OSTEOPOROSIS – TREATMENT

The problem in osteoporosis is an increase in the amount of bone resorption. Treatment has been tried to reverse this process and the best method is still a matter of argument.

There is no doubt that oestrogens given from the time of the menopause tend to prevent the development of osteoporosis but are less effective in reversing the process once it has developed.

The anabolic steroids were thought to increase the protein matrix but their use has been disappointing.

These drugs are derived from male hormones, but the virilising or masculinising effect has, to a large degree, been removed. They are widely used by weightlifters and those who take part in athletic field events to increase muscle bulk.

Calcitonin is a hormone derived from salmon and is now used to treat another bone condition, Paget’s disease. It is used also to treat osteoporosis but how effective it will be is still undetermined.

Vitamin D supplements have also been used but they appear to have some effect only where a definite deficiency of this vitamin can be demonstrated.

*522/71/1*

COMMON COLD – INTRODUCTION

Whatever happened to the common cold? The people who consult me with the winter sniffles, even those with whom I pass the time of day, rarely complain that they have ‘a cold’.

It seems more serious and deserving of sympathy to complain of ‘the flu’. Any respiratory infection is often called this, but most aren’t real influenza.

The common cold, or coryza, remains the commonest respiratory infection. It is an acute illness of a few days’ duration. It may be accompanied by a low fever and there is inflammation of the lining of the nose and throat.

There are more than 80 cold viruses and the immunity produced by infection with one virus may wear off after a few years. Those who suffer frequent colds are probably affected by a different virus each time; by the time they meet the original one again, the chance is that they will again be vulnerable, as any immunity will have worn off.

Why doctors are concerned to determine whether an infection is due to a virus or a bacterium is that bacterial infections can be treated with antibiotics whereas only a few viral infections respond to these drugs.

*266/71/1*

BLEEDING DISORDERS; BOW LEGS

Blood clotting, which seems such a simple process is so complicated that some doctors have trouble remembering the exact mechanics.

Two or three routine laboratory tests can now identify most children with bleeding disorders.

Bow legs, usually associated with in-toeing, are so common as to be almost normal in a child under two.

It is often incorrectly thought that bow legs are due to the nappy forcing the baby’s legs apart.

Bowing occurs in the tibia, the main bone of the lower leg, not in the femur or thigh bone.

The cause is unknown but many doctors believe it is due to a baby’s habit of sleeping in the “knee-chest” position, that is, on his face, with his knees tucked under him and his feet turned inwards.

Most babies stop sleeping this way at around 18 months and so the condition corrects itself. However, if the bowing persists, correction may be achieved by strapping the legs together to alter the child’s sleeping posture.

In-toeing can occur when the baby sits on the floor with his knees turned in or when he sleeps on his face with his feet turned in.

There is no functional impairment from in-toeing, so correction is done only on cosmetic grounds. One way to help is to encourage the child to sit crosslegged on the floor and to avoid the other posture.

Out-toeing may be caused by sitting on the knees but with the feet turned in. Treatment is the same for in-toeing.

*14/71/1*

YOUR CANCER YOUR LIFE – RIGHT TO TREATMENT BY EXPERIENCED PRACTITIONERS (EXAMLE)

Every year, medical diagnosis and treatment become more and more complicated. No one doctor can possibly know everything about the diagnosis and treatment of cancer.-For this reason doctors specialise. Whenever you consider having any specialised diagnostic or treatment method you have the right to insist on referral to someone who is qualified and experienced in the use of that method.

For example, say you have a shadow in your lung which looks like cancer. You may be advised that, to make a diagnosis, a specimen must be taken with a needle passed through the skin and lung guided by X-rays. Make sure this is done by someone who has had plenty of experience with the method. An experienced person is more likely to succeed in getting a good specimen without puncturing your lung or causing undue pain.

You may have a cancer of the lower bowel and be advised to have this removed, leaving you with a colostomy (bowel ending in an opening on the abdominal wall). Ask to be referred to a surgeon who has done a lot of these operations. A well placed and well constructed colostomy is quite easy to look after, a poorly placed and badly constructed colostomy is a nightmare.

*23/40/1*

HORMONAL REPLACEMENT THERAPY: GETTING THE DOSAGE RIGHT

There is such a wide range of dosages available that your doctor should be able to adjust your prescribed dose to your symptoms. If your symptoms are mild, you will start on a low dose; if they are severe you will start on a higher dose. (The further you are from the menopause, the more likely you are to get side-effects in the early days of taking oestrogen, so a low dose would probably be prescribed for you initially.) If the low dose is not getting rid of the symptoms, ask your doctor if he can give you a higher dose; if the higher dose is producing unpleasant side-effects, ask for a lower dose. Women who have had a hysterectomy or oophorectomy will usually be started on a higher dose, as their symptoms will probably be more severe than women passing through a natural menopause.

If you have severe symptoms of breast tenderness, nipple sensitivity, leg cramps, continuing weight gain and feelings of nausea, you might feel better on a lower dose of oestrogen. If you develop acne, bloatedness, disturbances of your digestive system, a drop in libido, breast discomfort, and feelings of pre-menstrual irritability, then you might feel better on a lower dose of progestogen. However, before you rush off to the doctor, be prepared to stick with your initial treatment for two or three months, unless the HRT is giving you really awful side-effects; in most cases they diminish considerably, and often go completely after a few months.

Women who start HRT before their periods stop completely may find it takes longer to get the dosage exactly right This is because if you are still having natural periods, then you are still producing some oestrogen, even though its falling levels may be causing hot flushes, night sweats and all the rest If you take extra oestrogen in the form of HRT, don’t be surprised if you suffer some of the effects of this extra dose. Also, as your own level of oestrogen falls steadily, your HRT dose may need gradually to be increased in order to compensate.

The other group of women who may initially suffer side-effects from higher doses of oestrogen (tender breasts, for example) are those who are many years past the menopause and haven’t produced much oestrogen of their own for a very long time. If this happens to you, your doctor may suggest that you start on a lower dose, and then progress to a higher dose when your body has adjusted to the oestrogen. Alternatively, it may help if you take the HRT on alternate days to start with. You may also find that evening primrose capsules bring relief for breast tenderness.

As well as adjusting the dosage to menopausal symptoms, your doctor will want to consider whether you are at risk of osteoporosis or arterial disease. If you are, he will probably suggest starring at a medium or high dose, as the low dose may not give enough protection for some women.

*32\42\4*

LAPAROSCOPICALLY ASSISTED HYSTERECTOMY

Surgeons gain access to, and remove, one or more of the reproductive organs in a number of ways. This is the basis for another method of classifying hysterectomy.

In recent years, another technique has been developed that combines elements of both the abdominal and vaginal approaches. It entails using the laparoscope, described in chapter 3, to gain access to the abdomen through several small (about 1 cm) pelvic incisions. The laparoscopic view of the inside of the abdomen is transmitted to a video screen and the surgeon manipulates cutting, burning or laser instruments within the pelvis according to what is seen on the screen. Direct vision laparoscopy tends to be used only when perception of depth is unclear, otherwise all surgery is performed while watching the screen.

After detaching the uterus and any other organs to be removed with diathermy, and closing blood vessels and realigning tissues using staples or sutures, the surgeon makes an incision near the top of the vagina where it meets the cervix. The unwanted tissue is then extracted through the opening in the vagina. This technique is called laparoscopically assisted hysterectomy or laparova-ginal hysterectomy. It has now been carried out on hundreds of women who would otherwise have had an abdominal hysterectomy. Laparoscopically assisted hysterectomy requires special equipment and a team of doctors and nurses skilled in gynaecological laparoscopy. It is considered to be suitable when:

• fibroids are of intermediate size

• endometriosis is a major reason for the surgery

• a reduced recovery period is important

• there is an early stage endometrial cancer and the ovaries are to be removed.

Margaret had a laparoscopically assisted hysterectomy instead of an abdominal or vaginal hysterectomy largely because of business pressures. A senior staff member of a company involved in a takeover bid, she was appreciative of the shorter hospital stay (one to four days instead of seven to ten days) and the reduced period of convalescence (one to four weeks instead of up to two or more months). After her convalescence it took her another few months to regain total well-being, but nevertheless she was able to contribute meaningfully at a critical time in her company’s business operations.

There is some evidence that laparoscopically assisted hysterectomy has a lower complication rate than either vaginal or abdominal hysterectomy, although this claim has been disputed and the results of clinical trials are awaited with interest. The operation takes somewhat longer to carry out than the other types of hysterectomy (one to two hours on average, although the French have reduced their operating time to less than an hour, compared with thirty minutes to an hour for an abdominal hysterectomy) and requires more costly instruments.

*47\198\4*

BIOLOGICAL CLOCK: ORCADIAN RHYTHM

Have you noticed that, even without looking at a watch, we usually wake up at about the same time every morning and feel sleepy and go to bed nearly the same time each night? We do not need to know the time to do all these things. Somehow our body knows the time, as if we have a clock inside. This internal clock is called the biological clock.

It is well known that all living things have a biological clock within them. This is because we live on a planet that rotates once every 24 hours, such that a period of light is followed by a period of darkness within every 24 hour cycle. Our sleep patterns, body temperature, hormonal excretion, body metabolism, and other biological functions fluctuate within this cycle as day becomes night and night becomes day. The biological clock governs our body rhythm repeatedly every day, and this rhythm is known as the arcadian rhythm. Orcadian is a Latin word meaning ‘about a day’.

This circadian rhythm is endogenous and is as if governed by an internal clock which is situated inside our brain. The body functions such as sleep patterns, body temperature, etc. appear to follow this internal clock. This body clock is quite robust and possesses a certain amount of durable inertia, and resetting of this clock may take from a few days to a week to complete. This is illustrated by the interesting case of the fiddler crab.

Scientists have noticed that the fiddler crab of North America changes colour according to whether it is night or day. These crabs are flown by air from New York on the east coast to California on the west coast. Because our earth rotates towards the east, New York on the east coast sees the sunrise many hours earlier than California. When the crabs first arrive in California they continue to change colour as if they were still back in New York; they have

not yet adjusted to the new timing of day and night in California. But after about ft week the crabs adjust to the local time in California and change colour according to this new local time. Obviously the crabs do not wear watches. Their biological clock is gradually reset to the new timing of daylight in California.

*45\174\4*

HOW TO DO THE EXERCISES FOR SELF-MANAGEMENT OF ANXIETY: DIFFICULTIES IN ATTAINING RELAXATION OF THE MIND

It is extraordinary how people tend to give up even before they have started. “Relaxing the body, yes, I can do that; but relaxing my mind, that is impossible; that is why I have come to you.” I hear this almost daily. Yet experience has shown that anyone who can achieve physical relaxation can likewise attain the sensation of relaxation of his mind, if he will only try—and try in the right way.

A common difficulty is that our thoughts seem to become too active. We keep thinking of the problems of the day. All the small inconsequential things of our business keep running through our mind. In an effort to stop it, we consciously turn our thoughts to our home. But the same thing happens again, and we become exasperated by the flow of unwanted thoughts. This particular difficulty is more common in people who have well-developed obsessive traits in their personality. The main problem is the rather vivid awareness of these thoughts, the way they intrude into our consciousness and the way they disturb us. We cope with this difficulty simply by giving our thoughts full rein, as it were, and letting them wander where they will without us worrying about them. We do this in a way similar to what happens in our moments of reverie. In it we are idle, and we daydream. Our thoughts wander far and wide; but it does not disturb us, and we still remain completely relaxed in our mind. This is the approach to the difficulty of active thoughts while we are first trying to relax. We just let the thoughts go. There is no tension. We let them go easily, just where they like, and it does not worry us.

There is another approach to this same problem which is also a help. As we do our exercises we have to maintain the physical reaction of our body. We do this by thinking of different parts of our body in turn, and making sure that each is relaxed.

I can feel my legs relaxed, both of them relaxed.—My body, it is relaxed, and I just feel the weight of it.—My arms relaxed, my face smooth, my jaw loose, the muscles around my eyes relaxed, my forehead relaxed deeply.

The sequence is then repeated easily and leisurely, starting with the legs again. By this simple means the mind is kept occupied so that other thoughts do not get the chance to intrude and worry us.

*71\57\2*

THE ROLE OF NUTRITION IN ARTHRITIS TREATMENT: BALANCED DIET

The worn-out cliche, “the balanced diet,” has been so misused and abused that it no longer has much meaning. The term optimum diet would better signify a diet so well planned and chosen as to assure optimum health.

What is a balanced diet? Is it a diet made up of “four basic foods” as you were taught in grade school? Or is it the “seven basics” as it is sometimes advised? Whichever it is, meat has always been considered the most basic food. We have all been brainwashed for years with the pseudoscientific slogan “high protein—low carbohydrate.” We believe that we should eat as much protein as possible. We are living in an era of the high-protein cult!

When I recently met Dr. Karl-Otto Aly, M.D., the prominent Swedish doctor, upon his return from an extensive lecture tour in the United States and asked him, ‘What is singularly the most memorable impression of your trip?” he had an immediate answer:

“The American high-protein craze! Not only the general public, but even so-called health enthusiasts are so thoroughly brainwashed on the question of protein in their diet, that, to my mind, this point alone may be held responsible to a great degree for the deplorable state of health of the American people.”

*28\176\2*

WHAT ELSE MAY BE USED TO TREAT EPILEPSY?

The use of anti-epileptic drugs is clearly the principal method of treating epilepsy. In those situations where a specific cause for the seizures has been found, then other treatments may be necessary. This will include antibiotics if the cause is meningitis or a cerebral abscess, antiviral drugs for certain types of encephalitis caused by viruses, supplementation of the diet with vitamins or other substances in those rare disorders where there may be a deficiency, and the use of surgery to remove cysts, tumours, or abnormal areas of the brain. Counselling and other specific psychological programmes designed to help modify behaviour may also be required for certain people, including those who drink alcohol to excess, or who use illicit drugs.

Dietary manipulation-There have been a number of attempts to control epileptic seizures by modifying the diet. This arose from the observation many years ago that fasting or starvation seemed to be associated with a reduction in the frequency of seizures. In the fasting state, normal metabolism is altered with the appearance of substances in the blood and urine, called ketones. It is not known how or why ketones are linked with seizure control. Of course, there may be no direct relationship between the two, and the occurrence of the two together may be coincidental. A diet was discovered which produced ketones, but without the child having to be starved. The diet is very rich in fat and oils, which makes it rather unpalatable. Because 70 per cent of the diet is in this fat form (the remaining 30 per cent coming from protein and carbohydrate), extra vitamins and minerals (such as calcium and magnesium) must be given. In spite of all the fat and oil eaten in this diet, there is no change in the blood level of cholesterol which is responsible for causing coronary heart disease. The main disadvantages with this diet are the unpalatability, often unpleasant diarrhoea, and the fact that the diet must be strictly followed. Its use is usually restricted to infants and children with very severe epilepsy (often with the Lennox-Gastaut syndrome). Unfortunately its success is limited and usually short-lived.

A rarely used and less successful diet is oiled the oligoantigenic diet. This entails trying to identify those substances in the diet which may cause an increase in epileptic seizures, and then to exclude them from the diet.

There are few, extremely rare conditions, where the epilepsy is caused by an ‘inborn error of metabolism’. This means that either the body is missing, or is unable to use, a particular substance—usually a vitamin or enzyme, and, as a result the person develops epilepsy, and often other problems (for example, skin rashes, loss of hair, failure to grow). If the missing substance is then given in large doses, then the epilepsy may stop. An example of this is a condition called pyridoxine (vitamin B6)-dependent seizures, which usually begins by affecting babies or infants in the first few days or weeks of life.

*65\188\2*