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OBSTRUCTIVE SLEEP APNOEA (OSA): CASE STUDIES

admin — Tue, 14 Sep 2010 09:59:32 +0000

One of the physician’s tasks in the sleep disorders clinic is to distinguish between patients with potential sleep apnoea and those with other complaints which adversely affect the quality of sleep. Stress related insomnia, for example, has no place in the laboratory dedicated to sleep related breathing disorders. The following case studies are fairly typical of patient histories which warrant complete evaluation of their symptoms. While they do not accurately reflect the incidence of snoring or OSA in any particular age group or sex, they have been included to demonstrate a diversity of presentations.

A 38 year old travelling salesman had been a heavy snorer for years, aggravated to some extent by the consequences of a broken nose. He was a restless sleeper and often awoke in the morning with a headache. Daytime drowsiness was beginning to affect his attention span and driving competence which eventually led to his falling asleep while driving the car on a long business trip. He was not seriously hurt but the incident prompted investigation of his daytime sleepiness. Examination by his local doctor found him to be moderately overweight for his height and it was noted that he enjoyed five or six cans of beer at night. The doctor advised that his long working hours and drinking habits could explain the worsening symptoms and suggested he lose some weight and take time off for a holiday. Some weeks later he was involved in another near miss driving incident, prompting him to seek advice from another practitioner who referred him to a sleep disorders clinic. Overnight studies confirmed OSA and he began a trial of nasal CPAP which he tolerated well. His quality of sleep and daytime alertness were improved to the extent that he purchased his own CPAP equipment for use both at home and in motel rooms when required to sleep away from home. Weight loss and reduction of alcohol intake improved his condition slightly but not enough to eliminate his dependence on nightly CPAP, a situation he has come to accept as necessary for his wellbeing in the foreseeable future.

Comment: An example of OSA as it is most commonly seen. The patient is middle aged, male, overweight, drinks alcohol at night and has a predisposing factor to airway obstruction (a broken nose). For those who have suffered the symptoms of OSA for years, CPAP offers remarkable relief, an advantage which clearly outweighs the disadvantages and inconvenience associated with its use.

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CHRONIC CONFUSION: DEPRESSION

admin — Tue, 14 Sep 2010 09:57:26 +0000

Depression in the elderly is also called ‘pseudo-dementia’, i.e. false-dementia; this is because the symptoms and signs of depression can be very difficult to separate from those of some of the dementing illnesses. Depression is common in old age, and the elderly have the highest rate of successful suicide attempts. Depression often accompanies physical ill-health and, as we have seen before, old age is also a time of loss, making coping with the burdens of everyday life that bit more difficult.

All of us have days where we feel sad, but for most the mood passes. It becomes a problem when the melancholic outlook on life persists and begins to intrude into the person’s daily activities. Common feelings in depressed people are those of worthlessness and a hopeless outlook to the future. Sleep becomes disordered and there is early morning waking with an inability to get back to sleep and a subsequent feeling of a poor night’s rest. Gloomy thoughts intrude and ideas of suicide begin to form. The person may worry about their general health and consult their doctor about many trivial complaints (hypochondriasis), or they may begin to feel that their body is rotten and that they are decomposing internally. Many slow down and lose the will to do anything, even speak. The person may refuse to eat or drink and thus put their life in danger.

The condition gets confused with dementia because when various questions are asked to try and establish a diagnosis, to get an idea of orientation and memory, etc., often the person does not answer, hence scoring badly. The important difference is that the depressed person, if given enough time or if they wanted to answer, would give the correct answers; as it is though, they appear confused. Some people have a long history of depression; others have their first attack in old age. Making the diagnosis is the first step, and the sooner the better. Most people with depression do go to their GP but often do not complain of feeling low. The astute GP will realize that something is wrong and begin to ask the right questions. In difficult cases the person should be referred to a psychiatrist. There is still great stigma attached to psychiatric disease, which is odd considering that a significant proportion of the population will suffer from it during their lifetime. As psychiatric units cease to be housed in vast institutions and become part of the general hospital or community facilities, hopefully this feeling will fade. There has been a tendency for GPs to diagnose depression but be reluctant to prescribe anti-depressants for the elderly age group. This is now recognized as poor management: good clinical practice is the use of anti-depressant drugs when the diagnosis is made.

In a few the depressive illnesses will be part of a reaction to bereavement or disability or other stressful life events. Most of these cases will be monitored by the GP and psychiatrist and a few will need treatment with counseling. In the other cases antidepressant drugs are needed as well as the other support networks (day hospitals, self-help groups, counseling etc.) The drugs are very effective and have minimal side-effects, except in the very old and frail. Most courses of treatment are given via the GP or on an outpatient basis. Sometimes however the condition of the person is so severe that treatment has to be started on an inpatient basis. This is certainly true when ЕСТ (electroconvulsive therapy) is used. Many people who do not understand this form of therapy or who have never seen it given are very opposed to it. However, it is an effective, safe and necessary form of therapy in severe depression and can be life saving. A mild anesthetic is given and one electrode on the side of the head gives a minor shock, often just enough to cause a slight twitch. The only side-effects are of mild memory loss surrounding the ЕСТ in some people. Most treatments (both drug and ЕСТ) are given voluntarily. Occasionally, however, the depression is so severe that the person does not recognize that they are seriously ill and they have to be admitted to hospital under one of the sections of the Mental Health Act. This is usually done by a social worker and the GP.

Recovery from depression can be extraordinary, although some people relapse and may need further courses of treatment. Because it is common and treatable great lengths must be taken to ensure that no one is labeled as ‘demented’ when in fact they are suffering from depression. Occasionally the two conditions of depression and dementia coexist; as the depression is treated the dementia does not go away but is usually noted to be less severe.

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THE EFFECT OF MOVING ON PHYSICAL AND MENTAL HEALTH

admin — Tue, 01 Jun 2010 10:24:39 +0000

When we say Mr. Smith’s heart attack was caused by the stress of retirement, blame our brother’s death on his anguish over being widowed, or nod ruefully when we catch the flu the week we move, we are agreeing to a belief as old as ancient times: that major disruptions in the pattern of life make people sick. For most of this century, however, this idea was pooh-poohed by a medical profession bent on explaining illness in purely medical terms: “Physical diseases have physical causes. Except for a very few stress-related conditions (e.g., ulcers), our emotions have no effect on how our bodies behave.” In the late 1960s, Thomas Holmes and Robert Rahe decided that rather than simply accepting the unquestioned dogma, they would actually test the “old wives’ tale” that stressful events can make us ill.

They assigned change rankings to a list of events, scores ranging from a high of one hundred for being widowed to lows in the teens for minor upsets such as getting a traffic ticket. Because they felt that the sheer quantity of change itself, not whether the change is bad or good, produces illness, they included both negative and positive events on what became their well-known life-change scale. After testing thousands of subjects, Holmes and Rahe proved that there was indeed a nonspecific link between outer-world changes and internal ones. People who had unusually high change scores during a short period were more likely to get sick. Depending on their particular vulnerabilities, they were more susceptible to illnesses as varied as cancer and colds.

Not everyone who retires, moves to Florida, and loses his wife in 1988 is fated for a hospital bill – or even a cold – in 1989. People vary greatly in their physical stamina and in their capacity to absorb and tolerate change. Events also have very different meanings for different people. As we saw, for instance, it is not true that the man who hates his job is affected in the same way by leaving work as his friend for whom retirement is a catastrophe.

In fact, contrary to what Holmes and Rahe predict, a recent study suggests that happy events may not be illness producing at all. Researchers at Indiana University School of Medicine questioned elderly residents of a public housing complex about their health and then compared their answers with the total number of changes versus the number of negative changes they had recently undergone. Only the negative events tally was related to declining health, suggesting that it really is our new misfortunes – not our new blessings – that affect our physical well-being.6

So we need not fear the physical consequences of moving. Change in itself does not seem to be bad. However, we do need to ensure that moving will be a positive change in our life.

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GENERAL HEALTH

CHANGING RESIDENCE: NOT MOVING – THE NORM

admin — Tue, 01 Jun 2010 10:24:05 +0000

Older people do not move even once, however. In spite of their reputation as migrants, people over sixty-five are the least likely to change residence of adults of any age. Our early twenties, not our sixties, are the time of life when we are most likely to move. As the years pass and we establish roots in a place, we are increasingly likely to stay put. For instance, while more than a third of all twenty- to twenty-four-year-olds (and about a fifth of the nation as a whole) changed residence from 1982 to 1983, only about five out of every hundred people over sixty-five moved that year.

The strong resistance to moving that characterizes many older people is suggested by another demographic fact. Apart from Florida, the counties with the highest concentration of older residents are in rural areas in our nation’s heartland. Whereas younger people living in these often economically depressed counties have left in droves for more urban areas, the older people refused to move. And when the elderly do move, they tend to resettle within their area, moving to a new community or state is rarer.

A survey sponsored by the American Association of Retired Persons offers other clues to this stability. Why are most older people so wedded to where they are? What type of housing are older Americans likely to have, and what are the pluses and minuses about where they live? In the fall of 1982 the AARP commissioned a polling organization to conduct telephone interviews with a nationwide sample of more than a thousand Americans over age fifty-five. The poll showed that people stay in one place not out of fear or lack of money but because they like living where they are. Most people rated their housing as good or excellent. It scored the highest points on comfort and location. The most frequent complaint people had was the lack of good public transportation.

Not unexpectedly, more affluent people were likely to give their housing high ratings. People, who felt safe (not afraid of crime), those who were in good health, and – surprisingly – those who lived in large versus small cities (presumably because public transportation in large cities tends to be good), were also especially pleased with where they lived.

The poll suggested that as we get older we vote no to moving because our roots are too deep to be casually pulled up. The vast majority of the people surveyed owned their homes (about 80 percent). More than half had been living there a long time, at least ten years. The largest fraction, 39 percent, had lived where they were from twenty years to a lifetime.

When we live in one place for so long, our home becomes part of us. It is more than an asset to be traded away. So even though it may seem logical to move to a smaller space, or to a place where life is easier, we hesitate. Our home is so thick with memories that leaving can be like cutting off our past.

Economics as well as emotions lock people in. For instance, because rent increases in New York City are limited by law, it is not rare to see widows living hand-to-mouth in large luxury apartments. Although the space and the exclusive address far from affordable shopping are more of a burden than a gift, these women cannot afford to give up the 1950 prices and leave.

Moving also becomes less of a compelling idea when people calculate the cost of living in their homes versus apartments. For most of us a home is our primary asset. Eighty percent of homeowners over age sixty own their homes free and clear. So particularly in states that offer older people a reduction in property taxes, an older homeowner’s living expenses are small. The price Mrs. Jones’s home would bring on the market may seem dazzling, but what happens after she sells? The alternatives – exorbitant rent, a high purchase price and monthly assessment for a condominium – may seem worse than what she has now – space, memories, the yard, the luxury of not shelling out a hefty monthly check.

And even when they are financially able to move and want to do so in theory, people do not move because they are afraid: ‘ ‘What will happen if the choice is wrong?” ”Isn’t the stress of changing likely to be too much for me at my age?” Especially moves to places known as old-age destinations can be fraught with ghoulish symbolism: “People retire to Florida to die.” “If I give up my home for Century Village I will age just by proximity, being around all those ‘old’ people.

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GENERAL HEALTH

YOUR CHILD’S HEALTH/BONE AND JOINT DISORDERS: FRACTURES (BROKEN BONES) TREATMENT

admin — Fri, 11 Sep 2009 10:15:05 +0000

If you suspect that your child has a fracture, see your doctor.

Most fractured limbs need to be splinted or put into a plaster cast. This enables the bones to unite and mend without being disturbed by any movement. If the fracture is a complicated one, or it is open to the surface, your child may require an operation under anaesthetic. Because of this, avoid giving him any food or drink until you get medical advice. Children’s bones mend rapidly, usually without any complications. Encourage the use of the affected limb after the cast has been removed — a child provides his own best physiotherapy.

If your child has a fracture of the skull, he will need careful medical attention because of the delicacy of the underlying brain tissue.

After the application of a plaster cast, care must be taken to ensure that there are no complications.

1. Keep the limb elevated (in a sling for the arm or by using crutches with a leg in plaster) for 48 hours — this is how long it takes the plaster to dry completely.

2. Encourage your child to wiggle the fingers or toes of the affected limb.

3. Return to your doctor the following day for a plaster check. This is very important in order to ensure that the plaster in the correct position.

4. See your doctor or go to the emergency section of a hospital immediately if

any of the following occur:

• swollen or blue toes or fingers;

• severe pain in the limb, not eased by painkillers or by elevating the limb;

• stiffening of the fingers or toes;

• pins and needles or numbness of the fingers and toes.

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YOUR CHILD’S HEALTH/BONE AND JOINT DISORDERS: BOW LEGS AND DISLOCATION OF A JOINT

admin — Fri, 11 Sep 2009 10:14:58 +0000

BOW LEGS

Young babies commonly have marked bowing of their legs, especially if they are of a rather sturdy build. When the child stands with his feet together, the ankles touch but the knees are separated. This is considered to be a normal variant, caused by poor alignment of the bones of the thighs and legs during growth. Most children have bow legs to some extent in infancy and this becomes more noticeable when they start to walk. The legs usually gain realignment by the time the child starts school, and no treatment is required. If the bowing does not improve after this age, night splints may be considered where the bowing is severe.

DISLOCATION OF A JOINT

Many joints in the body are of the ball-and-socket type. When these become dislodged from each other, as a result of injury, we call this a dislocation.

Clinical features

The pain after dislocation is usually similar to that of a fracture. There is marked pain and swelling over the area of injury and deformity is usually obvious.

Investigations

The diagnosis should always be confirmed on X-ray. Sometimes a fracture will also be present. If the dislocation has to be manipulated back into place, a follow-up X-ray will be necessary.

Treatment

Under an anaesthetic, the bone is manipulated back into place. A sling is usually worn for several weeks.

Complications

If the tendons or ligaments that surround the joint are badly damaged, the dislocation may recur. A paediatric orthopaedic surgeon should be consulted if this occurs.

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YOUR CHILD’S HEALTH/BONE AND JOINT DISORDERS: CURVATURE OF THE SPINE (SCOLIOSIS)

admin — Fri, 11 Sep 2009 10:14:53 +0000

Scoliosis is an abnormal sideways curvature of any part of the spine, and most commonly occurs in preadolescent girls. The cause of scoliosis in this group of children is unknown. Rarer causes of scoliosis include cerebral palsy and muscular dystrophy.

Scoliosis is usually discovered during routine screening at school. It rarely causes problems during childhood, but curvature of the spine is visible in most cases. Pain may occur at a later stage.

Investigations

Most children who are thought to have scoliosis will undergo an X-ray of the spine to confirm the diagnosis. X-rays may be repeated at certain intervals to monitor the degree of scoliosis as the child grows.

Treatment

Most mild cases of scoliosis will not require specific treatment, but the child should be monitored routinely to see how the condition is progressing. A more severe curvature may require some form of temporary back brace to minimise the deformity. This will be done under the supervision of an orthopaedic surgeon. Surgery is only necessary in the most severe of cases.

When to see your doctor

See your doctor if you are concerned that your child may have scoliosis.

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YOUR CHILD’S HEALTH/BONE AND JOINT DISORDERS: CLUBFOOT (TALIPES EQUINOVARUS)

admin — Fri, 11 Sep 2009 10:14:47 +0000

Clubfoot is a deformity of the foot which is present at birth. The baby’s foot is turned inward, with the inner edge turned upwards. The calf muscles may be poorly developed. This condition occurs in approximately 1 in 1000 births. The cause is uncertain, but the condition is probably due to an abnormality of the developing bones and ligaments. Talipes has a tendency to run in families.

The child with talipes should be referred to a paediatric orthopaedic surgeon. Treatment to correct the position of the foot is commenced soon after birth. Special splints or plaster casts are used to hold the foot in a straight position. Careful follow-up is essential, as the condition may recur. Surgery is sometimes necessary.

This condition is different from talipes calcaneovalgus (‘turned’ foot), which is more common and usually of no consequence. Here the toes are turned upwards towards the shin, and the whole foot is turned to the outside. This is the most common foot abnormality seen in the newborn. In the majority of cases, the condition corrects itself within 6 months and no treatment is required. Occasionally stretching and splinting are necessary. This condition is associated with congenital dislocation of the hips, so the hips must be carefully checked.

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YOUR CHILD’S HEALTH CARE: HEALTHY TEETH

admin — Thu, 21 May 2009 06:55:34 +0000

You can help your child to have healthy teeth by ensuring the following:

• Check to see if the water in your area is fluoridated. If not, add fluoride supplements to the baby’s diet. Your dentist can recommend the correct dose and form.

• Do not let your baby or young child go to bed with a bottle in his mouth. This practice will cause dental caries, especially in the front top teeth. Use the bottle for feeding not pacifying.

• Do not put jam, honey or glycerine on your baby’ s dummy.

• Try to avoid giving your child sweet drinks or lollies. If your child does have lollies, keep them to a minimum. Don’t get into the habit of using them as rewards. Encourage your child to brush his teeth afterwards. Fruit juice or plain water is preferable to carbonated sweet drinks or cordials.

• Once your child is old enough to rinse and spit out, encourage him to brush his teeth regularly using fluoridated toothpaste on a child-size toothbrush. Parents can brush the teeth of younger children.

• Have your dentist check your child’s teeth from toddler age onwards, or earlier if you have any concerns.

A note on fluoride

Some people are concerned about fluoride being added to the water supply. These arguments are sometimes about ‘freedom of choice’, or about chemicals being added to the water. You should rest assured that the levels of fluoride added do not harm your child in any way — there is absolutely no risk of fluoride poisoning. In fact, water already contains many chemicals — from those occurring ‘naturally’ to those added to purify the water and kill any bugs which may be harmful to your health.

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VITAMINS – B-SERIES

admin — Mon, 18 May 2009 06:06:52 +0000

Nicotinamide, or Vitamin B7, is also widely distributed in most foodstuffs.

Lack of this vitamin — and usually wittf an associated lack of riboflavin — produces the disease known as pellagra, and this usually is seen in those whose staple diet is maize and little else.

Vitamin B6, or pyridoxine, is required for the proper functioning of nervous and skin tissue.

B6 has recently been used in relieving premenstrual tension (PMT).

Most of the B-group vitamins form part of the molecules of enzymes in the body, those chemical substances which are necessary for the build-up and break-down of all the body tissues.

Vitamin B12, or cyancobalamin, is formed in the body by the action of a chemical in the stomach acting on another chemical taken in with the food.

It is necessary for the proper development of the red blood cells and nervous tissues.

A lack of Vitamin Â12, because of degeneration of these special cells of the stomach, which produce the intrinsic factor, is the cause of pernicious anaemia.

This disease, called pernicious when it was first discovered because the anaemia does not respond to the intake of iron, is treated by giving Â12 by injection.

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