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.

Breaking the Tobacco Smoking Habit

 

We are now 100 years into an epidemic of avoidable, tobacco-induced health problems and over 50 years into the attempt to stop it, with more knowledge accumulating every year about the toll tobacco smoking takes on every part of the human body. Each year, smoking costs US society $130-170,000,000 in medical care, $150,000,000 in lost productivity and 400,000 lives lost prematurely. Over 160 million people live with serious, smoking related illnesses. Still, 20% of adults smoke regularly, and young people continue to join their ranks. If you never picked up the habit, be glad. If you have picked it up and managed to kick it, congratulations. You are part of a slow public health success story, and, by understanding the smoking habit, you may be able to help someone else quit.

The evolution of cigarettes

Tobacco was the first crop sold for profit by the American colonists, who introduced Europeans to pipe-smoking and tobacco chewing in the 1600s. However, the smoking habit did not begin in earnest until the invention of a cigarette rolling machine in 1883. By the 1940s smokers in the United States lit up 300 billion cigarettes per year and during WWII, soldiers’ ration kits included cigarettes. By the 1950s, 44% of US adults smoked regularly. Psychiatry texts in the 1960s urged doctors to light up with their patients and, by then, cigarette consumption topped 500 billion per year. Older adults today recall being raised in smoke-filled houses, driven around (without seatbelts) in smoke-filled cars, and sent to the corner store to buy cigarettes for their elders.

Recognition of the problem

Though the 1964 Surgeon General’s report confirmed what many people by then knew – that tobacco was bad for health, wrinkled skin prematurely and caused lung cancer, other lung problems and vascular disease  – cigarette consumption rates continued to climb well into the 1980s. But then decades of educational, political, legal and economic pressures on smokers began to work. By 2012, public places were largely free of tobacco smoke, ex-smokers outnumbered active smokers, and cigarette consumption rates had fallen back to the 1940’s levels. Anti-smoking advocates are rightly proud of their efforts, but the credit must also go, in great measure, to the individuals who did battle with the smoking habit and succeeded. Breaking the smoking habit is difficult, often requiring many attempts and relapses before the goal is achieved.

Nicotine is addictive

Smoking becomes a habit because tobacco contains nicotine, which changes the chemistry of the brain in a way that makes the tobacco user uncomfortable when the nicotine level falls. Tobacco companies have exploited the addictive qualities of nicotine by manufacturing their products to diminish negative physical effects and enhance addictive ones. Menthol soothes the smoke-irritated throat. Nicotine is added in just the right dose – not enough to provoke toxic symptoms like nausea, vomiting dizziness and diarrhea, but just enough to ensure the desire for more.

In addition to physical addiction, smokers develop psychological addiction, a learned desire or craving for smoking that arises from the association of smoking’s pleasure with certain situations such as social gatherings, meals, stressful or anxiety provoking circumstances or boredom. Sophisticated advertising techniques add to the social cachet of smoking and subtly enhance these psychological cravings. The combination of physical and psychological addiction means a two-pronged attack is often necessary to help a smoker who wants to quit.

Two-part attack on a two-part addiction

    Physical addiction to any substance produces withdrawal symptoms when the substance is no longer available to the body. In the case of tobacco, irritability, anxiety, insomnia, abdominal cramps and depression occur within hours of smoking cessation. These symptoms peak and begin to diminish within several days and will stop in a predictable period of time – about 2-4 weeks – after the last does of nicotine.

    Since nicotine can be delivered to the brain without the many carcinogenic chemicals in cigarette smoke, nicotine replacement therapy (NRT) is helpful to someone who is trying to stop a smoking habit, allowing time to deal with the psycho Nicotine is available in non-prescription gums, lozenges and skin patches. Nicotine inhalers and nasal sprays require a prescription. Eventually, though, the physical withdrawal symptoms will have to be suffered when the ex-smoker decides to give up the nicotine.

    E-cigarettes also deliver smoke-free nicotine, by vaporizing it in water. They are highly engineered products containing plastics, ceramics and metals and their long term risks are as yet unknown. Unlike the other nicotine delivery systems, e-cigarettes involve regular smoking behaviors and cannot be expected to help diminish the psychological cravings involved in the habit. 

    Psychological cravings that prompt smoking are often far longer lasting than physical withdrawal symptoms – and more responsible for relapse. In most studies of smoking cessation, behavioral therapy is key to long term cessation. Such intervention can take many forms, including one-on-one counseling, supportive group therapy and even online group participation. Many online resources are available to help smokers cope with this aspect of tobacco addiction. (see list below).

Two drugs are also commonly prescribed to help smokers quit. One, varenicline (Chantrix), attaches itself to nicotine receptors partially stimulating them and relieving withdrawal symptoms and at the same time blocking a sense of reward from inhaled nicotine. Another drug, Bupropion (Wellbutrin), is an antidepressant. These drugs improve smoking cessation rates slightly, and are more effective if used in conjunction with NRT. Both, however, are associated with some troublesome reports of behavioral changes, now noted in black box warnings on their packaging.

The cold turkey method- just as effective 

While public health measures have contributed significantly to decreasing smoking rates, breaking the smoking habit remains an individual project and the single most effective measure a smoker can take to improve health. One curious smoking cessation statistic confirms what many doctors have long observed – that cold-turkey quitting is as effective as any of the assisted methods. It appears that the whole-hearted decision to stop, once made without any reservations, could be the most important factor in long term success. This method has no unwanted side effects or risks and does not require withdrawal of nicotine replacements once the psychological smoking habit is tamed. Non-smokers can play a large role in aiding people whom they care about to make this final decision.

Resources for Smokers Who Want to Quit
http://smokefree.gov/
http://www.cdc.gov/tobacco/quit_smoking/how_to_quit/
http://www.lung.org/stop-smoking/how-to-quit/
http://www.nlm.nih.gov/medlineplus/quittingsmoking.html

Why We Cry..and How We Make the Tears

 

 

“It is such a secret place, the land of tears.” The Little Prince, Antoine de Saint-Exupery

Do animals cry? Probably not. Indian gamekeepers told Charles Darwin stories of elephants that shed tears of sadness, and dog lovers have tales of canine tears, but the emotional tears of humans are unparalleled in the animal kingdom.

We are always making tears

All land dwelling animals, including people, make tears constantly. Eyes are windows on the world, and baseline tears are constant window washers. The window pane is the cornea, a thin panel of collagen, containing very few cells, no blood vessels, and more nerves per square inch than any other part of the body. These nerves signal alarm and summon an army of reflexive tears in response to a speck of dust, a cold wind, or a whiff of an onion. Reflexive tears, which are just a lot of baseline tears, wash out intruders and fill in dry patches on the cornea, keeping it clear and moist to focus light entering the eye. Emotional tears appear in humans during infancy, but not immediately. The crying that infants first do to signal their needs is much like the crying of little chimpanzees – tearless. Emotional tears come later, just like talking. Both are outward expressions of the lives of our minds, and they take a while to learn.

What tears are made of

Tears are much more than little beads of salt water running down your face. They are a three layer sandwich. The oil-containing molecules in the outer layer tighten up the surface of the watery middle layer to keep it from spilling over eyelid and sliding off the surface it protects. The oil floats on the watery middle layer and smooths its surface, optimizing the passage of light through to the eye’s interior. The third part of the sandwich, inside and closest to the eye, is the mucinous layer, kind of a gluey protein that helps tears stick to the eyeball. The mucinous proteins capture and kill biologic intruders like bacteria and viruses, and soak up some of the watery layer to help transfer nutrients, oxygen and moisture to the cornea. Both the oil and mucin slow evaporation of tears as blinking spreads them over the eye.

Evaporation and drainage

Dry spots appear on the cornea after just fifteen non-blinking seconds – easy to do while concentrating or daydreaming. Even with blinking, tears evaporate, or they drain out from the eye into the nose via two tiny lacrimal ducts on the upper and lower eyelids near the nose. If these ducts become scarred or blocked by infection, tears overflow. Six to 10% of babies are born with tear ducts not yet open, but 95% of these will open by age one without any attempt at surgical repair. Conversely, one way of treating dry eyes is to block these ducts with small plastic pellets.

Dry eyes

Too few tears, tears with abnormal composition, and decreased blinking cause dry eyes that itch, sting, burn, get red, and cause blurred vision. Dry eyes are an increasing problem in our air-conditioned, airline-traveling, contact lens-wearing, Lasiked, medicated and aging society. The list of drugs that dry eyes includes many commonly prescribed classes: decongestants, antidepressants, antihypertensives, antihistamines, beta-blockers, hormones, diuretics, ulcer medications, acne drugs, and oral contraceptives. Other causes of dry eyes are infections and immune diseases like rheumatoid arthritis and Sjogren’s syndrome as well as  radiation and radioactive iodine treatment can also damage the tear producing cells. All of these conditions damage the tear producing cells  – the machinery for tear production. 

Remedies for dry eyes 

Treatment of dry eyes is always aimed at removing offending problems and increasing lubrication. The usual tactics include artificial tears, wind protection, air humidification, cessation of unnecessary medications, and treatment of underlying diseases and infections. Excessive tearing often means allergies, or blocked lacrimal ducts leading to poor drainage of baseline tears into the nose.

 

The tear producing machinery

The medical conditions mentioned above shut down tear production and cause pain and swelling in the lacrimal gland, a spongy little structure tucked up under the upper outer corner of the eyelid. The lacrimal gland is the tear producing factory, aided by the oil-producing Meibomiam glands near the eyelashes, and a cluster of mucin-producing cells in the eyelid lining.

The controls for the machinery

When the lacrimal glands get a call for more tears, either reflexive or emotional, the messages come through the autonomic nervous system, which oversees the automatic functions of the body. Reflexive tears spring from messages sent from the eye and nose. Emotional tears come from messages sent by the limbic system, the deepest and oldest part of the brain, the part that conjures up feelings.

What are emotional tears?

What are emotional tears? Are they just more voluminous baseline tears? Or does emotional crying rid us of “humors of the brain,” as Hippocrates thought? In Roman times, mourners used small glass vials called lachrymators to collect their tears for burial with the one for whom they cried. In today’s laboratory, emotional tears are almost as hard to come by as research money to investigate them. Some dedicated men such as Professor William H. Frey II (Dept. of Pharmaceutics at the U. Of Minnesota) have learned enough to suggest that tears of grief rid the body of some of the products of stress, supporting the claim that crying makes people feel better. Compared to reflexive tears, emotional tears contain up to 25% more proteins, of classes related to stress. Why? No one knows – yet. Emotional tears are still a land of mystery, part of the unique expression of inner life that separates the human animal from the others.

 

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