study each), from 1950 through 1979, whereas it increased linearly in the studies from 1980 to 1989 and from 1990 to 1999, with the highest rate for the most extended studies reported for 1980–1989.

There were few differences between the studies for 1980–1989 and the studies for 1990–1999 on the other outcome measures—recovery, improvement, and chronicity—whereas the studies from 1950 to 1979 primarily stood out because of high recovery rates and low rates of improvement and chronicity during short-term courses For all four outcome measures, the effect sizes for duration of follow-up were markedly stronger than for time period.

Prognostic Factors

Knowledge of the identified prognostic factors for anorexia nervosa is summarized in Table 5. First, the findings were considerably heterogeneous for the majority of the prognostic factors. Most clearly, this interpretation applies to the ambiguous findings regarding age at onset of illness. Furthermore, most studies indicated that a short duration of symptoms before treatment resulted in a favorable outcome. The impact of the duration of inpatient treatment is unclear because of ambiguous findings across the outcome studies. Similarly, no definite conclusions could be drawn as to whether greater weight loss at presentation had long-term effects on outcome.

Although hyperactivity and dieting as weight-reduction measures did not have any prognostic significance, it is quite clear that vomiting, bulimia, and purgative abuse imply an unfavorable prognosis. A few studies also showed that premorbid developmental and clinical abnormalities, including eating disorders during childhood, carry the risk for a poor outcome of anorexia nervosa. In contrast, a good parent-child relationship may protect the patient from a poor outcome.
In addition, the data clearly show that chronicity leads to poor outcome, a finding that implies that there are cases of anorexia nervosa in which treatment is refractory. A substantial number of studies provided evidence that the features of histrionic personality disorder indicate a favorable outcome. In contrast to comorbid OCD, which has no effect on outcome (118), the features of coexisting obsessive-compulsive personality or compulsivity add to chronicity. Finally, no definite conclusions can be drawn from the outcome studies as to the relevance of socioeconomic status.

Discussion

Besides use of a more extended database than in previous reviews, the present review on the outcome of anorexia nervosa is the first to my knowledge that was not confined to descriptive statistics only. For the first time an attempt was made to analyze trends by use of inferential statistics in order to isolate factors that might have influenced the course of anorexia nervosa in the last century. Findings based on this large group of 5,590 patients contained in a large number of studies indicate that despite wide variations of all outcome parameters across studies, anorexia nervosa remains a mental illness with a serious course and outcome in many of the affected individuals. This conclusion is based on various parameters analyzed in the present review.
First, crude mortality rates were high and increased significantly with length of follow-up. Even stronger evidence comes from a series of studies that calculated standard mortality rates. A review of the standard mortality rate in 10 cohort studies (134) found standard mortality rates between 1.36 and 17.80, indicating a slight to an almost 18-fold increase in mortality in patients with anorexia nervosa, with a maximal standard mortality rate of 30 for female patients in the first year after presentation and a statistically significant increase for up to 15 years after presentation. The data suggest that there are more deaths from suicide and other and unknown causes and fewer deaths related to the eating disorder than have been previously reported.
Second, less than a half of the patients, or exactly 46%, fully recovered from anorexia nervosa, whereas a third improved with only partial or residual features of anorexia nervosa, and 20% remained chronically ill over the long term. This relatively poor global outcome is slightly obscured if one looks in isolation at the better outcome of the core symptoms of weight restoration (60%) and normalization of both menstruation (57%) and eating behavior (47%).
A third outcome indicator of the seriousness of the course of anorexia nervosa—namely, other psychiatric disorders—shows that exactly one-quarter of the anorexia nervosa patients had anxiety disorders and one-quarter had affective disorders. Substance use disorders, OCD, and obsessive-compulsive personality disorder were very common diagnoses at outcome. Furthermore, there was evidence that some of these comorbidities—that is, depression, anxiety disorder, phobias, and personality disorders—served as risk factors contributing to a less favorable outcome of anorexia nervosa (78, 94, 105, 106). However, so far, little is known about the comorbidity of these various psychiatric disorders among each other, their true coexistence with anorexia nervosa, and the sequential patterns across time. The two parameters of global outcome and other psychiatric disorders overlap greatly, so that at follow-up, more than 50% of the anorexia nervosa patients showed either a complete or a partial eating disorder in combination with another psychiatric disorder or another psychiatric disorder without an eating disorder. However, an exact figure could not be obtained from the present data set.
There are two main factors mitigating the problematic outcome of anorexia nervosa, namely, duration of follow-up and age at onset of the disorder. In contrast to the strong effect of the increasing crude mortality rate, the global outcome in the surviving patients clearly improves with increasing duration of follow-up. The data indicate with strong effect sizes that with increasing duration of follow-up, the illness course improved linearly if the patient survived. Thus, it is recommended that clinicians follow up with patients for extended periods.
Onset of the disorder during adolescence was associated with a lower mortality rate and a strong effect size that was clearly more important than the duration of follow-up. This finding simply reflects the probabilistic event that more deaths are to be expected with increasing age. Although the other three general outcome measures were affected by age at onset, indicating that younger age at onset was associated with better outcome, the duration of follow-up was a more influential factor. However, two limitations of the analyses have to be taken into consideration. First, the group with variable age at onset was not the most suitable contrast to the group with adolescent onset because of the wide variation in age. A group of patients with adult onset only would be more appropriate for comparison. However, such a contrasting group was not available for study. Second, it must also be kept in mind that onset of anorexia nervosa before puberty has a very poor outcome (135).
Trends over five decades of outcome research are less clear. The early studies, from 1950 to 1979, provided evidence for lower mortality during long-term follow-up (>10 years) and higher recovery rates with short-term follow-up which were introduced in 1975. Accordingly, the reliability of outcome measurement in the early studies may be questionable. With these caveats and the relatively small effect sizes in mind, there was only limited evidence that the outcome of anorexia nervosa has improved significantly across these five decades.
Research on the outcome of anorexia nervosa has also analyzed a large list of prognostic factors and produced both conflicting and clear evidence of their significance. There is clear and almost unanimous evidence from a sizable number of studies that vomiting, bulimia and purgative abuse, chronicity, and features of obsessive-compulsive personality represent unfavorable prognostic factors, whereas hysterical personality features represent the only favorable prognostic factors that have not been documented with conflicting evidence. The favorable functions of many other prognostic factors are obscured by the fact that besides some positive evidence, there are also a sizable number of studies that found these factors to be of no significance. These factors include early age at onset, short duration of symptoms before treatment, short duration of inpatient treatment, good parent-child relationship, and high socioeconomic status. Similarly, there was no clear evidence that major weight loss and premorbid abnormalities serve as unfavorable factors. Both the variability in findings on prognostic factors and the likely nature of the data preclude any delineation of rules as to individual prognosis in a patient suffering from anorexia nervosa.
So far, one of the major questions of developmental psychopathology as to the continuity and discontinuity of psychiatric disorder has received little attention in studies on the course of anorexia nervosa. Most of the studies have concentrated on outcome, leaving aside the process of course. Study of the latter requires prospective designs that have emerged only in the recent past. Some of these more recent studies have analyzed time trends of certain features of anorexia nervosa based on the survival-analysis model (116, 131, 136). Finally, the descriptive nature of data on treatment, the lack of rigorous evaluation of interventions in the majority of outcome studies, and the scarcity of randomized intervention studies with sufficient evaluation of outcome do not allow any definite statement as to the role and function of treatment for long-term course.

Footnotes

Received May 18, 2001; revision received Oct. 30, 2001; accepted Jan. 28, 2002. From the Department of Child and Adolescent Psychiatry, University of Zurich. Address reprint requests to Dr. Steinhausen, Department of Child and Adolescent Psychiatry, University of Zurich, Neumünsterallee 9, Postfach, CH-8032 Zurich, Switzerland; steinh@kjpd.unizh.ch '//-->(e-mail). The author thanks C. Winkler Metzke for assistance with data analysis.

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Lymphedema

2008-09-13T10:33:00.000-07:00

Definition
Lymphedema refers to swelling that occurs most often in your arms or legs. It may affect just one arm or leg, but sometimes lymphedema can involve both arms or both legs.
The swelling occurs when a blockage in your lymphatic system prevents the lymph fluid in your arm or leg from draining adequately. As the fluid accumulates, the swelling continues.
No cure for lymphedema exists. But lymphedema can be controlled. Controlling lymphedema involves diligent care of your affected limb.

Symptoms
Lymphedema is a type of abnormal swelling of an arm or leg. Swelling ranges from mild, hardly noticeable changes in the size of your limb to extreme swelling that can make it impossible to use the affected arm or leg.
Lymphedema symptoms include:
1. Swelling of part of your arm or your entire arm or leg, including your fingers or toes
2. A feeling of heaviness or tightness in your arm or leg
3. Restricted range of motion in your arm or leg
4. Aching or discomfort in your arm or leg
5. Recurring infections in your affected limb
6. Hardening and thickening of the skin on your arm or leg

Causes
Your lymphatic system is crucial to keeping your body healthy. It circulates protein-rich lymph fluid throughout your body, collecting bacteria, viruses and waste products. Your lymphatic system carries these through your lymph vessels, which lead to lymph nodes. The wastes are then filtered out by lymphocytes — infection-fighting cells that live in your lymph nodes — and ultimately flushed from your body.
Lymphedema occurs when your lymph vessels are unable to adequately drain lymph fluid from your arm or leg. Lymphedema can be either primary or secondary. This means it can occur on its own (primary lymphedema) or it can be caused by another disease or condition (secondary lymphedema).

Causes of primary lymphedema

Primary lymphedema is a rare, inherited condition caused by problems with the development of lymph vessels in your body. Primary lymphedema occurs most frequently in women and usually affects the legs, rather than the arms. Specific causes of primary lymphedema include:
Milroy disease (congenital lymphedema). This is an inherited disorder that begins in infancy and causes a malformation of your lymph nodes, leading to lymphedema.
Meige disease (lymphedema praecox). This hereditary disorder causes lymphedema in childhood or around puberty. It causes your lymph vessels to form without the valves that keep lymph fluid from flowing backwards, making it difficult for your body to properly drain the lymph fluid from your limbs.
Late-onset lymphedema (lymphedema tarda). This occurs rarely and usually begins after age 35.

Causes of secondary lymphedema

Any condition or procedure that damages your lymph nodes or lymph vessels can cause lymphedema. Causes include:
1. Surgery can cause lymphedema to develop if your lymph nodes and lymph vessels are removed or severed. For instance, surgery for breast cancer may include the removal of one or more lymph nodes in your armpit to look for evidence that cancer has spread. If your remaining lymph nodes and lymph vessels can't compensate for those that have been removed, lymphedema may result in your arm.
2. Radiation treatment for cancer can cause scarring and inflammation of your lymph nodes or lymph vessels, restricting flow of the lymph.
Cancer cells can cause lymphedema if they block lymphatic vessels. For instance, a tumor growing near a lymph node or lymph vessel could become large enough to obstruct the flow of the lymph fluid.
3. Infection can infiltrate your lymph vessels and lymph nodes, restricting the flow of lymph fluid and causing lymphedema. Parasites also can block lymph vessels. Infection-related lymphedema is most common in tropical and subtropical regions of the globe and is more likely to occur in undeveloped countries.
4. Injury that damages your lymph nodes or lymph vessels also can cause lymphedema.

When to seek medical advice
Make an appointment with your doctor if you notice any persistent swelling in your arms, legs or lymph nodes.

Tests and diagnosis
Your doctor may try to rule out other causes of swelling in order to arrive at a diagnosis of lymphedema. Swelling can have many causes, including a blood clot or an infection that doesn't involve your lymph nodes.
If you're at risk of lymphedema — for instance, if you've recently had cancer surgery involving your lymph nodes — your doctor may assume you have lymphedema based on your signs and symptoms.
If the cause of your lymphedema isn't as obvious, your doctor may order imaging tests to determine what's causing your signs and symptoms. To get a look at your lymphatic system, your doctor may use an imaging technique, such as:
1. Radionuclide imaging of your lymphatic system (lymphoscintigraphy). During this test you're injected with a radioactive dye and then scanned by a machine. The resulting images show the dye moving through your lymph vessels, highlighting areas where the lymph fluid is blocked.
2. Magnetic resonance imaging (MRI). This scan gives your doctor a better look at the tissues in your arm or leg. He or she might be able to use an MRI to see characteristics of lymphedema.
3. Computerized tomography (CT). A CT scan produces images of your arm or leg in cross sections.
4. Doppler ultrasound. This variation of the conventional ultrasound assesses blood flow and pressure by bouncing high-frequency sound waves (ultrasound) off red blood cells.

Complications
Lymphedema in your arm or leg can lead to serious complications, such as:
1. Infections. Lymphedema makes your affected arm or leg particularly vulnerable to infections, including cellulitis and lymphangitis. Any injury to your arm or leg provides an entry point for an infection.
2. Elephantiasis. This condition occurs when your arm or leg becomes so hardened with thickened skin that you have difficulty moving it. Elephantiasis may make the skin on your arm or leg very weak, leading to chronic ulcers and repeated infections.
3. Lymphangiosarcoma. This rare form of soft tissue cancer can result from the most severe cases of untreated lymphedema. Lymphangiosarcoma originates in the lymph nodes and lymph vessels.

Treatments and drugs
Lymphedema can't be cured. Treatment focuses on minimizing the swelling and controlling the pain. Lymphedema treatments include:
1. Exercises. Light exercises that require you to move your affected arm or leg may encourage movement of the lymph fluid out of your limb. These exercises shouldn't be strenuous or make you tired. Instead, they should focus on gentle contraction of the muscles in your arm or leg. Exercises help pump the lymph fluid out of your affected limb. Your doctor or a physical therapist can teach you exercises that may help.
2. Wrapping your arm or leg. Bandages wrapped around your entire limb encourage lymph fluid to flow back out of your affected limb and toward the trunk of your body. When bandaging your arm or leg, start by making the bandage tightest around your fingers and toes. Wrap the bandage more loosely as you move up your arm or leg. A lymphedema therapist can show you how to wrap your limb.
3. Massage. A special massage technique called manual lymph drainage may encourage the flow of lymph fluid out of your arm or leg. Manual lymph drainage involves special hand strokes on your affected limb to gently move lymph fluid to healthy lymph nodes, where it can drain. Massage isn't for everyone. Avoid massage if you have a skin infection, active cancer, blood clots or congestive heart failure. Also avoid massage on areas of your body that have received radiation therapy.
4. Pneumatic compression. If you receive pneumatic compression, you'll wear a sleeve over your affected arm or leg. The sleeve is connected to a pump that intermittently inflates the sleeve, putting pressure on your limb. The inflated sleeve gently moves lymph fluid away from your fingers or toes, reducing the swelling in your arm or leg.
5. Compression garments. Compression garments include long sleeves or stockings made to compress your arm or leg to encourage the flow of the lymph fluid out of your affected limb. Once you've reduced swelling in your arm or leg through other measures, your doctor may suggest you wear compression garments to prevent your limb from swelling in the future. Obtain a correct fit for your compression garment by getting professional help — ask your doctor where you can buy compression garments in your community. Some people will require custom-made compression garments.
In cases of severe lymphedema, your doctor may consider surgery to remove excess tissue in your arm or leg. While this reduces severe swelling, surgery can't cure lymphedema.

Prevention
If you're at risk of developing secondary lymphedema, you can take measures to help prevent it. If you've had or are going to have cancer surgery, ask your doctor whether your particular procedure will involve your lymph nodes or lymph vessels. Ask if your radiation treatment will be aimed at any of your lymph nodes, so you'll be aware of the possible risks.
To reduce your risk of lymphedema, try to:
1. Protect your arm or leg. Avoid any injury to your affected limb. Cuts, scrapes and burns can all invite infection, which can cause lymphedema. Protect yourself from sharp objects. For example, shave with an electric razor, wear gloves when you garden or cook, and use a thimble when you sew. If possible, avoid medical procedures, such as blood draws and vaccinations, in your affected limb.
2. Rest your arm or leg while recovering. After cancer treatment, avoid heavy activity with that limb. Early exercise and stretching are encouraged, but avoid strenuous activity until you've recovered from surgery or radiation.
3. Avoid heat on your arm or leg. Don't apply heat, such as with a heating pad, to your affected limb.
4. Elevate your arm or leg. When you get a chance, elevate your affected limb.
Avoid tight clothing. Avoid anything that could constrict your arm or leg, such as tightfitting clothing and, in the case of your arm, blood pressure readings. Ask that your blood pressure be taken in your other arm.
5. Keep your arm or leg clean. Make skin care and nail care high priorities. Inspect the skin on your arm or leg every day, keeping watch for changes or breaks in your skin that could lead to infection.

Coping and support
It can be frustrating to know that no cure exists for lymphedema. But if you find yourself getting down about the daily bandaging or constant need to protect your affected limb, know that you can control some aspects of lymphedema. To help you cope, try to:
1. Find out all you can about lymphedema. Knowing what lymphedema is and what causes it helps you better understand the signs and symptoms you experience. The more you know, the better you can communicate with your doctor or physical therapist.
2. Take care of your affected limb. Do your best to prevent complications in your arm or leg. Clean your skin daily, looking over every inch of your affected limb for signs of trouble, such as cracks and cuts. Apply lotion to prevent dry skin.
3. Take care of your whole body. Eat a diet full of fruits and vegetables. Exercise daily, if you can. Reduce the stress in your life that you can control. Try to get enough sleep so that you wake up refreshed each morning. Taking care of your body gives you more energy, encourages healing and helps you control your lymphedema.
4. Get support from others with lymphedema. Whether you attend support group meetings in your community or participate in online message boards and chat rooms, it helps to talk to people who understand what you're going through. Contact the National Lymphedema

5. Network to find support groups in your area. They can also put you in touch with other people with lymphedema with whom you can connect via e-mail or letter.
If you feel frustrated or overwhelmed by lymphedema, talk to your doctor or other health care provider about how you feel. He or she may be able to address your concerns.

Reference: Mayoclinic.com

Low blood pressure (hypotension)

2008-09-11T08:55:00.000-07:00

Definition
Low blood pressure, also called hypotension, would seem to be something to strive for. After all, high blood pressure (hypertension) is a well-known risk factor for heart disease and other problems. In fact, in recent years there has been an ongoing downward revision of what is considered a normal blood pressure reading. A blood pressure less than 120/80 millimeters of mercury (mm Hg) is now considered normal and optimal for good health.
So, it's easy to understand why you might assume the lower the better when it comes to blood pressure. And it's true that for some people — those who exercise and are in top physical condition — low blood pressure is a sign of health and fitness. But that's not always the case.
For many people, low blood pressure can cause dizziness and fainting or indicate serious heart, endocrine or neurological disorders. Severely low blood pressure can deprive the brain and other vital organs of oxygen and nutrients, leading to a life-threatening condition called shock.

Symptoms
Some people with low blood pressure are in peak physical condition with strong cardiovascular systems and a reduced risk of heart attack and stroke. But low blood pressure can also signal an underlying problem, especially when it drops suddenly or is accompanied by signs and symptoms such as:
Dizziness or lightheadedness
Fainting (syncope)
Lack of concentration
Blurred vision
Nausea
Cold, clammy, pale skin
Rapid, shallow breathing
Fatigue
Depression
Thirst

Causes
Blood pressure is a measurement of the pressure in your arteries during the active and resting phases of each heartbeat. Here's what the numbers mean:
Systolic pressure. The first number in a blood pressure reading, this is the amount of pressure your heart generates when pumping blood through your arteries to the rest of your body.
Diastolic pressure. The second number in a blood pressure reading, this refers to the amount of pressure in your arteries when your heart is at rest between beats.
Although you can get an accurate blood pressure reading at any given time, blood pressure isn't static. It can vary considerably in a short amount of time — sometimes from one heartbeat to the next, depending on body position, breathing rhythm, stress level, physical condition, medications you take, what you eat and drink, and even time of day. Blood pressure is usually lowest at night and rises sharply on waking.
Blood pressure: How low can you go?
Current guidelines identify normal blood pressure as lower than 120/80 — many experts think 115/75 is optimal. Higher readings indicate increasingly serious risks of cardiovascular disease. Low blood pressure, on the other hand, is much harder to quantify.
Some experts define low blood pressure as readings lower than 90 systolic or 60 diastolic — you need to have only one number in the low range for your blood pressure to be considered lower than normal. In other words, if your systolic pressure is a perfect 115, but your diastolic pressure is 50, you're considered to have lower than normal pressure.
Yet this can be misleading because what's considered low blood pressure for you may be normal for someone else. For that reason, doctors often consider chronically low blood pressure too low only if it causes noticeable symptoms.
On the other hand, a sudden fall in blood pressure can be dangerous. A change of just 20 mm Hg — a drop from 130 systolic to 110 systolic, for example — can cause dizziness and fainting when the brain fails to receive an adequate supply of blood. And big plunges, especially those caused by uncontrolled bleeding, severe infections or allergic reactions can, be life-threatening.
Causes of low blood pressure varyAthletes and people who exercise regularly tend to have lower blood pressure than do people who aren't as fit. So, in general, do nonsmokers and people who eat well and maintain a normal weight.
But in some instances, low blood pressure can be a sign of serious, even life-threatening disorders.
The American Heart Association considers the following as possible causes of low blood pressure:
Pregnancy.
Because a woman's circulatory system expands rapidly during pregnancy, blood pressure is likely to drop. In fact, during the first 24 weeks of pregnancy, systolic pressure commonly drops by five to 10 points and diastolic pressure by as much as 10 to 15 points.
Medications.
Many drugs can cause low blood pressure, including diuretics and other drugs that treat high blood pressure; heart medications such as beta blockers; drugs for Parkinson's disease; tricyclic antidepressants; sildenafil (Viagra), particularly in combination with nitroglycerine; narcotics; and alcohol. Some over-the-counter medications can cause low blood pressure when taken in combination with medications used to treat high blood pressure.
Heart problems.
Some heart conditions that can lead to low blood pressure include extremely low heart rate (bradycardia), heart valve problems, heart attack and heart failure. These conditions may cause low blood pressure because they prevent your body from being able to circulate enough blood.
Endocrine problems.
An underactive thyroid (hypothyroidism) or overactive thyroid (hyperthyroidism) can cause low blood pressure. In addition, other conditions, such as adrenal insufficiency (Addison's disease), low blood sugar (hypoglycemia), and in some cases, diabetes, can trigger low blood pressure.
Dehydration.
When you become dehydrated, your body loses more water than it takes in. Even mild dehydration can cause weakness, dizziness and fatigue. Fever, vomiting, severe diarrhea, overuse of diuretics and strenuous exercise can all lead to dehydration. Far more serious is hypovolemic shock, a life-threatening complication of dehydration. It occurs when low blood volume causes a sudden drop in blood pressure and a corresponding reduction in the amount of oxygen reaching your tissues. If untreated, severe hypovolemic shock can cause death within a few minutes or hours.
Blood loss.
Losing a lot of blood from major injury or severe internal bleeding reduces the amount of blood in your body, leading to a severe drop in blood pressure.
Severe infection (septicemia).
Septicemia can happen when an infection in the body enters the bloodstream. Lung, abdomen or urinary tract infections are usually the cause of septicemia. These conditions can lead to a life-threatening drop in blood pressure called septic shock.
Allergic reaction (anaphylaxis).
Anaphylaxis is a severe and potentially life-threatening allergic reaction. Common triggers of anaphylaxis include foods, certain medications, insect venoms and latex. Anaphylaxis can cause breathing problems, hives, itching, a swollen throat and a drop in blood pressure.
Nutritional deficiencies.
A lack of the vitamins B-12 and folate can cause anemia, a condition in which your body doesn't produce enough red blood cells. In addition to making you feel tired because you're not getting enough oxygen, anemia can lead to low blood pressure.

Types of low blood pressureDoctors often break down low blood pressure (hypotension) into different categories, depending on the causes and other factors. Some types of low blood pressure include:
Low blood pressure on standing up (postural or orthostatic hypotension).
This is a sudden drop in blood pressure when you stand up from a sitting position or if you stand up after lying down. Ordinarily, blood pools in your legs whenever you stand, but your body compensates for this by increasing your heart rate and constricting blood vessels, thereby ensuring that enough blood returns to your brain. But in people with postural hypotension, this compensating mechanism fails and blood pressure falls, leading to dizziness, lightheadedness, blurred vision and even fainting.
Postural hypotension can occur for a variety of reasons including dehydration, prolonged bed rest, pregnancy, diabetes, heart problems, burns, excessive heat, large varicose veins and certain neurological disorders. A number of medications can also cause postural hypotension, particularly drugs used to treat high blood pressure — diuretics, beta blockers, calcium channel blockers and angiotensin-converting enzyme (ACE) inhibitors — as well as antidepressants and drugs used to treat Parkinson's disease and erectile dysfunction.
Postural hypotension is especially common in older adults, with as many as 20 percent of those over age 65 experiencing postural hypotension. But postural hypotension can also affect young, otherwise healthy people who stand up suddenly after sitting with their legs crossed for long periods or after working for a time in a squatting position.
Low blood pressure due to nervous system damage (multiple system atrophy with orthostatic hypotension).
Also called Shy-Drager syndrome, this rare disorder causes progressive damage to the autonomic nervous system, which controls involuntary functions such as blood pressure, heart rate, breathing and digestion. Although multiple system atrophy can be associated with muscle tremors, slowed movement, problems with coordination and speech, and incontinence, its main characteristic is severe orthostatic hypotension in combination with very high blood pressure when lying down. Multiple system atrophy can't be cured and usually proves fatal within seven to 10 years of diagnosis.
Low blood pressure after eating (postprandial hypotension).
A problem that almost exclusively affects older adults, postprandial hypotension is a sudden drop in blood pressure after eating. Just as gravity pulls blood to your feet when you stand, a large amount of blood flows to your digestive tract after you eat. Ordinarily, your body counteracts this by increasing your heart rate and constricting certain blood vessels to help maintain normal blood pressure. But in some people these mechanisms fail, leading to dizziness, faintness and falls. Postprandial hypotension is more likely to affect people with high blood pressure or autonomic nervous system disorders such as Parkinson's disease. Lowering the dose of blood pressure drugs and eating small, low-carbohydrate meals may help reduce symptoms.
Low blood pressure from faulty brain signals (neurally mediated hypotension).
Unlike orthostatic hypotension — which occurs when you stand up from a sitting or lying position — this disorder causes blood pressure to drop after standing for long periods, leading to symptoms such as dizziness, nausea and fainting. Although the end result is similar, neurally mediated hypotension differs from orthostatic hypotension in other important respects: It primarily affects young people, for instance, and rather than resulting from failed blood pressure regulation, it seems to occur because of a miscommunication between the heart and the brain. When you stand for extended periods, your blood pressure falls as blood pools in your legs. Normally, your body then makes adjustments to normalize your blood pressure. But in people with neurally mediated hypotension, nerves in the heart's left ventricle actually signal the brain that blood pressure is too high, rather than too low, and so the brain lessens the heart rate, decreasing blood pressure even further. This causes more blood to pool in the legs and less blood to reach the brain, leading to lightheadedness and fainting.

Risk factors
Low blood pressure (hypotension) can happen to anyone, though certain types of low blood pressure are more common depending on your age or other factors:
Age. Drops in blood pressure on standing or after eating occur primarily in older adults. Orthostatic hypotension happens after standing up, while postprandial hypotension happens after eating a meal. Neurally mediated hypotension happens as a result of a miscommunication between the brain and heart. It primarily affects children and younger adults.
Medications. People who take certain medications, such as high blood pressure medication, have a greater risk of low blood pressure.
Certain diseases. Parkinson's disease and some heart conditions put you at a greater risk of developing low blood pressure.

When to seek medical advice
In many instances, low blood pressure isn't serious. If you have consistently low readings but feel fine, your doctor is likely to monitor you during routine exams. Even occasional dizziness or lightheadedness may be relatively minor — the result of mild dehydration, low blood sugar or too much time in the sun or a hot tub, for example. In these situations, it's not a matter so much of how far, but of how quickly, your blood pressure drops. Still, it's important to see your doctor if you experience any signs or symptoms of hypotension because they sometimes can point to more serious problems. It can be helpful to keep a record of your symptoms, when they occur and what you were doing at the time. If these occur at times that may endanger you or others, you should talk to your doctor.

Tests and diagnosis
The goal in evaluating low blood pressure is to find the underlying cause. This helps determine the correct treatment and identify any heart, brain or nervous system problems that may be responsible for lower than normal readings. To help reach a diagnosis, your doctor may recommend one or more of the following:
Blood tests. These can provide a certain amount of information about your overall health as well as whether you have low blood sugar (hypoglycemia) or a low number of red blood cells (anemia), both of which can cause lower than normal blood pressure.
Electrocardiogram (ECG, EKG). This noninvasive test, which can be performed in your doctor's office, detects irregularities in your heart rhythm, structural abnormalities in your heart, and problems with the supply of blood and oxygen to your heart muscle. It can also tell if you're having a heart attack or if you've had a heart attack in the past. Sometimes you may be asked to wear a 24-hour Holter monitor to record your heart's electrical activity as you go about your daily routine.
Echocardiogram. Using the same technology that allows you to view a fetus in the womb, an echocardiogram uses sound waves to produce images of your heart that may show abnormalities in your heart muscle or valves.
Stress test. Some heart problems which can cause low blood pressure are easier to diagnose when your heart is working harder than when it's at rest. During a stress test, you'll exercise, such as walking on a treadmill. (Or, you may be given medication to make your heart work harder if you're unable to exercise.) When your heart is working harder, your heart will be monitored with electrocardiography or echocardiography. Your blood pressure also may be monitored.
Valsalva maneuver. This noninvasive test checks the functioning of your autonomic nervous system by analyzing your heart rate and blood pressure after several cycles of a type of deep breathing: You take a deep breath and then force the air out through your lips, as if you were trying to blow up a stiff balloon.
Tilt-table test. If you have low blood pressure on standing, or from faulty brain signals (neurally mediated hypotension), your doctor may suggest a tilt-table test, which evaluates how your body reacts to changes in position. During the test, you lie on a table that's tilted to raise the upper part of your body, which simulates the movement from a prone to a standing position.

Complications
Even moderate forms of low blood pressure can seriously affect quality of life, leading not only to dizziness and weakness but also to fainting and a risk of injury from falls. And severely low blood pressure from any cause can deprive your body of enough oxygen to carry out its normal functions, leading to damage to your heart and brain.

Treatments and drugs
Low blood pressure that doesn't cause signs or symptoms rarely requires treatment. In symptomatic cases, the appropriate therapy depends on the underlying cause, and doctors usually try to address the primary health problem — dehydration, heart failure, diabetes or hypothyroidism, for example — rather than low blood pressure itself. When low blood pressure is caused by medications, treatment usually involves changing the dose of the medication or stopping it entirely.
If it's not clear what's causing low blood pressure or no effective treatment exists, the goal is to raise your blood pressure and reduce signs and symptoms. Depending on your age, health status and the type of low blood pressure you have, this may be accomplished in several ways:
Use more salt. Experts usually recommend limiting the amount of salt in your diet because sodium can raise blood pressure, sometimes dramatically. But for people with low blood pressure, that can be a good thing. But because excess sodium can lead to heart failure, especially in older adults, it's important to check with your doctor before upping your salt intake.
Drink more water. Although nearly everyone can benefit from drinking enough water, this is especially true if you have low blood pressure. Fluids increase blood volume and help prevent dehydration, both of which are important in treating hypotension.
Use compression stockings. The same elastic stockings and leotards commonly used to relieve the pain and swelling of varicose veins may help reduce the pooling of blood in your legs.
Medications. Several medications, either used alone or together, can be used to treat low blood pressure that occurs when you stand up (orthostatic hypotension). For example, the drug fludrocortisone is often used to treat this form of low blood pressure. This drug helps boost your blood volume, which raises blood pressure. Doctors often use the drug midodrine to raise standing blood pressure levels in people with chronic orthostatic hypotension. It works by restricting the ability of your blood vessels to expand, which raises blood pressure. Other drugs, such as pyridostigmine, nonsteroidal anti-inflammatory drugs (NSAIDs), caffeine and erythropoietin are sometimes used, too, either alone or with other drugs.

Lifestyle and home remedies
Depending on the reason for your low blood pressure, you may be able to take certain steps to help reduce or even prevent symptoms. Some suggestions include:
Drink more water, less alcohol. Alcohol is dehydrating and can lower blood pressure, even if you drink in moderation. Water, on the other hand, combats dehydration and increases blood volume.
Follow a healthy diet. Get all the nutrients you need for good health by focusing on a variety of foods, including whole grains, fruits, vegetables, and lean chicken and fish. If your doctor suggests increasing your sodium intake but you don't like a lot of salt on your food, try using natural soy sauce — a whopping 1,200 milligrams of sodium per tablespoon — or adding dry soup mixes, also loaded with sodium, to dips and dressings.
Go slow. You may be able to reduce the dizziness and lightheadedness that occurs with low blood pressure on standing by taking it easy when you move from a prone to a standing position. Before getting out of bed in the morning, breathe deeply for a few minutes and then slowly sit up before standing. Sleeping with the head of your bed slightly elevated also can help fight the effects of gravity. If you begin to get symptoms while standing, cross your thighs in a scissors fashion and squeeze or put one foot on a ledge or chair and lean as far forward as possible. These maneuvers encourage blood to flow from your legs to your heart.
Eat small, low-carb meals. To help prevent blood pressure from dropping sharply after meals, eat small portions several times a day and limit high-carbohydrate foods such as potatoes, rice, pasta and bread. Drinking caffeinated coffee or tea with meals may temporarily raise blood pressure, in some cases by as much as 3 to 14 millimeters of mercury (mm Hg). But because caffeine can cause other problems, check with your doctor before increasing your caffeine intake.

Reference: MayoClinic.com

EDEMA

2008-09-08T01:54:00.000-07:00

What is edema?
Edema is observable swelling from fluid accumulation in body tissues. Edema most commonly occurs in the feet and legs, where it is referred to as peripheral edema. The swelling is the result of the accumulation of excess fluid under the skin in the spaces within the tissues. All tissues of the body are made up of cells and connective tissues that hold the cells together. This connective tissue around the cells and blood vessels is known as the interstitium. Most of the body's fluids that are found outside of the cells are normally stored in two spaces; the blood vessels (as the "liquid" or serum portion of your blood) and the interstitial spaces (not within the cells). In various diseases, excess fluid can accumulate in either one or both of these compartments.
The body's organs have interstitial spaces where fluid can accumulate. An accumulation of fluid in the interstitial air spaces (alveoli) in the lungs occurs in a disorder called pulmonary edema. In addition, excess fluid sometimes collects in what is called the third space, which includes cavities in the abdomen (abdominal or peritoneal cavity - called "ascites") or in the chest (lung or pleural cavity - called "pleural effusion"). Anasarca refers to the severe, widespread accumulation of fluid in the all of the tissues and cavities of the body at the same time.

What is pitting edema and how does it differ from non-pitting edema?
Pitting edema can be demonstrated by applying pressure to the swollen area by depressing the skin with a finger. If the pressing causes an indentation that persists for some time after the release of the pressure, the edema is referred to as pitting edema. Any form of pressure, such as from the elastic in socks, can induce pitting with this type of edema.
In non-pitting edema, which usually affects the legs or arms, pressure that is applied to the skin does not result in a persistent indentation. Non-pitting edema can occur in certain disorders of the lymphatic system such as lymphedema, which is a disturbance of the lymphatic circulation that may occur after a mastectomy, lymph node surgery, or congenitally. Another cause of non-pitting edema of the legs is called pretibial myxedema, which is a swelling over the shin that occurs in some patients with hyperthyroidism. Non-pitting edema of the legs is difficult to treat. Diuretic medications are generally not effective, although elevation of the legs periodically during the day and compressive devices may reduce the swelling.
The focus of the rest of this article is on pitting edema, as it is by far the most common form of edema.

What causes pitting edema?
Edema is caused by either systemic diseases, that is, diseases that affect the various organ systems of the body, or by local conditions involving just the affected extremities. The most common systemic diseases associated with edema involve the heart, liver, and kidneys. In these diseases, edema occurs primarily because of the body's retention of too much salt (sodium chloride). The excess salt causes the body to retain water. This water then leaks into the interstitial tissue spaces, where it appears as edema.
The most common local conditions that cause edema are varicose veins and thrombophlebitis (inflammation of the veins) of the deep veins of the legs. These conditions can cause inadequate pumping of the blood by the veins (venous insufficiency). The resulting increased back-pressure in the veins forces fluid stay in the extremities (especially the ankles and feet). The excess fluid then leaks into the interstitial tissue spaces, causing edema.

How does salt intake affect edema?
The body's balance of salt is usually well–regulated. A normal person can consume small or large quantities of salt in the diet without concern for developing salt depletion or retention. The intake of salt is determined by dietary patterns and the removal of salt from the body is accomplished by the kidneys. The kidneys have a great capacity to control the amount of salt in the body by changing the amount of salt eliminated (excreted) in the urine. The amount of salt excreted by the kidneys is regulated by hormonal and physical factors that signal whether retention or removal of salt by the kidneys is necessary.
If the blood flow to the kidneys is decreased by an underlying condition such as heart failure, the kidneys react by retaining salt. This salt retention occurs because the kidneys perceive that the body needs more fluid to compensate for the decreased blood flow. If the patient has a kidney disease that impairs the function of the kidneys, the ability to excrete salt in the urine is limited. In both conditions, the amount of salt in the body increases, which causes the patient to retain water and develop edema.
Patients experiencing a disturbance in their ability to normally excrete salt may need to either be placed on a diet limited in salt and/or given diuretic medications (water pills). In the past, patients with diseases associated with edema were placed on diets very restricted in salt intake. With the development of new and very potent diuretic agents, this marked restriction in dietary salt intake is generally no longer necessary. These diuretics work by blocking the reabsorption and retention of salt by the kidneys, thereby increasing the amount of salt and water that is eliminated in the urine.

Why does a patient with heart disease retain fluid?
Heart failure is the result of poor cardiac function and is reflected by a decreased volume of blood pumped out by the heart, called cardiac output. Heart failure can be caused by weakness of the heart muscle, which pumps blood out through the arteries to the entire body, or by dysfunction of the heart valves, which regulate the flow of blood between the chambers of the heart. The diminished volume of blood pumped out by the heart (decreased cardiac output) is responsible for a decreased flow of blood to the kidneys. As a result, the kidneys sense that there is a reduction of the blood volume in the body. To counter the seeming loss of fluid, the kidneys retain salt and water. In this instance, the kidneys are fooled into thinking that the body needs to retain more fluid volume when, in fact, the body already is holding too much fluid.
This fluid increase ultimately results in the buildup of fluid within the lungs, which causes shortness of breath. Because of the decreased volume of blood pumped out by the heart (decreased cardiac output), the volume of blood in the arteries is also decreased, despite the actual increase in the body's total fluid volume. An associated increase in the amount of fluid in the blood vessels of the lungs causes shortness of breath because the excess fluid from the lungs' blood vessels leaks into the airspaces (alveoli) and interstitium in the lungs. This accumulation of fluid in the lung is called pulmonary edema. At the same time, accumulation of fluid in the legs causes pitting edema. This edema occurs because the build-up of blood in the veins of the legs causes leakage of fluid from the legs' capillaries (tiny blood vessels) into the interstitial spaces.
An understanding of how the heart and lungs interact will help you to better comprehend how fluid retention works in heart failure. The heart has four chambers; an auricle and a ventricle on the left side of the heart and an auricle and ventricle on the right. The left auricle receives oxygenated blood from the lungs and transfers it to the left ventricle, which then pumps it through the arteries to the entire body. The blood then is transported back to the heart by veins into the right auricle and transferred to the right ventricle, which then pumps it to the lungs for re-oxygenation.
Left-sided heart failure, which is due primarily to a weak left ventricle, usually is caused by coronary artery disease, hypertension, or disease of the heart valves. Typically, when these patients initially come to the doctor they are troubled by shortness of breath with exertion and when lying down at night (orthopnea). These symptoms are due to pulmonary edema that is caused by pooling of the blood in the vessels of the lungs.
In contrast, right-sided heart failure, which often is due to chronic lung diseases such as emphysema, initially causes salt retention and edema. Persistent salt retention in these patients, however, may lead to an expanded blood volume in the blood vessels, thereby causing fluid accumulation in the lungs (pulmonary congestion) and shortness of breath.
In patients with heart failure due to weak heart muscle (cardiomyopathy), both the right and left ventricles of the heart are usually affected. These patients, therefore, can initially suffer from swelling both in the lungs (pulmonary edema) and in the legs and feet (peripheral edema). The physician examining a patient who has congestive heart failure with fluid retention looks for certain signs. These include:
1. pitting edema of the legs and feet,
2. rales in the lungs (moist crackle sounds from the excess fluid that can be heard with a stethoscope),
3. a gallop rhythm (three heart sounds instead of the normal two due to muscle weakness), and
distended neck veins. The distended neck veins reflect the accumulation of blood in the veins that are returning blood to the heart.

Why do patients with liver disease develop ascites and edema?
In patients with chronic diseases of the liver, fibrosis (scarring) of the liver often occurs. When the scarring becomes advanced, the condition is called cirrhosis of the liver. Ascites is excessive fluid that accumulates in the abdominal (peritoneal) cavity. It is a complication of cirrhosis and appears as an abdominal bulge. The peritoneum is the inner lining of the abdominal cavity, which also folds over to cover the organs inside the abdomen such as the liver, gallbladder, spleen, pancreas, and intestines. Ascites develops because of a combination of two factors:
1. increased pressure in the vein system that carries blood from the stomach, intestines, and spleen to the liver (portal hypertension); and
2. a low level of the protein albumin in the blood (hypoalbuminemia). Albumin, which is the predominant protein in the blood and which helps maintain blood volume, is reduced in cirrhosis primarily because the damaged liver is not able to produce enough of it.
Other consequences of portal hypertension include dilated veins in the esophagus (varices), prominent veins on the abdomen, and an enlarged spleen. Each of these conditions is due primarily to the increased pressure and accumulation of blood and excess fluid in the abdominal blood vessels. The fluid of ascites can be removed from the abdominal cavity by using a syringe and a long needle, a procedure called paracentesis. Analysis of the fluid can help differentiate ascites that is caused by cirrhosis from other causes of ascites, such as cancer, tuberculosis, congestive heart failure, and nephrosis. Sometimes, when ascites does not respond to treatment with diuretics, paracentesis can be used to remove large amounts of the ascitic fluid.
Peripheral edema, which is usually seen as pitting edema of the legs and feet, also occurs in cirrhosis. The edema is a consequence of the hypoalbuminemia and the kidneys retaining salt and water.
The presence or absence of edema in patients with cirrhosis and ascites is an important consideration in the treatment of the ascites. In patients with ascites without edema, diuretics must be given with extra caution. Diuresis (induced increased volume of urine by use of diuretics) that is too aggressive or rapid in these patients can lead to a low blood volume (hypovolemia), which can cause kidney and liver failure. In contrast, when patients who have both edema and ascites undergo diuresis, the edema fluid in the interstitial space serves as somewhat of a buffer against the development of low blood volume. The excess interstitial fluid moves into the blood vessel spaces to rapidly replenish the depleted blood volume.

Why does edema occur in patients with kidney disease?
Edema forms in patients with kidney disease for two reasons:
1. a heavy loss of protein in the urine, or
2. impaired kidney (renal) function.
Heavy loss of protein in the urine
In this situation, the patients have normal or fairly normal kidney function. The heavy loss of protein in the urine (over 3.0 grams per day) with its accompanying edema is termed the nephrotic syndrome. Nephrotic syndrome results in a reduction in the concentration of albumin in the blood (hypoalbuminemia). Since albumin helps to maintain blood volume in the blood vessels, a reduction of fluid in the blood vessels occurs. The kidneys then register that there is depletion of blood volume and, therefore, attempt to retain salt. Consequently, fluid moves into the interstitial spaces, thereby causing pitting edema.
The treatment of fluid retention in these patients is to reduce the loss of protein into the urine and to restrict salt in the diet. The loss of protein in the urine may be reduced by the use of ACE inhibitors and angiotensin receptor blockers (ARB's). Both categories of drugs, which ordinarily are used to lower blood pressure, prompt the kidneys to reduce the loss of protein into the urine.
ACE inhibitor drugs include:
enalapril (Vasotec),
quinapril (Accupril),
captopril (Capoten),
benazepril (Lotensin),
trandolapril (Mavik),
lisinopril (Zestril or Prinivil), and
ramipril (Altace).
Angiotensin receptor blockers include:
losartan (Cozaar),
valsartan (Diovan),
candesartan (Atacand), and
irbesartan (Avapro).
Certain kidney diseases may contribute to the loss of protein in the urine and the development of edema. A biopsy of the kidney may be needed to make a diagnosis of the type of kidney disease, so that treatment may be given.
Impaired kidney (renal) function
In this situation, patients who have kidney diseases that impair renal function develop edema because of a limitation in the kidneys' ability to excrete sodium into the urine. Thus, patients with kidney failure from whatever cause will develop edema if their intake of sodium exceeds the ability of their kidneys to excrete the sodium. The more advanced the kidney failure, the greater the problem of salt retention is likely to become. The most severe situation is the patient with end-stage kidney failure who requires dialysis therapy. This patient's salt balance is totally regulated by dialysis, which can remove salt during the treatment. Dialysis is a method of cleansing the body of the impurities that accumulate when the kidneys fail. Dialysis is accomplished by circulating the patient's blood over an artificial membrane (hemodialysis) or by using the patient's own abdominal cavity (peritoneal membrane) as the cleansing surface. Individuals whose kidney function declines to less than 5% to 10% of normal may require dialysis.

What is idiopathic edema?
Idiopathic edema is a pitting edema of unknown cause that occurs primarily in pre-menopausal women who do not have evidence of heart, liver, or kidney disease. In this condition, the fluid retention at first may be seen primarily pre-menstrually (just prior to menstruation), which is why it sometimes is called "cyclical" edema. However, it can become a more constant and severe problem.
Patients with idiopathic edema often take diuretics to decrease the edema in order to lessen the discomfort of bloating and swelling. Paradoxically, however, the edema in this condition can become more of a problem after the use of diuretics. The patients can develop fluid retention as a rebound phenomenon each time they discontinue diuretics. It is important to talk to your doctor before using any diuretics.
Patients with idiopathic edema appear to have a leak in the capillaries (tiny peripheral blood vessels that connect the arteries with the veins) so that fluid passes from the blood vessels into the surrounding interstitial space. Thus, a patient with idiopathic edema has a decreased blood volume, which leads to the typical reaction of salt retention by the kidneys.
The leg edema in these patients is exaggerated in the standing position, since edema tends to accumulate in those parts of the body that are close to the ground at the time.
These patients often have edema around the eyes (periorbital edema) in the morning because the edema fluid accumulates during the night around their eyes as they lay sleeping flat.
In contrast, edema around the eyes does not tend to develop in cardiac patients who keep their heads elevated at night because of shortness of breath when they lie flat. These patients characteristically experience varying amounts of edema in different parts of the body at different times of the day.
Patients with idiopathic edema often become dependant on diuretics, and this dependance is often difficult to interrupt. A period as long as three weeks off diuretics may be required to break the dependency cycle. The withdrawal from diuretics may lead to fluid retention that produces major discomfort and swelling. Furthermore, there are definite risks associated with the prolonged use of diuretics in these individuals, which are compounded by the tendency to increase the doses of the diuretics.
As a result of chronic diuretic use and abuse, patients may develop:
1. a deficiency of potassium,
2. depletion of blood volume in the blood vessels, and
3. kidney insufficiency or failure.
Other side effects of diuretics include:
1. high blood sugar (diabetes),
2. high uric acid (gout),
3. muscle cramps, tender and enlarged breasts (gynecomastia), and
4. pancreatitis (inflammation of the pancreas).
Although withdrawal from diuretics is the most important factor in treating these patients, other medications have been used to try to minimize the fluid retention. These medications include ACE inhibitors, low-dose amphetamines, ephedrine, bromocriptine (Parlodel), or levodopa-carbidopa (Sinemet) in combination. However, their effectiveness is uncertain and side effects of these drugs may occur. For example, hypotension (low blood pressure) may be seen with the use of ACE inhibitors, especially if the patient is also taking diuretics.

How does venous insufficiency cause edema?
The veins in the legs are responsible for transporting blood up to the veins of the torso, where it is then returned to the heart. The veins of the legs have valves that prevent the backward flow of blood within them. Venous insufficiency is incompetence of the veins that occurs because of dilation, or enlargement, of the veins and dysfunction of their valves. This happens, for example, in patients with varicose veins. Venous insufficiency leads to a backup of blood and increased pressure in the veins, thereby resulting in edema of the legs and feet. Edema of the legs also can occur with an episode of deep vein thrombophlebitis, which is a blood clot within an inflamed vein. In this situation, the clot in the deep vein blocks the return of blood, and consequently causes increased back-pressure in the leg veins.
Venous insufficiency is a problem that is localized to the legs, ankles, and feet. One leg may be more affected than the other (asymmetrical edema). In contrast, systemic diseases that are associated with fluid retention generally cause the same amount of edema in both legs, and can also cause edema and swelling elsewhere in the body. The response to therapy with diuretic drugs in patients with venous insufficiency tends to be unsatisfactory. This is because the continued pooling of fluid in the lower extremities makes it difficult for the diuretics to mobilize the edema fluid. Elevation of the legs periodically during the day and the use of compression stockings may alleviate the edema. Some patients require surgical treatment to relieve chronic edema that is caused by venous insufficiency.

Which diuretics are used to treat edema?
Edema can become a problem in systemic diseases of the heart, liver or kidneys. Diuretic therapy can be initiated, often alleviating the edema. The most potent diuretics are loop diuretics, so-called because they work in the portion of the kidney tubules referred to as the loop of Henle. The kidney tubules are small ducts that regulate salt and water balance, while transporting the forming urine. Clinical loop diuretics available are:
1. furosemide (Lasix),
2. torsemide (Demadex), and
3. butethamine (Bumex).
The doses of these diuretics vary depending upon the clinical circumstances. These drugs can be given orally, although seriously ill patients in the hospital may receive them intravenously for more prompt or effective response. If one of the loop diuretics is not effective alone, it may be combined with an agent that works further down (more distally) in the tubule. These agents include the thiazide type diuretics, such as hydrochlorothiazide (HydroDIURIL), or a similar but more potent type of diuretic called metolazone (Zaroxolyn). When diuretics that work at different sites in the kidney are used together, the response often is greater than the combined responses to the individual diuretics (synergistic response).
Some diuretics frequently cause an excessive loss of potassium in the urine, leading to the depletion of body potassium. These drugs include the loop diuretics, the thiazide diuretics, and metolazone. Patients on these diuretics are commonly advised to take potassium supplements and/or to eat foods high in potassium. High potassium foods include certain fruits such as:
1. bananas,
2. orange juice,
3. tomatoes, and
4. potatoes.
Patients with impaired kidney function often do not require potassium supplements with diuretics because their damaged kidneys tend to retain potassium. In certain instances, the volume of urine induced by the diuretic can be improved by adding a potassium-sparing diuretic, one that does not cause depletion of potassium. These diuretics include spironolactone (Aldactone), triamterene (Dyrenium, a component of Dyazide), and amiloride (Midamor). Adding one of these diuretics to the patient's diuretic regimen may preclude the need for potassium supplements. Another diuretic that can be used is acetazolamide (Diamox), which counteracts the development of an increased concentration of bicarbonate (too much alkali) in the blood. Increased bicarbonate sometimes occurs in patients receiving other diuretics

Are diuretics used for other purposes?
Diuretics have several other uses in addition treating edema.
1, A diuretic may be used as part of the treatment program for patients with hypertension. (High blood pressure may be caused by salt retention, or caused by some antihypertensive medications). In fact, most medications that dilate the blood vessels and reduce blood pressure, except for ACE inhibitors and angiotensin receptor blockers, lead to secondary salt retention by the kidneys.
2. Thiazide diuretics also have been used to prevent the formation of kidney stones. These drugs reduce the urinary excretion of calcium, which is a component of the kidney stone.
3. Acetazolamide (Diamox) taken a few days before going to high altitudes, appears to reduce the tendency for people to develop altitude sickness.

Edema At A Glance
1. Edema is a swelling, usually of the legs, due to the accumulation of excessive fluid in the tissues.
2. The edema that occurs in diseases of the heart, liver, and kidneys is mainly caused by salt retention, which holds the excess fluid in the body.
3. In certain liver and kidney diseases, low levels of albumin in the blood can contribute to fluid retention.
4. Heart failure, cirrhosis of the liver, and a kidney disease called nephrotic syndrome are the most common systemic diseases that cause edema.
5. Excess fluid that accumulates in the lungs is called pulmonary edema.
6. Excess fluid that accumulates in the abdominal cavity is called ascites.
7. Edema of unknown cause occurs primarily in women.
8. Varicose veins or thrombophlebitis (a blood clot in an inflamed vein) of the deep veins in the legs causes edema that is localized to the legs.
9. Therapy for edema consists of treating the underlying conditions, restricting salt intake, and often using diuretics (medicines to induce urination).

Reference: Harrison's Principles of Internal Medicine, McGraw-Hill, edited by Eugene Braunwald, et. al., 2001
Previous contributing authors and editors:

Medical Author: Mark Scott Noah, MD

Medical Editor: Leslie J. Schoenfield, MD, PhD

Are you overweight?

2008-09-07T10:09:00.000-07:00

Are you overweight? Find out by calculating your BMI (Body Mass Index)
A lot of people think they’re overweight even though they aren't. Just because you don't measure up to a supermodel doesn't mean you're bigger than you should be! In fact everybody should have some body fat. The average man should expect his body fat to be 10 to 18 percent of his bodyweight. The figure for women is higher, in fact 18 to 25 percent of a woman's bodyweight should be fat.
Calculate your BMI using the simple test below, then check your results on the table. The comments regarding your weight can be found in the top row.
If the BMI-test shows that you are overweight (a BMI number exceeding 25) you should consider doing something about it for the sake of your health.
Please note: This test is meant as a guide only, and should not replace a visit to your doctor to discuss weight problems. The BMI test should not be used by body-builders as the weight of the extra muscles could interfere with the calculation.
To get the correct reading PLEASE ENSURE that you correctly set the unit of measurement for your weight.

Obviously everyone is built differently, so there is a certain margin for your BMI. However, if it is above 25-27, you should do something about your weight before it affects your health. Obesity can cause diabetes, heart conditions, cancer and high blood pressure. If your BMI is above 30, you should definitely act straightaway.
Please note that body-builders or people with large bones cannot use the BMI since the weight of the muscles and bones alter the calculation.

REMEMBER: if you need to lower your BMI do it gently. Don't starve yourself or over-strain your body with strenuous exercise.
TIP: You can experiment with the test to see how much weight you should lose to get your BMI down.

Cardiovascular disease in India and the impact of lifestyle and food habits

2008-09-05T09:00:00.000-07:00

Dr Rajesh Pande

Cardiovascular disease is the world's leading killer, accounting for 16.7 million or 29.2 per cent of total global deaths in 2003. With modernization, a large proportion of Asians are trading healthy traditional diets for fatty foods, physical jobs for deskbound sloth, the relative calm of the countryside for the stressful city. Heart-attack victims are just the first wave of a swelling population of Asians with heart problems. While deaths from heart attacks have declined more than 50 per cent since the 1960s in many industrialize countries, 80 per cent of global cardiovascular diseases related deaths now occur in low and middle-income nations, which covers most countries in Asia.
In India in the past five decades, rates of coronary disease among urban populations have risen from 4 per cent to 11 per cent. In urban China, the death rate from coronary disease rose by 53.4 per cent from 1988 to 1996. A report released last week by the Earth Institute at Columbia University warned that without sustained effort on individual and national levels, the coming heart-disease epidemic will exact a devastating price on the region's physical and economic health. In Professor Philip Poole-Wilson, president of the World Heart Federation words. "We're trying to warn people sufficiently early so that they can do something about it, but this isn't a disease you can cure by turning on an electric switch."
The World Health Organization (who) estimates that 60 per cent of the world's cardiac patients will be Indian by 2010. Dr Timothy Gill, an Asia-Pacific specialist with the International Obesity Task Force, a medical NGO that coordinates with the WHO on obesity issues feels that of all Asians, South Asians have by far the worst problems when it comes to heart disease. Nearly 50 per cent of CVD-related deaths in India occur below the age of 70, compared with just 22 per cent in the West. This trend is particularly alarming because of its potential impact on one of Asia's fastest-growing economies. In 2000, for example, India lost more than five times as many years of economically productive life to cardiovascular disease than did the U.S., where most of those killed by heart disease are above retirement age.
Studies indicate that South Asians have elevated levels of LDL cholesterol and triglycerides, while also suffering from a deficiency in HDL cholesterol (good cholesterol, which helps clear fatty buildups from blood vessels). In addition, South Asians tend to gain weight in the abdominal region (Waist: hip ratio >1.0 in men, >0.9 in women) and are at greater risk of heart disease. Environmental factor like low birth weight, malnutrition also possibly predisposes Indians to increased risk of diabetes and heart attacks in adulthood.
Statistics suggest that South Asians seem more naturally vulnerable to heart disease than other ethnic groups. Lancet 2000 study showed that, even after adjusting for all known risk factors; South Asians in Canada appeared to have a higher rate of heart disease than Europeans or Chinese living there. Some doctors think that this vulnerability can be explained by the "thrifty-gene" theory, which holds that South Asians adapted over many generations to the region's frequent famines. Now with a very recent overabundance of food, their bodies are having difficulty making a metabolic U-turn and the result is high insulin intolerance, with accompanying raised levels of diabetes and obesity.

The 10 leading selected risk factors for death and disability, by type of country as given by WHO:
High-mortality developing countries
Low-mortality Developed countries
Developed countries
1 Underweight
Alcohol consumption
Tobacco consumption
2 Unsafe sexual practices
High blood pressure
High blood pressure
3 Unsafe water, poor sanitation
Tobacco consumption
Alcohol consumption
and poor hygiene
4 Indoor smoke from solid fuels
Underweight
High cholesterol level
5 Zinc deficiency
Overweight
Overweight
6 Iron deficiency
High cholesterol level
Low fruit and vegetable intake
7 Vitamin A deficiency
Low fruit and vegetable intake
Physical inactivity
8 High blood pressure
Indoor smoke from solid fuels
Illicit drug use
9 Tobacco consumption
Iron deficiency
Unsafe sexual practices
10 High cholesterol level
Unsafe water, poor sanitation and poor hygiene
Iron deficiency

Some new markers have been identified: Nearly 95 percent of people who developed a fatal cardiovascular disease had at least one of these major risk factors: high blood cholesterol, high blood pressure, smoking, diabetes besides a poor diet and overweight. But it can also develop in the absence of any traditional risk factors and evidence is accumulating that several other risk factors may help predict or contribute to cardiovascular disease.
Among the leading new potential culprits: C-reactive protein (CRP), Homocysteine, Fibrinogen, Lipoprotein (a). Information about how these four substances are connected to cardiovascular disease is still emerging, and researchers continue to debate their importance. Indeed, there's much to be learned before screening for these substances becomes as routine as getting the blood pressure or cholesterol checked. Routine screening of the general public for these markers is not recommended but there may be a role for screening in people who have a strong family history of cardiovascular disease, have early onset disease with no apparent traditional risk factors, or whose disease isn't well controlled despite optimal management of traditional risk factors. It's not clear yet what role these four substances play in predicting or causing disease and testing for these substances isn't fully standardized. There is hope that they may help lead to additional prevention and treatment strategies for cardiovascular disease.
C-reactive protein : (CRP) is a protein produced by the liver as part of the normal immune system response to injury or infection. CRP is an inflammatory marker and inflammation has a central role in atherosclerosis the accumulation of plaques of fats, cholesterol and other material in the arteries. High levels of CRP in the blood have been associated with an increased risk of cardiovascular disease, including heart attack and stroke. But it's not clear if CRP actually causes heart disease or is just a sign of inflammation, which may cause heart disease. The AHA and the Centers for Disease Control and Prevention recommend CRP screening for an intermediate risk a 10 percent to 20 percent chance of developing coronary heart disease in the next 10 years. Low risk: Less than 1 mg/L, Average risk: 1 to 3 mg/L, High risk: Over 3 mg/L. If the CRP is greater than 10 mg/L, it's likely the result of an infection or other condition and isn't useful in assessing the cardiovascular risk and the test should be repeated in about two weeks, or after the infection is gone, to assess cardiovascular risk.
Homocysteine: It is an amino acid normally present in the blood and is utilized by the body to make protein and to build and maintain tissue. Studies indicate a link between high plasma levels of homocysteine and an increased risk of stroke, certain types of heart disease, and peripheral vascular disease. Raised levels may be associated with four times higher risk than normal homocysteine levels. The exact mechanism of its action isn't clear and as with CRP, it's not known if homocysteine is a cause of cardiovascular disease or a marker of its presence. Recent work suggests that increased homocysteine levels may eventually cause the tissues lining arteries to thicken and scar. Cholesterol can build up in those scarred areas, providing a surface for blood clots to form. There's no consensus on what homocysteine levels are optimal, but in general, less than 12 micromoles is desirable. Readings in healthy people can range between 5 and 15 micromoles. Elevated homocysteine levels can be decreased by dietary supplementation of folate, vitamin B.
Fibrinogen: Although fibrinogen is needed for normal blood clotting, its excess may promote excessive clumping of platelets and can result in thrombosis in an artery, leading to a heart attack or stroke. Besides inactivity, excessive alcohol consumption and estrogens, whether from birth control pills or hormone therapy, which elevate fibrinogen, smoking is the most significant lifestyle factor that raises fibrinogen levels. The normal range for blood (serum) fibrinogen is 200 to 400 mg/dL, and levels around 400 mg/dL is associated with a twofold increase in risk of heart attack or stroke.
Lipoprotein(a): It's formed when a low-density lipoprotein (LDL) cholesterol particle attaches to a specific protein. Studies show that an increased level of Lp(a) is associated with an increased risk of cardiovascular complications, including early coronary heart disease, heart attack and stroke. Elevated Lp(a) level, generally do not respond to most lipid lowering agents but niacin, omega-3 fatty acids or estrogen may help in some cases.
Deaths from cardiovascular diseases, principally acute myocardial infarction and cerebrovascular accidents, have decreased substantially over the past two decades, largely as a result of advances in acute care and cardiac surgery, aggressive antihypertensive therapy, the recognition of the hazards of tobacco abuse, improved nutritional patterns coupled with a decrease in cholesterol values in the general population, and an increased emphasis on physical activity.
However, these developments have produced a growing population of patients who have survived a myocardial infarction or who have a stable, if not controlled, pattern of angina pectoris due to atherosclerotic coronary artery disease. These patients, and those with peripheral vascular disease, hypertension, hyperlipidemia, diabetes mellitus, and chronic obstructive pulmonary disease, are potential participants and likely benefactors of heart smart strategies that include change in dietary habits and cardiac-rehabilitation programs. These techniques are particularly useful in the Indian context where the semi urban and rural population is largely unaware about the importance of lifestyle techniques in prevention of cardiovascular disease.
Cardiac rehabilitation is a medically supervised exercise and counseling program designed to help overcome some of the physical complications of heart disease, limit the risk of developing additional heart trouble, help a person return to an active social or work schedule, and improve the psychological well-being. It has four main components: Medical evaluation, supervised exercise, lifestyle education and psychosocial support. Cardiac rehabilitation takes time at least six months and it's not always easy. It's also not suited for everyone with a heart problem, and the results may vary for reasons beyond the participant's control.
But for most people in cardiac rehab, the hard work put into it offers many rewards. Participation maximizes their ability to regain independence and provides the knowledge to ensure that healthy living will become a permanent part of their future.

Five heart-smart strategies directed towards healthy dietary habits.
1.Limit intake of unhealthy fats and cholesterol
The best way to cut saturated and trans fat intake is to limit the amount of solid fat like butter, margarine that is added to food when cooking and serving. If fat is to be used, choose oils high in monounsaturated fat, such as olive oil or canola oil. Avoid butter, lard, bacon, gravy, cream sauce, nondairy creamers, hydrogenated margarine, cocoa butter found in chocolate, coconut, palm and palm kernel oils.
Use of monounsaturated fats lower the total cholesterol and low-density lipoprotein (LDL) cholesterol (the "bad" cholesterol).
2. Choose low-fat protein sources
Although meat, poultry and fish along with dairy products and eggs are some of the best sources of protein, they are high in total fat, saturated fat and cholesterol. Skim milk rather than whole milk or skinless chicken breast rather than fried chicken patties are lower fat versions and may be substituted for the above. Fish is another good alternative to high-fat meats. Some types of fish such as cod, tuna have less total fat, saturated fat and cholesterol than do meat and poultry whereas certain types of fish like salmon, mackerel and herring are heart healthy because they're rich in omega-3 fatty acids. These fats may help lower triglyceride levels and may reduce the risk of sudden cardiac death.
Legumes like beans, peas and lentils are good sources of protein and contain less fat and no cholesterol, making them good substitutes for meat. Soybeans may be especially beneficial to the heart and may be regularly substituted for animal protein.
3. Eat more fruits and vegetables
Fruits and vegetables are low in calories, good sources of vitamins and minerals, and rich in dietary fiber. They also contain phytochemicals, substances found in plants that may help prevent cardiovascular disease. Eating more fruits and vegetables helps us indirectly also by satisfying hunger and thereby reducing intake of high-fat foods. Don't smother vegetables in butter, dressings, creamy sauces or other high-fat garnishes. Avoid fruits in cream or heavy sauces.
4. Select whole grains
Whole grains do not have their bran and germ removed by milling, making them good sources of fiber, which the body can't digest besides other nutrients. A diet high in fiber can help lower blood cholesterol levels and reduce the risk of heart disease. Whole grains are also important sources of vitamins and minerals, such as thiamin, riboflavin, niacin, folate, selenium, zinc and iron. Doughnuts, biscuits, cakes, Buttered popcorn and high-fat snack crackers should be avoided.
5. Practice moderation and balance
Knowing which foods to eat is the first step in creating a heart-healthy diet. The next step is to know how much food to consume. Overloading can lead to excess calorie, fat and cholesterol intake. Keep track of the number of servings you eat - and use proper serving sizes - to help control how much food you eat.
A serving size is a specific amount of food, defined by common measurements such as cups, ounces or pieces. For example, the Food Guide Pyramid developed by the Department of Agriculture and Department of Health and Human Services suggests that one serving of pasta is 1/2 cup, or about the size of an ice cream scoop. A serving of meat, fish or chicken is 2 to 3 ounces or about the size and thickness of a deck of cards. Judging serving size is a learned skill. You may need to use measuring cups and spoons and a scale until you're comfortable with your judgment.

References:
Walsh B: Asia's War With Heart Disease Time, November 22, 2004 / Vol. 164, No. 21
Lancet 2000
World Health Organization. World health report: reducing risks, promoting healthy life. Geneva: WHO, 2002.
Mayo clinic.com
The writer is senior consultant and head of department of Critical Care Medicine Fortis Hospital, Noida.

Travellers' diarrhoea

2008-09-04T07:22:00.000-07:00

Written by Dr Charlie Easmon, specialist adviser in travel medicine

Causes of travellers' diarrhoea
The toilet roll is not supposed to be your most important travelling companion. Think before you eat and drink as it is very easy to pick up a bout of diarrhoea while holidaying abroad.
The most common cause of holiday or travellers' diarrhoea is the different types of virus and bacteria at the destination. The local drinking water in particular is an obvious source of risk in many places and should, therefore, be completely avoided. Replace it with water from previously unopened bottles for drinking as well as for cleaning teeth and making ice for drinks. Approximately 40 per cent of all cases of travellers' diarrhoea are due to infections with ETEC (enterotoxin-forming Escherichia coli bacteria). It is also possible to be infected with other and more specific and unpleasant bacteria and parasites, such as cholera, typhoid fever, paratyphoid fever, Salmonella, Clostridia, Yersinia, Shigella, Bacillus cereus, amoebae and Giardia lamblia. Such infections will typically require medical treatment and possibly antibiotics, whereas the common, but troublesome travellers' diarrhoea is self-limiting and passes within a week.

Incidence
The risk of suffering from diarrhoea is very high and estimates vary from 30-80 per cent of travellers! It rises among other things with the exotic nature of the destination, the climate (particularly in the tropics) and poor general and personal hygiene, but stomach infections can occur anywhere in the world, and unpleasant bacteria also flourish in the UK (for example Salmonella, Campylobacter and Listeria).

Factors affecting infection and general prevention
Travellers' diarrhoea is typically due to one or more of the following factors:
food that has gone off
contaminated food and drink
poisonous substances (toxins).

Many problems can be avoided by knowing and understanding the mechanisms of infection and spread, which include:
1. infection from faeces to hand and then to mouth. A typical example of this is if a chef or waiter is a little slapdash in going to the toilet, uses little toilet paper and does not bother washing his hands. He then warmly shakes the guest's hand before the latter picks up a chicken leg and puts his teeth into it without washing his hands. Or what about the change you put in your pocket, using the same hand to put a sweet or something else in your mouth? This is a typical way of contracting Shigella dysentery. Prevention consists of washing the hands frequently, particularly before eating.
2. from faeces to food or drink and then to mouth. For example, the butcher, chef and farmer, etc have the same lack of hygiene as described above, but in this case transfer the infection directly to food or drink. And the farmer no doubt may also use cheap human manure rather than expensive commercial fertiliser for his salad crops. In this infection mechanism, prevention consists of adequate heat treatment of food/drinks. Remember that ice cubes may also be infected.
3. toxins (poisonous substances) that occur for example in botulism and when rice dishes are left standing (go cold). In the latter case, the cause is a toxin from Bacillus cereus, and toxins of this kind cannot be removed by reheating or renewed boiling.

The familiar old slogan: 'Cook it, boil it, peel it, - or leave it' is still the most important basic rule to follow.
1. A good many stomach infections can be avoided by taking some simple precautions.
Always wash your hands twice with soap before using them to put anything at all in your mouth and dry your hands by air or a clean towel. Wet hands still carry a significant risk of infection. In the field you can always take a plastic bottle of soapy water or special antiseptic wipes with you.
2. Avoid the local drinking water, dairy products and ice cream in destinations where there is a high risk.
3. Eat only fresh foods that have been directly and sufficiently heat-treated.
4. Salads washed in the local drinking water are obviously a risk - watch out for the dressing as well.
5. Shellfish and fish that have been on display in the sun all day or have lived in the water from a sewage outlet are obviously not the things to eat.
6. Food stalls on the street are exciting, but are not advised owing to their doubtful hygiene
7. Take a look inside the kitchen at the place where you are intending to eat. If it is swarming with flies, which spread more infection than all other insects put together, or if there is leftover food in the pots, and the chef/waiter has visible boils or infected sores, find somewhere else to eat.
8. Products from home distilleries can be a real health disaster.
9. Avoid pouring ice-cold drinks down into a warm stomach (does not cause infection, but stomach cramps).

Prevention with medicines
Vaccination against hepatitis A, either with active vaccine or with gammaglobulin, is always to be recommended. Although hepatitis A does not cause travellers' diarrhoea, the infection is typically transmitted with infected food/drinks. In Europe, freeze-dried lactic acid bacteria capsules are popular, but there is no proof that they work.

Treatment of travellers' diarrhoea
As mentioned, the majority of cases will calm down within five to eight days and do not require any drug treatment. On the other hand, the following can be recommended:
1. drink plenty of fluids (at least 3-4 litres a day and aim to replace everything that is put out!) – more in the case of fever, vomiting and diarrhoea in the tropics. Fruit juice, diluted fresh juice (1:4), cola, broth/soup are also useful as it is also important to take in salts. A certain amount of sugar is in order, but must not be overdone. Dairy products, coffee and alcohol should be avoided. Rehydration powder for dissolving in boiled water can be purchased in pharmacies and contains an ideal mixture of salts.
2. many specialists now recommend the use of a single tablet of ciprofloxacin 500mg (antibiotic). This is the dose for adults who are not pregnant or breastfeeding. If the traveller feels well after 24 hours on this, the problem was probably bacterial. As ciprofloxacin requires a prescription, you could ask your own doctor to write a prescription in advance of travelling if you are worried that access to a hospital or doctor may be difficult. Such prescriptions need to be issued privately, ie the cost of the drug has to be paid for in full to the pharmacist.
3. solid food such as boiled rice, peeled fruit, toast, biscuits and crisps is recommended.
rest and relaxation (reduced level of activity).
4. antidiarrhoea drugs (loperamide, diphenoxylate, codeine) are advocated by many people and may be useful for a long journey or in acutely embarrassing situations. They are not recommended for young children.
5. if you have spent more than one week in a malarial area, it is important to remember that malaria can also lead to diarrhoea.

Danger signals - consult a doctor if possible
1. Bloody diarrhoea may be seen in several diseases, but on certain trips consideration must be given to the possibility of Shigella dysentery and amoebic dysentery in particular. Shigella dysentery (bacillary dysentery) occurs quite suddenly and typically causes many (10-25) bloody episodes of diarrhoea a day, a high temperature, gastric pain, and pain on defaecation (tenesmus). The immediate danger is weight loss (through dehydration). The treatment will typically be a quinolone antibiotic, eg ciprofloxacin. Amoebic dysentery typically arises more slowly and is not associated with fever. It requires full treatment with metronidazole to exclude the possibility of late complications such as liver disease.
2. High fever. Fever is seen in many infectious conditions and is not a danger signal in itself. However, in places where more exotic infections are possible, including malaria, medical assistance should be sought in the case of a high fever and/or poor general condition.
3. Diarrhoea with yellowish or greenish mucus.
4. Dehydration. If the patient is unable to drink sufficiently, which may be apparent for example from dark and scanty urine production, lethargy or even confusion, and dry mucous membranes (lips and tongue).
5. Acute diarrhoea in infants and young children, the elderly and anyone else who is weak or ill in advance.

Headaches

2008-09-02T22:40:00.000-07:00

Reviewed by Dr Reginald Odbert, GP

What is a headache?
There is no single cause for headaches and, while they are painful and annoying, the majority of headaches do not indicate that there is a serious problem. Headaches involve mild to severe pain in one or more parts of the head as well as the back of the neck. There are many different types of headache patterns and a variety of causes. While painful and annoying, the majority of headaches do not indicate a serious disorder and, in non-chronic cases, may be relieved by medicines and/or changes in lifestyle.

What causes headaches?
There is no single cause of headaches. A number of causes have been identified which fall into two general categories.
Tension headache
This type of headache results from contraction of head and neck muscles. It is the most common form of headache and accounts for 70 per cent of headaches. It can occur in people of either sex and at any age but it is most common in adults and adolescents. Tension headache usually occurs in isolated incidents but can become chronic for some people. Possible causes of muscle contraction associated with tension headaches include:
stress.
fatigue.
poor posture.
eye strain.
tobacco and alcohol use.
in women, hormonal changes occurring before and after a menstrual period.
Migraine headache
Migraine is the cause of 20 per cent of all headaches. This type of headache occurs when blood vessels of the head and neck constrict, resulting in a decrease in blood flow to the vessels. Migraine is usually experienced as a throbbing pain on one side of the head with an associated feeling of sickness and sensitivity to light and sound. Migraines are known to affect more women than men and are often chronic. Below are some of the factors that have been identified as being associated with migraines:
family history of migraine.
prolonged muscle tension and stress.
alcohol use.
smoking or exposure to tobacco smoke.
lack of sleep.
for women, menstrual periods and the use of oral contraceptives.
certain foods such as chocolate, nuts and fermented or pickled condiments, as well as foods containing the amino acid tyramine (aged cheese, red wine, smoked fish) and foods containing preservatives and artificial sweeteners.

What are the symptoms of tension and migraine headaches?
Tension headache
Pain is often felt in the generalised area of the head and neck as opposed to on one side. Pain may also be situated in the back of the head and neck and feel like a 'tight band'. Sometimes accompanied by muscle tightness in back of neck. Of relatively short duration if treated in time.
Migraine headache
Throbbing, pulsating feeling usually worse on one side of the head. Pain may be dull or severe and often begins in the morning, gradually worsening in an hour or so. Pain may be accompanied by other symptoms such as nausea, vomiting, vertigo-like feeling and visual disturbances.
Sensitivity to loud noises and light. Commonly lasts from a few hours to one or two days in some cases.

When should you consult a doctor?
Most people with isolated tension headaches usually avail themselves to over-the-counter pain relievers and anti-inflammatories, or self-treatment such as relaxation and sleep. However, for chronic headaches contact your GP to discuss possible causes and prevention.If any of the below symptoms are present your GP should be contacted immediately:
a sudden, severe headache accompanied by nausea and vomiting.
persistent and recurring headaches accompanied by memory problems, difficulty concentrating and tiredness.
a high fever with neck stiffness (unable to bend the chin down to the chest).
convulsions (fits).
persistent vision disturbances (light flashes).
trouble controlling arms and legs.
loss of feeling in the arms and legs.
tiredness and apathy with difficulty communicating.

How does the doctor make a diagnosis?
An accurate history of any previous illnesses, family background, diet and lifestyle is crucial to help the doctor decide whether to perform further tests and to advise on treatment.The doctor will ask for information about the headache, its length, duration, location, associated features, quality and causative factors. For headaches with indication of a chronic or more serious disorder, the following diagnostic procedures might be performed, usually following assessment by a specialist:
head CT (computerised tomography) scan.
head MRI (magnetic resonance imaging).
sinus X-rays.
temporal artery biopsy.
lumbar puncture.

What kind of treatment is available?
A 'headache' diary is very useful to help your doctor figure out what kind of treatment is most appropriate for your diagnosis. The easiest way to do this is to write the dates of headaches on a calendar. Make a note of when the pain started and how long it lasts. Note down any additional factors that seem important such as what has been drunk and eaten, the intake of medicines, daily activities, details about periods if you are a woman, and weather conditions.It is a good idea to keep up the diary for between one and two months so that any patterns can be identified. By establishing what triggers the headaches, it is possible to learn to avoid factors that cause them. If you are unable to find a connection it might be a good idea to show the diary to a doctor, who may be able to ask pertinent questions that will help identify a pattern.While each person will require their own form of treatment, generally over-the-counter pain relievers (eg paracetamol, aspirin) and non-steroidal anti-inflammatories (eg ibuprofen) are quite helpful in relieving the symptoms of tension-like headaches. Prescription medicines may be helpful for other types of headache pain such as chronic migraines.In migraine, the most effective treatment is an explanation of the problem and identifying and avoiding trigger factors. There are various treatments available for relieving acute attacks, starting with over-the-counter painkillers such as paracetamol or ibuprofen. These are most effective if taken as early as possible into the attack, preferably in a soluble form. Some OTC medicines designed specifically for migraine also contain an antisickness medicine such as buclizine. If OTC painkillers are ineffective your doctor may prescribe alternative treatments containing different antisickness medicines, stronger painkillers, or one of a group of antimigraine medicines called triptans, eg sumatriptan or zolmitriptan.Your doctor may prescribe a preventive treatment if migraine attacks are especially frequent. The strongest evidence for preventive treatment of migraine is available for sodium valproate (unlicensed use) and beta-blockers, eg propranolol. For people experiencing burning sensations in the stomach or for those already diagnosed with a stomach ulcer, medicines containing acetylsalicylic acid such as aspirin should be avoided. Aspirin should not be given to children under 16 years of age, unless on the advice of a doctor.NOTE: The above mentioned medicines should not be given to children unless you are advised to do so by your GP.

What can you do to help yourself?
If the doctor has examined you without finding any serious cause for the headaches, these tips should prove helpful:
avoid excessive use of alcohol and tobacco.
engage in correct posture while sitting and working. The type of chair you use is important. It should be one that maximises comfort and good posture and may need to be adjusted to suit your needs.
perform relaxation techniques on a consistent basis.
get plenty of fresh air and exercise.For migraine headaches, symptoms may be reduced by:
resting in a quiet room with the lights turned off.
avoiding food or drink in your diet that have been identified as having possible factors associated with migraine headaches.

References B Rasmussen. The epidemiology of headache. Cephalgia 1995; 15:45-68.M Ferrari. Migraine. Lancet 1998; 351: 1043-51.Based on a text by Dr Carl J Brandt, Dr Per Rochat and Dr Claus Madsen, specialist

Smoking - health risks

2008-08-25T10:45:00.000-07:00

Reviewed by Dr Gavin Petrie, consultant chest physician
Why quit smoking?

Smoking kills over 120,000 people in the UK each year. Cigarettes contain more than 4000 chemical compounds and at least 400 toxic substances. While the smoker is inhaling, a cigarette burns at 700 degrees Celsius at the tip and around 60 degrees in the core. This heat breaks down the tobacco to produce various poisons. As a cigarette burns, the residues are concentrated towards the butt. The products of a cigarette that are most damaging to health are tar (which can cause lung cancer), carbon monoxide and nicotine (cardiovascular disease), and the components of the gas and particulate phases, which cause chronic obstructive pulmonary disorder. The effects are influenced not only by the number of cigarettes, but also how the cigarettes are constructed (with or without filters) and how the tobacco has been prepared. Paradoxically, the 'side-stream smoke' that comes off a cigarette between puffs carries a higher risk than directly inhaled smoke. Clearly, there are many health-related reasons to give up cigarettes - not only from the point of view of smokers, but also to protect those around them.

Smoking affects how long you live
Research has shown that smoking reduces life expectancy by seven to eight years. An interesting calculation predicts that on average, each cigarette shortens the life of the smoker by around seven to eleven minutes.
Non-smokers and ex-smokers can also look forward to a healthier old age than smokers.

Major diseases caused by smoking
Cardiovascular disease

Cardiovascular disease due to atherosclerosis is the main cause of death due to smoking, with an overall increase of death of 1.7 times. Atherosclerosis is the term used to describe the clogging up of the arteries with fatty material, leaving them narrow, blocked or rigid. It can take many forms depending on which blood vessels are involved, and all of them are more common in people who smoke. Coronary thrombosis is a blood clot in the arteries supplying the heart. Approximately 30 per cent of cases are caused by smoking. Nine out of ten people who require a heart bypass operation are smokers or ex-smokers. The vessels to the the brain can become blocked, which may lead to collapse, stroke and paralysis. If the kidney arteries are affected, then high blood pressure or kidney failure results. Blockage to the vascular supply to the legs may lead to gangrene and amputation. If a patient quits smoking, their chances of survival improve. A Swedish study showed that patients suffering from atherosclerosis in the legs were more likely to survive if they gave up smoking, when the risk of dying from this disease was reduced from approximately 40 per cent to about 5 per cent.

Cancer

The risk of getting cancer is generally greater for smokers than non-smokers by a factor of 2.24. This is particularly true of lung cancer, cancer of the throat and cancer of the mouth, which hardly ever affect non-smokers. Eighty-five percent of all cases of lung cancer are related to smoking and a smoker is 12 times more likely to develop lung cancer. If a smoker quits, it will take approximately 15 years before their risk of getting lung cancer is the same as a non-smoker.

There are several other types of cancer that are more common amongst smokers than non-smokers. These are: cancer of the oesophagus, cancer of the kidneys, cancer of the pancreas, cancer of the cervix and cancer of the bladder. It is estimated that 94.5 per cent of 20-a-day smokers have some emphysema if the lungs are examined after death and more than 90 per cent of non-smokers have little or none.

Smoker's lung (COPD) typically starts when a person is 35 to 45 years of age. At that age, lung function starts to decline even in non-smokers, and in susceptible smokers, the rate of decline in lung function can be three times the usual rate. As lung function declines, then breathlessness on exertion starts. At first, smoker's lung consists of a cough and sputum, which are the symptoms of bronchitis. As the condition progresses, the person feels short of breath climbing stairs, walking up a slope or even when walking. Severe short-term problems will usually require several periods of hospital care. The final stage is a very distressing death due to slow and relentlessly progressive breathlessness. Too many people die every year from this disease which, in 80 per cent of cases, is caused by smoking.

Giving up smoking at any stage reduces the rates of decline in lung capacity and postpones disability and handicap. Anti-smoking measures are very important in preventing smoker's lung and all the other adverse effects caused by smoking. It is difficult for many addicted smokers to quit. Nicotine replacement treatment in the form of gum, skin patches or nasal spray help some people to quit successfully. Bupropion (Zyban) is a medicine that is now licensed in the UK to help smoking cessation. Behaviour modification and alternative therapies including acupuncture and hypnosis are also in use, but there is no best buy for smokers who are thinking of trying to kick their habit. The weight of evidence suggests that smokers should set a date to stop, then do their best to quit completely from then on. This is a difficult strategy to adhere to, and additional treatments such as those outlined above provide support.

Other risks caused by smoking
Nicotine in cigarettes increases the amount of cholesterol in the blood, which may cause the arteries to clog up with fatty tissue called atheroma (see section on major diseases above).
High blood pressure or hypertension, which are related to heart attacks and stroke.
Smoking causes an acid taste in the mouth and contributes to the development of ulcers.
Couples who smoke are more likely to have fertility problems than couples who are non-smokers.
Generally smokers have 25 per cent more sick days year than non-smokers.
Smoking also affects your looks: smokers have thicker and rougher skin.

How smoking harms children

Babies born to mothers who smoke:
are twice as likely to be born prematurely and with a low birth weight (below 2.5kg or 5lb 8oz).
have a birth weight on average 200g (7oz) less than those born to non-smokers.
have organs that are smaller on average than babies born to non-smokers. This is particularly evident in the case of the lungs of a newborn baby which do not function as well as the lungs of a baby whose mother does not smoke.
are twice as likely to die from cot death. There seems to be a direct correlation between cot death and parents' smoking.
are ill far more frequently than non-smokers' children.
get painful diseases such as inflammation of the middle ear and asthmatic bronchitis more frequently in early childhood.
may become addicted to the nicotine in their mother's smoke before they are born.
are more likely to become smokers.
have a higher risk of developing allergies.
children who are exposed to passive smoking every day if one or both of their parents smoke have twice the risk of getting asthma and asthmatic bronchitis.

Other benefits of quitting smoking
General health improves - tiredness and headaches can be linked to smoking.
The sense of taste and smell improve.
The heart will be less strained and work more efficiently.
An increase in self-confidence, knowing that you have beaten an old habit.

What are the effects of passive smoking?
Passive smoking irritates the eyes, nose and chest, and can cause headache.
Children exposed to passive smoking are more likely to have allergy and asthma, while those under two years old are more prone to severe respiratory infections and cot death.
Small reductions in lung function are also seen in children, although there is substantial difficulty in interpreting the various studies available.
For adults there seems to be a small increase in the risk of lung cancer, but the evidence for increased heart disease is not conclusive at present.

References Peto R, Lopez AD, Boreham J, Thun M, Heath Jr C. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet 1992; 339: 1268-78. Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years' observations on male British doctors. British Medical Journal 1994;309:901-911 Doll R, Crofton J, eds. British Medical Bulletin: Tobacco and Health. London: The Royal Society of Medicine Press, 1996; (vol 52). Cook DG, Strachan DP, Anderson Ross H. Series of papers: health effects of passive smoking. Thorax 1997-1998. Eds Britton JR, Weiss ST. Based on a text by Dr Carl J Brandt,

Drug abuse and addiction

2008-08-25T10:44:00.000-07:00

Written by Dr John Powell, MRC Psych, specialist registrar

What is drug abuse and addiction?

Drug abuse refers to the use of a drug for purposes for which it was not attended, or using a drug in excessive quantities. Drug addiction is a state of physical or psychological dependence on a drug.Physical addiction is characterized by the presence of tolerance (needing more and more of the drug to achieve the same effect) and withdrawal symptoms that disappear when further medication is taken. All sorts of different drugs can be abused, including illegal drugs (such as heroin or cannabis), prescription medicines (such as tranquilisers or painkillers), and other medicines that can be bought off the supermarket shelf (such as cough mixtures or herbal remedies).

What causes drug abuse and addiction?

This depends on the nature of the drug being abused, the person taking the drug and the circumstances under which it is taken.Some medications - for example certain sleeping pills or painkillers - are physically addictive. They have a specific effect on the body which leads to tolerance and withdrawal symptoms. Others may lead to a psychological addiction if people have a craving for the effect that the drug causes.There has been some speculation that some people may be more prone to drug abuse and addiction than others. Research is being carried out into whether there may even be genes that predispose certain people to addiction.Social circumstances are important in drug abuse. Peer pressure, emotional distress and low self-esteem can all lead individuals to abuse drugs. Ease of access to drugs is another influence.People abuse drugs for a reason. Understanding what the person's motivation is helps to explain why that person is abusing drugs.

How is drug addiction treated?

The first step in treatment is recognition by the individual that they have a problem. The person's GP will be able to advise on treatment for drug addiction. He or she may suggest that they see a specialist.Effective treatments are tailored to the needs of the individual. There is no one therapy that is used in all cases. The choice of treatment will also depend on which drug is being abused. Treatments include psychological therapies, such as behaviour therapy and medication to help the individual's withdrawal symptoms.Specific areas that may be focussed on during treatment include:
detoxification (coming off the drug if physically addicted)
preventing relapse
coping with relapse
longer term rehabilitation.

Key sources of evidenceLeshner AI. Science-based views of drug addiction and its treatment. Journal of the American Medical Association. 1999;282:1314-1316.US National Institute on Drug Abuse. Principles of drug addiction treatment - a research based guide. US National Institutes of Health. 1999.February 2000.

Do I drink too much alcohol?

2008-08-25T10:38:00.000-07:00

Written by Dr Dan Rutherford, GP

It can be hard for someone to tell exactly how much they normally drink. Accustomed drinkers are less aware of feeling drunk, so it may be a good idea to keep a diary of alcohol consumed over a period of time and make a note every time you have a drink.

Safe drinking

Present advice on safe drinking is:
What counts as a unit of alcohol?
Half a pint (250ml) of average strength beer.
125ml glass of wine.
One standard pub measure of spirits (25ml).
25ml of fortified wine, such as sherry or port.
no more than two units of alcohol per day for women
no more than three units per day for men
you should have at least two drink-free days a week.

When drinking at home, people are almost always more generous, so it’s a good idea to get into the habit of using a spirit measure. Staying within the ‘safe’ limits does not mean that a person is capable of driving a motor vehicle. When driving, it is best not to drink at all.

Advice for pregnant women

Pregnant women are advised to drink no more than one to two units of alcohol once or twice a week. Heavy drinking during pregnancy can cause the baby to be born with a condition known as foetal alcohol syndrome (FAS). FAS causes growth deficiencies, central nervous system defects, lowered IQ and facial malformations.

If I don't feel drunk, I don't have a problem - do I?

Alcohol tolerance can lead someone with a dangerously high consumption to be falsely reassured that as long as they don’t feel drunk, they will be fine. The reverse is true. Needing a lot of alcohol to get drunk proves that you are already drinking too much, too often. Alcohol tolerance can be compared to a lack of the ability to feel pain. If you didn't feel pain, you wouldn't immediately remove your hand from a hot stove and notice it was burnt until it was too late. If you have developed a tolerance for alcohol, you can no longer trust your body's signals to tell you when you've had too much. Instead, you will have to keep count of drinks to know when you've drunk too much.

How do I reduce how much I drink?

A person who drinks too much may feel it is impossible for them to reduce their alcohol consumption. If a drinking habit is very heavy, it is often hard work to reduce it - simply because it is always difficult to change habits. You may not even be sure whether you want to cut down. Fortunately, there are many different ways to reduce alcohol consumption and most people are able to find a way that suits them.

A step-by-step guide to reducing alcohol consumption

Keep a record of all alcohol consumption. Work on ways to make it easier to reduce the alcohol intake. Talking to a partner or friend could flag up some self-help ideas.
I can stop drinking alcohol on weekdays.
I can stop drinking alcohol during the day at work.
I can substitute every second drink with water, non-alcoholic beer, coffee or a soft drink.
I can take a different route home, so I won't be tempted to visit a pub.
I can visit my family instead of my drinking friends.

What if I can't reduce my drinking by myself?

It may be difficult for a person to reduce their alcohol consumption without outside assistance. There are several places where it is possible to get help and counselling. A GP will be able to help by:
giving advice and drug prescription

referring a heavy drinker to a counsellor or an organisation that can provide help, such as Alcoholics Anonymous.

Dedicated alcohol detoxification facilities are rare in the NHS, but there are several private units. These are expensive and it is unusual for the NHS to fund placement, but it does occur.

What about withdrawal symptoms?

For a very heavy drinker, stopping alcohol abruptly can be dangerous. In addition to the anxiety that abrupt withdrawal can cause, a small proportion of people develop a potentially serious condition called delirium tremens (DTs). This can cause confusion and even convulsions. Patients at risk of DTs are best managed by planned withdrawal from alcohol in hospital, along with supportive counselling and drug therapy to counteract the physical effects.

Is there a drug to stop me drinking?

Antabuse (disulfiram) is a prescription-only medicine that's designed to deter people from drinking. Antabuse does not remove the craving for alcohol, but it will help a drinker avoid being tempted in a weak moment.

Will it help me?
For some people, Antabuse is a good idea and a safety measure. Ex-drinkers who have used Antabuse say it is a relief to know they can't drink. It allows alcoholics to focus on things other than not drinking too much. However, Antabuse is a controversial medicine. It does not help everyone who takes it, nor is it the only way to give up alcohol. This is because if a person drinks while they are taking Antabuse, it will cause serious and unpleasant symptoms such as:
severe headache
blushing
a feeling of pressure in the chest
breathlessness
palpitations
nausea
in the worst cases, shock and collapse.In the event of shock, treatment will be required from a doctor or in a hospital emergency department.

Acamprosate is another drug that may be helpful to deter drinking. It works in the brain where it is thought to act by reducing the desire to drink alcohol. It doesn’t produce the same effect that Antabuse does if alcohol is consumed..

I think I have a drink problem. How do I find help?

If you drink more than the recommended amount and you find it difficult to cut down, there are several places you can turn to for advice and guidance. Throughout the country, there are local alcohol advice centres where you can ask for help. They can put you in touch with clinics where you will find specialists, nurses and social workers who can help. Phone numbers are listed in the telephone directory or can be obtained from the local health trust or your GP.

What help can I get at a clinic?
You may know you need help cutting down and want to go directly into treatment. You may want to speak to people at the clinic to judge the seriousness of your problem or get advice about what possibilities are open to you. You can also make contact if you are worried about one of your relatives or friends, who you think may have a drink problem.

Alcoholics Anonymous (AA)

Alcoholics Anonymous is the world's biggest union of self-help groups concerned with alcohol abuse. The therapy in these groups takes place without the interference of public bodies, doctors, psychologists or other professionals.Attending the meetings is on a voluntary basis. The only requirement is an honest desire to quit drinking. You will meet people who have been through the same hardships as yourself. You can contact AA on 0845 769 7555 or by visiting www.alcoholics-anonymous.org.uk.

Smoking - cutting down or quitting

2008-08-25T10:37:00.000-07:00

Reviewed by Dr Gavin Petrie, consultant chest physician

Addiction to tobacco is both physical and psychological. Every smoker knows how difficult it is to stop smoking or even cut down.
Reducing the amount you smoke is a start - and better than nothing, but the ultimate goal should be to quit altogether. And, as many ex-smokers will tell you, it is possible.

There are two parts to addiction:
Physical addiction occurs because you become addicted to the nicotine in the cigarette. This addiction causes real withdrawal symptoms if you cut down or quit.
Psychological addiction occurs because smoking becomes part of your daily routine. This means if you want to cut down or quit, you will have to change your habits.

Tackling physical addiction
Research has shown that using nicotine replacement therapy such as nicotine patches or chewing gum can reduce the number of cigarettes smoked and cut down the amount of dangerous smoke inhaled.
However, there is a slight risk the body will get used to this new form of nicotine. For this reason, it's important to keep an eye on how much of the substitute you're using.
Bupropion (Zyban) is an antidepressant medicine that is also effective in relieving the symptoms of nicotine withdrawal.

Tackling psychological addiction
Dealing with cravings
Here are some ideas to help you cope with cravings for a cigarette:
call a friend
chew some gum or eat something healthy
take a walk
brush your teeth
take a shower
take a deep breath
write a letter
occupy your hands by doing something such as sewing or knitting.

There are several ways smokers can help break a psychological addiction.
Decide how you want to quit - either by cutting down gradually or, preferably, stopping completely on a pre-determined date .
Make a list of reasons why you want to quit. Carry this with you at all times. When you have an urge for a cigarette, read your list and it will help strengthen your resolve.
Choose a date when you want to quit and stick to it.
Tell your family and friends - that way you'll have to keep to the date.
Find someone who can support you, for example a family member, friend or doctor.
When the day arrives, do something active - throw out your cigarettes and remove all ashtrays, lighters and matches. And spoil yourself by doing something you enjoy, such as going to the cinema or shopping.
Find something else to do for the times when you usually smoke a cigarette.

I've tried to give up before - it didn't work!
You're not the only one. The chances of success get better every time you try to quit. Most people need four attempts or more before they finally succeed. If you fail, just think of it as a rehearsal before you really quit.

How do I remain an ex-smoker?
Keep referring to your list of reasons to quit.
Update your list with any new reasons.
Avoid spending too much time around smokers.
Be proud of yourself - celebrate after each week, month and year that has passed since you quit.
Avoid drinks that make you feel like smoking, such as alcohol and coffee.
Don't let one slip ruin your whole quit plan.

How long does it take before the cravings disappear?
After just a few days the need for a cigarette will get less. And for some people, it may have completely vanished after just two to four weeks.

Will I gain weight?
You may gain a little weight, but don't let that put you off. A few extra pounds is nothing compared to the health advantages stopping smoking gives you.
Avoid dieting unless your doctor tells you to do so, because this will increase your desire to smoke. If you snack, choose something healthy and low fat. Be more active and work off the extra calories through exercise.

Isn't it enough to switch to a low tar brand?
Tar is just one of more than 4000 toxic substances contained in cigarettes. Tar holds the other toxic substances together and is one of the biggest causes of lung cancer.
The risk of getting some diseases may be smaller the less tar you breathe in.
By comparing tobacco mixtures and cigarettes you can see the amounts of tar and nicotine that each contain.
High tar contains more 20mg of tar per cigarette.
Medium tar contains 15-20mg of tar per cigarette.
Low tar contains less than 15mg of tar per cigarette.
However, even if you change to lower tar cigarettes, you will still be at risk of contracting any number of smoking-related diseases.
There is no 'safe' number of cigarettes to smoke, other than zero.

Click here for more support and advice to help you quit, including NetDoctor's free 90-day Stop Smoking Programme.

References
United States Department of Health and Human Services. The health benefits of smoking cessation - a report of the Surgeon General. US DHHS. Public Health Service, Centers for Disease Control. Center for Chronic disease prevention and health promotion. Office on smoking and health. DHHS Publication number (CDC) 90-8416,1990.

Silagy C, Mant D, Fowler G, Lancaster T. Nicotine replacement therapy for smoking cessation. The Cochrane Library, Issue 3, 1999.

Based on a text by Dr Carl Brandt,

Coping with smoker's lung

2008-08-25T10:36:00.000-07:00

Written by Dr Carl J Brandt, GP

Smoker's lung is a chronic inflammation of the lungs. It is also known as chronic bronchitis, emphysema or chronic obstructive pulmonary disease (COPD). It causes the respiratory passages to be swollen and irritated, increases mucus production and may damage the lungs. The symptoms are coughing and breathlessness that gets worse over time. The main cause of this disease is smoking, but it can also be aggravated by air pollution or allergies.

What can I do to prevent it?
If you smoke - stop. Your doctor or pharmacist can provide advice on smoking cessation products and techniques.
Get professional help if you need it.
Ease the symptoms with medicine and other treatments from your doctor.
Try to cope with the stress when it becomes difficult to breathe.
Learn to breathe more efficiently so you can continue with your daily activities.
Use less energy when doing activities.
Protect yourself against infections and items that may irritate your respiratory passages.
Acknowledge your emotions, and talk to a friend or a family member when you are angry or depressed.

Consider learning:

gradual muscle relaxation. Tighten, then relax, every set of muscles from your head down to your toes.
meditation. Concentrate on a word or a calm scene to help you relax.
biofeedback. Teach yourself to relax by using equipment that reveals muscle tension.

What kind of medication can be prescribed?

Medication is available that can:
widen the respiratory passages
fight lung infections
loosen phlegm
relieve anxiety
relieve pain.

Will oxygen therapy help?

Oxygen therapy may improve your life emotionally and physically, but it is only helpful in people who are severely limited in their physical ability. Oxygen therapy needs to be sanctioned by a consultant in chest disease, who will advise whether it is appropriate for an individual affected by COPD (or any other disabling lung condition). Once approved, oxygen therapy is provided on prescription from the NHS.

What to ask the doctor
Quitting smoking
I have smoker's lung - isn't it too late to quit smoking?
Stopping smoking at any age will have a beneficial effect on your lungs.

Tips to help you quit
Write down your reasons to quit on a piece of paper.
Keep a diary of when and where you smoke.
Try to find a pattern in your smoking habits.
Find someone who can support you, such as your doctor or friend.
Choose a method for quitting - remember, the only 'safe' amount to smoke is zero.
Nicotine patches or chewing gum may help.
Choose a date when you want to quit.
Tell people the date you've chosen, so you'll stick to it.
Ask about side effects from any medication that is prescribed.
Find out when you need to tell your doctor about side effects.
Keep an eye on changes to your condition and find out what to do if you notice any.
Learn how to recognise warning signs of a problem.
Ask questions about anything you would like to know about the condition or about medication, diet, exercise or breathing techniques.
Ask about non-prescription medicine.
How to take medication
Take your medicine strictly according to the prescription.
You must never increase, cut down or stop any treatment with prescribed medicine without talking to your doctor first.
Never change a fixed oxygen supply.
Don't use any medicines that aren't prescribed without first consulting your pharmacist or doctor.

How can I make breathing easier?

These techniques can help your lungs work more effectively and help you relax when you feel short of breath.
Breathe with the stomach
Place one hand on your chest. This hand should remain still when you breathe.
Place the other hand on your stomach with your thumb on your belly button. This hand should rise up and down when you breathe
Breathe in through your nose as you count to three. Breathe out as you count to six.
Repeat this for approximately 15 minutes.
Practice this as often as possible - learning to coordinate stomach movements and breathing takes time. You can breathe with the stomach while you are sitting, standing or lying down.
Tight-lipped breathing technique
Breathe in slowly through your nose.
Tighten your lips a little. Now breathe out slowly with a soft, hissing sound.
Try combining tight-lipped breathing with the stomach breathing.

How can I get rid of phlegm?

Controlled coughing can help you cough up phlegm without getting short of breath or damaging your respiratory passages.
Take a slow, deep breath through the nose.
Hold your breath for a couple of seconds.
Open your mouth a little and cough two to three short, forceful coughs.
Relax and repeat. Your nurse or physiotherapist will be able to teach you other techniques for loosening and getting rid of phlegm. Family members can also learn how to help you.

Does the food I eat make a difference?

Many people with smoker's lung have difficulty eating large amounts of food. Therefore, the food you eat needs to be nutritious and provide you with enough calories.

You can also:
vary the foods you eat every day and eat only healthy food.
have several small meals instead of a few big meals.
talk to your doctor if certain types of food give you problems. Cabbage, beans and corn may make breathing unpleasant.
drink lots of water, unless your doctor recommends otherwise.

Is exercise important?

People who are fit use less oxygen. Remaining active also helps you feel good about yourself. But remember to consult your doctor before starting an exercise programme - you will need to ask the following questions.
What kind of exercise do I need? (Walking is often recommended.)
How long and how often should I exercise?
Is it necessary to change doses of medication and/or oxygen when I exercise?
How can I avoid straining my lungs?
Try to avoid colds and influenza (the flu) by asking infected people to stay away until they're better.
Ask your doctor about immunisations against influenza and pneumonia.
Avoid contact with people who have a cold or the flu.
Call your doctor at the first sign of a cold or influenza. Signs could be: increased coughing, a stuffed-up nose, fever and yellow or green phlegm.
Avoid things that may irritate your breathing. These could include smoke from cigarettes or fireplaces, dust and smells from paint, exhausts or perfume, cold air, very dry or moist air, or air pollution.
Ask your doctor about air cleaners or air dehumidifiers.

Can I lead an active life despite my condition?
At work
Your condition should not prevent you from working.
Talk to your employer - a few changes in your workplace may be all it takes.
Consider training in another field if it is impossible to keep your present job.
Sex
Use a position that doesn't take much energy (such as side by side).
Use tight-lipped breathing.
Consider other ways of being intimate, such as cuddling, kissing, etc.
Rest before and after intercourse.
Travel
Ask your doctor about medical facilities in the location you plan to visit.
Ask your oxygen supplier where you can buy oxygen.
Remember to take prescriptions with you.
Tell the airline in advance if you may need oxygen.
Take some extra medicine in your hand luggage, in case your main luggage gets lost.
When doing manual work or housework
Conserve your energy.
After a hard task, do an easy task.
Break hard tasks into smaller parts. Rest every now and then.
Try using the tight-lipped breathing technique. Breathe out when you strain yourself.
Sit down as much as possible.
Keep the things you need close to you, so that you don't strain yourself more than necessary.
When possible, push and pull instead of lifting.
Use relaxation techniques.

How can family members help?
Share your emotions. You could be feeling the same way as the person with smoker's lung. You also need to talk about your emotions.
Give your full support if the person wants to quit smoking.
If you smoke, don't smoke anywhere near the person with smoker's lung - passive smoking is harmful.
Consider quitting smoking for your own sake.
Don't overprotect. Let the person who needs your help do as much as they can by themselves. Their self-confidence depends on it.
Help with the treatment. Ask the doctor or nurse how you can help at home.

Join a support group such as the British Lung Foundation. Talking to other families affected by smoker's lung can help you cope.

Alcoholic liver disease

2008-08-25T10:35:00.000-07:00

Written by Dr Matthew Warren, specialist registrar in liver medicine and Professor Christopher P Day, professor of liver medicine

Alcohol consumption in the UKMost people in the UK drink alcohol. Total alcohol consumption per head in the UK rose steeply between 1950 and 1975 and then levelled off until the mid 1990s, when it again started to climb. The General Household Survey of 2001 found that 39 per cent of men and 22 per cent of women were likely to have exceeded the recommended daily maximum (4 units for men and 3 for women) in the week preceding interview. There has been a marked increase in the past decade in the proportion of women drinking more than 14 units weekly, the steepest increase being in those aged 16-24. (A unit of alcohol is a single measure of spirits, a half pint of ordinary beer or lager or a standard size glass of wine.)

What is alcoholic liver disease?

Excessive consumption of alcohol can cause liver disease, as well as harming many other body organs. The prevalence of alcoholic liver disease (ALD) in a population is usually determined by measuring death rates from alcoholic cirrhosis (in which healthy liver tissue becomes increasingly replaced by scar tissue).These rates have increased alarmingly in recent years. Death rates in the UK rose by up to 88 per cent between 1974 and 1994 with the highest increase in young men aged 35-44 (7.6 deaths per year per 100,000 people).

How much alcohol is harmful?

The amount of alcohol that can cause liver damage seems to vary widely between individuals. But it is certain that:
there is a genetically inherited susceptibility to the harmful effects of alcohol.
women are also believed to be more sensitive to the harmful effects of alcohol than men.
daily drinking, and drinking outside meal times is more harmful than only drinking at weekends.
there is good evidence that the more you drink the greater your risk of developing ALD.

How does ALD progress?

There are three main stages of ALD, although the progression through these stages is variable. Examining a sample of the liver under the microscope from a biopsy gives the most accurate measure of the degree of liver damage.
Minimal change, or fatty liver: heavy drinkers often develop fatty change in the liver. This is not linked to deterioration in liver function, but abnormalities may be seen in some of the blood tests that give an indirect measure of liver disease (also called ‘liver function tests’ or ‘LFTs’). Fatty liver is reversible with abstinence from alcohol, but it is the first stage in the progression to cirrhosis.
Alcoholic hepatitis: the effects of this condition can be mild but may also be life threatening. The LFTs will almost always be abnormal, and the patient may develop jaundice. As with fatty liver, abstinence from alcohol can reverse the effects, but those who continue to drink heavily have a high risk of developing cirrhosis.
Cirrhosis: this is the final, irreversible stage of ALD and is characterised by scarring of the liver and development of liver nodules. It severely affects liver function and reduces life expectancy. The LFT's are usually abnormal, there may be jaundice (yellow colouring of the eyes and skin) and sometimes bruising or bleeding caused by abnormalities of the blood clotting system. In an advanced stage of ALD (severe alcoholic hepatitis or cirrhosis) the remaining liver capacity is insufficient for it to carry out its normal functions, then the body’s metabolism becomes badly affected and the stage of ‘decompensated ALD’ is reached. Complications of this are discussed below.

What are the symptoms?

The symptoms of ALD are usually non-specific, and do not necessarily indicate the severity of the underlying liver damage. Many people will have vague symptoms such as fatigue, nausea and vomiting ( typically in the morning), diarrhoea or abdominal pains. Many patients, even with advanced ALD will have no symptoms and are detected by the finding of liver blood tests performed as part of routine health screening, or during the investigation of other conditions.Only in the more advanced stages of decompensated ALD will the sufferer present with more specific liver-related symptoms such as jaundice, ascites (fluid collecting in the abdomen, causing distension), haematemesis (vomiting of blood) or encephalopathy (confusion, reduced level of awareness and altered sleep pattern, eventually progressing to coma). These are signs of severe liver damage and require urgent medical treatment.

How is ALD diagnosed?

If there is a history of alcohol excess sufficient to cause liver damage, tests can establish the presence and severity of the liver damage. Blood tests can give an idea but they are not accurate predictors. Further tests in hospital can confirm the diagnosis and determine the severity of the disease. Ultrasound scans create an image of the liver and surrounding organs, which helps in taking a liver biopsy. The ultrasound scan can help to assess the severity of disease and exclude other common causes of abnormal LFTs such as gallstones.Liver biopsy is the most accurate test to determine the stage of ALD present and to ensure alcohol is the cause of the liver disease. Research has shown that in up to 20 per cent of heavy drinkers with abnormal LFTs an alternate cause of liver disease is found on investigation. Liver biopsies are performed under local anaesthetic, and provide a tiny sample of the liver for analysis under the microscope.

What else could it be?

The above investigations will rule out whether the symptoms are caused by any of the following:
viral hepatitis, including hepatitis B and C.
haemochromatosis (an inherited disorder of iron metabolism).
Wilson's disease (an inherited disorder of copper metabolism).
autoimmune hepatitis (a liver disorder caused by the immune system attacking the liver).
Good advice Nutrition: a good diet and a 'normal' body weight can significantly improve the outcome of ALD. Obesity seems to increase the risk of advanced liver disease in heavy drinkers. Many patients are severely malnourished, due to loss of appetite and nausea. In advanced liver disease (alcoholic hepatitis and cirrhosis) nutritional supplements have been shown to significantly improve the liver blood tests. A diet high in antioxidants such as vitamin E and selenium is thought to help prevent and treat ALD. These can be taken as supplements or by eating more fresh fruit and vegetables.

Abstinence: even in advanced liver disease, it is still beneficial to stop drinking. Compensated cirrhotics who continue to drink are far more likely to develop decompensated disease whereas the survival rates of those who stop are as high as 89 per cent. But a decompensated cirrhotic who continues to drink only has a 33 per cent chance of survival.Supervision may be required to safely reduce alcohol consumption. A rapid reduction can lead to a physical withdrawal syndrome in up to 40 per cent of cases, characterised by agitation, sweating, anxiety and fits. Up to 5 per cent of people will experience visual hallucinations known as delirium tremens, or the 'DTs'. The withdrawal syndrome can be life threatening. Sedatives and hospital admission may be necessary.

How is ALD treated?

The treatment for ALD depends on the stage of the disease:
Minimal change or fatty liver

Abstinence from alcohol and improved nutrition with avoidance of obesity.

Alcoholic hepatitis

This will depend on the severity of the alcoholic hepatitis. In mild cases only abstinence from alcohol and nutritional support are required. But in acute severe alcoholic hepatitis (characterised by jaundice, easy bruising, abnormal blood tests and sometimes the presence of extra fluid within the abdomen (ascites) hospital admission is necessary. Steroids can also help some of these patients, but even with steroids 90 per cent die within three months of developing the disease. Kidney failure, if it occurs leads to an almost 100 per cent mortality rate.

Cirrhosis

Cirrhosis of the liver can be 'compensated' or 'decompensated'. Compensation implies cirrhosis without complications. The complications that may develop include bleeding from varices (abnormal veins that form in the gullet), ascites, jaundice and encephalopathy (confusion, reduction in conscious level and coma). Compensated cirrhosis may be managed with abstinence from alcohol and nutritional support as above.

Treatment of decompensated cirrhosis

In patients with decompensated cirrhosis, specific treatments may be required to deal with the complications of the disease:
Bleeding varices

Bleeding varices may need treatment by endoscope (a flexible camera which can be passed into the stomach) to destroy the abnormal veins in the wall of the gullet. Long-term treatment with tablets such as beta-blockers (eg propranolol) may reduce the risks of further bleeding. Patients with alcoholic cirrhosis often have a 'screening' endoscopy test to identify any varices before a bleed occurs. Where varices are found, treatment with beta-blockers has been shown to reduce the risk of a first bleed.
Ascites

Ascites require a low salt diet, and reduction of fluid intake is often advised. Patients will usually be treated with diuretics (water tablets) and may require intermittent drainage of the fluid with a catheter or plastic drainage tube being inserted into the abdomen (paracentesis). In some cases these measures will be unsuccessful, and further interventions such as a liver transplant may be needed.
Encephalopathy

Usually linked to additional stress on the body. This may include the use of inappropriate sedating or painkilling medicines, bleeding from the gullet or stomach, constipation, infections or abnormalities in the salts (electrolytes) in the blood. The main factor involved in causing the encephalopathy is an increase in ammonia levels in the brain. The treatment involves correcting the underlying problem, and treatment with lactulose (a liquid laxative). Lactulose decreases the production of ammonia in the gut and its absorption into the body. It lowers ammonia levels in the blood and may need to be taken long term to prevent recurrence of the encephalopathy.
Liver transplantationIn some patients with cirrhosis, liver function continues to deteriorate despite abstinence from alcohol and they may be severely affected by complications. These individuals may need a liver transplant. But for patients to be considered for transplantation, they must:
have been abstinent from alcohol for six months.
have advanced liver disease with complications.
have no other organ damage.
have good social or family support.Approximately 85 per cent of appropriate patients reach the five-year survival rates following a transplant.

References Living in Britain - the 2001 general Household Survey. Department of Health. http://www.doh.gov.uk/public/livinginbritainsurvey.htm

Alcoholism

2008-08-25T10:33:00.000-07:00

Written by Dr Dan Rutherford, GP

If you feel you can't function without a drink, seek help. Alcoholic drinks have been prepared and drunk for thousands of years, and the problems that can accompany excess alcohol intake have undoubtedly been around just as long.

Friend or foe?

High levels of alcohol consumption can lead to physical illness and psychological and social distress. Alcohol has therefore always had an ambivalent position in society. In moderation, it can be the oil that makes a social occasion go with a bit more flow or helps a shy person overcome their inhibitions. Small, regular amounts of alcohol also seem to have a positive effect on the heart and circulation. But too much alcohol is often a recipe for disaster. The increasing use of alcohol, along with other drugs of abuse, is a serious public health problem across all age ranges, but especially so in the young.

What is alcohol dependence?
CAGE questionnaire
The ‘CAGE’ questionnaire is a short list of questions that can indicate if alcohol dependence is a possibility.
Two or more positive answers to these questions suggests dependence.
Have you ever:
thought you should Cut down on your drinking?
felt Annoyed by others criticising your drinking?
felt bad or Guilty about your drinking?
had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eye-opener.)
Alcoholism, or alcohol dependence is a medical term with a deliberately more precise meaning than the problems that can occur, sometimes as one-offs, through an uncharacteristic binge. In alcohol dependence a number of features come together in the behaviour of the person affected.
Drinking begins to take priority over other activities. It becomes a compulsion. Tolerance develops, so it takes more alcohol to produce drunkenness. Withdrawal symptoms such as anxiety and tremor develop after a short period without a drink, and are reduced by taking more alcohol.Often alcohol dependence remains undetected for years. Both the availability of alcohol and the way it is used (the social patterns) appear to be major factors in influencing the likelihood of a person becoming alcohol dependent. There may also be a genetic component, because alcohol dependence clusters in some families. However, it’s hard to be sure that this is not because of learned behaviour.

What problems are caused by too much alcohol?

Excess alcohol can lead to health problems including:
depression
liver cirrhosis
heart failure
damage to the brain and nervous system. Along the way there is often damage to relationships, finances and jobs and problems with the law.

Mental health and alcoholism

Mental health problems are common with alcoholism. Each can lead to or reinforce the other. Depression is a common cause of alcoholism as the depressed person seeks a way out of their problems or a relief from insomnia. Unfortunately, alcohol is itself a depressant, so the problem is only compounded. Anxiety can be temporarily relieved by alcohol, but this may lead to repeated intake and dependence. Without adequate attention to the mental health needs of a person with alcohol dependence, little progress will be made. Often alcoholism remains unsuspected even by the doctor, and it may come to light only when medical tests are done for other reasons.

Treating alcoholism

The difficulty of treating alcoholism should not be minimised – it can be very hard, even with support from family, friends and your GP. However, there are a a number of steps you can take including not drinking alcohol on weekdays.

Vitamins - what do they do?

2008-08-21T10:41:00.000-07:00

Reviewed by Dr Dan Rutherford, GP
Recommended daily amounts (RDAs)Throughout this factsheet, recommended daily amount refers to the European Union recommended daily amounts (EU/RDA) for nutritional labelling of food products. Nutritional requirements are often slightly different for young children and adolescents, and during pregnancy and breastfeeding. Ask your doctor or pharmacist if you are concerned about your own or your children's vitamin intake.
Vitamin A (retinol) propertiesGood for:
eyesight
growth
appetite and taste.Signs of vitamin A deficiency:
night-blindness.Good sources of vitamin A:
liver
fish-liver oil
carrots
green leafy vegetables
egg yolks
enriched margarine
milk products
yellow fruits.Recommended daily amount: 800 micrograms.
Poisoning: vitamin A is a fat-soluble vitamin and so it is stored for a long time in the human body, especially in pregnancy. An overdose may be dangerous. Destroyed by: fatty acids.
Vitamin B1 (thiamine) properties Good for:
nervous system
digestion
muscles
the heart
alcohol-damaged nervous tissues.Signs of vitamin B1 deficiency:
tingling in fingers and toes
confusion
difficulties in maintaining balance
loss of appetite
exhaustion
weakened powers of concentration. Good sources of vitamin B1:
liver
yeast
rice
wholemeal products
peanuts
pork
milk.Recommended daily amount: 1.4mg.Poisoning: no poisoning dangers as the vitamin dissolves in water, so excess is excreted in the urine. Destroyed by: high temperatures, alcohol and coffee.
Vitamin B2 (riboflavin) properties Good for:
growth
skin
nails
hair
sensitive lips and tongue
eyesight
protein, fat and carbohydrate breakdown. Signs of vitamin B2 deficiency:
itching and irritation of the eyes
itching mucous membranes
itching lips and skin. Good sources of vitamin B2:
milk
liver
yeast
cheese
green leafy vegetables
fish.Recommended daily amount: 1.6mg.Poisoning: no danger of poisoning as the vitamin dissolves in water, so excess is excreted in the urine.Destroyed by: light (this is why milk-cartons are better than bottles) and alcohol.
Vitamin B6 (pyridoxine) properties Good for:
preventing skin conditions
nerve problems
helping the body absorb proteins and carbohydrates.Signs of vitamin B6 deficiency: skin inflammation.Good sources of vitamin B6:
fish
bananas
chicken
pork
whole grains
dried beans.Recommended daily amount: 2mg. Women taking the contraceptive pill may need more. Poisoning: may cause nerve problems in large doses, but current evidence is conflicting about the maximum safe dose. Discuss this with your pharmacist if you are concerned. Destroyed by: the contraceptive pill, roasted or boiled food, alcohol and oestrogen (the female hormone).
Vitamin B12 (cobalamin) properties Good for:
making red blood cells
the formation of the nerves. Signs of vitamin B12 deficiency:
tiredness due to anaemia
abnormalities of nervous tissue function.Good sources of vitamin B12:
fish
liver
beef
pork
milk
cheese. Vitamin B12 deficiency can arise in strict vegans because our dietary sources of vitamin B12 are animal in origin. The other main cause of vitamin B12 deficiency is pernicious anaemia.Recommended daily amount: 1 microgram. Poisoning: no danger as the vitamin dissolves in water, so excess is excreted in the urine. Destroyed by: water, sunlight, alcohol, oestrogen and sleeping pills.
Vitamin C (ascorbic acid) properties Good for:
the immune defence system
protection from viruses and bacteria
healing wounds
reducing cholesterol content of the blood
a natural laxative
cell lifespan
preventing scurvy. Signs of vitamin C deficiency:
tiredness
bleeding gums
slow-healing wounds. Good sources of vitamin C:
citrus fruits - especially kiwi fruit
berries
tomatoes
cauliflower
potatoes
green leafy vegetables
peppers.Recommended daily amount: 60mg. Poisoning: Large doses can cause diarrhoea and nausea. Some scientists have recently argued that 1 to 5g per day may influence your genes. Destroyed by: boiling food, light, smoking and heat.
Vitamin D propertiesGood for:
strong bones and teeth.Signs of vitamin D deficiency:
unhealthy teeth
osteomalacia (causes weakening of bones)
rickets in children.Good sources of vitamin D:
cod-liver oil
sardines
herring
salmon
tuna
milk and milk products
sunlight (the action of sunlight on the skin allows our bodies to manufacture vitamin D).Recommended daily amount: 5 micrograms.Poisoning: this vitamin is fat-soluble so can accumulate in the body and overdoses are dangerous. Destroyed by: mineral oil.
Vitamin E (tocopherol) properties Good for:
fighting poisons - vitamin E is a powerful 'anti-oxidant'.Signs of vitamin E deficiency:
weak muscles
fertility problems. Good sources of vitamin E:
nuts
soya beans
vegetable oil
broccoli
sprouts
spinach
wholemeal products
eggs.Recommended daily dose: 10mgPoisoning: there is a theoretical but slight risk of overdose, as vitamin E is fat soluble. Destroyed by: heat, oxygen, frost, iron, chlorine and mineral oil.
Folic acid properties Good for:
production of red blood cells
essential during the first three months of pregnancy to prevent birth defects such as spina bifida, cleft palate or cleft lip. Signs of folic acid deficiency: anaemia, red tongue.Good sources of folic acid:
carrots
yeast
liver
egg yolks
melon
apricots
pumpkin
avocado
beans
rye and whole wheat
green leafy vegetables.Recommended daily amount: 200 micrograms. Pregnant women and women planning a pregnancy should take a daily supplement of 400 micrograms, continued for the first 12 weeks of pregnancy.Poisoning: no danger of poisoning as it dissolves in water, so excess is excreted in the urine.Destroyed by: water, sunlight, oestrogen, heat.
Based on a text by Dr Carl J Brandt

Vitamins

2008-08-21T10:37:00.000-07:00

Reviewed by Dr Dan Rutherford, GP
What are vitamins? The term 'vitamin' is derived from 'vital amine'. They are a group of substances required in small amounts for growth and development but which cannot be manufactured by the body.Without vitamins the human body would not survive. We all need vitamins in order to live a long and healthy life. Most of us get sufficient quantities of vitamins from our food, but it may be necessary for some people to take a vitamin supplement (eg pregnant women and the elderly).
How easy is it to get all the vitamins we need from our diet? A varied diet is essential if we are to obtain the nutrients we need. However, this is not always easy: fruit and vegetables age (an apple in a bowl loses vitamins hour by hour) and deep frozen products may often contain more vitamins than vegetables stored for a long time at room temperature. Therefore, it is especially important to eat a wide variety of fresh foods.Too little of just one vitamin may disturb the body's balance and cause health problems. But taking too many vitamins can also be dangerous. This is especially true of the fat-soluble vitamins A, D, E and K: it is harder to get rid of excess of these vitamins through urine - the most common way for us to eliminate body waste products.
Which vitamins do we know about?New vitamins are discovered occasionally, but presently we know of the following vitamins: A, B1, B2, B3, B5, B6, B10, B11, B12, B13, B15, B17, C, D, E, F, G, H, K, L, M, P, T and U.
Where do vitamin supplements come from?Most vitamin supplements have been extracted from natural foods. For instance, vitamin A comes from fish-liver oil. Vitamin B comes from yeast or liver. Vitamin C is often extracted from small berries in roses, and vitamin E is extracted from soy beans or maize. Vitamins may also be synthetically manufactured, but synthetic vitamins are not always as effective as their naturally-derived equivalent.
How should vitamins be stored?It is important to keep vitamins in a dark, cool place, or they will 'go off', just like apples in a bowl. The best place to store vitamins is in the refrigerator - make sure there is a lid on the container. A few grains of rice in the container will prevent moisture getting into the tablets.
When should you take vitamin supplements?The best time to take vitamins is during the day, after a meal. Never take vitamins on an empty stomach - they will quickly passed out in your urine. This is especially true for the B and C vitamins that dissolve in water. The fat-soluble vitamins A, D, E and K can be stored in the body for up to 24 hours and can sometimes be stored in the liver for even longer.
Are vitamins and minerals the same thing?Vitamins and minerals are two completely different things: minerals help the vitamins work. The 10 most important minerals are: calcium, iodine, iron, magnesium, phosphorus, copper, manganese, chromium, selenium and zinc. There is a specific recommended daily allowance for each of these, as well as for each of the vitamins. Based on a text by Dr Carl J Brandt, GP

Heartburn

2008-08-21T10:32:00.000-07:00

Written by Dr Dan Rutherford, GP and Ove Schaffalitzky de Muckadell, consultant and professor of internal medicine
Heartburn occurs when the acid contents of the stomach pass backwards up into the food pipe (called the gullet or oesophagus). This is also known as stomach acid reflux. Most people have stomach acid reflux at some point in their lives, either as heartburn or acid regurgitation.
What causes heartburn? Heartburn typically occurs after eating a large meal or drinking a lot of alcohol. Some people get heartburn when they bend over or lie down. The frequency of stomach acid reflux varies from one person to another. For most people, it happens very rarely. But weekly or daily incidents of heartburn or acid regurgitation may occur.
Is heartburn dangerous? Heartburn is annoying and may have a detrimental effect on a person's wellbeing. Sometimes the tendency for heartburn may develop into a mucous membrane inflammation in the food pipe, also known as oesophagitis. In the worst cases, oesophagitis may become complicated with ulcers, which, in rare cases, may bleed or cause chronic anaemia. Occasionally, reflux oesophagitis may become complicated if scars cause a tightening or narrowing (stricture) in the food pipe. A gullet stricture can prevent swallowing. This is a serious condition, which requires immediate examination and treatment.
How does gastric acid end up in the food pipe? At the lowest part of the food pipe there is a ring of muscle (sphincter) where it passes through a hole in the diaphragm.
The diaphragm
The diaphragm is a thin sheet of muscle dividing the lungs from the stomach.
The diaphragm holds the gullet sphincter in place and the system works as a one-way valve.If the one-way valve does not function properly, acid from the stomach (gastric acid) will be able to pass up into the food pipe. This tendency increases if:
the stomach contains large amounts of food or fluids (especially if the food is fatty, the drink alcoholic)
there is something pressing on the stomach, eg such as occurs when people are overweight.
What increases the risk of heartburn? There is often no known reason for increases in heartburn. But occasionally one of the factors below may contribute.
Hiatus hernia
Other risks
Chocolate, peppermint, coffee and alcohol hamper sphincter function.
Tobacco hampers the function of the sphincter.
Constipation increases the chance of acid reflux.
This is the name for the condition where the upper part of the stomach has passed up through the hole in the diaphragm. This means the muscle fibres of the sphincter can't press on the lower part of the food pipe. As a result, the lower part of the gullet is normally open, when it should be closed.
ObesityIn people who are overweight, the fat in their abdominal cavity exerts more pressure on the stomach. This causes high pressure inside the stomach, and the contents of the stomach may then be pushed up into the food pipe. Weight loss will reduce the chance of stomach acid reflux.
PregnancyThe enlarged uterus (womb) presses on the stomach. This causes the same kind of high pressure inside the stomach as in people who are overweight. The change that pregnancy brings to the balance of the hormones also leads to a general relaxation of the gullet sphincter.
Large meal portionsThe risk of stomach acid reflux increases with more food in the stomach. The risk will be greater after large (and especially fatty) meals, where the food is in the stomach for a long time before it passes on to the intestines. If you avoid eating more than is necessary, the risk of stomach acid reflux is reduced.
Lying downIf you lie down, the chance of stomach acid reflux increases due to gravity. You can avoid this to some extent by raising the head-end of your bed (see tips below).
What can I do to help myself?
If you are overweight, try to lose a few pounds.
Avoid large fatty meals and try not to eat just before bedtime.
Try to cut down on coffee.
Avoid drinking too much alcohol.
Quit smoking.
If suffering from nightly symptoms, try using an extra pillow or putting a couple of books under the legs at the head of the bed.
If heartburn or acid regurgitations are rare (less than five times a month) medicines bought from a chemist such as antacids can be used.
What medicines treat heartburn?
Antacids Since heartburn is caused by acid from the stomach, one of the simplest ways to relieve the discomfort is to neutralise the acid with an antacid. Antacids usually contain a mixture of magnesium and aluminium salts, calcium carbonate or sodium bicarbonate. Those containing high amounts of sodium may not be suitable for pregnant women or those on a sodium restricted diet, such as people with high blood pressure or heart disease. Antacids are available as tablets that can be sucked or chewed and liquids. The choice is down to personal preference, but liquids may work faster and tablets may have a longer lasting effect. Antacids can reduce the absorption of certain other medicines from the gut, so if you are taking any other medicines you should always check with your pharmacist before taking an antacid at the same time.
AlginatesSome antacid products, eg Gaviscon, also contain sodium alginate. Sodium alginate is a substance that forms a ‘raft’ that floats on top of the stomach contents. The raft prevents stomach acid from passing back into the food pipe and protects the food pipe from the acid. Products containing alginates are particularly useful for heartburn caused by pressure on the stomach, such as during pregnancy. They are also available as tablets and liquid.
H2 antagonistsH2 antagonists include medicines such as cimetidine, ranitidine, nizatadine and famotidine. All of these can now be bought from pharmacies by adults over 16 years of age. They work by blocking histamine receptors in the stomach, which prevent the cells in the stomach from producing too much acid. This type of medicine may not be suitable for people with liver or kidney problems. They should only be used for a maximum of two weeks without consulting your doctor. Cimetidine has the potential to interact with various medicines, both bought and prescribed, so you should always check with your pharmacist before taking it with any of your existing medicines.
When should I consult my doctor? If heartburn or acid regurgitation occurs often, or the symptoms are very annoying, consult your doctor. You should also consult a doctor if you:
have trouble swallowing
are middle-aged or older and have new symptoms
have suddenly lost a lot of weight.Your doctor will decide whether a further examination or more effective medicine is needed.

Constipation

2008-08-21T10:25:00.000-07:00

Reviewed by Dr Dan Rutherford, GP
Stomach pain is a common symptom of constipation.
What is constipation?Although constipation is a common term, from a medical perspective it is hard to define precisely. The dictionary definition is: ‘A condition in which bowel emptying occurs infrequently or in which the stools are hard and small or where bowel movement causes difficulty or pain.’ But defining infrequent is difficult when some 90 per cent of people in Western countries have a bowel pattern that ranges from three bowel movements a day to three per week. And it is possible to move your bowels every day and still be constipated if the stools are hard and difficult to pass. Equally, a daily bowel movement is by no means essential for, nor a sign of, good health. Provided the bowels move regularly and without discomfort, it doesn't matter if your natural bowel frequency is once every two or three days.
How common is it?Constipation is thought to affect a quarter of the population at some time. Constipation is more common in the elderly because:
the power of the bowel muscles diminishes with age
they tend to take more medicines that have constipating side effects.
Bypass diarrhoea
This happens when a hard plug of stool in the lower bowel (faecal impaction) stops a proper evacuation.
Only the more liquid stool from higher up in the bowel can then be passed.
For this reason correct diagnosis is important.
Medicine to slow the bowel down will make the condition worse if a person is actually constipated.
What are the symptoms of constipation?
Tummy pain associated with bowel movements.
A feeling of incomplete emptying of the bowel.
A bloated feeling in the stomach region.
Diarrhoea: constipation is one of the most common causes of diarrhoea, especially in the elderly in care. Diarrhoea caused by constipation is known as bypass diarrhoea.
What causes constipation?
Poor general health.
Immobility or an inactive lifestyle.
Insufficient fluid intake.
A diet low in fibre. Fibre retains fluid and makes the stools light and soft.
Irritable bowel syndrome (IBS).
Inadequate toilet facilities.
An underactive thyroid gland.
Spinal injury.
Multiple sclerosis.
Colon or rectal cancer.
Kidney failure.
Too much calcium in the blood.
Tumours and other lesions of the bowel.
Certain medicines, eg codeine-containing painkillers (co-dydramol, co-proxamol), morphine-like painkillers, antidepressants, aluminium-containing antacids, iron supplements, and anticholinergics such as procyclidine (used in Parkinson's disease).Constipation should not simply be accepted or ignored. Persistent constipation or any change in bowel habit (whether towards constipation or looseness) should be investigated, especially in adults over 40 years. However, for most people with long-standing constipation there is no identifiable cause.
What can help prevent constipation?
A well-balanced diet high in fibre, including bran, fruits and vegetables, is often helpful.
Cutting down on white bread, cakes and sugar.
Drinking at least 8 to 10 glasses of water a day. Hot beverages, such as coffee, tea or hot water may stimulate bowel movements.
Prunes and plum juice can also be beneficial.
Regular exercise improves digestion and reduces stress.
A regular bowel habit. The best time is usually the first hour after breakfast. Don't hurry and sit for at least 10 minutes, regardless of whether you manage to pass a stool. Don't strain.
What are the complications of constipation?
Haemorrhoids. These are swollen veins at the anus, caused by straining at a stool over a long period of time. If large enough they will be visible from the outside. They can be painful or cause local bleeding.
Dependency on laxatives. The bowel in someone who has abused laxatives over a long period of time becomes sluggish and eventually dependent on the use of these drugs.
Hernia (bulging of the abdominal contents through a weak point in the abdominal wall). This is made worse by too much straining when trying to get rid of hard stools.
A prolapse of the womb or rectum. These complications result from excess straining and weakness of the muscles in this area.
What medicines are used to treat constipation?
Bulking agents such as bran and ispaghula husk. These work gently and are the most common type of laxatives (examples are Fybogel and Regulan). They don’t need to be in the form of medicines – increasing the fibre content of your diet should be the main treatment. Bulking agents should always be taken with plenty of fluids.
Stimulant laxatives that cause the bowel muscles to contract such as senna or bisacodyl.
Osmotic laxatives (such as lactulose) that increase the amount of water in the stools by drawing water in from the bowel lining.
Detergents that break down surface layers in the stool, letting water penetrate and soften it (eg docusate).
Macrogols (polyethylene glycols). These are administered along with extra fluids, so they don't draw more water into the bowel from the body. Examples are Idrolax and Movicol. Macrogols may be of long-term benefit to patients with persistent constipation and faecal impaction.
Which treatment is best?
Laxatives
Large amounts of laxatives are bought over the counter every day.
This is due in part to the belief that it's desirable to move the bowels daily.
Laxatives of all types are among the most commonly prescribed medicines.
Yet little detailed medical research has been done to work out the best ways of treating constipation.
There are many different combination laxatives available both on prescription and over the counter. None of these laxatives is superior to any other, and in most people the choice is an individual one. Sometimes, a medicine prescribed for a separate condition may have constipating side effects. Changing this medicine will be all that's required to get rid of the constipation. Someone who has had a period of immobility will probably find their constipation improves once they are up and about again. References Kamm MA. Constipation and its management. British Medical Journal 2003;327:460-462. http://bmj.com/cgi/content/full/327/7413/459 Tramonte SM, et al. The treatment of chronic constipation: a systematic review. Journal of General Internal Medicine 1997 12: 15-24. Summary at http://www.jr2.ox.ac.uk/bandolier/band46/b46-3.html Based on a text by Dr Torben Nathan, Dr Carl J Brandt and Dr Ove Schaffalitzky de Muckadell, professor of Internal Medicine

Stings and insect bites

2008-08-18T10:05:00.000-07:00

Reviewed by Dr John Pillinger, GP
Insect bites often cause one or more red bumps that are usually itchy and sometimes painful. Often there is a small hole in the middle of the bite, perhaps with the end of the sting sticking out. Apart from this local irritation, the bite is not usually dangerous provided the victim is not allergic to insect bites.
Bee and wasp stings are more likely to cause allergic reactions than other kinds of insect bites.
Bee and wasp stings are more likely to cause allergic reactions than other kinds of insect bites.
Which insects cause stings or bites?Stings or bites are caused by midges, horseflies, bees, wasps, ants, some spiders, fleas, lice, etc.
What does a bite look like? There will be one or more swollen red bumps on the skin. In the middle, you will often see a small hole, which might have the insect's sting sticking out of it.If you wake up in the middle of the night having noticed a painful or itchy lump, check to see if other parts of the body are affected. If there is only one bump, or four or five of them close together, you have probably been stung or bitten. Fleas often bite four or five times in the same area so you may find a couple of these clusters on your body. Some children's diseases can also cause bumps and red, swollen skin. If in doubt, consult your doctor.
What are the symptoms of insect bites?The skin becomes red, swollen, itchy and can be painful. These are the most common symptoms. Sometimes bites cause an allergic reaction. Bites can become infected by scratching. Look out for a rash or swelling that gets worse instead of better. If this happens, see a doctor.Call your doctor immediately if you notice any of the following symptoms:
the person has been stung by many insects at the same time
a rash or swelling that gets worse instead of better
if the site is red, tender and swollen
headache
dizziness
nausea (feeling sick)
pains in the chest
choking or wheezing
difficulty breathing. These may be symptoms of allergy and can be life-threatening if the victim goes into shock. See a doctor immediately or dial 999 for an ambulance.
How to treat an insect bite or stingRemove the sting. Use tweezers to prise it out or scrape it off with your fingernail, or a credit card. Do not attempt to press out the sting, as this will only help the poison spread under the skin.Wash the bite with soap and water, then cool off the skin with ice cubes or an ice-pack that has been wrapped in a cloth or thin towel. Rest the affected area and elevate it if possible to prevent excessive swelling. Do this immediately after the victim has been stung. If necessary, use a painkilling cream or gel or an antihistamine to soothe the itch. If you or a member of your family are allergic to insect bites, talk to your doctor or pharmacist before going on holiday. They may tell you to take an antihistamine with you in tablet form or as an injection. If so, make sure you ask how to use it correctly. Anyone who gets a rash or an itch requiring medical treatment, or who may simply feel unwell following a bite or sting should not drive, as there is a risk of passing out. If in doubt, consult your doctor.
Insect bites and allergiesPeople who are allergic to insect bites should carry a card, bracelet or necklace that lets other people know about their allergy. If the doctor has prescribed medication for you to be used in case of an allergic reaction, it is important that both you and your family know exactly how to use it.
How to avoid getting stung
If surrounded by a swarm of bees or wasps, move out of the way SLOWLY. Do not try to wave the insects away. Violent movements will only excite them and make them more aggressive and likely to attack.
Insect repellents are effective.
Never aim a blow at a wasps' or bees' nest or attempt to throw them because the insects will immediately attack.
Stay away from things that attract insects, such as flowers, trees, bushes and piles of wood.
Be extra careful if you are eating or drinking (especially sweet things) outside.
Smells and bright colours attract insects. Avoid scented creams and strong perfumes if you are going to spend time outside.
Long sleeves, long trousers, socks, shoes and gloves help protect you from stings.
Close the windows in the house and the car to keep the insects out.
Look out for insects' nests in your home or garden and have them removed immediately.
Protective gear such as mesh covers for the face can be very effective against the nuisance of the highland midge in summer for example.
Based on a text by Vibeke Manniche, paediatrician, PhD

House dust mite allergy

2008-08-18T10:02:00.000-07:00

Reviewed by Dr Paul Klenerman, specialist and Professor Brian Lipworth, professor of allergies and respiratory medicine
What is house dust mite allergy? House mite allergy is a hypersensitive reaction to proteins in the excretion of dust mites. The protein attacks the respiratory passages causing hay fever and asthma. It will aggravate atopic dermatitis in people who have a tendency to this problem. House dust mites are found in all homes. They are microscopic organisms that thrive in warm and humid houses with lots of food - human skin. The mites prefer to live in beds and, because we spend about a third of the day in bed, we inhale large quantities of dust mite allergens.
How do you become allergic to house dust mites? The excretion of the mites contains a number of protein substances. When these are inhaled or touch the skin, the body produces antibodies. These antibodies cause the release of a chemical called histamine that leads to swelling and irritation of the upper respiratory passages - typical asthma and hay fever symptoms. The predisposition for allergy is often hereditary. Unlike pollen, dust mites are present all year round causing constant allergy - 'perennial' allergic rhinitis. The excretion from the mites dries out and can be launched into the air when someone walks over a rug, sits down in a chair, or shakes the bed clothes, giving allergic people immediate symptoms.
What are the symptoms of house dust mite allergy?
Hay fever, runny nose, itching, sneezing.
Watering eyes.
Asthma, difficulty in breathing.
Infantile eczema (a skin disease) may get worse.
What makes the symptoms worse?
Air pollution such as tobacco smoke or car fumes.
How does the doctor make the diagnosis? It is often enough to tell the doctor when, where and how you get the symptoms. Skin tests and various blood tests can be used for confirmation.
Good adviceIt is best to do everything possible to avoid hypersensitivity to house dust mites. People who have perennial rhinitis, inflamed mucous membrane of the nose, or are allergic to house dust mites should try to adapt their homes.
Have as little furniture as possible in which mites can live.
Clean walls, woodwork and floors with wet cloths. The floor can be polished.
Only use rugs that can be washed once a week.
Use bedding that can be washed often, cotton sheets, washable bottom sheets and synthetic blankets or duvets. Don't use woollen blankets or quilts.
Make sure your chairs are made of wood or plastic.
If you can, use plastic curtains and dust them daily.
Use wet cloths and a vacuum cleaner with a no bag vortex and allergen filter to clean the house thoroughly, preferably every day, but at least twice a week.
Avoid dust traps like teddy bears, cushions, dried flowers, bric-a-brac and toys.
Wash bedding etc at a temperature of at least 60°C to kill the house dust mites.
Leave bedding, duvets, pillows and mattress hanging outside for an hour every day or as often as practical.
Put duvets and pillows in plastic bags and put them in the freezer for 24 hours at least once a month.
You may want to sleep on a cheap mattress that you can exchange for a new one at least every six months.
Dust mites hate dry and cold air, so try to air the house every day and don't use an air humidifier, which will only make matters worse. If the lower edge of the window is moist when you wake up in the morning, there is too much humidity in the air.
Do not spray the house, it may worsen your symptoms.
Do not touch dusty objects like books and old clothes.
When you are likely to be exposed to substances that give you a reaction, eg when you are house cleaning, you should wear a mask.
Don't allow smoking in the house.
What complications are possible?
You are predisposed to other respiratory diseases.
You are also predisposed to otitis, inflammation of the ear.
You may have trouble sleeping and suffer from chronic fatigue.
Hospitalisation following a severe asthma attack.
Future prospects If you are allergic to house dust mites, it is important that you don't expose yourself to the dust mite allergen because it increases your chances of developing asthma. The best remedy against house dust mites is described under the heading 'Good advice' above. Your symptoms can be controlled by treatment, but you can't escape your hypersensitivity. If severe dust mite allergy is the only form of allergy you suffer from, your doctor may want to try hyposensitisation - a 'vaccination' against the allergen. This tolerance treatment involves regular allergen injections in increased doses over a period of five years, but is not routinely given and is not always successful.
What medicine is given?
Antihistamine tablets or syrup (eg loratidine, cetirizine). These lessen the allergic reaction by blocking the actions of histamine. They relieve hayfever symptoms.
Nasal sprays or drops containing sodium cromoglicate, corticosteroids (eg beclometasone) or antihistamines (eg levocabastine) can be used to reduce nasal inflammation and control symptoms in the nose.
Eye drops containing sodium cromoglicate, nedocromil, or antihistamines (eg azelastine) reduce eye inflammation and can be used if eye symptoms are a particular problem.
If the allergy causes asthmatic symptoms, some of the asthma medication below may be used
Relievers (bronchodilators): these are quick-acting medicines that relax the muscles of the airways. They are used when required to relieve shortness of breath.
Preventers: these act over a longer time and work by reducing the inflammation within the airways. They should be used regularly for maximum benefit. When the dosage and type of preventive medicine is correct, there will be little need for reliever medicines.
RelieversThere are three groups of these.
Beta-2 agonistsBeta-2 agonists cause the airways to relax and widen. Examples of those which act for a short time (3 or 4 hours following a single dose) are salbutamol and terbutaline. These medicines are inhaled from a variety of delivery devices, the most familiar being the pressurised metered-dose-inhaler (MDI). When inhaled, these types of medicines work within minutes to open the airways, making breathing easier.Longer-acting beta-2 agonists include salmeterol and formoterol. Their action lasts over 12 hours, making them suitable for twice daily dosage to keep the airways open.
AnticholinergicOne of the ways in which the size of the airways is naturally controlled is through nerves that connect to the muscles surrounding the airways. The nerve impulses cause the muscles to contract, thus narrowing the airway. Anticholinergic medicines such as ipratropium block this effect, allowing the airways to open. The size of this effect is fairly small, so it is most noticeable if the airways have already been narrowed by other conditions, such as chronic bronchitis.
Theophyllines and aminophyllineTheophyllines and aminophylline are given by mouth and are less commonly used in Britain because they are more likely to produce side effects than inhaled treatment. They are still in very wide use throughout the world. All three types of reliever can be combined if necessary.
PreventersThere are three main groups of these.
CorticosteroidsCorticosteroids (or 'steroids') work to reduce the amount of inflammation within the airways, reducing their tendency to contract. They are usually given as inhaled treatment, although sometimes oral steroid tablets may be required for severe attacks. Although steroids are powerful medicines with many potential side effects their safety in asthma has been well established. It is also important to balance the problems that arise from poorly treated asthma against the improvement in health which occurs when the condition is well treated.
CromonesThere are two kinds of cromones: sodium cromoglicate and nedocromil. They also act to reduce inflammation of the airways. They tend to be best for mild asthma symptoms and are more effective in children than adults. The medicines are given by inhalation and are usually very well tolerated.
Leukotriene receptor antagonistsLeukotriene receptor antagonists are compounds released by inflammatory cells within the lungs and which have a powerful constricting effect upon the airways. By blocking this effect with these antagonist medicines the constriction is reversed. There are two such medicines currently available: montelukast and zafirlukast.Most cases of allergic asthma are best controlled with an inhaled corticosteroid, eg beclometasone, which is taken at regular intervals as a preventative measure. A beta-2 agonist, eg salbutamol, is used in conjunction with this to relieve symptoms when necessary. For patients who have associated perennial or seasonal allergic rhinitis the use of an antihistimine, eg cetirizine, is often useful.
Based on a text by Dr Flemming Andersen

Hay fever and perennial allergic rhinitis

2008-08-18T09:57:00.000-07:00

Hay fever and perennial allergic rhinitis
Reviewed by Professor Brian Lipworth, professor of allergies and respiratory medicine
What is hay fever? Hay fever, otherwise known as seasonal allergic rhinitis, is an allergic reaction to airborne substances such as pollen that get into the upper respiratory passages - the nose, sinus, throat - and also the eyes.
What's in a name?
The name hay fever is misleading because symptoms don't just occur in autumn when hay is gathered and never include fever.
Hay fever is the most common of all the allergic diseases - about 15 per cent of the population in industrialised countries suffer from this condition. Symptoms usually appear in childhood first and then lessen by the age of 30 or 40.Perennial allergic rhinitis is a similar allergy that occurs all year round and is caused by things such as house dust, mites and pets. However the predominant allergen changes from time to time.
Why do you get hay fever?
Frequent sneezing is characteristic of hay fever.
Different microscopic substances get into the nose and cause the body to produce antibodies and release histamine. Histamine irritates the upper respiratory passages, making them swell and producing the typical hay fever symptoms. A tendency to suffer allergies is often hereditary. The most common causes of hay fever are:
tree pollen such as elder, elm, hazel and especially birch (spring hay fever).
grass pollen (summer hay fever).
mugwort and hybrids such as chrysanthemum (autumn hay fever).
house dust mites and mould fungus - particularly associated with perennial allergic rhinitis.
What are the symptoms of hay fever?
Itchy and watery eyes
Frequent sneezing, a bunged up or runny nose
Itching on the roof of the mouth
Coughing
Wheezing or a burning sensation in the throat.
What can cause hay fever?
The pollen to which you are allergic.
Genetic predisposition associated with other atopic diseases, eg eczema or asthma.
How does the doctor make the diagnosis? Often it will be enough to tell the doctor when, where, and how your symptoms occur. Skin tests and specific blood tests can be used to confirm what exactly you are allergic to.
Good advice
If your hay fever is caused by various pollens, try to keep doors and windows shut during the pollen season.
Let someone else mow the lawn.
Check pollen forecasts. Try to avoid outdoor activities if very high.
In the long termHay fever sufferers are more vulnerable to other allergic respiratory diseases, eg asthma, and sleeping difficulties that can lead to chronic fatigue (because of blocked nasal passages and snoring).If you suffer from hay fever you should do whatever you can to avoid substances that provoke hypersensitivity. Otherwise you will increase the risk of developing other, more serious, allergic diseases.Symptoms can be controlled through treatment, but you can't get rid of the allergy itself. However, hay fever is usually more of a nuisance than a harm to health, and the symptoms of many people improve over time.
What medicine can I take? There are numerous medicines that can be used to relieve the symptoms of hay fever. Many of these are now available over-the-counter from pharmacies and your pharmacist will be able to advise on which are most suitable for you. The choice will often depend on which symptoms trouble you the most.
Antihistamine tablets and syrups Antihistamines prevent the histamine your body produces to the allergen from causing the allergic symptoms. They are good at relieving sneezing, itching and runny nose and eye symptoms, but are slightly less effective at reducing a blocked nose. There are two main types:
those that cause drowsiness, such as chlorpheniramine and promethazine
newer medicines that cause less or no drowsiness, such as acrivastine, cetirizine and loratadine. Many people prefer to use the newer medicines because they can usually be taken once daily and allow you to get on with your daily activities without problems. Many antihistamines can be bought over-the-counter, but some, eg terfenadine, are available on prescription only.
Antihistamine nasal sprays and drops Antihistamines that are used directly in the nose are azelastine and levocabastine, both of which can be bought over-the-counter. These can be used to provide rapid relief of sneezing, itching and runny nose, but have no effect on other symptoms such as itchy eyes.They can also be used regularly to prevent nasal symptoms, but are less effective than nasal corticosteroids.
Nasal corticosteroids There are two steroid nasal preparations that can be bought from pharmacies: beclomethasone and flunisolide. Others are also available on prescription only. Nasal steroids reduce inflammation in the nasal passages and are better than oral antihistamines at relieving most nasal symptoms, including a blocked nose. They also relieve eye symptoms. Nasal steroids have to be used regularly to be effective. They are best started a couple of weeks before the pollen season begins.
Nasal cromoglicate Nasal sprays containing sodium cromoglicate are also used to prevent nasal symptoms, ideally starting treatment a couple of weeks before the pollen season. They are less effective than nasal corticosteroids, but are often the first choice for young children.
Nasal decongestants Nose drops and sprays containing decongestants such as xylometazoline can be bought over-the-counter to treat a blocked nose. They should only be used for a few days, otherwise they can cause ‘rebound congestion’ when you stop using them.
Antihistamine eye dropsAntihistamine drops can be useful if eye symptoms are your biggest problem. They include antazoline, azelastine and levocabastine, which you can buy from pharmacies. The drops provide rapid relief from itchy, red, watery eyes.
Cromoglicate eye dropsDrops containing sodium cromoglicate or nedocromil should be used regularly, as with nasal cromoglicate products, to prevent the allergic reaction occurring. Cromoglicate drops can be bought from pharmacies and are also suitable if eye symptoms prevail.
Immunotherapy (desensitising vaccines)This treatment is only used when allergen avoidance and medicines have proved ineffective at treating a severe allergy. Injections of small amounts of the known allergy-causing substance are given to create tolerance to the allergen and prevent the immune system producing too much histamine when it encounters it. This treatment has to take place over a long time and requires strict adherence.
Based on a text by Dr Flemming Andersen

Food allergies

2008-08-18T09:56:00.000-07:00

Reviewed by Professor Brian Lipworth, professor of allergies and respiratory medicine
What are food allergies? A food allergy is an abnormal hypersensitive reaction that occurs after eating a normal amount of a certain food. The reaction is repeated every time the food in question is eaten. Although food allergies are rare, they most commonly occur in children under the age of four. The most frequent food allergies are to milk, eggs, fish, nuts, citrus fruit and tomatoes. Children with food allergies often have several different recurrent symptoms. These include severe children's eczema (or skin rash), vomiting and diarrhoea (for no apparent reason), asthmatic bronchitis or asthma and allergic cold.
How do food allergies begin? A hypersensitive reaction towards food is usually a type 1 allergic reaction to something in the diet. Almost one third of the population omit certain foods from their diet or their family's diet because they believe they will cause an allergic reaction. But in fact, only about one third of children suffer allergic reactions towards food, and most of them will outgrow this before they reach the age of three. Among adults, only about 1 per cent suffer from an allergy to a particular food.
How to avoid food allergies Type 1 allergic diseases are to some extent inherited. For this reason, it is advisable to talk to your general practitioner or allergy specialist before you get pregnant.
What should I do if I suspect my child has a food allergy?
If you are in any doubt contact your doctor.
Do not put your child on a strange restricted diet that could result in malnutrition.
A change in a child's bowel movements is not a sign of food allergy.
It is completely normal for a child's bowel movements to change if their diet is changed.
Most importantly: relax. Don't assume that your child is suffering from a food allergy until this has been confirmed by an allergy specialist.
Can allergies be treated? If your child suffers from a food allergy the treatment will be a diet that eliminates the food that causes the reaction. Based on a text by Dr Flemming Andersen

Pet allergies

2008-08-18T09:55:00.000-07:00

Reviewed by Dr Paul Klenerman, specialist and Professor Brian Lipworth, professor of allergies and respiratory medicine
What is a pet allergy? The proteins from the hair, saliva or urine of household pets cause an allergic reaction that attacks the eyes and the airways, like hay fever, and can result in asthmatic symptoms. It may also cause atopic dermatitis or a nettle rash.It is often difficult to avoid the allergens that can come from other people's pets or be transported by people who have been in contact with animals. School classes can be overloaded with pet allergens.Most often the allergies are to cats or dogs, but rats, mice, guinea pigs, hamsters, pet birds, horses, cows or poultry can be involved.
Why are we allergic to pets?Pet allergens are proteins, which when in contact with the skin or breathed in, cause an allergic reaction that provokes the body into producing histamine. The histamine produces swelling and irritation of the upper airways and causes typical hay fever and asthmatic symptoms. The tendency toward allergic reactions is often hereditary.People who have had asthmatic bronchitis as children in a household with pets, especially a cat, are at a high risk of developing allergies towards cats as they get older.Pets are very important in modern life. When moving house or flat, the chances of the former owners having had a pet are high. It may take months, and in a modern insulated flat years, before the level of allergens are so low that an allergic reaction is not a possibility.If pet allergies are suspected, the new house owner should try to stay away from home for a fortnight to see whether the symptoms disappear. A doctor or specialist could be asked to conduct an allergy test to confirm the diagnosis.
What are the signs of pet allergy?When touching the fur or feathers of pets; objects containing pet allergens; or breathing in pet allergens; the following reactions may result:
hay fever (seasonal allergic rhinitis). Sneezing and a running or blocked nose.
eye symptoms such as itching and watering eyes.
asthma. Coughing and wheezing. (Children with asthma).
children's eczema. Itchy skin disease with red patches.
nettle rash. An itchy reddish rash.
What makes the symptoms worse?
Polluted air, tobacco smoke and car fumes may precipitate asthma.
Any other allergens in the environment (eg pollens).
How does the doctor make the diagnosis?Often it is enough for the doctor to know when and where the patient got their symptoms. Skin tests and blood samples can confirm the diagnosis.
What should I do? If you have allergic symptoms, you should avoid things that provoke them and it is advisable to ensure that in your house:
there are no pets.
there are as few pieces of furniture as possible.
the walls, wood and floors are as clean as possible. The floor should be polished. If necessary clean the walls, woodwork and floors regularly.
only carpets that can be cleaned every week are used.
only sheets that can be washed regularly, like cotton sheets, washable mattresses and synthetic blankets and pillows should be used. Do not use woolen or cotton blankets.
only plastic or wooden chairs should be used . Do not have upholstered furniture.
hang plastic curtains if possible. Dust them every day.
use moist rags and a vacuum cleaner that has a vortex with no bag and an allergen filter to clean the house thoroughly, at least twice a week.
avoid objects that attract dust like teddy bears, pillows, dried flowers, bric-a-brac and toys.
What else can I do?
Do not touch objects that are very dusty, such as books and old clothes.
If you are exposed to allergy provoking elements you should wear a mask. Even better, make people without allergies do the cleaning!
Do not allow smoking in your house.
But what if I still want pets?You have to be aware that there is a huge possibility that you may have to find another home for your pet. If you are in this situation, you should contact the RSPCA and ask them for advice.There are low allergen producing animals, such as furless cats, which may sometimes be OK. (But you may be allergic to cat spit and not cat fur? If you want a black and white cat to stroke, how much fun is a cat without fur?)You should still decorate your house as mentioned above. Even if the animal is only visiting you so that you can check if you are able to live with it, it may still take half a year or more before you develop symptoms. Dogs and cats should be bathed at least once a month in plain water. Remember to dry the animals properly afterwards. It has been proved that a monthly 'cat wash' lowers the level of allergens in the house.But what about fish or turtles? This may sometimes work but then you may be allergic to the food they eat.Rabbits and guinea pigs do not produce so much hair but their urine may cause trouble. They should not live in the house but outside and be cared for by a person without allergies. It is possible to buy anti-allergen filters and special air filtering systems (HEPA). Talk to your doctor or an organization for patients with asthma or allergies before you buy these devices.Keep animals out of bedrooms and public rooms. It would be preferable to keep them outside of the house. Every time you touch a pet, wash your hands thoroughly.
What complications are possible?
Greater susceptibility to other illnesses of the airways.
Ear infections.
Difficulties sleeping and insomnia.
Worsening of asthma, and maybe even the possibility of a severe asthma attack.
What are my prospects?Pet owners should know it is important to avoid their allergens because of the increase in the risk of developing, or worsening, asthma. The symptoms can be controlled with medication but the allergy itself cannot be removed.For people who have only one allergy, it may be possible to have a tolerance treatment. This desensitisation treatment is a vaccination against the allergen. Exposure to the allergens several times in a period of up to five years will be necessary.
What medication is given?
Antihistamine tablets or syrup (eg loratidine, cetirizine). These lessen the allergic reaction by blocking the actions of histamine. They relieve hayfever type symptoms.
Nasal sprays or drops containing sodium cromoglicate, corticosteroids (eg beclometasone) or antihistamines (eg levocabastine) can be used to reduce nasal inflammation and control symptoms in the nose.
Eye drops containing sodium cromoglicate, nedocromil, or antihistamines (eg azelastine) reduce eye inflammation and can be used if eye symptoms are a particular problem.
If the allergy causes asthmatic symptoms, some of the asthma medication below may be used
Relievers (bronchodilators): these are quick-acting medicines that relax the muscles of the airways. They are used when required to relieve shortness of breath.
Preventers: these act over a longer time and work by reducing the inflammation within the airways. They should be used regularly for maximum benefit. When the dosage and type of preventive medicine is correct, there will be little need for reliever medicines.
RelieversThere are three groups of these.
Beta-2 agonists These medicines cause the airways to relax and widen. Examples of those which act for a short time (3 or 4 hours following a single dose) are salbutamol and terbutaline. These medicines are inhaled from a variety of delivery devices, the most familiar being the pressurised metered-dose-inhaler (MDI). When inhaled, these types of medicines work within minutes to open the airways, making breathing easier.Longer-acting beta-2 agonists include salmeterol and formoterol. Their action lasts over 12 hours, making them suitable for twice daily dosage to keep the airways open.
Anticholinergics One of the ways in which the size of the airways is naturally controlled is through nerves that connect to the muscles surrounding the airways. The nerve impulses cause the muscles to contract, thus narrowing the airway. Anticholinergic medicines block this effect, allowing the airways to open. The size of this effect is fairly small, so it is most noticeable if the airways have already been narrowed by other conditions, such as chronic bronchitis.
Theophylline These medicines are given by mouth and are less commonly used in Britain because they are more likely to produce side effects than inhaled treatment. They are still in very wide use throughout the world. All three types of reliever can be combined if necessary.
PreventersThere are three main groups of these.
Corticosteroids Corticosteroids (or 'steroids') work to reduce the amount of inflammation within the airways, reducing their tendency to contract. They are usually given as inhaled treatment, although sometimes oral steroid tablets may be required for severe attacks. Although steroids are powerful medicines with many potential side effects their safety in asthma has been well established. It is also important to balance the problems that arise from poorly treated asthma against the improvement in health which occurs when the condition is well treated.
Cromones There are two medicines in this group: sodium cromoglicate and nedocromil. They also act to reduce inflammation of the airways. They tend to be best for mild asthma symptoms and are more effective in children than adults. The medicines are given by inhalation and are usually very well tolerated.
Leukotriene receptor antagonists Leukotrienes are compounds released by inflammatory cells within the lungs and which have a powerful constricting effect upon the airways. By blocking this effect with these antagonist medicines the constriction is reversed. There are two such medicines currently available: montelukast and zafirlukast.Most cases of allergic asthma are best controlled with an inhaled corticosteroid, eg beclometasone, which is taken at regular intervals as a preventative measure. A beta-2 agonist, eg salbutamol, is used in conjunction with this to relieve symptoms when necessary. For patients who have associated perennial or seasonal allergic rhinitis the use of an antihistimine, eg cetirizine, is often useful.
Based on a text by Dr Flemming Andersen

House dust mite allergy

2008-08-18T09:17:00.000-07:00

Burns

2008-08-17T10:50:00.002-07:00

Reviewed by Dr Stephen Collins, GP
What are burns?Burns are skin damage caused by contact with fire, heat, electricity, radiation, or caustic chemicals. Burns are classified according to the depth and extent of the skin damage, in the following way:
In second and third degree burns a skin graft can be necessary.
first-degree burns - the skin is red, painful and very sensitive to touch. The damaged skin may be slightly moist from leakage of the fluid in the deeper layers of the skin.
second-degree burns - the damage is deeper and blisters usually appear on the skin. The skin is still painful and sensitive.
third-degree burns - the tissues in all layers of the skin are dead. Usually there are no blisters. The burned surface can have several types of appearance, from white to black (charred) or bright red from blood in the bottom of the wound. Because the skin nerves are damaged the burn can be quite painless. On touch the burned skin lacks sensation. It is important not to confuse a pale third-degree burn for normal skin – the lack of sensation or blanching of the skin blood vessels on pressure indicates damaged skin. . A skin graft is usually necessary for significant areas.
First aid for burnsThe first thing to do is to limit the extent of the damage, and prevent the burn from becoming worse.
The burnt area must be cooled by being placed under cold running water. The water must not be unpleasantly cold.
The damaged area must stay under running water for at least one hour, or longer if the pain has not stopped. Up to four hours of this treatment can be beneficial.
First-degree burns, eg mild sunburn, do not require this treatment.
Which burns need treatment by health professionals?
Burns that are bigger than the palm of the hand.
Burns on the face, neck, hands, and in the groin.
All third-degree burns.
Most second-degree burns. Remember that it can be difficult to distinguish between second- and third-degree burns, so always have a nurse or doctor check all but the most minor burns.
If possible, keep pouring water over the burn on the way to the doctor, or use clean, soaking wet towels.
Do not lance the blisters yourself.
Never apply an ointment to burns or try other folk remedies - water is the only thing that should be used.
Do not forget to have a tetanus injection if you have not had a booster within the last 10 years.
What complications can occur?
When skin is burned, it loses its ability to protect, which increases the risk of infection. So it is important that the damaged area be thoroughly cleansed within the first six hours, and that the area is kept clean while it is healing. If, after a few days, there are signs of an infection - ie the skin is becoming increasingly red, hot, and swollen, and the victim experiences a throbbing pain - contact a doctor or your practice nurse.
Severe burns can cause scarring.
In cases of extensive severe burns, the body may lose large quantities of fluid. This can disturb the blood circulation and cause problems with the body's salt balance. Such injuries should be assessed at your local Accident and Emergency department.
What can be done to prevent burns? The kitchen is the most dangerous room in the house, and the most likely place for burns and scalds to occur. When cooking, keep small children away from hot drinks, pans and kettles, barbecues and other open flames. Remember that barbecues can suddenly 'spit' flames when inflammable liquids are poured over them. Barbecues are a major cause of serious burns. When there are small children in the house, fill baths by running the cold tap first. Never throw water over oil fires, such as in a chip pan, because this will cause a fire explosion that can have severe consequences. Instead the fire should be smothered by covering the pan with a damp cloth.Buy a proper fire-smothering blanket and keep it somewhere in the kitchen where it is easily accessible.Based on a text by Eric Olesen, plastic surgeon

Sprains and bruises

2008-08-17T10:50:00.001-07:00

Reviewed by Dr Dan Rutherford, GP
What are sprains and bruises? A sprain causes pain, swelling and discolouration (blue colouring). This happens because the small blood vessels and fibres in the flesh burst, causing blood to enter the surrounding tissue. This results in swelling and the blue colouring. It is the same principle with a bruise: the skin is exposed to such a hard blow that the blood vessels break.
What should I do about a sprain? If you have a sprain, you will also suffer pain. The injured area must be kept still or the bleeding in the tissue will continue more intensely. The most important treatment for a sprain is: rest, ice, compression, elevation (RICE).
RestRest is important to ensure that healing occurs as quickly as possible. You should rest the injured area for at least one or two days, because the bleeding can continue for up to 24 hours. If possible, the sprained area should be kept straight - an arm, for example, can be supported in a sling. Try to keep the injured area in the same position while you are sleeping, perhaps by placing a couple of pillows under your sprain.
IceSince blood enters the tissues when you have a sprain, the main thing is to limit the bleeding. This can be done by cooling. Try the following techniques.
Put ice cubes in a plastic bag, then place over the sprained area.
In an emergency, use frozen vegetables in a bag.
Use custom-made cooling-packets, which are bags containing a special jelly that can be chilled in your freezer. In each case, wrap the cold bag in a towel before placing it on the sprain. Always put a piece of fabric between your skin and the coolant, otherwise your skin may get frostbite. Stop the cooling long before your skin turns white or hard. Contact a doctor if your skin does not regain its usual colour after the process has stopped. It is a good idea to cool the skin for 15 minutes, stop for 15 minutes, then cool again, and so on. Usually, the cooling is felt in different ways. This can range from cold to painful, burning and finally numbing. Be careful if you are diabetic. To prevent damage to your blood circulation, do not cool an area without consulting your doctor.
CompressionYou can also wrap bandages around the damaged area to prevent movement. Most people use a pressure bandage at first, followed by tape when the swelling has disappeared. If you are wearing bandages, it is important to monitor the area surrounding them. If this becomes blue-coloured and the surrounding tissue seems cold, you should remove the bandages and contact a doctor.
ElevationThe injured area shouldn't point downwards, otherwise fluid build-up may occur. This prolongs the healing process and causes more pain.
How can I relieve the pain?The most important treatment for a sprain is rest, ice, compression and elevation, as described above. However, the pain experienced following a sprain can also be relieved with over-the-counter anti-inflammatory painkillers, such as aspirin and ibuprofen. These reduce swelling and combat pain.
Good advice
Ask a pharmacist for advice on which products are suitable for you.
Paracetamol can also be useful. Aspirin and ibuprofen should not be used by people with asthma or stomach problems, and aspirin should not be given to children under 16 years of age, unless on the advice of a doctor. Topical painkillers containing non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen gels or creams, can also relieve pain effectively. These should also not be used by people with asthma or stomach problems.
When to consult a doctor
If the sprain is accompanied by severe pain and severe swelling.
If one of your joints gives way and is unable to carry your weight.
If the pain is still present after two days.
If the sprain has not improved after four days of self-treatment.
What should I do to prevent sprains? Ask yourself what caused your accident and focus on the cause. Note that the following information is a very rough guide: if in doubt, consult a doctor.
Running too quickly?
Exercising without any warm-up or stretching exercises?
Running, working out or playing sport without the proper shoes?
Running on hard or uneven surfaces?
Are any of your muscles overcompensating for weakness in another - for instance, due to a bad knee?
Recovering from sprains When the pain and the swelling have gone, start exercising the injured part of the body gently. After one or two days' rest, it is important to start moving again to reduce the amount of scarring formed in the damaged tissue. As with any activity, warm up slowly and use stretching exercises to begin with. If it's possible to stay physically active without further injuring the sprained area, do so. Keep your other muscles functioning and maintain physical fitness.
How to treat bruises Bruises and swellings are caused by bleeding under the skin. Again, bruises are best treated with cooling. To do this, follow the instructions given above for cooling treatment of sprains.If several bruises surround a large one, and you have not had any other accidents, consult your doctor to find out whether your blood is clotting as it should. Based on a text by Dr Hans Gad Johansen, specialist and Dr Ejnar Kuur, consultant

Salmonella and food poisoning

2008-08-17T10:49:00.001-07:00

Reviewed by Dr Dan Rutherford, GP
What is salmonella?Salmonella is a type of bacteria. It is usually found in poultry, eggs, unprocessed milk and in meat and water. It may also be carried by pets like turtles and birds.
What kind of infection does salmonella cause?The salmonella bacteria attacks the stomach and intestines. In more serious cases, the bacteria may enter the lymph tracts, which carry water and protein to the blood, and the blood itself. The bacteria attack all age groups and both sexes. Children, the elderly and people who are already ill are much more likely to get a serious infection.
What are the symptoms of salmonella poisoning?
Diarrhoea or constipation.
Headaches.
Stomach cramps.
Nausea and vomiting.
Fever.
Possibly, blood in the faeces. In the case of less serious infections there are fewer symptoms - usually only diarrhoea two or three times a day for a couple of days. Most mild types of salmonella infection clear up in four to seven days without requiring any treatment other than rest and plenty of liquid. A more severe infection may cause excessive diarrhoea, stomach cramps and general health problems. In such cases, treatment with antibiotics may be necessary and a doctor should be consulted.
When is it necessary to contact a doctor?
If diarrhoea continues for more than 24 hours.
If the diarrhoea is frequent and intense.
If the patient has severe stomach cramps.
If there is blood in the faeces.
If the patient has fever of 38oC or higher.
If there are signs of jaundice - a yellowish discolouration of the skin or eyes. This may indicate problems with the liver or the bile ducts that take the bile from the liver to the stomach.
Dehydration.
What is the danger of dehydration?Frequent diarrhoea and vomiting may drain the body of fluids, salts and minerals. Dehydration occurs when the patient loses more liquid than they can take in. Cases of dehydration should always be checked by a doctor and can be very dangerous in babies and the elderly.Signs of dehydration are:
the tongue or the mucous membranes in the mouth are dry
dry, chapped skin
increased thirst
dark urine
lack of, or decreased, urine output
weakness.
How can salmonella infections be prevented?
Pay attention to cleanliness.
Make sure that all food is thoroughly cooked.
What are the basic rules for preparing food hygienically?
Always wash your hands with soap after going to the toilet and before preparing food. Dry them on a dry towel.
Wash your hands when you switch from preparing one type of food to another, eg vegetables to meat. This helps prevent the exchange of bacteria between different ingredients.
Kitchen utensils must be properly washed with soap and water before use with another type of food. Again, this stops bacteria being exchanged.
Use different cutting boards and knives for preparing different foods.
Change the dishcloth every day. Wash dishcloths in water that is at least 60oC.
Store food in the refrigerator. Meat, poultry and fish must not be left out of the fridge for long periods.
How should food be cooked to avoid salmonella poisoning?The only effective way to kill salmonella bacteria is with heat. For this reason it is essential to cook food thoroughly.
Poultry must always be thoroughly cooked or boiled.
Minced meat must always be thoroughly cooked or boiled.
Never crack a raw egg on a bowl containing other foods - use a knife to crack the shell.
In most eggs, the salmonella bacteria exist only on the shell. Eggs should be scalded in boiling water for five seconds before use.
Based on a text by Christel Bech, nurse

Poisoning in children

2008-08-17T10:48:00.002-07:00

Reviewed by Dr Stephen Greene, consultant paediatrician
Poisoning accidentsAccidents in the home are much too common, especially since many can be avoided by taking a few simple precautions. Some of the more serious accidents are poisoning incidents involving children. When young children explore the world, they use all their senses including taste. They typically put everything in their mouth to find out what it is. For this reason, adults must make sure that children do not have access to anything poisonous. It is surprising just how many ordinary household articles are dangerous in this respect. To make your home safe from poisoning, examine it carefully one room at a time. Identify any potentially harmful substances and either lock them away or store them somewhere out of your children's reach.
What is poisonous in the kitchen? Cleaning materials are usually kept in the kitchen, often in a low cupboard under the sink where they are easily accessible to curious children. Potentially dangerous products include:
all kinds of detergents and cleaning products, which often contain chemicals that are poisonous to children.
plant fertilizer. This is extremely dangerous.
detergents used in automatic dishwashers. These are highly caustic and, therefore, very dangerous if consumed. Move these products to a locked cabinet where children cannot see or reach them. It's not enough to simply store them on a worktop since children are excellent climbers. Buy products with childproof lids wherever possible - but lock them away nonetheless. Think about the appearance of the containers. Chemicals and detergents often come in colourful containers which appeal to small children, while the scent of some detergents also tends to be attractive. As strange as it may seem, nasty tastes don't seem to put children off experimenting further. Never pour chemicals or detergents into empty soft drink or water bottles. Children may think the bottles still contain the original liquid.
What is poisonous in the bathroom? Medicines, cosmetics, creams and lotions contain harmful substances (such as alcohol) that may poison a child. Many tablets, medicines, herbal remedies and even vitamins are dangerous for children. Remember that children are less tolerant than adults and even a small quantity may be poisonous. Always keep such items in a locked cabinet that the children do not have access to. Put any medicines back in the cabinet immediately after use.
What is poisonous in the living room? Alcohol is very dangerous for children. Always lock cabinets containing wine and spirits - screwing down the lids tightly is not enough. Children are very good at opening things and even a small amount of alcohol can be harmful to a young child. Remote controls for electronic equipment may contain small mercury batteries, which can cause poisoning if swallowed. Cigarettes and tobacco are often left lying around. Tobacco, in all forms, is an extremely dangerous poison and just one cigarette stub may poison a child. All kinds of tobacco should be kept out of the reach of children.
Are plants poisonous?Many houseplants and garden plants are poisonous if eaten. A pharmacist can provide advice about poisonous plants. If you have small children, do not keep any poisonous houseplants - even if you place them out of reach, leaves may fall to the floor. Plant poison often causes blisters and/or ulcers in your child's mouth or their tongue may start swelling.
What is poisonous in the garden? Check which of the plants growing in your garden may have leaves, berries, flowers or fruit that could poison a child.A garden shed is likely to contain decorating materials, paint, methylated spirits, turpentine, plant fertilizer, weedkiller, barbecue fire lighters and many more substances that are all extremely poisonous. Garden sheds should be locked at all times.
Guests When you have guests politely ask them not to leave cigarettes or medicines where your children can get their hands on them. Be vigilant when taking your child to visit friends - particularly those who don't have small children themselves and may not be aware of the potential hazards around their home. Find a diplomatic way to suggest that your hosts move any toxic substances to a safe place - tell them, if you like, that you're child is particularly curious and has a tendency to open interesting-looking bottles. Keep an eye on your child at all times.
What if my child is poisoned? Try to stay calm and call a doctor immediately. The doctor will need as much of the following information as possible.
What did the child eat/drink? Write it down.
How much? Find out whether it is one tablet or half a bottle.
The doctor will ask you what the child weighs.
If you are going to Accident & Emergency, take some of the substance that your child has eaten/drunk.
Which medicines are used? Inactivated charcoal is often used in hospital emergency departments as an antidote in cases of poisoning. Large doses are used to prevent the poison being absorbed from the stomach. Inactivated charcoal tablets are available to buy from pharmacies, but these are for the treatment of indigestion and flatulence only and should not be used at home to treat poisoning, as the dose they contain is far too small. For this reason you shouldn't keep charcoal tablets as poisoning treatment in your first-aid kit. You should always consult a doctor or hospital emergency department in cases of poisoning.In some cases of poisoning your doctor will recommend that you give your child milk. But only do this if the doctor has advised it.Induced vomiting - or forcing your child to throw up - is necessary only in some cases of poisoning. Do it only if you know exactly what has poisoned the child and the doctor has told you to go ahead. If your child has swallowed a caustic substance it could be extremely dangerous for them to vomit, so always get medical advice first.
How can I protect my child Although it is important to keep an eye on your children as much as you possibly can, it is simply not possible to know what they're up to 100 per cent of the time. For this reason, when it comes to preventing poisoning, the most important and practical measure is to ensure toxic substances are completely out of reach in the first place. Make a thorough check of your house and garden, removing any harmful products and placing them in a securely locked cabinet. Based on a text by Dr Per Grinsted, GP

Is it dangerous to take several different medicines at the same time?

2008-08-17T10:48:00.001-07:00

Reviewed by Dr Christine Clark, pharmacist
What is drug interaction? This can occur when people take two or more different drugs at the same time.
Make sure you always know what medicines you are taking and why.
The drugs might be taken for the same illness, such as quinsy (an abscess in the throat), for which a person needs antibiotics and painkillers. Or it may be because they suffer from two different diseases at the same time, such as gastric ulcers and arthritis, for which they need acid neutralisers and medicines for arthritis.If the drugs influence each other producing an increased effect, extra side effects, or decreased effectiveness of one or more drugs, it is called a drug interaction.
How can two different drugs influence each other's effect?Nearly all medicines are broken down by specific enzymes in the liver, and then excreted as smaller molecules through the kidneys.If medicine A impedes the enzyme responsible for breaking down medicine B, the result can be an excessive amount of medicine B in the bloodstream. This can increase the chance of serious side effects. If a doctor thinks that both medicines are necessary at the same time, they will ensure that the dose of medicine B is reduced, to avoid any adverse effects.If, on the other hand, medicine A increases the amount of the enzyme responsible for breaking down medicine B, the breakdown will occur much faster and the effect of medicine B will be lost or decreased. In that case, a doctor will increase the dose of medicine B.Medicines can also influence each other in other ways; for instance, they can affect absorption from the intestines or secretion from the kidneys. In both instances, this can result in effects similar to those described above - too much or too little medicine in the bloodstream, which may lead to serious side effects or little or no effect at all.
Do I have to tell my doctor about the medicines I am using?As long as a doctor has taken into account the effect of taking two or more medicines at the same time it should be perfectly safe. However, always tell a doctor about all the medicines you are using, including herbal remedies and those bought from a pharmacist.When buying over-the-counter medicines from a chemist you should also remember to tell the pharmacist all the medicines you are using.Based on a text by Unni Elmer Jeppesen

Heart attack - emergency first aid

2008-08-17T10:47:00.000-07:00

Reviewed by Dr Neal Uren, consultant cardiologist and Dr Reginald Odbert, GP
Important: this is a brief guide to the emergency help that can be given in the event of a heart attack or cardiac arrest before the arrival of emergency services. It is not intended as a replacement for a first aid or resuscitation course.
What should you do if someone has a heart attack? If someone has a cardiac arrest or heart attack, there are only a few minutes to act before it is too late. It is vital to know what to do beforehand. To perform CPR (cardiopulmonary resuscitation) and artificial respiration (mouth to mouth resuscitation) effectively, training and frequent practice on resuscitation dummies are essential.First aid courses are offered all over the country at night schools or by voluntary organisations such as St John Ambulance or The Red Cross.
How can you tell if someone is having a heart attack? If the person is unconscious:
are they breathing? Look at the patient's chest to see if it is rising and falling.
do they have a pulse? Place two fingers on one or other side of the person's voice box in their throat to feel if they have a carotid pulse. If the patient has a pulse but is not breathing:
could it be because of suffocation? Feel inside the mouth with a finger to see if there is anything blocking it or the windpipe and remove any food or other objects. Provided that dentures are not broken, it is better not to remove them.
call for help immediately, stating that the casualty is not breathing, and provide resuscitation (see below) until the patient begins to breathe or the ambulance arrives. If there is no breathing or pulse, the patient has had a cardiac arrest.
What help is needed?
If possible, raise the legs up 12 to 18 inches to allow more blood to flow towards the heart
Immediately place the palm of your hand flat on the patient's chest just over the lower part of the sternum (breast bone) and press your hand in a pumping motion once or twice by using the other hand. This may make the heart beat again. If these actions do not restore a pulse or if the subject doesn't begin to breathe again:
call for help, stating that the casualty is having a cardiac arrest but stay with the patient.
find out if any one else present knows CPR.
provide artificial respiration immediately (see below).
begin CPR immediately (see below).
How to give artificial respiration
Tilt the head back and lift up the chin.
Pinch the nostrils shut with two fingers to prevent leakage of air.
Take a deep breath and seal your own mouth over the person's mouth.
Breathe slowly into the person's mouth - it should take about two seconds to adequately inflate the chest.
Do this twice.
Check to see if the chest rises as you breathe into the patient.
If it does, enough air is being blown in.
If there is resistance, try to hold the head back further and lift the chin again.
Repeat this procedure until help arrives or the person starts breathing again.
How do I perform CPR (cardiopulmonary resuscitation)? See if there is breathing. If not, start artificial respiration as described above. Checking for a pulse in the neck (carotid artery) may waste valuable time if the rescuer is inexperienced in this check. The procedure is:
place your fingers in the groove between the windpipe and the muscles of the side of the neck. Press backwards here to check for a pulse. If there is no pulse, or if you are unsure, then proceed without delay thus:
look at the person's chest and find the 'upside-down V' shaped notch that is made by the lower edge of the ribcage. Place your middle finger in this notch and then place your index finger beside it, resting on the breastbone. Take the heel of your other hand and slide it down the breastbone until it is touching this index finger. The heel of your hand should now be positioned on the middle of the lower half of the breastbone.
now place the heel of your other hand on top of the first. Keep your fingers off the chest, by locking them together. Your pressure should be applied through the heels of the hands only.
keep your elbows straight, and bring your body weight over your hands to make it easier to press down.
press down firmly and quickly to achieve a downwards movement of 4 to 5cm, then relax and repeat the compression.
do this 15 times, then give artificial respiration twice, and continue this 15:2 procedure until help arrives.
aim for a rate of compression of about 100 per minute. You can help your timing and counting by saying out loud 'one and two and three and four ...' etc.
Artificial respiration and CPR should both be performed at the same time
If possible, get someone else to help - one person to perform artificial respiration and the other to perform CPR. (This is not easily done without prior practice and it is well worth attending sessions on CPR training to become familiar with the technique.)
The ratio of chest compressions to breaths is 15:2 for both one-person and two-person CPR.
Continue until the ambulance arrives or the patient gets a pulse and starts to breathe again.
If the pulse returns and breathing begins but the person remains unconscious, roll them gently onto their side into the recovery position. This way mucus or vomit can get out of the mouth and will not obstruct the patient's breathing. It also prevents the tongue from falling back and blocking the air passage.
Make sure the patient continues breathing and has a pulse until the ambulance arrives
If you succeed in resuscitating the person who has been taken ill, he or she may be confused and alarmed by all the commotion. Keep the patient warm and calm by quietly, but clearly, telling them what has happened. Again, it needs to be emphasised that the only way to provide proper first aid and resuscitation is through learning the technique, then regular practice and guidance.
Based on a text by Dr Henrik Omark Petersen

Foreign body in the eye

2008-08-17T10:46:00.000-07:00

Reviewed by Dr Caroline MacEwan, consultant ophthamologist
Any material such as dust, sand or paint that gets into the eye is called a foreign body. Foreign bodies fall into two categories.
Superficial foreign bodies: these stick to the front of the eye or get trapped under one of the eyelids, but do not enter the eye.
Penetrating foreign bodies: these penetrate the outer layer of the eye (cornea or sclera) and enter the eye. These objects are usually travelling at high speed and are commonly made of metal.
How do you get foreign bodies in the eye? Non-perforating superficial foreign bodies are generally either blown or fall into the eye. This may occur, for instance, when working under a car or when outside on a windy day. Penetrating eye injuries tend to occur when people are hammering or grinding. Under these circumstances small pieces of metal travelling at high speed hit the eye and enter it through the outer coat of the eye.
Is it a serious condition? Superficial foreign bodies are not usually serious. A penetrating eye injury can be extremely serious - it may lead to blindness if not detected and treated promptly. Even if treated appropriately, it may cause loss of vision.
What does it feel like? Superficial foreign bodies tend to be very uncomfortable. The foreign body may be stuck on to the cornea or the conjunctiva, causing a red, watery and gritty eye. The foreign material may have become stuck under the upper lid, whereby every time the eye opens and closes the pain increases. Penetrating eye injuries, although they are much more serious injuries, paradoxically are often much less painful. The vision may be reduced, but this is not always the case.
How can I get rid of a foreign body?If you get a superficial foreign body in your eye, first-aid treatment in the form of gentle rinsing with warm water is appropriate. An 'eye bath' can make this easier to do on your own, or you can get someone to help rinse the eye from the side, with you lying down.Do not try to remove a foreign body with cotton buds, matchsticks or any other type of solid object. You could do more harm than good - go to the nearest casualty doctor or contact your GP's surgery.It is also advisable to consult a doctor if you think you've had a foreign body in your eye and it's continuing to cause irritation. If you think something has gone into your eye while you have been grinding or hammering, even if you have little in the way of pain or loss of vision, it is essential that you consult a doctor immediately and tell them about the circumstances of your injury.
How does the doctor make a diagnosis?
Superficial foreign bodies If you tell your doctor you have felt something going into your eye, he or she will examine the eye using a fluorescein stain, which helps to detect any foreign material on the surface of the eye. The eyelid also needs to be turned outwards so that the underside of the lid can be examined and any foreign material removed from that surface. The material can be removed using a cotton bud, although occasionally a small needle may be required to lift any embedded particles from the eye. This is carried out with local anaesthetic drops and does not hurt.
Penetrating foreign material
Good advice
Wear protective glasses or goggles to prevent foreign bodies entering your eyes.
For example, when:
welding
using a grinder
using a sander
using a Strimmer
doing DIY.
If you tell your doctor that you have suffered a possible eye injury while carrying out a high-risk activity such as hammering, the eye will be examined in full detail. Your vision will be assessed, and it is possible that this may be reduced. There may be evidence that the pupil is distorted and there may be blood inside the eye. If the lens of the eye has been hit by the foreign material, there may be evidence of an early cataract. X-rays or scans may be required if there is any suspicion there is foreign material inside the eye.
What happens if the foreign body is not removed from my eye?
Superficial foreign materialThis will tend to cause persistent irritation and may lead to conjunctivitis. Sometimes the foreign material becomes buried and stops causing problems, although there may be some scarring.
Penetrating foreign bodies The damage caused by an intraocular foreign body depends on:
the type of material that makes up the foreign body
the amount of damage it causes as it passes into the eye.Metal foreign bodies that have iron in them can cause a condition called 'siderosis', which gradually leads to poor vision over the following months and years. Some other metals and vegetable materials may cause rapid destruction of the eye or infection inside the eye. It is possible for a small foreign body to enter the eye and cause no apparent damage, but it may lead to bleeding within the eye, early cataract formation or damage to the retina. Surgery may be required to correct this damage.
How is a penetrating foreign body removed? An operation is needed to remove foreign bodies that have penetrated inside the eye. This usually takes the form of a vitrectomy, which involves going into the eye to remove the foreign material. At the same time, any damage to the eye caused by the entry of the foreign material can be repaired. This may involve removal of haemorrhage, removal of the lens or repair of retinal damage.
Will there be any long-term effects? Superficial foreign bodies are not sight-threatening injuries and the eye tends to make a full recovery. Penetrating foreign bodies are potentially very serious and may lead to blindness or loss of the eye, even if treated appropriately. Based on a text by Dr Per Grinsted

Health Advisor

American Heart Association changes CPR guidelines

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Swine Flue

Coronary bypass surgery

The Outcome of Anorexia Nervosa in the 20th Century

Lymphedema

Low blood pressure (hypotension)

EDEMA

Are you overweight?

Cardiovascular disease in India and the impact of lifestyle and food habits

Travellers' diarrhoea

Headaches

Smoking - health risks

Drug abuse and addiction

Do I drink too much alcohol?

Smoking - cutting down or quitting

Coping with smoker's lung

Alcoholic liver disease

Alcoholism

Vitamins - what do they do?

Vitamins

Heartburn

Constipation

Stings and insect bites

House dust mite allergy

Hay fever and perennial allergic rhinitis

Food allergies

Pet allergies

House dust mite allergy

Burns

Sprains and bruises

Salmonella and food poisoning

Poisoning in children

Is it dangerous to take several different medicines at the same time?

Heart attack - emergency first aid

Foreign body in the eye

2010 CPR Guidelines
How the American Heart Association's CPR Guidelines Have Changed for 2010