The Health Blog

A television documentary recently reported an unusual case of insomnia in England. Loughborough University advertised for people who thought they did not need to sleep to come forward to join in a sleep research study. So people who were short sleepers volunteered to be tested under laboratory conditions. At night they were allowed to lie in bed to rest and their brain waves were monitored continuously. There was a man who claimed that after an accident causing head injury a few years earlier he did not sleep at all. He also claimed that he was functioning normally and did not feel worried when he was lying awake. Brain wave recordings showed that he slept only four minutes during the three day study.

The study findings suggest that perhaps the brain is programmed to sleep periodically. The man who did not have the need to sleep after the head injury may have had his brain reprogrammed in such a way that sleep was no longer required. Maybe in hundreds or thousands of years from now we will be able to reprogram the brain so that we will have the choice of not having to sleep at all. There is a Chinese saying, ‘Life is not as long as it seems, as half of it is spent sleeping’.

It is possible that there are other biological functions, yet to be discovered, which only happen in sleep. We have only just started to study sleep as a science, and sleep laboratories have been around only in the last 50 years. We are certain that we are only scratching the surface of the science of sleep and that there is much more to discover, for there are still many unanswered questions and why we need to sleep is one of them.

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The ready availability of reliable oral contraception has undoubtedly been a significant factor in relieving tens of thousands of women of tension and anxiety. On the other hand the advent of the contraceptive pill has brought tension and guilt to many women who might otherwise have been free of it.

If a woman believes that contraception is morally wrong, or if she is forbidden by her church to use it, and if she follows her conscience in these matters and does not use it, she may still suffer considerable mental tension arising from her knowledge that women all around her are using contraception. As a result, she is constantly under temptation in a manner in which other women are not. This is shown by the way in which many such women do in fact take the pill for a while, then feel guilty about taking it and stop. Then they take it again, and in the same way discontinue it; and so it goes on.

The position of course is much more difficult when husband and wife see the problem of contraception from different points of view. In such cases the unfortunate woman may have contraception forced upon her without consideration of her inner feelings at all.

It is not uncommon for couples who have religious doubts about contraception to feel that sexual withdrawal is less of a sin than chemical means of prevention. But this half measure only leads to further anxiety. There is still the tension from feelings of guilt, and added to this the woman is tensed fearing that her husband will not withdraw in time. In addition, the fact of withdrawing just at the moment when biological fulfilment demands deepest penetration

produces tension in both man and wife. This of course has been known for centuries and was considered by Freud as an important cause of anxiety.

There is yet another important social side-effect of the widespread use of the contraceptive pill. Girls who have been sexually promiscuous in the past are now relieved of much of their anxiety. However, the ready availability of the pill has undoubtedly led many girls into promiscuity who would have otherwise been continent. Many of these young women suffer nervous tension not from doubts about taking the pill itself, but from moral qualms about their new way of life.

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Most studies of the anti-depressant effects of St John’s Wort have used 300 mg three times per day. In my experience with using many other anti-depressants, however, I have been impressed by the wide variation in dosage required by different people. To some degree, this relates to the ability of a person’s liver to break the antidepressant down into inactive substances, which are then excreted.

This ability varies tremendously from person to person. To some extent, one can get an indication of how sensitive a person is going to be to a new medication by reviewing that person’s sensitivity to medications in the past. The amount of medication needed is often not related to the size of the person being treated and I have been impressed over the years by small women patients who have been able to tolerate enormous dosages of anti-depressants, in contrast to very large men who have been sensitive to tiny dosages.

I believe that there will be a range of optimal dosages for St John’s Wort as well. A good practical way to begin treatment is to start with approximately 300 mg a day, with breakfast, for a two to three days, followed by 600 mg a day (300 mg each at breakfast and lunch) for a further two to three days, followed by 900 mg a day (300 mg each at breakfast, lunch and dinner). As Kira is sold in the UK in 135-mg tablets, this would mean starting with two tablets per day, then increasing to four (two tablets twice a day) then six (two tablets three times a day). Then stay on this dosage for several weeks unless side-effects require reduction in dosage. The reason to begin with a low dosage is that whereas therapeutic effects often take weeks to appear, the side-effects of any antidepressant may occur very soon after taking it. If this should happen, one is always better off having taken a small rather than a large dosage. In addition, it sometimes takes a while for your system to get used to a new medication, and gradually increasing the dosage gives your system a chance to adjust to it.

Taking medications with meals reduces the likelihood of developing gastro-intestinal side-effects such as nausea, indigestion or abdominal pains, which may occur with St John’s Wort. The meal will not interfere with the effects of the treatment in any way. If you should develop side-effects after increasing the dosage to, say, four 135-mg pills a day and the side-effects are mild, try to remain on that dosage for at least a few days. Side-effects may settle down within a few days. If you increase the dosage without waiting for this to happen, it will most likely make the side-effects worse and discourage you from staying on the medication. It may turn out that the current dosage will be just right for you. Alternatively, if this dosage proves to be too low, once the side-effects diminish sufficiently you may be able to increase the dosage at a later time if you need to.

Taking a medication three times a day can be quite inconvenient. Somehow the midday dosage often gets missed out. It is generally much easier to the take medications twice a day, and some people have found that a twice-daily dosage of St John’s Wort (four 135-mg pills at breakfast and two at dinner) works well for them. One or two of my patients developed indigestion when they have used the herb in this way and found that taking it three times a day with meals completely resolved that side-effect. If you should happen to forget the midday dosage, however, it is preferable to double up the evening dose rather than missing one dose for the day, bringing the day’s total to six 135-mg St John’s Wort tablets. Because no one is sure of what the active ingredients are in St John’s Wort, it is impossible at this time to say what the best dosing schedule really is; more research is required to answer this question. At this time, I recommend that you start using St John’s Wort three times a day and, later on, after you have established that it works for you, it may be worth experimenting with different dosing schedules. It is possible that for some people, like the man whose wife mixed his St John’s Wort in with the breakfast vitamins, a once-a-day schedule will prove to be sufficient.

Just as it is possible that some people will not need six 135-mg St John’s Wort tablets per day but may respond fully to two or four tablets, so others may require more than six tablets per day. It is probably worth staying on six 135-mg tablets per day for at least five weeks before deciding to increase the dosage. In one study of more serious depression, 1,800 mg of Hypericum proved to be as effective as a conventional anti-depressant and the researcher running the study remarked that the frequency of side-effects did not appear to be greater than he had encountered on the more conventional lower dosage of 900 mg per day. It would be surprising to me if, just as with other anti-depressants, different people did not end up needing different amounts of Hypericum and I would encourage you and your doctor to experiment with different dosages up to 1,800 mg (approximately 13 135-mg tablets per day) provided you do not experience any particularly unpleasant side-effects and provided you give the lower dosage of 900 mg (six tablets) a fair trial of five to six weeks before increasing the dosage.

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Alcohol may undoubtedly precipitate seizures in those who already have had previous seizures.

There is also an association between chronic alcohol abuse and the occurrence of fits even when sober. Those who drink alcohol to excess are usually aware that they are running the risk of cirrhosis of the liver, but not many realize that chronic alcoholism can result in loss of cerebral nerve cells, seizures, and impairment of intellect.

Degenerative disorders-As advances in knowledge occur, fewer and fewer diseases will be assigned to this non-specific group. Creutzfeld-Jakob disease, the human equivalent of ‘mad cow’ disease for example, used to be regarded as degenerative , before it was shown to be caused by an infective agent. Pre-senile dementia (Alzheimer’s disease), in which the cerebral nerve cells gradually become fewer in number, is associated with seizures. Some cases are inherited, and almost certainly in most there is a biochemical abnormality responsible for this loss of nerve cells, and, hopefully, when this has been identified, some sort of pharmacological treatment will be possible. This sequence of events has already occurred in Parkinson’s disease. This was regarded as a degenerative disorder until 30 years ago. A defect in the metabolism of a transmitter called dopamine was identified, and a suitable drug (L-dopa) produced. A number of degenerative disorders which start in childhood (including one called Batten’s disease) present with frequent seizures.

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Mr. E.B., age 67, of Michigan reports that his arthritis symptoms first appeared over five years ago and had become a serious problem in his right knee for about two years. His hands were also affected. He writes that his doctor performed an arthroscopy and advised him that his “right knee was bone on bone, but it was not the right time for knee replacement.” CMO seemed worth a try.

He is now “lifting weights, ice skating once or twice a week, and getting ready to take a 200 mile bike riding trip. I can now get up ladders and paint. I know this doesn’t work for everyone, but I feel it helped me a lot. If my knee never gets worse, I will never think of having a replacement.”

Mr J.S. of Texas writes: “In early November of 1996, 1 was introduced to CMO through the Arthritis Pain Care Centres. The product impressed me so much that it overwhelmed my belief. Knowing that I had arthritis in my hands and elbows and lower back, I was willing to give it a try. Being an avid golf nut, I was willing to try anything that would give me some relief.

“So I did the CMO treatment… and around the fifth or sixth day, I noticed remarkable improvement in my hands, especially those sore knuckles, and my lower back. By the end of twelve days I noticed that a burning pain from the small of my back down through my leg to my foot was also disappearing. It’s now been eight weeks since I finished my treatment and I’m here to tell you that all my pain is gone.

“So golfers, tennis players, softball players and anybody with arthritis pain, do yourself a favour and do the CMO treatment.” [Editor's note: Now, over a year later, J.S. reports that he is still golfing vigorously and painlessly as a result of his one set of CMO capsules.]

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Precautions

•     Reye’s syndrome has been linked to the use of aspirin during influenza. Although a cause-and-effect relationship has not been established, aspirin should not be given if your child is suspected of having influenza. Watch for signs of complications and report them to your doctor.

•     If there are no complications, the fever accompanying influenza often peaks in two cycles. The child’s temperature is elevated for a day or two, normal for a day, then elevated for a day or two. Do not misinterpret 24 hours of normal temperature as a “cure,” and do not allow your child to resume activities until the temperature is normal for two or more days.

Medical treatment

If there are no complications, the doctor will tell you to continue with the home treatment described above. If complications occur, cultures, blood tests, antibiotics, and hospitalization may be required. Vaccines to prevent influenza are not very helpful for children. The influenza viruses have a number of different strains that change their structures from year to year. Therefore, last year’s vaccine may be useless against this year’s virus. Moreover, reactions to influenza vaccines in children are frequent, although these reactions are rarely serious. At the moment, medical experts advise that only children at special risk from influenza should be immunized annually. The conditions that constitute “special risks” are: rheumatic heart disease, congenital and hypertensive heart disease, cystic fibrosis, severe asthma, tuberculosis, nephrosis, chronic nephritis, chronic diseases of the nervous system, and diabetes.

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It is a condition in which a person has a reduced blood flow to the brain, causing him or her to feel faint, weak and eventually even to lose consciousness. On falling to the floor the person becomes horizontal and the blood flow to the brain is restored. Sometimes people, who feel they are about to faint feel giddy, sweat a lot and have a fast heartbeat. When a person faints they look pale, breathe rapidly and have a feeble pulse. After a few minutes consciousness usually returns.

Causes of fainting

• An emotional upset.

• Sickening for an acute infection.

• An overheated, ill-ventilated room.

• Prolonged standing, especially on an empty stomach.

• Severe pain.

• Pregnancy.

• Severe anaemia.

• Severe bleeding.

• Adolescence (notably in girls).

• A minor epileptic attack can be mistaken for a faint.

Prevention

The prevention of most of the above is fairly obvious and needs no elaboration. However, if you feel faint or likely to faint here are a few simple preventive hints.

• Always have breakfast if you know you are going to have to stand up for any length of time.

• Ensure that your environment does not become too hot and stuffy.

• As soon as you feel at all like fainting sit down, loosen your tie, belt or any other constricting clothing; get someone to open a window or to take you to an open window or outside the stuffy room. If you feel worse, lie down flat. Within a few minutes you should feel normal again. Look for the cause of the faint and take steps to prevent similar occurrences.

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Although the medical treatment you receive in a private hospital will be similar to that available at any NHS hospital, there are some basic differences between the two systems.

As with the NHS, you will have to be referred to see a consultant privately by your GP. Most GPs have contacts with particular consultants (and private hospitals) to whom they tend to refer patients. If there is a private hospital you particularly want to go to, or a consultant you have some reason to prefer, you can ask your GP to make an appointment for you.

After your visit to your GP, you are unlikely to have to wait longer than a week or two before you see the consultant at an out-patient appointment. Your appointment may be at the private hospital where your operation is to be carried out, at an NHS hospital which has private wards, or at the consultant’s private consulting rooms. Once the decision has been made to go ahead with surgery, you will probably be able to enter hospital at your convenience within another week or two.

You will receive confirmation of the date of your operation from the Bookings Manager of the hospital you are to attend. You will also probably be sent leaflets and any further relevant details of how to prepare for your admission to hospital. Do read these carefully, as knowing how your particular hospital organizes things will help you to be prepared when you arrive for your operation. You will also be sent a pre-admission form to fill in and take with you when you are admitted.

If your operation is being paid for by insurance, you will be asked to take a completed insurance form with you when you are admitted to hospital. You should have been given some of these forms when you first took out your policy, but your insurance company will be able to supply the correct form if you have any problems. If you are covered by company insurance, the form will probably be filled in and given to you by your Company Secretary.

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Laser laparoscopy for endometriosis is surgery which attempts to remove and destroy endometrial implants, cysts and adhesions using a laser beam.

Lasers are fine, highly concentrated beams of light that can be precisely aimed and controlled. They have been used in some branches of medicine for many years. Ophthalmologists use lasers to treat a variety of eye diseases and dermatologists use them to remove skin cancers and other skin growths.

There are several different types of lasers used in laser laparoscopy and each one has its own particular characteristics and uses. The three types of lasers that are most commonly used in the treatment of endometriosis are the carbon dioxide laser, the argon laser and the Nd: YAG laser. The type of laser used by your gynecologist will usually depend on which type is available.

Who is suitable for laser laparoscopy?

Laser laparoscopy is most suitable for women with minimal to moderate endometriosis. It is not usually suitable for women with severe endometriosis.

Things to discuss before laser laparoscopy

At some stage before the operation you and your gynecologist should discuss what procedures are proposed and what should be done if a laparotomy is needed.

What happens with laser laparoscopy?

A laser laparoscopy involves the same basic routine as that which is used for a diagnostic laparoscopy except that a laser instrument is inserted through a channel in the laparoscope. The laser beam then travels through special fibres known as fibre-optics before being directed onto the relevant tissue in the pelvic cavity.

The laser beam can be used to remove or destroy superficial endometrial implants and endometriomas, and to remove adhesions. The implants, endometriomas and adhesions are removed or destroyed by directing and focusing the laser on to them and using the intense energy of the laser beam to ‘vaporize’ or break up their cells.

Effectiveness of laser laparoscopy

Laser laparoscopy has several advantages over other surgery. It involves less risk of accidentally damaging underlying organs because the gynecologist is able to precisely control the depth and amount of tissue being destroyed. Similarly, because the laser destroys only the target tissue and leaves the surrounding tissue undamaged, there is likely to be less pain and discomfort and faster healing of the affected area. It is thought that the main advantage of laser laparoscopy is that it may produce less scarring and fewer adhesions than other types of surgery. In addition, because laser surgery usually involves a laparoscopy it has all the advantages associated with having laparoscopic surgery rather than a laparotomy.

The main disadvantage of laser laparoscopy as opposed to conventional laparoscopic surgery is that some women have taken significantly longer to recover from the operation because they were under the general anaesthetic for a greater period of time as laser laparoscopy takes longer to perform.

So far, there are few statistics on the effectiveness of laser laparoscopy. At present there is no evidence to suggest that laser laparoscopy is any more effective than other surgeries in terms of eradicating the disease or relieving the symptoms. Rather, in the hands of an experienced operator, the results of laser laparoscopy appear to be similar to those of other surgical treatments.

Risks and complications of laser laparoscopy

The risks and complications of laser laparoscopy are the same as those associated with a diagnostic laparoscopy.

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In the first stage the patient’s main goal is to return to a pattern of regular eating. We want to establish a routine whereby she plans to eat three or four meals per day and possiblyó two planned snacks. .

The key here is planning. A patient should know w due to eat next. She shouldn’t skip meals, nor should she re ó on her appetite to tell her when to eat. If her plan calls for her to eat lunch at one o’clock, then she should do so, eating everything she planned to eat whether she feels hungry or not. She shouldn’t snack unless the snack is part of the plan. Of course, the woman should not go for long periods without food. She shouldn’t skip breakfast, for example.

Sticking to the plan takes priority over other activities. It’s okay to accept dates, for example, but the patient must structure her social life around her meal plan. Her schedule may change on weekends, but she needs to plan those changes carefully.

The content of meals is less important than the regular pattern of meals during this phase. I urge the patient not to count calories, for instance. Instead she should eat average-size portions. She should wear loose clothing when she eats, since feeling constricted can lead to feelings of fullness. Here are some other helpful hints on controlling eating:

Tips for controlling eating

• Don’t engage in other activities while eating: Don’t watch TV, read, talk on the phone, do

homework and so on

• Restrict eating to one room of the house

• Limit food available when eating. Discard leftovers. Practice leaving some food on the plate.

Limit supplies of binge foods in the house; keep “safe” foods around instead

• Plan food-shopping expeditions. Make a shopping list and stick to it. Don’t shop when hungry.

Carry just a little money when shopping, especially if you feel you aren’t in good control

• Buy foods that need a lot of preparation, rather than those that can be eaten immediately

• Get rid of laxatives and diuretics

• Discard clothes that are too small

• Make adequate plans for your time – too much or too little unstructured time increases the

possibility of bingeing

If a patient eats too rapidly, she needs to slow down. Satiety signals need a little time to take effect. One tip: Put the fork down between mouthfuls and swallow before taking the next bite. It helps to savor food, pausing once in a while to decide whether or not to keep eating. I ask patients not to drink a lot of fluids during the meal, since doing so can exaggerate the feeling of fullness.

At first a patient may feel full after eating very little. Such feelings may trigger the urge to vomit. We work together to create a list of alternative activities so that she can distract herself and counteract these urges. One such list might include the following:

• Make a list of friends’ names and telephone numbers and call them when urges strike

• Visit friends

• Exercise (moderately)

• Go to a movie

• Take a bath or shower

• Write a letter

• Garden

• Knit or sew

• Read

• Listen to music

During this first stage the patient needs to keep checking on her progress. She should evaluate her eating daily. If she is successful, she needs to praise herself. On the other hand, she shouldn’t overreact to failure. She needs to avoid turning a small slipup into a major catastrophe.

Once regular eating patterns return, her binge frequency should drop. The patient can then begin to examine the causes of her bingeing. Does she eat to relieve anxiety or depression? Is she bored? Does eating bring on sleep? Is she trying to compensate for something (perhaps even a monotonous diet)? Is purging self-punishment, or a way of expressing anger that she should direct at other people?

We also talk about situations that may contribute to the problem. Does she keep too much food in the house? Does her home environment interfere-is there too much stress or chaos?

One way of keeping track of these elements is through the food diary. The patient uses these sheets to record her feelings and actions connected with food. The food diary is a crucial element in therapy, offering a window on the patient’s behavior. The vital information on these sheets becomes the raw material for our therapy sessions.

During the first stage of therapy, we work out a plan for keeping track of the patient’s weight. Weighing too often can lead to anxiety and obsessions about weight. As I mentioned, everyone has day-to-day fluctuations in weight. For a patient, a slight rise can trigger panic and a sense of failure. These feelings may cause her to give up, leading her back down the path of bingeing and purging. On the other hand, if she never weighs herself, she just continues to feed her phobia about doing so. We have to strike the right balance-usually about once a week is enough.

I encourage the patient to discuss her disorder openly with friends and family. Removing some of the secrecy helps alleviate guilt and shame. It also lets other people take a more active role. Knowing that a family member is having trouble helps others to understand her behavior and offer emotional support.

By the end of this first stage we usually see a lot of improvement. The patient’s mood is better, and the frequency of her bingeing drops. If not, though, I will consider adding medication or admitting her to the hospital.

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