Human Diversity: A Mind Thing

(A version of this essay was published in Minnesota Medicine in March, 2005.)

The first snowy egret I ever saw was standing in a shallow pool, a beautiful white creature with a wispy headdress floating in a gentle breeze. When he lifted off, trailing his long black legs, I was startled by a flash of bright yellow – he looked like he was wearing a child’s rubber boots, designed to hug a bird’s clawed feet. He did a loop around the pond in  flying low in a peculiar, non-aerodynamic position. His legs hung down rather than stretching out parallel to his body. He dipped closer to the water and his dangling yellow feet brushed the surface. He’s landing, I thought. But he didn’t. He repeated the maneuver four times.  He’s afraid to land, I thought. But then he touched down with hardly a splash, and dipped his beak to catch a fish, then another, and another. In a moment of bird-watching epiphany, I realized that his feet were like a fisherman’s lure. He’d rounded up his lunch. 

I looked around the pond. I’d just watched a bird with bright yellow feet use them to attract the curiosity of his prey. Across the water was a bird with a lower bill that expanded into a pouch to collect fish as he skimmed, openmouthed, over the water. Perched high above was another, just about to dine on a large fish he’d  skewered with  fearsome talons. What an impressive display of diversity!  If people were this diverse, New England fishermen would grow waterproof, blubber lined hands, typists would develop extra fingers, and mothers really would have eyes in the backs of their heads.  

But people are pretty much the same as far as their bodily equipment goes.  Five fingers on each of two hands, ten toes divided between two feet, two eyes, upright posture, and a narrow range of physical abilities, notwithstanding the spread between ordinary and Olympian. The traits we associate with human diversity are superficial – hair color and texture, skin color, facial appearance. Almond shaped or round, eyes still see. Long, elegant skeletal frames and short squat ones all support bodies against the universal force of gravity. Skin pigmentation protects the body covering from the sun, more or less depending on the power of the sun in the areas of the world where the people originated. We are much more like each other than we are different in our biology. The birds have it all over us in the diversity contest.  

After my egret experience, I packed up my binoculars, got on my bike and headed home, humbled a little by the thought that all of the talk and concern about diversity among people is overblown, maybe just another representation of man’s abiding sense of self-importance. But along the way I passed bikes and cars, houses and stores, a radio broadcast tower, and a museum.  I crossed a bridge between two islands and waved to a fisherman in his boat. And I realized that each of these man made things  I passed began as an idea, somewhere, some time, in somebody’s head. We might not differ much in anatomy and physiology, but no two of us have identical thoughts. The mind is the site of the real diversity among humans. The mind is plastic and ever developing. It records, collates, recalls, communicates, and combines unrelated information in new ways. Yellow feet catch the eye, but minds change the world.

Medicating Childhood Behavior: Caution Ahead

In Hannibal Missouri, Huckleberry Finn’s house sits next door to Mark Twain’s.  Tom Blankenship, the real boy who lived in the tiny house, was the model for the wild and fictional Huck, as Mark Twain was for the impish prankster Tom Sawyer.  In the sleepy little town set on the banks of the Mississippi River, it is easy to imagine the two real boys living the lives Twain created for his characters. And it is just as easy to imagine what would happen to two such boys in the modern world. Twain and Blankenship would be disruptive children, seeing the school psychologists and being medicated for attention deficit disorder.  Is this progress, or are too many children today labeled with psychological disorders and taking drugs to modify behavior?

Reasons for psychoactive medication use in children

The most legitimate reason for identifying and labeling children as disordered is that some psychological disorders that appear early in life express themselves more severely in adulthood than later onset versions do. Early treatment helps prevent more dysfunction later, especially in problems like autism. Other reasons may be less admirable.  Prescribing drugs to treat emotional and behavioral symptoms is easier and less time consuming than dealing with the psychological problems that lie beneath the symptoms, problems which do not reflect abnormal brains.

How did we get to medicating behavior?

Attempts to treat psychological symptoms with drugs began in earnest with the serendipitous discovery in the 1950s that certain drugs, used for treating infections and high blood pressure, appeared to elevate mood. They seemed to have a direct effect on behavior.  Pharmaceutical companies then began to develop drugs specifically targeted to brain function.  Later, scientists discovered that these drugs led to changes of levels of chemicals in the brain that transmit information between nerve cells and they developed the neurochemical theory of psychological disorders.  The drug age of treatment of anxiety, depression and psychosis took off on the assumption that the drugs treated some native chemical imbalance in the brain. Because there is no direct evidence for such imbalance, some respected psychiatrists now question the neurochemical theory. Additionally, careful review of many drug studies show their effects to be little better than placebos (sugar pills). Nevertheless, drug treatment of psychological symptoms has ballooned in all age groups, particularly in the late 1900s and early 2000s. Between 1987 and 1996 the use of psychoactive drugs in children from ages 6-17 jumped 2-3 times. By 2000, 8.8% of 6-17 year olds were taking some kind of psychoactive drug. By 2017 the number of children medicated for behavior was over 7 million.

The diagnoses that prompt drug treatment in children

The behaviors of modern children that prompt treatment are divided into diagnostic categories: attention deficit disorder (ADD or ADHD); mood, anxiety and disruptive behavioral disorders; autistic spectrum disorders and childhood schizophrenia. The latter two categories reflect distinct disorders of brain function, but the first four are defined by behaviors that are often related to age and circumstances. But even autistic spectrum disorder diagnoses capture many children with behaviors that were once considered part of the normal range of human personality and behavior – social ineptness, obsessional interests and unusual styles of learning and communicating.

Non-medical factors involved in the rise in psychoactive drug prescriptions

Non-medical factors which have added to the enthusiasm for drug treatment of behavioral symptoms have been the tremendous changes in society since World War II –in family structure and values, leisure time activities, employment patterns, the educational system and in the non-governmental institutions like churches and community groups that used to provide moral and structural support.  While schools once neglected girls’ needs, boys are now immersed in an educational system geared to girls, who are more verbally adept at younger ages than boys are.  Sitting still and learning to read is a task that boys confront several years earlier than they used to, and many lack the required maturity.  When they fail and act out, they are thought to be inattentive and impulsive, garnering them ADD evaluations and drug treatment significantly more often than girls.

Changes in the practice of medicine

Changes in the practice of medicine, with more emphasis on tests and drugs now than on time spent in direct contact with patients and families, also contribute to the ease with which drugs are used as the primary approach to all kinds of medical problems, not just psychological ones. Another problem for children is “off-label” drug use, a term applied to the perfectly legal practice of prescribing drugs for reasons other than those used in the trials that determined their safety. It is estimated that 70% of all pediatric drug use is off-label, and for most of the psychoactive drugs used in children, testing has been done only in adults. In addition, the majority of psychoactive drugs used in children are prescribed by family practice or general pediatricians, not by psychiatrists. Pediatric psychotherapists, whose help might supplant the need for drugs or improve the outcome of drug treatment, are in short supply. For children without private insurance, psychoactive drug prescription rates are higher than for the privately insured.

Long term concerns

The concerns about widespread use of psychoactive drugs in children extend beyond the many side effects such as decreased appetite, insomnia, cardiac problems, and sudden death  (stimulants used for ADD), and weight gain, sleepiness, liver problems , diabetes, and increased suicide rates (antidepressants , antipsychotics and mood stabilizers).  Some neurodevelopmental biologists think  we may be trading one set of problems for another delayed and potentially more troublesome set,  because psychoactive drugs  have long term effects on the immature brain that are not seen in the adult. The developing brain is meant to learn from experience and modify its behavior in a process we call maturation and  it is not at all clear that interfering in development with drugs that change behavior passively is superior to helping the child learn without drugs,  by improving the social environment and providing competent psychological help.  We should remember that role models for Huck and Tom grew up to be a judge and a famous writer.

Nausea and Vomiting: the Great Equalizers

In 1832, British scientist Charles Darwin, who is famous for his evolutionary theory of biology, wrote a letter to his father after having been at sea for more than a month, saying: “The misery I endured from sea-sickness is far far beyond what I ever guessed at.” Much later in the letter, Darwin goes on to make the following pronouncement: “If it was not for sea-sickness, the whole world would be sailors.”

In these statements, Darwin, is, of course, referring to the all-consuming symptoms of nausea and vomiting associated with seasickness. In Darwin’s case, these symptoms were particularly severe and continued to plague him even on land. Modern medical detectives theorize that he may have had a rare genetic problem called mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke (MELAS) syndrome, which he would have inherited from his mother. One does not, however, need to have any experience with rare diseases to empathize with the misery he describes. Nausea and vomiting are the great equalizers of men, stripping all sufferers of energy, ambition, and desire. Virtually everyone has experienced both symptoms.

Why do we vomit? 

Like diarrhea, nausea and vomiting are probably evolutionarily developed, protective mechanisms designed to rid the body of toxins. Why these symptoms spill over into motion sickness and inner ear problems is a mystery, but the answer may have something to do with the fact that many toxins affect the inner ear. Some scientists speculate that over eons of evolutionary time the ear came to use the same warning symptoms experienced with seasickness to alert the body to other problems, such as trouble controlling balance. Nausea and vomiting are universal symptoms. The threshold for their appearance is highly variable. While triggers are usually physical, the symptoms can also come from the mind itself. Vomiting can be triggered by great distress, and in some people undergoing chemotherapy, antianxiety agents can diminish “anticipatory” nausea.

The scientific literature devoted to studying nausea and vomiting is full of words like “probably,” “possibly,” and “perhaps,” which reflects the lack of full understanding of the subjects. Nausea is a subjective sensation, a queasy feeling, which seems to come from the stomach but is felt primarily in the head—a feeling that vomiting may soon occur, though not necessarily. Nausea is often accompanied by the need to lie down or even to sleep, by an inability to concentrate, and by lack of interest in one’s surroundings. In people suffering from nausea, the muscular activity of the stomach and intestines is slower than normal. As nausea progresses toward vomiting, sweating and increased saliva production occurs, the skin pales, and the heart rate increases.

Vomiting is an action

Vomiting is an action and is much better understood than the sensation of nausea. It begins with a masterfully coordinated sequence of muscular actions that are carried out by the upper portion of the gastrointestinal tract, working in reverse to bring stomach contents back up the esophagus to the throat and mouth. When a person vomits, the muscles are all recruited to expel the mess with great force. Once vomiting occurs, nausea often subsides, at least temporarily.

Nausea is a sensation

Nausea has many different causes, including the presence of drugs and toxins, primary gastrointestinal problems, inner ear problems, hormonal and other metabolic problems, and brain problems. In most circumstances of nausea and vomiting, the symptoms are acute (appearing suddenly in a previously stable individual) and self-limited, meaning that they get better on their own within hours to days. The most common causes of short-lived symptoms are side effects of medications, surgery when anesthesia is used, viral or bacterial toxins, motion sickness, and migraine headaches. The most common causes of longer lasting episodes are the hormonal changes that take place during pregnancy, the side effects of chemotherapy and radiation treatments used to treat cancer, and episodes of inner ear problems that provoke a severe, spinning dizziness that is triggered when a person changes head position.

Searching for the cause of nausea: pay attention to other symptoms

Nausea and vomiting may also be symptoms of more serious illnesses, particularly when the cause is not easily identified or the symptoms do not resolve in the usual few days of discomfort that are experienced with a stomach flu. Often other, associated symptoms point to the source of trouble. Primary stomach disorders, like ulcers, can produce nausea, particularly after eating, and abdominal pains or blood in the stool lead to the correct diagnosis. Other abdominal problems, like bowel obstruction, gall bladder disease, and pancreatic cancer, can cause significant abdominal pain along with nausea and vomiting. Nausea caused by liver disease might be associated with increased abdominal size or yellowing of the whites of the eyes. Severe headaches and lethargy are symptoms of increased pressure in the brain, which can cause what is known as “projectile vomiting,” – sudden, unexpected, and very forceful expulsion of the stomach’s contents. Dizziness and double vision along with nausea may point to an impending stroke in the brainstem.

Treatment

The stomach and the brain work together in normal digestion, and when something goes awry, the neurotransmitters in the brain play a role in producing nausea. This brain-gut connection is at the heart of attempts to treat the symptoms of nausea with drugs, which fall into two categories. The first category consists of drugs that increase normal gut muscle action; drugs in the second category act by blocking neurotransmitters in the brain and the nerves leading to the gastrointestinal tract.

Drugs from both of these categories are used in postoperative care and in cancer chemotherapy and radiation treatment, and drugs from one or both of these categories are often tried in cases of persistent nausea, while an attempt is made to discover the underlying cause of the symptom. Drugs that block histamine receptors, such as over-the-counter remedies containing dimenhydrinate and prescription patches containing scopolamine, are most helpful in cases of motion sickness.

All of these drugs have side effects, the most common of which are drowsiness and mood disturbances. The most troublesome possible side effect is involuntary, small, twitchy movements. In self-limited cases of nausea and vomiting such as stomach flus, it is probably safest to retreat to bed and sleep, without using pharmacologic interventions other than over-the-counter nausea and vomiting remedies. When suffering from an acute case of nausea and vomiting, remaining hydrated is important, but the stomach is likely to revolt against more than a tablespoon or two of water at a time until the vomiting has stopped completely. Ginger may have some value in calming the stomach; ginger ale is a good first beverage in recovery. Unlike Charles Darwin, who had more complex, chronic and undiagnosed bouts of vomiting, you will most likely recover and forget how miserable you felt.

Hospice: Not a Place

In her 1972 testimony before Congress, Dr. Elizabeth Kubler-Ross, author of the 1969 best-selling book On Death and Dying, stated that “We live in a very particular death-denying society. We isolate both the dying and the old, and it serves a purpose. They are reminders of our own mortality.” What she wanted was recognition on the part of the government that families could be helped more with home care and visiting nurses at the end of a loved one’s life than with institutional and aggressive medical care. Her testimony was a description of a philosophy of medical care known in England as hospice – a medieval word for the traveler’s hostels run by monks in the Alps.

The hospice movement begins in the USA

The hospice movement in the US had begun in the 1960s when the nursing school dean at Yale University invited Dame Cicely Saunders, the mother of the hospice movement in England, to teach for several months. Hospice growth was stuttering over the next few decades, with growing pains coming not only from wrangling over Congressional allocations of money, but also from the process of trying to identify the suitability of patients for hospice care. The requirement for a prediction that a patient entering hospice care would live less than 6 months proved extremely difficult, particularly when the patients did not have cancer.

Misconceptions

Initially, hospice care was viewed negatively by many as either giving up on life or as a form of euthanasia or doctor-assisted suicide. It is none of these. Hospice is a shift away from attempting to cure medical problems and toward care of the whole patient by a multidisciplinary team with the patient and family at the center. From demonstration hospice projects launched in 1979 to the current care of more than 1.65 million Americans a year, the philosophy of caring rather than curing has proven itself good.  In 2007, a paper in the Journal of Pain and Symptom Management reported that patients who had hospice care lived slightly longer than similarly ill patients who were treated conventionally. This surprising conclusion was followed two years later by a New England Journal of Medicine report that patients with non-small cell lung cancer may live longer with hospice care than with other therapies.

Shifting the focus

Hospice is medical care, but care with an aim different from the curative focus of conventional medical care. There is no fighting imagery used in hospice – no war on the cancer, no battle to be bravely fought. The care in hospice is palliative, emphasizing comfort and acceptance, with the meeting of physical needs in an environment as close to home as possible. The patient and family are the unit of care, and the team consists of the patient’s doctor, a hospice doctor, nurses, nurses’ aides, social workers, physical therapists, spiritual counselors, bereavement counselors and volunteers. The focus of patient care is pain and symptom control, as well as emotional and spiritual support for all involved.

The process

Hospice care begins with a doctor’s referral when a patient and his family realize they are ready to turn away from the aggressive attempts to cure a problem which will eventually result in death. The Medicare Guidelines for entering a hospice program require that a patient have a terminal illness with less than six months to live. (Medicare is the payment source for most hospice care). But that six-month prognosis should not be confused with length of care in hospice – care is provided for however long it is necessary. Over 12% of hospice patients live past the initial 6 months of care.

The team

Once a hospice referral is made, a team member, usually a nurse, begins an assessment of physical and emotional needs and crafts a team to meet those needs. Hospice provides the home equipment, medications and support for family as they learn to provide physical care. Volunteers help with respite care to allow family members time to themselves. Social workers evaluate economic needs and pastoral care members address spiritual and emotional needs. Short term hospitalizations are arranged if necessary for symptom control. While most hospice care takes place in the home, similar teams operate in institutions like hospitals, nursing homes and fee-standing hospice facilities, depending upon the availability and competence of family members.

A longer period of comfort

Sadly, over a third of hospice enrollees live less than a week. The time to begin thinking about hospice care is early in the course of a potentially lethal illness since preparation may help a patient live a longer period of a terminal illness in more physical and emotional comfort.

It is helpful to have time to see what hospice organizations are available locally, to check certifications, and to talk with people who provide hospice services. The National Hospice and Palliative Care Association is an invaluable source of information.*  Hospitals are committed to helping arrange hospice care and a direct appeal to the hospital’s hospice coordinator  is possible if the patient’s doctor does not make a referral. If a patient is not ready for hospice care, but is also unwilling to continue aggressive curative attempts, palliative care is also available – care aimed at comfort and symptom control alone rather than cure. An example is quitting or refusing chemotherapy for cancers which respond poorly.

Finances

Hospice care is paid for by most insurance policies in the US (but not in other countries) and under the Medicare Hospice benefit. Medicaid is also a payer. Surveys report that 94% of families feel their experience with hospice care was very good or excellent. The US Department of Health and Human Services is now behind expanding the availability of hospice care because it “holds enormous potential benefits for those nearing the end of life…”  So as medicine moves into the brave new age of genetics, with new, individualized treatments for cancer, and more and more procedures to rewire, replumb and reconstruct the body, hospice care also moves forward, bringing the elderly and the dying out of isolation and educating the people who love them about the universal and necessary process of dying.

 

*https://nhpco.org

Whooping Cough: Not Just For Kids

Remember the last time you had a regular cold followed by weeks of annoying, dry coughing? Did it ever cross your mind that your problem might be whooping cough? Most likely, neither you nor your doctor gave the diagnosis a minute’s thought. Isn’t whooping cough is one of those childhood diseases, like measles and chicken pox, that immunizations have largely defeated? Yes and no. Yes, whooping cough is a serious illness in babies and toddlers, but it also afflicts adolescents and adults of all ages. And no, the disease has not gone the way of the dinosaurs, though immunization of babies and toddlers has dramatically cut morbidity and mortality rates from the infectious illness.

What is whooping cough?

Whooping cough is a highly infectious respiratory disease caused by the bacterium called Bordtella pertussis. The symptoms of whooping cough begin a week or so after exposure to someone who has the illness. At first, the stuffy, runny nose and mild cough, with little, if any, fever seem like ordinary cold symptoms. But within ten to fourteen days paroxysms of more severe, unproductive coughing begin. Coughing lasts, on average, six weeks. While coughing paroxysms are the signature feature of the illness in all age groups, older children and adults may lack the “whoop” on intake of breath that gives the illness its name.

Babies can die; adults break ribs 

In babies and children coughing bouts are frequently followed by vomiting. Infants can quickly develop respiratory distress and pneumonia, and most whooping cough fatalities occur in babies. Older children and adults suffer less severe disease, but the intensity of coughing can make life miserable for weeks, and can lead to hernias and broken ribs. Antibiotic treatment with erythromycin works, but only if the disease is suspected and confirmed early – before the worst of the coughing begins.

Many cases go undiagnosed

Many cases of whooping cough go undiagnosed because people do not seek medical help, or because the diagnosis is unsuspected. Even when whooping cough is suspected as the cause of a chronic cough, accurate laboratory diagnosis is difficult. By the time persistent cough finally brings people to the doctor, a throat or nasal swab may not pick up any bacteria. In addition, routine laboratory culture methods don’t work for pertussis bacteria like they do for streptococcal infections. Proof of infection can be inferred by the presence of blood antibodies against the bacteria, but blood tests to measure titers of are expensive and seldom done.

Vaccine development cut the death rate

Whooping cough occurs worldwide and causes an estimated 300,000 deaths per year across the globe. In the United States, death rates were in the 5,000-10,000/year range between the 1920s and 1940s, but the development of a pertussis vaccine reduced that toll enormously in the latter half of the 20th century. Recently, however, increasing numbers of whooping cough cases are being reported. In 2010 California declared a whooping cough epidemic based on 9,477 confirmed, probable and suspected cases. Washington State did the same in 2012. By that year, 48,000 confirmed cases were reported across the country. At the height of the California epidemic, there were 10 deaths – too many for a preventable disease, but a far cry from the tolls of the past.

Natural cycles, parental backlash and a  changed vaccine 

Bordtella pertussis has never disappeared from its niche in the human population, and several factors are at work in the recent, apparent increase in rates of infection. Foremost is a natural bacterial population cycle. Whooping cough bacteria seem to increase their numbers in 3-5 year cycles which probably correspond to naturally declining immunity in a population as children get older. This natural variation has coincided with some parental backlash against vaccinations because of fears that they do more harm than good, though childhood immunization rates as a whole are still very high. A third factor may be weaker population immunity because of alterations made to whooping cough vaccine in the 1990s.

Clearly, the original pertussis vaccine, derived from whole, dead pertussis bacteria and delivered as part of the first series of a baby’s shots, helped produce immunity sufficient to make death rates among babies drop dramatically. But in the early 1990s, the formulation of the vaccine was changed to decrease adverse responses to it – responses like fever, swelling at injection sites and rare cases of encephalitis. That change may be responsible for lessened immunity and more whooping cough cases among older schoolchildren. It also raised the number of shots that must be given over several months to achieve immunity in a baby.

Should drug companies fund vaccine research?

Some people who worry that too many vaccines are now being required and are less effective than advertised claim that the makers of the vaccines are anxious to find reasons to give booster shots to as many people as possible. Indeed, the largest and most influential of the scientific groups studying whooping cough – the Global Pertussis Initiative (GPI) – is funded by vaccine makers. But Dr. James D. Cherry has been studying whooping cough for several decades and maintains that the monetary sponsorship by pharmaceutical companies is necessary. Compiling data about infection rates and vaccine efficacy is expensive and surprisingly difficult. The prevention and treatment of infectious diseases depend on accurate assessment of disease rates and currently public health surveillance and reporting is hampered by lack of uniform standards for the diagnosis of whooping cough, especially in older children and adults. In addition, the development of vaccines is extraordinarily complicated and expensive, and will be of increasing importance as antibiotic resistant bacteria continue to evolve and thrive.

Who needs to be concerned about whooping cough?

Whooping cough is of most concern to people who work around and live with small babies who are too young to have completed their series of early DTaP immunization shots (against diphtheria, pertussis and tetanus). The booster vaccination has little risk and is probably advisable for all adults who are in regular close contact with susceptible infants. In the meantime, if you develop one of those miserable chronic coughs after a cold, stay away from vulnerable babies who have not yet had all their shots.

The Troublesome Appendix

“The modern king has become a vermiform appendix – useless when quiet, when obtrusive in danger of removal”
Austin O’Malley (United Irish leader, 1760-1854)

 

The vermiform (wormlike) appendix is  narrow pouch, approximately a 2-4” long, that hangs off the colon, or large intestine, in the lower right side of the abdomen. Charles Darwin, who popularized evolutionary theory of human development, consigned the appendix to the lowly status of vestigial organ – a body part left over from the process of natural selection, but having no continuing function. Beginning in the 1700s though, doctors recognized the troublesome tendency of the appendix to become inflamed and rupture – an often fatal condition called appendicitis. Long before anesthesia and antibiotics had been invented physicians attempted surgical removal of the organ and results were generally poor.

Fortunately for us, modern surgery makes appendicitis a far less fearsome condition. Recent medical research also suggests that Darwin was wrong and that textbooks may need to be rewritten, striking out the vestigial label. Clinical and research trends are converging, and it is possible that we may soon see more attempts at preserving the inflamed appendix rather than immediately removing it.

Who gets appendicitis?

No one knows why appendices become inflamed. They do so far more often in developed countries with high levels of sanitation than in undeveloped countries where severe diarrhea frequently purges the intestines. They act up more in younger people, below age 30 but no age is immune, and, at least in Western countries, seven out of every hundred people will develop appendicitis at some point in their lives.

What are the symptoms?

Appendicitis usually begins with pain, which is often mild and located near the belly button. Over the next few hours, as inflammation progresses, the pain tends to migrate and settle in the lower right side of the abdomen. Other symptoms may or may not occur and include nausea, vomiting, fever, and poor appetite. Diarrhea or constipation may occur, or there may be no change in bowel habits. As with many illnesses, the most important things to note are changes from normal patterns, and persistence of symptoms despite attempts to make them better. Since appendicitis typically develops over 4-48 hours, abdominal pain that lasts more than 4 hours is reason enough to seek a medical opinion.

Rupture often relieves pain – temporarily

Because the appendix is a blind pouch, its opening into the colon can become obstructed by the swelling that comes with inflammation. When this happens, pressure builds within the appendix and its wall may rupture. Paradoxically, rupture often relieves pain, at least for awhile. But because the colon and appendix house bacteria and rupture spills these “dirty” contents into the normally sterile abdomen, the patient soon becomes desperately ill with a condition called peritonitis. The coronation of King Edward VII of England was delayed by just such a series of events in 1902. His initial symptoms seemed to improve, and he planned to go through with the scheduled ceremony, but when he worsened, his doctors told him that if he continued as planned he would “go as a corpse.” Instead of being crowned, he underwent surgery and an abscess around the appendix was drained. The appendix was not removed because it had decompressed and sealed itself. The lucky monarch survived the surgery and was crowned later.

Diagnosis is not always easy

Appendicitis has proved a vexing condition to diagnose. The clinical history brings the patient to the doctor, who examines the abdomen for tenderness, measures temperature, and draws blood to see if the white blood cell count is elevated. There are many organs in the abdomen, and many possible causes of abdominal pain. No single test proves the presence or absence of appendicitis. Abdominal X-rays and ultrasound tests are sometimes done, but the CT scan has proven best for the diagnosis of appendicitis. But the definitive test is still a direct examination of the appendix at surgery, where removal is done even if the appendix is normal in appearance, as it is in about 10% cases. Since failing to discover and remove an inflamed appendix can result in far greater illness and possibly death, a 10% rate of misdiagnosis is considered very acceptable. Removal of a normal appendix also prevents confusion if future episodes of pain occur.

A role for antibiotics

Since CT scanning has been helpful in showing which appendices have ruptured and absolutely require surgery, some studies have been done to see whether treatment of early, uncomplicated appendicitis with antibiotics alone can be safely accomplished. Four randomized trials in England suggest that this is possible and will reduce the need for appendectomy in over 60% of cases of early appendicitis. Adopting this approach means that all patients with suspected appendicitis require the X-Ray exposure of abdominal CT scanning and that 20 % of patients will have recurrent symptoms within the year. In addition, if antibiotics do not quell the inflammation, the delay in getting to surgery can result in more complications. If the appendix is an unnecessary organ anyway, is it worth the expense and radiation exposure of CT scanning, attendant risks of delaying surgery, and the risk of recurrent appendicitis? Possibly.

Not so vestigial after all?

Until recently it has been assumed that there is no real role for the appendix. People seem to do very well without them. But researchers have always wondered why the appendix contains tissue that produces immune cells. It now appears that the immune cells are there to protect the bacteria that live in peace in the large intestine and play a crucial role in its health. When diarrhea has emptied the colon of its all its contents, the appendix still contains normal bacteria which, researchers think, repopulate the colon and bring it back to a healthy state. It is also possible that the immune cells in the appendix recognize new proteins that come in through the intestines, and teach the body’s immune system what to tolerate. In the case of the appendix, vestigial may only mean that we have not previously understood its function and if it can be preserved perhaps it should be.

The Fibrillating Heart

Fibrillation is a word used to describe rapid, uncoordinated, wormlike wriggling of muscle fibers. Heart muscle fibrillation is the most common cause of cardiac “arrest.” Many people have seen devices called cardiac defibrillators and heard campaigns urging education in their use. Some people have even seen people rescued from imminent death by the electrical shock of a defibrillator. But many people also know friends and family members who have a heart condition called atrial fibrillation – one with which they live normally. Why is fibrillation sometimes lethal and sometimes simply a chronic heart condition? The answer lies in the heart’s muscular and electrical anatomy.

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An electrically driven pump

The heart is a pump made from muscle and driven by an electrical system. Normal heart muscle contraction begins with electrical activity in the atria, the two upper chambers of the heart. There, the  “sinus node,” the body’s inborn pacemaker, begins generating a rhythmical electrical signal three to four weeks after the human egg is fertilized. An orderly wave of electrical activity and muscular contraction spreads through the atria to the lower chambers, the left and right ventricles. The muscle contraction pushes blood from atria through valves into the two ventricles below. The wave of contraction in the ventricles pushes blood from the right ventricle into the lungs and from the left ventricle out to the body. You feel each contraction of the ventricles as your pulse. Once the heart has emptied, it relaxes and blood passively accumulates in the atria, coming from throughout the body through big veins in the abdomen and the neck. After fraction of a second, the sinus node fires again and the pump goes into another round of action.

When the sinus node is no longer in charge

When atrial muscle fibrillates and the contraction of the atria no longer follows an orderly path, the atria no longer squeeze and push blood – but  most of the atrial blood still falls through the valves into the ventricles. Some decline in exercise capacity might result from incomplete emptying of the atria, but life goes on.  The disordered electrical activity from the atria often stimulates much too rapid, but still well-ordered activation of the ventricles and pulse rates as high as 170-200. When this happens the ventricles don’t have enough time to fill with blood between contractions, making symptoms worse and rate controlling drugs necessary. More on this later.

Ventricular fibrillation – an intolerable situation

When ventricular muscle fibrillates and there is no longer any coordinated pumping action to push blood out to the lungs and the body. Consciousness promptly fails, and the victim loses muscle tone. Technically the heart has not stopped, but its pumping action has. While there is still electrical activity, as there is in fibrillating muscle, an external shock can restore orderly heart muscle activity, which is why defibrillators work.

The origins of fibrillating heart muscle

Why does heart muscle fibrillate? The reasons are many and varied, but all are related to the fact that the primitive cells that formed the heart all possessed the ability to produce spontaneous electrical activity. Some of these, by virtue of their location in the developing heart, became the dominant pacemakers and conductors of electrical current. In the aging adult, changes in the heart’s structure wrought by both age and disease disturb the tidiness of the electrical conduction system, particularly in the thin walled, expandable atria. Some of the original electrical excitability of muscle returns and disordered patterns of muscle contraction result.

Who Fibrillates

Atrial fibrillation (AF) is a relatively common problem. It is age related, and more common in men than women. Underlying problems with coronary arteries, with heart valves, with high blood pressure, congestive heart failure and diabetes seem to trigger it. Transient atrial fibrillation is common after heart surgery, particularly valve surgery. It is also associated with binge drinking and stimulant use, and with use of prescription strength non-steroidal anti-inflammatory drugs (no study has been done yet to see if the same association is present in users of over-the-counter NSAIDS). AF is more common in people with long histories of high level endurance exercise (Nordic skiers), possibly because years of high volume demand on the heart stretch its muscular and electrical architecture. Hyperthyroidism can trigger AF and people with sleep apnea or lung diseases may develop it. Lone atrial fibrillation is the name applied when no risk factors are present. In these cases, abnormal electrical activity appears to originate near the pulmonary veins.

Ventricular fibrillation is almost always the result of underlying scarring in the heart, from prior heart attacks, from heart infections, or from deprivation of blood flow to the ventricular muscle during an acute heart attack. Other causes include congenital heart disease which affects electrical conduction pathways, cocaine and methamphetamine use and severe electrolyte imbalances such as seen in anorexia nervosa.

What does fibrillation feel like?

Atrial fibrillation may occur in brief episodes before it becomes a chronic heart rhythm. The cardinal symptom is an irregular pulse. Some beats are stronger than others. Sometimes the pulse is very rapid as well as irregular. While the normal, orderly electrical activity of the heart responds to physical demands via some complex physiology, the fibrillating atria do not allow that to happen and the predictable increase in pulse demanded by exercise such as climbing stairs can’t be met. In people who have fibrillating atria, shortness of breath with exertion is a common first symptom. An electrocardiogram shows a characteristic abnormal electrical activation pattern.

Symptoms of ventricular fibrillation are immediate and devastating – consciousness is lost within 30 seconds or less. Brain cells begin to die in 4 minutes. Ventricular fibrillation can be preceded by a very high pulse rate called ventricular tachycardia, often accompanied by lightheadedness and shortness of breath, or by premature or “ectopic” heartbeats which cause a sensation of skipped heart beats followed by very strong beats. They warrant medical attention.

Diagnosis and treatment of atrial fibrillation

Diagnosis of atrial fibrillation is important because not only for relief of symptoms, but also for preventing strokes. A fibrillating atrium is often dilated, with blood flow inside slow and sludgy. Clots may form in the nooks and crannies of the atrial chambers, later to be dislodged and sent upstream to the brain. It is estimated that 20-25% of strokes are caused by AF and sometimes a stroke is the symptom which brings the heart problem to attention. Because AF can be intermittent, it may not show up on one EKG. A monitor which can be worn for several days at home may be required to pick up episodes.

Shocking treatments: cardioversion and radio frequency ablation

A fibrillating atrium can be shocked back into a normal contraction pattern, in a controlled laboratory situation. This treatment is called cardioversion and is usually accompanied by drugs to prevent recurrence of fibrillation, and also drugs to control rate of ventricular contraction should atrial fibrillation recur. Surgical procedures using radio frequency ablation of sites of overactive electrical activity on the surface of the heart can be very successful in terminating AF and in preventing its recurrence, especially in cases of lone AF.

Preventing strokes

Blood thinners are necessary, temporarily, for patients being cardioverted or undergoing ablation surgery, to make certain that no clot is present in the heart at the time of conversion of the heart rhythm. Once it is clear that normal rhythms are holding, anticoagulants may be stopped. In chronic AF patients, however, blood thinners are always necessary.

Prevention

A variety of cardiac drugs, called anti-arrhythmics, are prescribed prevent abnormal heart rhythms in people who are at risk for ventricular fibrillation, usually people who have known heart disease. They are the same as or similar to similar the drugs used to keep the heart rate from becoming too fast in people who already have AF.  careful control of other medical problems like diabetes is important. recognition and treatment of AF early may help prevent the development of chronic atrial fibrillation.

The biggest controllable risk factor: alcohol

While doctors know that excessive alcohol use is one of the leading risk factors for atrial fibrillation and realize that most patients underreport their alcohol consumption, they often do not emphasize the value of drastically cutting alcohol consumption once atrial fibrillation has occurred. Some of the other risk factors for atrial fibrillation, like aging, are beyond control, but alcohol consumption requires lifting the glass to the lips and swallowing. That is a choice and one well worth avoiding when the heart muscle has protested.

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