GYNECOLOGICAL CANCER: PROTECTING CHILDREN FROM DISTRESS To protect young children from this distressing time, parents too often choose to keep all information about the cancer away from them. This is a mistake. What we now know is that if children, regardless of their age, are appropriately supported with open and honest information (relevant to their age) they will have a better capacity to cope with your illness. The extent of detail will depend on their age and personality, and level of both professional and family support that is available.Even though our primary concern toward the children may be in protecting them from cancer by not talking about it too much we need to understand that children are exceptionally perceptive to any change in emotions within their immediate environment.Children are usually acutely aware of changes within family dynamics and will sense a tension long before it becomes obvious to others. Even the youngest of children now understand the word ‘cancer’ and have some idea… usually wrong…about it and what it may mean. The last thing a child wants is to hear from friends that their mum has a malignancy and might die. ‘Your Mum’s got cancer and she’s going to cark it’ was a comment made to one of our contributor’s sons at school. It is important to inform the child’s school, sporting clubs or any group they are associated with. Advise each group how you would like the situation handled and the extent of detail that you want to be discussed with the child and other members. The repercussions can take a long time to repair.Sharing the truth with a child allows them to offer support in a way that is meaningful to them even if it is just doing a drawing for you to keep with you in hospital. You will be quite emotional in sharing the news; so it may be helpful to have someone with you while you are breaking the news . . . being hopeful and optimistic about your treatment will reassure them that you are in good hands.It also allows you to discuss how you would like the child to help and involve them in the planning for your recovery. Many women do not use the term ‘cancer’ when discussing their illness, especially in the early stages, because of the widespread fear that the word tends to generate. Many speak of it as an illness that will require them to go to hospital, which the treatment will make them tired, and they may lose their hair. You will know the best way to communicate to your child and what you reasonably think they can cope with at each stage. Most importantly you need to reinforce to the child that it is not their fault. . . that your illness is something that many women get; that they will be well cared for and supported while you are having your treatment.Be realistic about their need to grieve as well, and show it acceptable to cry. After all your absence will fill them with fear.When children sense that there is a situation that might mean that Mum, Grandma or Auntie may not be around, or are not there all the time to look after them, protect and nurture them, they may feel enormously threatened especially as a sophisticated understanding of the situation is impossible for them and they cannot verbalize their fears. They may manifest their feelings in becoming over dependent; clinging; taking a morbid fascination in death, fretful during your absences in hospital.It is useful to have a picture of yourself near the phone at home so that when they are talking to you at least they can visualize you.*59/144/5*
DIAGNOSIS AND TREATMENT OF LOW BACKACHE: PROBLEMS OF HIGHER LUMBAR JOINTSIf the nerves that are scratched, irritated or compressed go along the lower part of the body, then you can get pain in different directions. The higher nerves will go to the groin area, while the lower they emerge the more they go to the side. (Take an animal on all fours. The nerves of the big toe and front of the leg come from higher segments, while those in the small toe and back of the leg come from lower segments.) If you get a pain in the big toe or the groin or inner thigh then the chances are the fault is higher up. The lower down you go the more lateral it is. That is the general rule. If it is the outer toes, the little toes, then it is lower down. So if it is on the outer side it is lower down, inner side it is higher up. If everybody knew this, patients would not panic, but it is something that doctors don’t tell you. So if you get pain in the groin and inner thigh then it comes from lumbar 1 (top lumbar) or lumbar 2. If it is much lower or to the side then it could be from L4 or L5. The nerve from L1 and L2, besides going to the groin also goes to the thigh area, so if you get a burning sensation when you touch the thigh area, if your slacks irritate the skin, which is too sensitive, then you know there is a problem with L1 and L2. Now those two areas rarely go out of alignment. Because the higher [you are - 'it is'?] the less the chances of it being displaced. This is because maximum compression takes place between L3/L4 and L5/S1. These are very close to the powerful sacrum bone, and that’s where maximum weight is. So if it is higher than L4, then consider this: (1) have you drunk enough water? The kidneys are embedded in the lumbar muscles. If they are dehydrated they weaken the muscles in that area, resulting in all sorts of pain, which can actually press on the nerve or push a vertebra to irritate a nerve root. (2) If this is not the problem, then ask someone to massage you in that area and there could be instant relief from the sensitivity and the pain in the groin.*202\330\8*
ARE YOUR DISORDERS RELATIVES OF BDD?IS BDD A SYMPTOM OR AN ILLNESS?1 HypothesisBDD Is a nonspecific symptom that can occur in a wide variety of psychiatric disorders (such as schizophrenia, depression, or personality disorders)Medical AnalogyBDD is like a fever2 HypothesisBDD is a symptom or form of another specific psychiatric disorder (not of a wide variety of psychiatric disorders, as proposed by hypothesis I)Medical Analogy BDD is like the butterfly rash in lupus3 HypothesisBDD is a distinct diagnostic entity-separate disorder-that is, aMedical AnalogyBDD is like diabetesWhich hypothesis is correct is important for several reasons. If hypothesis 1 is correct, then treatment would presumably be directed at whatever the underlying disorder was thought to be in a particular person. If in one person it were schizophrenia, the schizophrenia would be treated. If in another person it were OCD, the OCD would be treated. The BDD symptoms would be expected to resolve as the underlying illness did.If BDD is a symptom of a particular other disorder (hypothesis 2), then treatment would in all cases be directed at that one underlying disorder. But if BDD is a separate illness (hypothesis 3), then treatment would be directed at the BDD itself. Treatment directed at another coexisting illness—if one were present—wouldn’t necessarily successfully treat the BDD.What I’ve written about BDD to this point has implied that it’s a separate disorder, and indeed DSM-IV classifies it that way. But some authors have proposed that hypotheses 1 or 2 are more accurate. G. G. Hay, a British psychiatrist, proposed hypothesis 1 when he wrote in 1983 that “dysmorphophobia is a symptom, not a diagnosis or an illness”; he believed that it could occur as a symptom of a “variety of psychiatric syndromes.” Hay thought that the underlying illness could vary from a personality problem (such as a “sensitive” personality type) to schizophrenia to mood disorder.It seems unlikely that this hypothesis is valid. While it’s true that various types of body image symptoms can occur in other disorders, the syndrome BDD—as described in the published scientific literature and in this book—is a well-defined syndrome. It has characteristic symptoms that have been consistently described around the world for more than 100 years. Research that’s been done, especially in the past 10 years, has increasingly clarified its clinical features, which aren’t identical to those of any other disorder, let alone a variety of disorders. Also compelling is what patients say: 62 percent of those I’ve seen have reported that BDD is their most severe and primary problem or their only problem, suggesting that BDD isn’t simply a nonspecific symptom of other psychiatric problems or disorders. In addition, BDD can occur in the absence of other psychiatric disorders. If BDD were simply a nonspecific symptom of other disorders, it would be expected that symptoms of some other disorder, such as schizophrenia or depression, would always be present. This isn’t always the case.*358\204\8*
IBS AND PRESCRIBED DRUGS: TAGAMET, ZANTAC (CIMETIDINE, RANITIDINE)These drugs have been a breakthrough in the treatment of gastric ulcers and have saved countless people from the surgeon’s knife. It would seem, however, that because the drugs have been around for some time, because they are useful, and because they do not seem to have any serious side-effects, a complacency towards them has developed. People are being left on them far too long, month after month, year after year, without any review. A conscientious medical practitioner would be shocked by this, but this is the reality of the situation. It is not surprising, therefore, that there are increasing calls about this group of drugs.The odd thing is that while these drugs seem effective in the treatment of ulcers, some people complain of developing bowel problems during therapy. Here is Olivia’s story:Five years ago I was prescribed Tagamet and a bland diet for a suspected ulcer. This improved and after a few months I returned to a normal diet. I began to have very painful bowel movements and felt uncomfortable and bloated. The doctor diagnosed the Irritable Bowel Syndrome. I was issued repeat prescriptions for Tagamet and after two years decided I should stop taking it; I felt dreadful, anxious, irritable and depressed. After a couple of weeks I felt so ill I was glad to start taking it again; the symptoms vanished. Two years later I decided I must come off no matter how I felt. Months of headaches, anxiety and depression followed, but the bowel symptoms disappeared. For the first time in years I have a pain-free, normal bowel movement.Caution: These drugs increase the potency of tranquillizers and sleeping pills.Anecdotal evidence (in the United Kingdom and the United States) suggests that they can cause dependence; withdrawal reactions have been reported.Post-withdrawal fungal infections have been reported.Bowel problems during Cimetidine therapy have been reported.*90\326\8*
LIVING WITH EPILEPSY/SCHOOL: LEARNING AND BEHAVIOR – ATTENTION PROBLEMS AND HYPERACTIVITYIn order to learn, you must pay attention to what is being taught. Teachers know that the attention span of young children is short. Therefore they teach in short blocks of time interspersed with activities such as marching around the room or recess. As the child gets older (as the nervous system and attention span mature), the child is able to sit and to concentrate or attend for increasingly long periods of time. Thus, a potential cause of a learning problem in the early years of school is that the child’s nervous system is not yet sufficiently mature to allow the child to attend for long periods of time.Another cause of attention problems could be that the child is not sufficiently bright to keep up with what is going on in the class and, therefore, is easily distracted. The other side of that coin is the very bright child who is bored by the slow pace of the class, her mind wandering to fill the time. A child who hasn’t eaten and is hungry may also be less likely to pay attention. A child with insufficient sleep may have similar problems. There are many different reasons for a child’s not paying attention in school.*244\208\8*
TESTS TO DIAGNOSE HEART DISEASE: WHY WOULD A DOCTOR EVER USE TESTS THAT ARE NOT COMPLETELY ACCURATE?
TESTS TO DIAGNOSE HEART DISEASE: WHY WOULD A DOCTOR EVER USE TESTS THAT ARE NOT COMPLETELY ACCURATE?Although very sophisticated tests are available to help diagnose heart disease, no test is perfect. There is always a chance that a test will give incorrect information, no matter how carefully it is done or analyzed.Occasionally, a test may indicate that there is no problem when there really is one. This is called a false-negative result. Sometimes, a test may indicate that there is a problem when there really is not. This is called a false-positive result.When evaluating a patient’s problem, the physician must consider the likelihood of a test being accurate and whether the test result fits with other information about the patient.Why would a doctor ever use tests that are not completely accurate? To begin with, no test is 100 percent accurate, and all tests are open to interpretation. Furthermore, as just discussed, doctors usually try to gain as much information as possible from tests that have the least risk, expense, and inconvenience. The screening tests are used to identify whether you may need to have more extensive (and definitive) testing.In addition, even tests with incomplete accuracy can give important information. For example, a chest X-ray cannot directly show the coronary arteries, valves, and other complex structures of the heart, but it can show the size and shape of the heart, which may be very useful information to the doctor. Chest X-rays are generally quick, safe, and relatively inexpensive. Using the information from the chest X-ray, the doctor may be satisfied that all is well, or he or she may decide more precise tests are needed to determine the problem exactly.*331\252\8*
HEART DISEASE: BYPASS SURGERY – A ROAD DESTINED TO CLOSECoronary artery bypass grafting (CABG): Coronary artery bypass surgery is another expensive surgical procedure which is a more extensive, mutilating and aggressive process of temporary solution to coronary artery disease. In this operation, the chest is opened in the centre in front. Blood vessels from the leg are surgically removed and used to bypass the coronary arteries which have cholesterol deposits (blockages) in them. In males, as there are no breasts, an artery of the chest is available (internal mammary artery) which may also be used in the operation. The operation is extremely complicated and intricate, and can also have serious and fatal outcome. The heart’s function is maintained by a sophisticated machine known as a Heart Lung Machine. The procedure leaves a mark by a huge scar running down the front of the chest, and one on the leg. Although, with the help of this procedure we are able to bypass the blockages in the main coronary arteries and their major branches, by no means can we operate on the smaller branches of the coronary arteries which also contribute extensively to the reduced supply of blood and oxygen to the muscles of the heart.Definitely bypass surgery is an abnormal procedure and cannot be an exact replacement of the original. The reblockages would again occur within a gap of 2 to 12 years with an average of 5 years. Those who do not follow a proper life-style can even get a reblockage within a year but those following a very good life-style would not get a reblockage for even 15 years.
Complications of CABG1. Respiratory complications Alveolar dysfunction Pulmonary oedema Infection Phrenic nerve injury Prolonged ventilatory insufficiency2. Post-operative hypertension3. Heart attack (myocardial infarction) during operation4. Cardiogenic shock5. Left ventricular failure6. Cardiac tamponade7. Septic shock8. Arrhythmias Atrial fibrillation Atrial flutter Ventricular fibrillation 9. Blood clotting disorders10. Wound infection, non-healing of wound11. Peripheral vascular complications12. Renal failure13. Gastro-intestinal complications Bleeding in the stomach, duodenum, shock liver syndrome14. Reblockages15. Damage the brain during the heart-lung machine running the blood supply to the brain.
Comment: After surgery (CABG) when someone gets a reblockage after 5 years and gets angina again – it is clear that the blockage is already more than 70% or more. Now suppose this 70% had developed in 5 years – i.e. 14% per year of reblockage. Many people accept it as a normal thing. This may also be calculated as more than 1% reblockage in a month after bypass surgery. How absurdly people still accept ongoing blockage – even after bypass surgery and still do not consider a lifestyle change!*47/283/5*
HIV: RESOURCES-WHERE TO GO FOR HELP: SELECTED NATIONAL RESOURCESThe following is a list of national resources, selected either because they run information hotlines or because they publish newsletters. These organizations sometimes change their telephone numbers. If you call and get a message that the number is not in service, try directory assistance. For 800 numbers, the directory assistance number is 1-800-555-1212. AIDS Clinical Trials Groups (ACTGs). These are the medical centers that are part of a national program of the National Institute of Allergy and Infectious Diseases (NIAID) to test new treatments for HIV infection. ACTGs need people to participate in these clinical trials; they are also superb sources of information and treatment. The list of ACTGs changes with time, so the best way to find the ACTG nearest you is to call the NIAID hotline at 1-800-TRIALS-A. American Foundation for AIDS Research (AmFAR), 1515 Broadway, Suite 3061, New York, N.Y. 10036,212-719-0033. This organization keeps track of funding, research, and experimental treatments. AmFAR publishes the AIDS/HIV Experimental Treatment Directory, a directory of drugs being tested in clinical trials, updated quarterly. AmFAR also publishes AIDS Targeted Information Newsletter, a monthly newsletter of reports of, and comments on, the latest medical research appearing each month. It’s expensive, $125 per year; 1-800-638-0672. Gay Men’s Health Crisis (GMHC), Department of Medical Information, 129 W. 20th Street, New York, N.Y. 10011. GMHC publishes Treatment Issues, a monthly newsletter on experimental drugs, which comes out ten times a year; no cost, but a donation is requested. National AIDS Hotline, 1-800-342-AIDS (tape) or 1-800-342-7514 (operator). This is a 24-hour-a-day, 7-day-a-week hotline, contracted through the Centers for Disease Control. Ask them questions about types of services, about general information, and about what services are available in your local area. For Spanish-speaking callers, the number is 1-800-342-SIDA (8 a.m. to 2 a.m., Eastern Time). National AIDS Information Clearinghouse, 1-800-458-5231. This is a sort of library for information on HIV infection; it sends publications, videos, and lists of services and community organizations for all areas. National Commission on AIDS, 202-254-5125. It provides information on federal laws about funding for and research on HIV infection; located in Washington, D.C. National Institute of Allergy and Infectious Diseases, National Institutes of Health, Building 31, Room 7A32, Bethesda, Md. 20892. The Institute publishes NIAID AIDS Agenda, a monthly newsletter about federally funded research projects. Pharmaceuticals Manufacturers Associations, Communications Division, 1100 15th Street, N.W., Washington, D.C, 202-835-3400. It publishes Update: AIDS Products in Development, a quarterly chart of drugs, diagnostic tests, and vaccines. PWA Coalition, 31W. 26th Street, New York, N.Y. 10010, 212-532-0290. PWA stands for People With AIDS, though the organization welcomes everyone with HIV infection. It publishes the PWA Coalition Newsline, a monthly newsletter on alternative and experimental drugs, community-based research programs, and outreach activities; free to people with HIV infection, donation requested of all others. San Francisco AIDS Foundation, Box 6182, San Francisco, Calif. 94101, 415-863-AIDS. It publishes BETA, Bulletin of Experimental Treatments for AIDS, a newsletter about experimental treatments of HIV infection, updated periodically; no subscription price, but a donation is requested. University of California at San Francisco, AIDS Health Project, Box 0884, San Francisco, Calif. 94143, 415-476-6430. It publishes Focus, a newsletter with practical information about AIDS research.*250\191\2*
TULAREMIA: DIAGNOSIS, TREATMENT AND POSTEXPOSURE PROPHYLAXISDiagnosisThe clinical presentation and laboratory features of tularemia are generally nonspecific. Radiographic findings include lobar consolidations, miliary infiltrates, hilar or mediastinal lymphadenopathy, or pleural effusions, but these, too, are nonspecific. As with the other diseases caused by the agents of bioterrorism, clinical suspicion is necessary for diagnosis. Physicians who suspect this disease should alert local or state public health authorities so that the appropriate epidemiologic and environmental investigations can be begun. The clinical microbiology laboratory should also be warned of the diagnosis, since isolation of the organism represents a clear hazard to laboratory personnel.Francisella tularensis may be directly identified in human tissues or body fluids using antigen detection assays (direct fluorescent antibodies or immunohistochemical stains). A diagnosis can also be made by recovery of the organism from cultures of blood, ulcers, conjunctival exudates, sputum, gastric aspirates, and pharyngeal washings, although these should only be attempted in Biosafety Level-3 containment facilities. The organism is quite fastidious, and growth may be delayed, so cultures should be held for 10 days before discarding. Culture may still be possible after the initiation of appropriate antimicrobial therapy. Most diagnoses of tularemia are made serologically, and a fourfold change in titer between acute and convalescent serum specimens or a single titer of at least 1:160 is diagnostic for infection. Serum titers usually do not reach diagnostic levels until 10 or more days after the onset of illness.
Treatment and Postexposure ProphylaxisStreptomycin has historically been the drug of choice for tularemia, but alternative therapies should be considered, since this antibiotic is not readily available. Gentamicin is an acceptable alternative, and treatment should be continued for 10 days. Ciprofloxacin, which has intracellular activity, has been used successfully to treat tularemia after 10 days of therapy. Doxycycline and chloramphenicol can also be used, but since these drugs are bacteriostatic, therapy should be continued for at least 14 days to reduce the risk of treatment failure and relapses.In a bioterrorist release, exposed persons should be prophylactically treated with a 2-week course of either oral ciprofloxacin (500 mg twice daily) or doxycycline (100 mg twice daily). These individuals should be instructed to begin a fever watch.
Infection ControlIsolation is not necessary for patients with tularemia, since person-to-person transmission has not been documented. Physicians should use standard precautions when caring for patients with tularemia.*216/348/5*
RECOMMENDED IMMUNIZATIONS: HEPATITIS В, HEPATITIS A AND ВHepatitis ВHepatitis В is highly prevalent in parts of South America, Africa, Southeast Asia, and the South Pacific, and it is transmitted through unprotected sexual exposure and activities that involve contact with blood or blood-derived products. The risk of hepatitis В infection for international travelers is generally low but increases the longer a person remains in an endemic area. The risk of infection may be associated with medical or dental care received abroad, exposure to blood products due to an accident or illness, and sexual or intravenous needle contact.Hepatitis В vaccination should be considered for the following people:- Travelers who expect to have close contact with local populations that have high rates of hepatitis В transmission.- Individuals who plan an extended stay (6 months or longer) in an area of hepatitis В endemicity.- Persons who might have need for medical treatment while abroad.- Travelers who anticipate sexual contact with local residents.- Persons born overseas who travel back to their country of origin to visit family and friends.Two hepatitis В vaccines are currently available in the United States, Recombivax-HB (Merck) and Engerix-B (GlaxoSmithKline). The standard schedule with either formulation for adults 20 years of age and older calls for three doses of vaccine (each 1.0 mL) at 0, 1, and 6 months. For patients leaving immediately, an accelerated schedule with Engerix-B is available and consists of vaccination at 0, 1, and 2 months with a booster given 12 months after the first dose. Serologic testing to assess immune response is not necessary in healthy hosts. Pain at the injection site and occasional low-grade fever are the most common side effects among vaccines. The vaccine is not contraindicated in pregnancy.
Hepatitis A and ВA new combination hepatitis A and В vaccine (Twinrix, GlaxoSmithKline) containing the same antigenic components as Engerix-B and pediatric Havrix was approved by the Food and Drug Administration in 2001 for use in adults older than 18 years, and this vaccine is as efficacious as each of the monovalent vaccines. The indications for this vaccine are similar to those for hepatitis A and В vaccines in travelers. Primary immunization occurs at 0, 1, and 6 months. An accelerated schedule of 0, 1, and 3 weeks, with a fourth dose 12 months after the first dose, is as efficacious as with the standard schedule. The main adverse effects are headache and nausea. Its safety in pregnancy has not been determined.*184/348/5*